Jyrki Mäkelä

Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastomosis.

AbstractPURPOSE: To identify the risk factors for anastomotic leakage after left-sided colorectal resections with rectal anastomosis. METHODS: Forty-four patients with anastomotic leakage identified from a computer-generated database were compared with 44 control patients standardized for gender, age, and operative indication. RESULTS: The mean hospital stay was significantly prolonged in the leakage group, which resulted in a higher total cost of hospital treatment. The preoperative variables significantly associated with anastomotic leakage included malnutrition, weight loss, hypoalbuminemia, cardiovascular disease, two or more underlying diseases, and use of alcohol. The surgery-related factors that turned out to be significant were The American Society of Anesthesiologists physical status, operation time greater than two hours, multiple blood transfusions, intraoperative contamination of the operative field, and a short distance of the anastomosis to the anal verge. Obesity, body mass index, diabetes, smoking, serum hemoglobin, serum creatinine, serum bilirubin, bowel preparation, mode of antibiotic prophylaxis, type of anastomosis, technique of stapling, size of stapler used, and use of drain were nonsignificant variables. Malnutrition, weight loss, use of alcohol, intraoperative contamination, long operation time, and multiple blood transfusions remained significant in logistic regression model. Eighty-six percent of the patients with three or more risk factors of anastomotic leakage belonged to the leakage group. CONCLUSIONS: Patients with multiple risk factors have higher risk for anastomotic leakage. When patients have three or more risk factors, the creation of a protective stoma should be considered in cases with a low rectal anastomosis, and all these patients should be carefully monitored postoperatively for signs of possible leak.

Factors influencing wound dehiscence after midline laparotomy

PURPOSE To identify patients who have high risk of wound dehiscence and who might benefit from the use of internal retention sutures. PATIENTS AND METHODS Forty-eight patients with midline abdominal wound dehiscence were compared with 48 control patients standardized by sex, age, and operative indication. RESULTS The mean hospital stay was significantly prolonged in the dehiscence group, resulting in a higher total cost of hospital treatment. The variables that were significantly associated with wound dehiscence included hypoalbuminemia, anemia, malnutrition, chronic lung disease, and emergency procedure. The additional postoperative factors that were found to be significant were vomiting, prolonged intestinal paralysis, repeated urinary retention, and increased coughing. Obesity, chronic heart disease, diabetes, alcoholism, preoperative intestinal obstruction, jaundice, systemic and local infection, use of steroids, type of incision, operating time, and type of wound closure were nonsignificant variables. The number of wound dehiscences increased significantly (P = 0.0001) when the number of risk factors increased from zero to five. CONCLUSION We recommend using internal retention sutures for patients who have three or more risk factors.

Bowel preparation with oral polyethylene glycol electrolyte solutionvs. no preparation in elective open colorectal surgery

PURPOSE: Efficient mechanical bowel preparation has been regarded as essential in preventing postoperative complications of colorectal surgery, but the necessity of bowel cleansing has been disputed recently. The aim of this study was to evaluate the outcome of elective colorectal surgery in patients with or without bowel preparation. METHODS: Altogether, 267 consecutive adult patients admitted for elective open colorectal surgery were randomly assigned either to the bowel preparation group with oral polyethylene glycol electrolyte solution (138 patients) or no preparation group (129 patients). Patients who were unable to drink polyethylene glycol electrolyte solution, those who had had bowel preparation within the previous week, and patients not needing opening of the bowel were excluded. Routine colorectal surgery was undertaken, and infectious and other complications were registered daily. Late complications were checked up one to two months after surgery. RESULTS: No deaths were recorded, and 76 percent of the patients in the polyethylene glycol electrolyte solution group and 81 percent in the unprepared group recovered without complication. Anastomotic leaks occurred in 4 percent of the polyethylene glycol electrolyte solution patients and in 2 percent of the other cases, and other surgical site infections occurred in 6 and 5 percent, respectively. None of the differences was statistically significant. There was no difference in restoration of bowel function. The median postoperative stay was eight days in both groups. CONCLUSIONS: Preoperative bowel preparation seems to offer no benefit in elective open colorectal surgery.

Palliative operations for colorectal cancer

A review of 96 consecutive patients who underwent palliative surgery for primary colorectal cancer was undertaken to clarify the value of palliation achieved with surgical treatment. The overall rate of postoperative mortality was 8 percent (8 of 96) and the overall rate of postoperative morbidity was 24 percent (23 of 96). The mortality rate was 5 percent (3 of 66) after resective surgery and 17 percent (5 of 30) after nonresective surgery. Three deaths were related to the malignant disease, three were related to the intra-abdominal infection, and two were related to formation of intestinocutaneous fistulas. Of the 8 patients who died, 1 had a tumor with local visceral involvement only and 7 had a tumor with more distant spread. Median survival was 10 months for all patients, 15 months for patients treated with resective surgery, and 7 months for nonresected patients. Five patients (5 percent) have survived for longer than 5 years. The median relief of preoperative cancer symptoms was 4 months (4 months after resective surgery and 1 month after nonresective surgery). Twenty-five patients have undergone second surgery. It is concluded that palliative resective surgery for colorectal cancer can improve patient comfort with an acceptable postoperative mortality rate when cancer growth is localized and in favorable cases with more distant spread, whereas nonresective surgery fails to achieve symptom relief.

Stage-dependent alterations of the serum cytokine pattern in colorectal carcinoma

Background:Inflammation contributes to the pathogenesis of colorectal cancer (CRC), and cytokine levels are altered during colorectal carcinogenesis.Methods:The serum levels of 13 cytokines and their relation to clinical and pathological parameters, and systemic inflammatory response (mGPS, CRP and neutrophil–lymphocyte ratio), were analysed from a prospective series of 148 CRC patients and 86 healthy age- and sex-matched controls.Results:CRC patients had higher serum platelet-derived growth factor, interleukin (IL)-6, IL-7, and IL-8 levels and lower monocyte chemotactic protein-1 (MCP-1) levels than the controls. A logistic regression model for discriminating the patients from the controls – including the five most predictive cytokines (high IL-8, high IL-6, low MCP-1, low IL-1ra, and low IP-10) – yielded an area under curve value of 0.890 in receiver operating characteristics analysis. Serum cytokines showed distinct correlation with other markers of systemic inflammatory response, and advanced CRCs were associated with higher levels of IL-8, IL-1ra, and IL-6. A metastasised disease was accompanied by an orientation towards Th2 cytokine milieu.Conclusion:CRC is associated with extensive alterations in serum cytokine environment, highlighting the importance of studying relative cytokine level alterations. Serum cytokine profile shows promise in separating CRC patients from healthy controls but its clinical value is yet to be confirmed.

Microsatellite instability: impact on cancer progression in proximal and distal colorectal cancers

Whilst individual planning of treatment and follow-up in every colorectal cancer case is an increasing demand, prognostic markers are needed for predicting cancer progression in the primary phase. We studied the effect of replication error (RER)-positivity on colorectal cancer progression by analysing 255 colorectal cancer specimens by polymerase chain reaction (PCR) and fragment analysis and correlating the results with the clinical and histological features of the tumour and with patient outcome. RER-positivity was detected in 12% (28/235) of cases. It was associated with proximal location of the tumour (P < 0.001), poor differentiation (P = 0.001) and large tumour size (P = 0.009). The 5-year cumulative survival rate of the patients with RER-positive cancer of the proximal colon was markedly better (100%) than that of those with RER-negative proximal cancer (74%), whilst in cases of cancer of the distal colon or rectum, RER-positivity (21%) indicated poorer survival than RER-negativity (57%). Thus, it is suggested that RER-positivity has an opposite impact on cancer progression in cases of proximal and distal cancers. RER-positivity appears to indicate improved prognosis only in cases of proximally located cancer, in which it could accordingly be useful as a prognostic marker.

Natural history of diverticular disease

PURPOSE: The natural history of patients admitted because of acute diverticulitis is largely unknown, and the selection of patients for surgical treatment varies notably. This study presents our experience concerning the outcome for 366 patients admitted during a 10-year period. METHODS: Three hundred sixty-six patients admitted to our hospital with acute diverticulitis from 1981 to 1990 were identified from a computer database, and their clinical data up to the end of 1996 were reviewed from the database and patient records. RESULTS: There were significantly more males than females in the age group less than 50 years old, and young males underwent surgical treatment during the first treatment period more frequently than the others. Young patients were operated on without mortality, and all their temporary colostomies were closed. Older patients died more often of diseases unrelated to the diverticular disease during the years after the first episode of acute diverticulitis. Recurrences of diverticular disease developed in 22 percent of patients, and they were significantly more common in patients less than 50 years old than in the older age groups. Males less than 50 years old more often developed complications of diverticular disease after two hospital admissions. CONCLUSIONS: Males first admitted when less than 50 years of age undergo more primary operations and develop more recurrences of diverticular disease than do older people. Based on our data, however, we recommend surgery for all patients after two episodes of acute diverticulitis that resolves after conservative treatment with antibiotics.

Treatment of Symptomatic Congenital Hepatic Cysts with Single-Session Percutaneous Drainage and Ethanol Sclerosis: Technique and Outcome

PURPOSE To evaluate the safety and efficacy of percutaneous aspiration and ethanol sclerotherapy as the sole treatment for symptomatic, nonneoplastic, congenital hepatic cysts. PATIENTS AND METHODS In a prospective study, 59 symptomatic, congenital hepatic cysts in 25 patients were treated with ultrasound-guided percutaneous aspiration and ethanol sclerotherapy. Eleven patients had a solitary cyst, and 14 patients had polycystic liver disease. Mean follow-up was 4 years. RESULTS Fifty-seven (97%) of 59 sclerotherapy procedures were technically successful, and there were no recurrences. Eight cysts in six patients disappeared totally. The mean diameter of the remaining 49 cysts decreased from 9 cm to 3 cm. At the last follow-up visit, 14 patients were asymptomatic, four had milder epigastric pain than before the treatment, and seven with polycystic liver disease had recurrent symptoms due to growth of nontreated cysts. No major complications occurred. CONCLUSION Percutaneous aspiration with ethanol sclerotherapy is a safe, effective, and minimally invasive treatment method for symptomatic congenital cysts. It is the initial treatment of choice for all patients with symptomatic congenital hepatic cysts.

Loss of heterozygosity at 18q21 is indicative of recurrence and therefore poor prognosis in a subset of colorectal cancers.

SummaryAdjuvant therapies are increasingly used in colorectal cancers for the prevention of recurrence. These therapies have side-effects and should, thus, be used only if really beneficial. However, the development of recurrence cannot be predicted reliably at the moment of diagnosis, and targeting of adjuvant therapies is thus based only on the primary stage of the cancer. Loss of heterozygosity (LOH) in the long arm of chromosome 18 is suggested to be related to poor survival and possibly to the development of metastases. We studied the value of LOH at 18q21 as a marker of colorectal cancer prognosis, association with clinicopathological variables, tumour recurrence and survival of the patients. Of the 255 patients studied, 195 were informative as regards LOH status when analysed in primary colorectal cancer specimens using the polymerase chain reaction (PCR) and fragment analysis. LOH at 18q21 was significantly associated with the development of recurrence (P= 0.01) and indicated poor survival in patients of Dukes’ classes B and C, in which most recurrences (82%) occurred. An increased rate of tumour recurrence is the reason for poor survival among patients with LOH at 18q21 in primary cancer. These patients are a possible target group for recurrence-preventing adjuvant therapies.

Factors That Predict Morbidity and Mortality in Patients with Perforated Peptic Ulcers

BACKGROUND The demographic changes of perforated peptic ulcer disease were assessed in a well-defined population in northern Finland. The high mortality from perforated peptic ulcer underlines the importance of risk stratification, and clinical variables and three scoring systems were therefore tested for their ability to predict the probability of morbidity and mortality. METHODS Two hundred and eighty patients admitted to a university hospital with peptic ulcer perforation during the 22-year period 1979-2000 were identified using a computer database, and their clinical data were reviewed from the database and patient records. RESULTS The annual operation rate for ulcer perforation has varied from 2.7/100,000 in 1979 to 6.2 in 1985 and 3.6 in 2000 without any significant changes during the examination period. More operations have been performed for duodenal (157) than for gastric (123) ulcer perforations, but their incidence rates were quite similar at the beginning and the end of the period. Of the clinical variables, two or more associated illnesses, duration of symptoms for more than 24 hours, the amount of abdominal liquid, and low albumin concentration predicted morbidity, while a long duration of symptoms and the amount of abdominal liquid were independent risk factors for mortality. The MPI score correctly predicted 96% of postoperative complications and all the three scores, i.e. the Boey score, the MPI score and the ASA score, were good predictors of mortality. CONCLUSION The incidence of peptic ulcer perforation has not changed during the 22-year period in northern Finland. All the three scores, i.e. the Boey score, the MPI score and the ASA score, predict mortality in patients with peptic ulcer perforation and are suitable for risk stratification preoperatively in the surgical ward.