Martin Janson

Randomized clinical trial of the costs of open and laparoscopic surgery for colonic cancer.

There has been no randomized clinical trial of the costs of laparoscopic colonic resection (LCR) compared with those of open colonic resection (OCR) in the treatment of colonic cancer.

Randomized trial of health-related quality of life after open and laparoscopic surgery for colon cancer

BackgroundRandomized controlled trials (RCTs) have reported improved or unchanged three-year survival following laparoscopic colon resection (LCR) for colon cancer compared with that following open resection (OCR). The aim of this study was to determine health-related quality of life (HRQL) in patients randomized to laparoscopic or open resection for colon cancer.MethodsIn total, 285 patients (130 LCR, 155 OCR) from seven Swedish centers were included. HRQL was assessed preoperatively and at 2, 4, and 12 weeks postoperatively with the EQ-5D and EORTC QLQ-C30 instruments.ResultsThe LCR patients did significantly better on the social function component of the EORTC QLQ-C30 at two and four weeks and on the role function component at two weeks.ConclusionLaparoscopic resection for colon cancer improved quality of life during the first postoperative month.

PepT1 oligopeptide transporter (SLC15A1) gene polymorphism in inflammatory bowel disease

Background: Human polymorphisms affecting gut epithelial barrier and interactions with bacteria predispose to the inflammatory bowel diseases (IBD) Crohns disease (CD) and ulcerative colitis (UC). The intestinal transporter PepT1, encoded by the SLC15A1 gene, mediates intracellular uptake of bacterial products that can induce inflammation and NF‐&kgr;B activation upon binding to NOD2, a protein often mutated in CD. Hence, we tested SLC15A1 polymorphisms for association with IBD. Methods: Twelve SLC15A1 single nucleotide polymorphisms (SNPs) were genotyped in 1783 individuals from 2 cohorts of Swedish and Finnish IBD patients and controls. An in vitro system was set up to evaluate the potential impact of SLC15A1 polymorphism on PepT1 transporter function by quantification of NOD2‐mediated activation of NF‐&kgr;B. Results: The common allele (C) of a coding polymorphism (rs2297322, Ser117Asn) was associated with CD susceptibility both in Sweden and in Finland, but with genetic effects in opposite directions (risk and protection, respectively). The best evidence of association was found in both populations when the analysis was performed on individuals not carrying NOD2 common risk alleles (Sweden allelic P = 0.0007, OR 1.97, 95% confidence interval [CI] 1.34–2.92; Finland genotype P = 0.0013, OR 0.63, 95% CI 0.44–0.90). The PepT1 variant encoded by the C allele (PepT1‐Ser117) was associated with reduced signaling downstream of NOD2 (P < 0.0001 compared to Pept1‐Asn117). Conclusions: A functional polymorphism in the SLC15A1 gene might be of relevance to inflammation and antibacterial responses in IBD. Whether this polymorphism truly contributes to disease susceptibility needs to be further addressed, and should stimulate additional studies in other populations. Inflamm Bowel Dis 2009

Predicting lymph node metastases in early rectal cancer

AIM In this population-based study, the aim was to investigate risk factors for lymph node metastases and to construct a risk stratification index with relevance for pre-operative planning in T1 and T2 rectal cancers. METHODS Data were retrieved from The Swedish Rectal Cancer Register, a mandatory, national, prospectively collected data base. All T1 and T2 rectal cancers treated with abdominal resection surgery without neo-adjuvant or adjuvant radio-chemotherapy from 2007 to 2010 were analysed. T-stage, sm-level, histologic differentiation, mucinous tumour type, blood vessel- and perineural infiltration, tumour location (in cm from the anal verge), age and gender were evaluated as potential predictors of lymph node metastases, using uni- and multivariate logistic regression. RESULTS T2-stage (odds ratio [OR]=2.0), poor differentiation (OR=6.5) and vascular infiltration (OR=4.3) were identified as significant risk-factors for lymph node metastases in the multivariate analysis. The risk stratification index shows the risk for lymph node metastases gradually increasing from 6% to 65% and 11% to 78% in T1 and T2 cancers respectively, when adding the risk factors one by one. CONCLUSION There is a considerable span in the risk for lymph node metastases between low risk T1 and high risk T2 rectal cancer. Using the risk stratification-model, with the concept of local excision as a macro-biopsy with standby for subsequent immediate radical resection surgery in high-risk cases, could benefit patients by providing the advantages of local excision yet ensuring adequate oncologic outcome.

Local Insufflation of Warm Humidified CO2 Increases Open Wound and Core Temperature During Open Colon Surgery: A Randomized Clinical Trial

BACKGROUND:The open surgical wound is exposed to cold and dry ambient air resulting in heat loss through radiation, evaporation, and convection. Also, general and neuraxial anesthesia decrease the patient’s core temperature. Despite routine preventive measures mild intraoperative hypothermia is still common and contributes to postoperative morbidity and mortality. We hypothesized that local insufflation of warm fully humidified CO2 would increase both the open surgical wound and core temperature. METHODS:Eighty-three patients undergoing open colon surgery were equally and parallelly randomized to either standard warming measures including forced-air warming, warm fluids, and insulation of limbs and head, or to additional local wound insufflation of warm (37°C) humidified (100% relative humidity) CO2 at a laminar flow (10 L/min) via a gas diffuser. Wound surface and core temperatures were followed with a heat-sensitive infrared camera and a tympanic thermometer. RESULTS:The mean wound area temperature during surgery was 31.3°C in the warm humidified CO2 group compared with 29.6°C in the control group (P < 0.001, 95% confidence interval [CI], 1.2°C to 2.3°C). Also, the mean wound edge temperature during surgery was 30.1°C compared with 28.5°C in the control group (P < 0.001, 95% CI, 0.2°C to 0.7°C). Mean core temperature before start of surgery was similar with 36.7°C ± 0.5°C in the warm humidified CO2 group versus 36.6°C ± 0.5°C in the control group (95% CI, 0.4 to −0.1°C). At end of surgery, the 2 groups differed significantly with 36.9 ± 0.5°C in the warm humidified CO2 group versus 36.3 ± 0.5°C in the control group (P < 0.001, 95% CI, 0.38°C to 0.82°C). Moreover, only 8 patients of 40 in the warm humidified CO2 group had a core temperature <36.5°C (20%, 95% CI, 7 to 33%), whereas in the control group this was the case in 24 of 39 (62%, 95% CI, 46% to 78%, P = 0.001) patients (difference of the percentages between the groups 42%, 95% CI, 22% to 61%, P < 0.001). With a cutoff at <36.0°C none of the patients in the warm humidified CO2 group compared with 7 patients (18%, 95% CI, 5% to 31%, P = 0.005) in the control group was hypothermic at end of surgery (difference of the percentages between the groups 18%, 95% CI, 6% to 30%, P = 0.005). The median (25th/75th percentile) operating time was 181.5 (147.5/288) minutes in the warm humidified CO2 group versus 217 (149/288) minutes in the control group (P = 0.312). Clinical variables did not show any significant differences between the groups. CONCLUSIONS:Insufflation of warm fully humidified CO2 in an open surgical wound cavity increases surgical wound and core temperatures and helps to maintain normothermia.

Local excision in early rectal cancer-outcome worse than expected : a population based study

BACKGROUND Considering the morbidity and mortality after abdominal surgery for rectal cancer, our aim was to determine whether local excision in Stage I rectal cancer provides long-term survival equivalent to TME surgery, particularly in elderly patients. METHODS Data on 3694 consecutive patients with Stage I rectal cancer operated 1995-2006, were collected from the Swedish Rectal Cancer Register, a population-based, prospectively sampled data-base. Risk factors for death within 5 years after surgery, local recurrence rates, cumulative relative and overall survival rates were calculated for patients ≥ and <80 years-of-age. ASA grading related to surgical technique was analysed in a separate sample. RESULTS Local excision (LE) was associated with an increased mortality risk both ≥80 (HR 1.55) and <80 years-of-age (HR 1.45). After LE the 5-year local recurrence rate was 11.2% and the total and relative cumulative 5-year survival was 0.62 and 0.81 respectively. Hartmanns procedure (HA) showed an increased mortality risk only in younger patients (HR 2.15). The overall local recurrence rate was 7.2% with HA. Male gender (HR 1.70) and age (HR 1.06) were associated with a significantly increased mortality risk in all age groups. The ASA-grade was higher among patients operated with LE compared to Anterior Resection/Abdominoperineal resection. CONCLUSION Local excision has a poor outcome in the elderly. A negative selection bias towards old age and high co-morbidity could explain this. Hartmanns procedure has a high risk for mortality and local recurrence in younger patients.

Complications after colonoscopy and surgery in a population-based colorectal cancer screening programme

Objectives To report complications after colonoscopy and surgery in patients with neoplasia detected through a population based colorectal cancer (CRC) screening programme in the capital region of Sweden. Methods Patients who after a positive FOBT screening result underwent colonoscopy from 1 January 2008 to 30 June 2012 were included. Mortality and complications within 30 days after colonoscopy or subsequent surgery were identified through national registers, and complications were assessed through review of medical charts. Complications were graded using the Clavien-Dindo classification. Results After 2984 colonoscopies, the complication rate was 1%. The risk of post-polypectomy bleeding was 14/1000. The risk of perforation was 1/1000 after a diagnostic colonoscopy and 2.5/1000 after a colonoscopy with polypectomy. One patient developed a post-polypectomy syndrome. There was one death which was not related to the colonoscopy. After surgery for 37 adenomas and 155 CRCs, the total complication rates were 27% and 50%, respectively. The rate of anastomotic leakage was 13% and 12% after surgery for adenomas and CRC, respectively. There were no deaths after surgery. The overall complication rate after colonoscopy and surgery for adenomas and cancer was 4%. Conclusions Overall complication rates were acceptable and mortality low; however, the rate of anastomotic leakage after surgery for both adenomas and CRC was higher than expected.

Screening vs. non-screening detected colorectal cancer: Differences in pre-therapeutic work up and treatment.

Objectives To compare preoperative staging, multidisciplinary team-assessment, and treatment in patients with screening detected and non-screening detected colorectal cancer. Methods Data on patient and tumour characteristics, staging, multidisciplinary team-assessment and treatment in patients with screening and non-screening detected colorectal cancer from 2008 to 2012 were collected from the Stockholm–Gotland screening register and the Swedish Colorectal Cancer Registry. Results The screening group had a higher proportion of stage I disease (41 vs. 15%; p < 0.001), a more complete staging of primary tumour and metastases and were more frequently multidisciplinary team-assessed than the non-screening group (p < 0.001). In both groups, patients with endoscopically resected cancers were less completely staged and multidisciplinary team-assessed than patients with surgically resected cancers (p < 0.001). No statistically significant differences were observed between the screening and non-screening groups in the use of neoadjuvant treatment in rectal cancer (68 vs.76%), surgical treatment with local excision techniques in stage I rectal cancer (6 vs. 9%) or adjuvant chemotherapy in stages II and III disease (46 vs. 52%). Emergency interventions for colorectal cancer occurred in 4% of screening participants vs. 11% of non-compliers. Conclusions Screening detected cancer patients were staged and multidisciplinary team assessed more extensively than patients with non-screening detected cancers. Staging and multidisciplinary team assessment prior to endoscopic resection was less complete compared with surgical resection. Extensive surgical and (neo)adjuvant treatment was given in stage I disease. Participation in screening reduced the risk of emergency surgery for colorectal cancer.