Knut Nygaard

Preoperative radiotherapy in esophageal carcinoma: A meta-analysis using individual patient data (oesophageal cancer collaborative group)

PURPOSE The existing randomized evidence has failed to conclusively demonstrate the benefit or otherwise of preoperative radiotherapy in treating patients with potentially resectable esophageal carcinoma. This meta-analysis aimed to assess whether there is benefit from adding radiotherapy prior to surgery. METHODS AND MATERIALS This quantitative meta-analysis included updated individual patient data from all properly randomized trials (published or unpublished) comprising 1147 patients (971 deaths) from five randomized trials. RESULTS With a median follow-up of 9 years, the hazard ratio (HR) of 0.89 (95% CI 0.78-1.01) suggests an overall reduction in the risk of death of 11% and an absolute survival benefit of 3% at 2 years and 4% at 5 years. This result is not conventionally statistically significant (p = 0.062). No clear differences in the size of the effect by sex, age, or tumor location were apparent. CONCLUSION Based on existing trials, there was no clear evidence that preoperative radiotherapy improves the survival of patients with potentially resectable esophageal cancer. These results indicate that if such preoperative radiotherapy regimens do improve survival, then the effect is likely to be modest with an absolute improvement in survival of around 3 to 4%. Trials or a meta-analysis of around 2000 patients would be needed to reliably detect such an improvement (15-->20%).

STAGING OF RECTAL CARCINOMA WITH TRANSRECTAL ULTRASONOGRAPHY

Background and Aims: Transrectal ultrasonography (TRUS) has proven useful for loco-regional staging of rectal carcinoma in specialised centres, but the investigation is not widely used. The aim of this study was to audit the introduction of TRUS performed by surgeons without previous experience with ultrasonography. Material and Methods: All patients admitted with rectal carcinoma in the period 1996–2002 entered this prospective, comparative study. TRUS with a stiff endorectal probe was performed preoperatively in 118 consecutive patients, 91 of whom subsequently had rectal resection without preoperative radiotherapy (PRT), and seven who had rectal resection after PRT. Twenty patients did not have resection. The main outcome measures was the feasibility of TRUS in staging of rectal cancer, and the accuracy of T- and N-staging, comparing TRUS with the histopathological examination of resected specimens. Results: TRUS was successful in 81/91 patients who underwent rectal resection without PRT. The accuracy of T-staging was 74 % overall; 40 % in five pT1 tumours, 81 % in 26 pT2 tumours, 80 % in 45 pT3 tumours and 25 % in four pT4-tumours. With regard to perirectal tissue invasion, the sensitivity and specificity of TRUS was 82 % and 84 %, respectively, and the positive and negative predictive values were 89 and 71 %, respectively. The accuracy of TRUS for N-staging was 65 %. The sensitivity for detection of lymph node metastases was 41 % and the specificity 68 %. TRUS was unsuccessful in 21/118 patients, in 12/98 who had rectal resection, and in 9/20 who did not have resection, because of stenosis or high location of the tumour precluding correct placing of the probe. Conclusions: TRUS is often unsuccessful in patients with advanced tumours, especially when the tumour is located in the upper rectum. The predictive values for perirectal tumour invasion were acceptable, but the sensitivity for detection of lymph node metastases was low. These results were obtained by surgeons without previous experience with ultrasonographic examinations.

Audit of Intraoperative and Early Postoperative Complications after Introduction of Mesorectal Excision for Rectal Cancer

OBJECTIVE To compare complication rates after rectal resection using a conventional surgical technique (1983-1992) and mesorectal excision (1993-2000), and to find out whether the rate of complications changed with time after the introduction of mesorectal excision. DESIGN Prospective, observational study. SETTING University hospital, Norway. PATIENTS All patients who had rectal resections for cancer in the period 1983-2000. INTERVENTIONS In the conventional surgery period 217, and in the mesorectal excision period 176, patients had rectal resections. The mesorectal excision period was split in two, the early and the late mesorectal excision period, 88 rectal resections being performed in each period. Total mesorectal excision was done in 118 patients, and partial mesorectal excision in 58. MAIN OUTCOME MEASURES Major surgical complications in both periods; intraoperative bleeding, transfusions during the hospital stay, and cardiovascular complications in the mesorectal excision period. RESULTS 23/217 (11%) developed major surgical complications in the conventional surgery period, compared with 17/88 (19%) in the early mesorectal excision period (p = 0.04). This was caused by an increased incidence of anastomotic leaks after low anterior resection, being 11/122 (9%) in the conventional surgery period and 12/52 (23%) in the early mesorectal excision period (p = 0.01). The incidence of anastomotic leaks declined to 5/61 (8%) in the late mesorectal excision period (p = 0.03). Multiple regression analysis identified a low anastomosis, major bleeding, and age over 75 years as significant risk factors for the development of anastomotic leaks. Major intraoperative bleeding occurred in 36/84 (43%) of the patients in the early and 22/82 (27%) in the late mesorectal period (p = 0.04). Blood transfusions were given to 61/84 (74%) in the early mesorectal period and 41/82 (50%) in the late period (p < 0.01). CONCLUSIONS The incidence of surgical complications increased significantly after the introduction of mesorectal excision, but declined with time.

Mesorectal excision for rectal cancer: functional outcome after low anterior resection and colorectal anastomosis without a reservoir

The anal sphincters, neorectal capacity and motility may be affected by injury to the autonomic nerves during rectal resection. Anorectal function also depends on the method used for restoration of intestinal continuity, and colonic reservoir reconstruction has been recommended in ultralow anastomosis. This study was undertaken to evaluate the results after nerve preserving mesorectal excision and colorectal anastomosis without a reservoir.

Pancreatic duct occlusion in the rat: report and assessment of a new technique.

Abstract Temporary reduction of the exocrine pancreatic secretion may be desirable in various experimental models. In the rat this can be achieved by obstructing the connection between the pancreas and the duodenum. A new, simple technique of pancreatic duct occlusion using metal hemostatic clips is described. The reduction of secretion produced by the procedure was assessed by measuring duodenal protein, amylase, and trypsin during stimulation with cholecystokinin. Stimulated duodenal amylase activity 1 and 4 weeks following duct occlusion was reduced by approximately 80% compared with sham-operated controls, whereas proteolytic activity was reduced by 96 and 60%, respectively. The magnitude and duration of pancreatic insufficiency achieved by this technique is equivalent to that achieved with more complicated methods.

Splenic injury—a prospective multicentre diagnostic study

One hundred and forty-seven patients with splenic injury were entered in a prospective multicentre study including 18 hospitals. The diagnosis was made by scintigraphy in 55 patients, ultrasonography in 51 and computed axial tomography in 31. Exploratory laparotomy was performed in 52 patients, in 23 of these after a positive peritoneal lavage. Splenic injury was found in 33 per cent of the ultrasound examinations, indicated in another 20 per cent and not indicated in 16 per cent. In 31 per cent increased intraperitoneal effusion was the only finding. There was a tendency towards an underestimation of the injury by ultrasonography. Peritoneal lavage was positive in all examinations.