K.-G. Tranberg

Follow-up after curative surgery for colorectal carcinoma

PURPOSE: This study investigated the value of intense follow-up compared with no follow-up after curative surgery of cancer in the colon or rectum. METHODS: One hundred seven patients were randomized to no follow-up (control group; n=54) or intense follow-up (follow-up group; n=53) after surgery and early postoperative colonoscopy. Patients in the follow-up group were followed at frequent intervals with clinical examination, rigid proctosigmoidoscopy, colonoscopy, computed tomography of the pelvis (in patients operated with abdominoperineal resection), pulmonary x-ray, liver function tests, and determinations of carcinoembryonic antigen and fecal hemoglobin. Follow-up ranged from 5.5 to 8.8 years after primary surgery. RESULTS: Tumor recurred in 18 patients (33 percent) in the control group and in 17 patients (32 percent) in the follow-up group. Reresection with curative intent was performed in three patients in the control group and in five patients (four of whom were asymptomatic) in the follow-up group. In the follow-up group two asymptomatic patients with elevated carcinoembryonic antigen levels were disease-free three and five and one-half years after reresection and were the only patients apparently cured by reresection. No patient underwent surgery for metastatic disease in the liver or lungs. Symptomatic metachronous carcinoma was detected in one patient (control group) after three years. Five-year survival rate was 67 percent in the control group and 75 percent in the follow-up group (P >0.05); the corresponding cancer-specific survival rates were 71 percent and 78 percent, respectively. CONCLUSION: Intense follow-up after resection of colorectal cancer did not prolong survival in this study.

Tumor Seeding Occurring after Fine-Needle Biopsy of Abdominal Malignancies

Percutaneous fine-needle aspiration biopsy is a commonly used diagnostic procedure with a high accuracy and a low complication rate. However, tumor seeding in the biopsy tracts has been recorded with a frequency of one in 20 000–40 000 biopsies. We report 5 cases of percutaneous tumor seeding recorded after 5 000 fine-needle biopsies of abdominal malignancies at our institution. The risk of implantation metastases induced by fine-needle biopsy warrants consideration in patients with abdominal malignancies since it may compromise the outcome of radical surgery. It should only be performed when the result of the procedure has a direct impact on the choice of therapy.

Temperature control and light penetration in a feedback interstitial laser thermotherapy system

The aim of this study was to describe the performance of a closed loop interstitial laser thermotherapy system in processed liver and to demonstrate its suitability for treating a vascularized tumour in vivo. The thermotherapy system consisted of an Nd: YAG laser and a temperature feedback circuit including an automatic thermometry system and thermistor probes. Experiments in processed liver were performed with a sapphire probe and temperature control at a distance of 10 mm. In most experiments at 1-2 W, and in half of the experiments at 3 W, there was no carbonization, a moderate change in the light penetration and excellent control of the temperature. In experiments with output powers of 4-5 W there was carbonization with rapid deterioration of light penetration and impaired control of the temperature. Carbonization affected the distribution of temperatures, which were lower below, and higher above, the laser tip in experiments with carbonization as compared to experiments without carbonization. Treatment of an adenocarcinoma implanted into rat liver was performed at 2 W with a bare fibre and without blood inflow occlusion. The feedback thermistor probe was placed 3 mm outside the margin of the tumour (largest diameter 9.5 +/- 0.3 mm (mean +/- SEM)). Temperature control and light penetration characteristics were similar to those found in vitro. No tumour could be demonstrated at sacrifice 6 days later. It is concluded that a closed loop feedback system can produce stable and reproducible local hyperthermia, that it performs better when carbonization is avoided and light penetration is preserved and that it has a great potential for interstitial thermotherapy of malignant tumours.

Interstitial laser treatment of malignant tumours: initial experience.

This is a prospective pilot investigation of interstitial laser treatment. Twelve patients were treated at 13 sites: seven patients had metastatic or primary liver cancer (with a total of 21 tumour nodules), two had pancreatic carcinoma and four patients had disease at other sites. Treatments were performed with an Nd-YAG laser, using a high power (6 or 10 W), short-time (5 min) technique or a feedback system for temperature regulation at low power (3 W) for 12-16 min. Treatment with high power invariably resulted in rapid carbonization of tissue, which may have contributed to the postoperative death in one patient. The local effect of treatment could be evaluated in 13 hepatic tumours (1.0-10 cm in diameter): 100% necrosis was seen in five and >50% necrosis in the remaining eight. Two tumours were eradicated, five became smaller, and six remained unchanged in size or showed continued growth. Treatment removed or alleviated symptoms in 7/8 symptomatic patients. The feedback system made it possible to avoid carbonization and allowed better control of the tissue temperature. The main problem with either method was to monitor tissue changes in real time, and ultrasonography was found to be of little help in this respect. It is concluded that interstitial laser treatment is a promising method for treatment of tumours. Further development should focus on real-time monitoring and increased volume effect without carbonization.

Feedback interstitial diode laser (805 nm) thermotherapy system: Ex vivo evaluation and mathematical modeling with one and four-fibers

In this study a newly developed microprocessor controlled power regulation and thermometry system integrated with a diode laser (805 nm wavelength) was evaluated with respect to temperature distribution, effectiveness of regulation, and ability to predict temperature distributions by computer simulation.

Subtotal pancreatectomy for cancer: closure of the pancreatic remnant with staplers

This paper presents a 2-year series of 26 consecutive pancreatectomies for periampullary cancer where the pancreatic tail was closed with a stapler in order to avoid complications related to a pancreatico-digestive anastomosis. The follow-up period was 14 months or more. Seven patients developed operative complications. Pancreatic fistulas developed in 3 patients. The fistulas closed spontaneously in 2 of the patients after 2-4 months, lntraabdominal abscesses developed in 4 patients and required surgical drainage. In 1 of these patients, the abscess eroded a large vessel with a fatal outcome resulting in an operative mortality rate of 3.8%. A transient postoperative gastric stasis was observed in seven patients. Postoperative hospital median stay was 27 days (range 10–83 days). Eighteeen patients have died after 4–30 months in recurrent disease and seven patients are alive after a follow-up period of 15–29 months. Pancreatic endocrine function seemed well preserved; diabetes mellitus has developed in only one patient. In conclusion, it appears that subtotal pancreatectomy with closure of the pancreatic remnant with staples gives a low morbidity and mortality. Although the conclusion should be tempered by the small number of patients, the results justify continued evaluation of this technique with long-term follow-up.

Repeated dearterialization of hepatic tumors with an implantable occluder.

A new implantable device for repeated hepatic dearterialization was evaluated in 13 patients with tumors of the liver. Eleven patients had colorectal secondaries and also received cyclic intraperitoneal infusion of 5‐fluorouracil. Two patients had primary hepatocellular cancer (HCC). Four patients had a variant arterial supply. The hepatic artery was occluded repeatedly for 1 hour twice daily for 1 to 17 months (mean, 8.5 months). A complete transient occlusion was obtained in all but three patients, in whom minor collaterals were missed at the initial operation. Collaterals developed in two patients during therapy. Leakage from the balloon occurred in two patients after 5 and 12 months. Two patients developed thrombosis of the hepatic artery during therapy due to the cuff being placed too tightly around the vessel. A complete remission was demonstrated in one patient with HCC, a partial response in three patients (one HCC and two metastatic), stable disease in two patients, and progression in five patients. Median survival for colorectal lesions was 15 months (range, 2 to 23 months) from start of the occlusions. Four of nine patients developed calcifications of their lesions during therapy. One patient with HCC was alive and free of disease 18 months after the start of the occlusions. Both patients with HCC had an obstructed portal vein which may have contributed to the favorable outcome. The occluder was uniformly accepted by the patients who were able to do their occlusions at home.

Enteral versus parenteral glucose as the sole nutritional support after colorectal resection: a prospective, randomized comparison

Twenty consecutive patients undergoing resection for colorectal carcinoma were randomized to receive either a glucose polymer by nasojejunal tube or glucose by intravenous infusion as the sole postoperative nutritional support for 4 days. Identical amounts of glucose were given by the two routes. Brief infusions of insulin (10 mU kg-1) and glucose (25 g) were given before and 4 days after surgery for the purpose of metabolic evaluation. Blood glucose was consistently lower in the enteral than in the parenteral group (p less than 0.05). Glucose tolerance and the hypoglycemic response to insulin were impaired after surgery in the parenteral group (p less than 0.01 in both cases) but not in the enteral group. Clearance and release of insulin were similar before and after surgery and were similar in both groups. Patients receiving enteral glucose had less postoperative distress and required fewer doses of analgesic drug (p less than 0.05 in both cases). It is concluded that enteral infusion of glucose preserves insulin action and glucose tolerance after colorectal resection, whereas intravenous infusion of glucose does not. The favorable metabolic effects seen after enteral infusion are accompanied by a reduction of postoperative discomfort.

A new self-propelling nasoenteric feeding tube.

A new fine-bore nasoenteric feeding tube was tested in 19 post-operative patients. It is a silicone rubber tube, which at its distal end has 5 loops with a diameter of approximately 4 cm. The loops are easily straightened during insertion into the stomach, but ease transpyloric passage after removal of the guidewire. 4 h after insertion, 18 tubes had reached the duodenum or upper part of the jejunum. In only 1 patient was there regurgitation of the tube into the stomach after insertion.

Interstitial laser thermotherapy: Comparison between bare fibre and sapphire probe

A sapphire probe and a bare fibre were compared with respect to temperature control and distribution and light fluence in interstitial laser thermotherapy. Experiments were performed in processed liver using an Nd-YAG laser and output power levels of 1–4 W. The temperature was controlled at a distance of 10 mm using a feedback circuit with an automatic thermometry system and thermistor probes. With the sapphire probe, carbonization was rare at power levels of 1–2 W but was observed in half of the experiments at 3 W and in all experiments at 4 W. Using the bare fibre, carbonization was seen in almost all experiments. Absence of carbonization was associated with a moderate decrease in the penetration of light and excellent control of the temperature, whereas carbonization led to rapid impairment of light penetration and temperature control. In addition, the temperature gradient was smaller with the sapphire probe than with the bare fibre or when carbonization was absent. It is concluded that a diffuser tip, such as the sapphire probe, may be preferable to the bare fibre for interstitial laser thermotherapy because it gives a smaller temperature gradient and helps to avoid carbonization which results in preserved light penetration and improved temperature control.