Kenneth Smedh

Initiation of anastomotic recurrence of Crohn's disease after ileocolic resection. Onset proximal to the junction and preceded by increased phospholipase A2 activity.

Colono-ileoscopy was performed on 11 patients after ileocolic resection for Crohns disease, to observe development of recurrent anastomotic inflammation and its relationship to mucosal phospholipase A2 (EC 3.1.1.4) activity. Ileal inflammation appeared soon after surgery in eight cases but in none of nine controls with noninflammatory bowel disease. The ileal inflammation was more severe 1-3 cm above than greater than 5 cm above the ileocolic junction (p less than 0.05), whereas the postanastomotic colonic mucosa remained unchanged. Ileal phospholipase A2 activity in the mucosa was equally raised at the two ileal sites (p less than 0.01 and less than 0.02), irrespective of the presence or absence of inflammation. In colonic postanastomotic mucosa the phospholipase A2 activity was the same as in the controls. Further followup showed preanastomotic ileal inflammation at both investigated levels in all patients with Crohns disease but still with greater severity close to the mucosal junction (p less than 0.05). The study indicates that recurrent inflammation in Crohns disease is initiated in the terminal ileum close to the ileocolic junction. Progression of severity is accompanied by greater proximal involvement. The increase in mucosal phospholipase A2 activity, which precedes endoscopically detectable inflammation, implies a role for this enzyme in Crohns disease.

No antibiotics in acute uncomplicated diverticulitis: does it work?

Abstract Background. The first randomized multicenter study evaluating the need for antibiotic treatment in patients with acute uncomplicated diverticulitis (AUD) could not demonstrate any benefit gained from antibiotic use. The aim of this study was to review the application of the no antibiotic policy and its consequences in regard to complications and recurrence. Methods. This retrospective population-based cohort study included all patients diagnosed with all types of colonic diverticulitis during the year 2011 at Västmanland Hospital Västerås, Sweden. All medical records were carefully reviewed. Primary outcomes were the types of treatment adopted for diverticulitis, complications and recurrence. Results. In total, 246 patients with computer tomography-verified diverticulitis were identified, 195 with primary AUD and 51 with acute complicated diverticulitis. Age, sex, and temperature at admission were similar between the groups but there was a significant difference in white blood cell count, C-reactive protein, and length of hospital stay. In the AUD group, 178 (91.3%) patients were not treated with antibiotics. In this group, there were six (3.4%) readmissions but only two developed an abscess. Of the remaining 17 patients (8.7%) who were treated with antibiotics in the AUD group, one developed an abscess. Twenty-five (12.8%) patients in the AUD group presented with a recurrence within 1 year. Conclusion. The no-antibiotic policy for AUD is safe and applicable in clinical practice. The previous results of a low complication and recurrence rate in AUD are confirmed. There is no need for antibiotic treatment for AUD. What does this paper add to the literature? Despite published papers with excellent results, there are still doubts about patient safety against the policy to not use antibiotics in acute uncomplicated diverticulitis. This is the first paper, in actual clinical practice, to confirm that the no antibiotic policy for acute uncomplicated diverticulitis is applicable and safe.

Patients with rectal cancer receiving adjuvant chemotherapy have an increased survival : a population-based longitudinal study

BACKGROUND The aim of this study was to investigate whether or not the use of adjuvant chemotherapy in stage III rectal cancer varies between regions and over time, and if this has had an effect on survival rates. PATIENTS AND METHODS Patients from the Uppsala/Örebro region below 75 years-of-age, operated 1995-2002 and registered in the Swedish Rectal Cancer Register, were monitored between 1995 and September 2008. A multivariate Cox proportional hazard regression model was used for analysis. Overall survival was described using the Kaplan-Meier method. RESULTS Four hundred and thirty-six patients with stage III rectal cancer were included. Adjuvant chemotherapy was given to 42% of the patients (proportions varying from 13% to 77% among counties), and there were substantial increases over time. The 5-year overall survival was 65.8% [95% confidence interval (CI) 50-84] for patients having adjuvant chemotherapy compared with 45.6% (95% CI 39-52) for patients not treated with chemotherapy. The multivariate hazard ratio for death was 0.65 (95% CI 0.5-0.8) for patients treated with adjuvant chemotherapy. CONCLUSIONS The use of adjuvant chemotherapy for rectal cancer has increased, but varies considerably between hospitals/counties. In this cohort, those having adjuvant chemotherapy had a longer overall survival.

Prevalence of fecal carriage of antibiotic-resistant bacteria in patients with acute surgical abdominal infections

Abstract Objective. Antibiotic resistance is increasing worldwide. The aims of the current study were to determine the fecal carriage of antibiotic-resistant bacteria and antibiotic treatment in surgical patients admitted to hospital due to acute intra-abdominal infections. Materials and methods. Eight Swedish surgical units participated in this prospective multicenter investigation. Rectal swabs were obtained on admission to hospital. Cultures were performed on chromogenic agar and antibiotic susceptibility testing was performed using the disk diffusion method. Extended-spectrum beta-lactamase (ESBL)-phenotype was confirmed by Etest. Results. Rectal samples were obtained and analyzed from 208 patients with intra-abdominal surgical infections. Surgery was performed in 134 patients (65%). Cephalosporins were the most frequently used empirical antibiotic therapy. The highest rates of resistance among Enterobacteriaceae were detected for ampicillin (54%), tetracycline (26%), cefuroxime (26%) and trimethoprim-sulfamethoxazole (20%). The prevalence of decreased susceptibility (I + R) for the other antibiotics tested was for ciprofloxacin 20%, piperacillin-tazobactam 17%, cefotaxime 14%, ertapenem 12%, gentamicin 3% and imipenem 0%. ESBL-producing Enterobacteriaceae were found in samples from 10 patients (5%). Three patients had five E. coli isolates producing AmpC enzymes. Conclusions. This study shows a high rate of resistance among Enterobacteriaceae against antibiotics which are commonly used in Sweden and should have implications for the future choice of antibiotics for surgical patients.

Treatment strategies for patients with stage IV rectal cancer: A report from the Swedish Rectal Cancer Registry

BACKGROUND The optimal treatment strategy for patients with stage IV rectal cancer is unclear. The aim of the present study was to describe trends and compare the different treatment strategies for this group of patients at a national level and over time. METHODS Data from 2758 rectal cancer patients with (stage IV) and 13,420 without metastases (stage I-III) were available from the Swedish Rectal Cancer Registry between January 1995 and December 2006. RESULTS Patients with stage IV disease increased from 15% to 19% between 1995 and 2006 (p<0.001) and the frequency of patients not operated on increased from 13% to 26% (p<0.001). Postoperative 30 day mortality after bowel resection was 2% and after exploratory laparotomy 9%. Median survival for stage IV patients after bowel resection was 16.3 months, exploratory laparotomy 6.1 months and for patients having no surgery 4.6 months. Over time survival was improved for patients aged 60-69 years, irrespective of the treatment given. An increased risk of death was associated with: age >80 years, operation at a local hospital, treatment in earlier time periods, not receiving preoperative radio- or chemotherapy and not having a bowel resection. CONCLUSIONS In the latest time period survival was improved for rectal cancer patients in stage IV despite the great increase in non-operated patients. Patients aged >80 years should be carefully assessed and staged before surgery. The survival advantage for stage IV rectal cancer patients who underwent primary tumour resection is probably due to selection to more favourable cases.

Mechanical bowel preparation does not affect the intramucosal bacterial colony count

PurposeThe aim of this study was to determine if mechanical bowel preparation (MBP) influences the intramucosal bacterial colony count in the colon.Materials and methodsMacroscopically normal colon mucosa was collected from 37 patients (20 with and 17 without MBP) who were undergoing elective colorectal surgery at three hospitals. The biopsies were processed and cultured in the same laboratory. Colony counts of the common pathogens Escherichia coli and Bacteroides as well as of total bacteria were conducted. The study groups were comparable with regard to age, gender, antibiotics use, diagnosis and type of resection.ResultsMBP did not influence the median colony count of E. coli, Bacteroides or total bacteria in our study.ConclusionsMBP did not affect the intramucosal bacterial count in this study. Further studies are suggested to confirm these findings.

Circumferential resection margin as a prognostic marker in the modern multidisciplinary management of rectal cancer.

BACKGROUND: A positive circumferential resection margin has been associated with a high risk of local recurrence and a decrease in survival in patients who have rectal cancer. OBJECTIVE: The purpose of this study was to analyze the involvement of circumferential resection margin in local recurrence and survival in a multidisciplinary population-based setting by using tailored oncological therapy and surgery with total mesorectal excision. DESIGN: Data were collected in a prospective database and retrospectively analyzed. Between 1996 and 2009, 448 patients with rectal cancer underwent a curative bowel resection. SETTINGS: Population-based data were collected at a single institution in the county of Västmanland, Sweden. RESULTS: Preoperative radiotherapy was delivered to 334 patients (74%); it was delivered to 35 patients (8%) concomitantly with preoperative chemotherapy. In 70 patients (16%), en bloc resections of the prostate and vagina were performed. Intraoperative perforations were seen in 7 patients (1.6%). The mesorectal fascia was assessed as complete in 117/118 cases. In 32 cases (7%), the circumferential resection margin was 1 mm or less. After a median follow-up of 68 months, 5 (1.1%) patients developed a local recurrence; one of them had circumferential resection margin involvement. The 5-year overall survival was 77%. In the multivariate analysis, the circumferential resection margin was not an independent factor for disease-free survival. LIMITATIONS: Mesorectal fascia was not assessed before 2007. The findings might be explained by a type II error but, from a clinical perspective, enough patients were included to motivate the conclusion of the study. CONCLUSIONS: Circumferential resection margin is an important measurement in rectal cancer pathology, but the correlation to local recurrence is much less than previously stated, probably because of oncological treatment and surgery that respects the mesorectal fascia and, when required, en bloc resections. Circumferential resection margin should not be used as a prognostic marker in the modern multidisciplinary management of rectal cancer.

CT-colonography in the follow-up of acute diverticulitis: patient acceptance and diagnostic accuracy

Abstract Objective. The aim of this study was to assess CT-colonography (CTC) in the follow-up of diverticulitis regarding patient acceptance and diagnostic accuracy for diverticular disease, adenomas and cancer, with colonoscopy as a reference standard. Methods. A prospective comparative study where half of the patients underwent colonoscopy first, followed immediately by CTC. The other half had the examinations in the reverse order. Patient experiences and findings were registered after every examination, blinded to the examiner. Results. Of a total of 110 consecutive patients, 108 were included in the study, with a median age of 56 years (range 27–84). The success rate was 91% for colonoscopy and 86% for CTC. Examination time was 25 min for both methods. The mean time for CTC evaluation was 20 min. Eighty-three per cent of the patients received sedation during colonoscopy. Despite this, patients experienced colonoscopy as more painful (p < 0.001) and uncomfortable (p < 0.001). Diverticulosis and polyps were detected in 94% and 20% with colonoscopy and in 94% and 29% with CTC, respectively. Sensitivity and specificity for CTC in the detection of diverticulosis was 99% and 67%, with a good agreement (κ = 0.71). Regarding detection of polyps, the sensitivity and specificity were 47% and 75%, with a poor agreement (κ = 0.17). No cancer was found. Conclusion. CTC was less painful and unpleasant and can be used for colonic investigation in the follow-up of diverticulitis. CTC detected diverticulosis with good accuracy while the detection accuracy of small polyps was poor. CTC is a viable alternative, especially in case of incomplete colonoscopy or in a situation with limited colonoscopy resources.

Is the circumferential resection margin a predictor of local recurrence after preoperative radiotherapy and optimal surgery for rectal carcinoma

Objective  Circumferential resection margin (CRM) involvement has been correlated with a high risk of developing local recurrence. The aim of this study was to examine the prognostic significance of the CRM involvement after curative resection of rectal cancer in patients treated with preoperative radiotherapy and postoperative chemotherapy where indicated.

Effect of local gentamicin–collagen on perineal wound complications and cancer recurrence after abdominoperineal resection: a multicentre randomized controlled trial

Aim  Perineal wound sepsis is a common problem after abdominoperineal resection of the rectum (APR), with a reported incidence of 10–15% in previously non‐irradiated patients, 20–30% in patients given preoperative radiation and 50% among patients submitted to preoperative radiation combined with chemotherapy. The local application of gentamicin–collagen was evaluated to determine whether its use in the perineal wound reduced risk complications and had an effect on cancer recurrence.