O. C. Lunde

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.

MR Cholangiopancreaticography and Endoscopic Retrograde Cholangiopancreaticography in Patients with Suspected Common Bile Duct Stones: A prospective blinded study

Purpose: To prospectively compare MR cholangiopancreaticography (MRCP) vs. endoscopic retrograde pancreaticography (ERCP) in patients with suspected common bile duct (CBD) stone disease. Material and Methods: Fifty consecutive patients with suspected CBD disease underwent MRCP and then ERCP within 12 h of each other. The result of the MRCP was blinded to the reader of the ERCP. The MRCP was done using a superconducting 1.0 T unit with a heavily T2-weighted breath-hold technique. The ERCP was done in the fluoroscopy suite by one of the clinicians and was evaluated by one of the radiologists who had not read the MRCP examinations. Results: There were 28 true-positives, 17 true-negatives, 1 false-positive, and 4 false-negatives. The sensitivity was 87.5% and the specificity 94.4%, respectively. The positive predictive value was 96.6% and the negative predictive value was 81.1%. Conclusion: MRCP was shown to be good enough to replace ERCP as a diagnostic method in patients with suspected CBD disease. MRCP is now our modality of choice after ultrasound in the diagnostic evaluation of these patients.

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.

MR CHOLANGIOPANCREATICOGRAPHY AND ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATICOGRAPHY IN PATIENTS WITH SUSPECTED COMMON BILE DUCT STONES

PURPOSE: To prospectively compare MR cholangiopancreaticography (MRCP) vs. endoscopic retrograde pancreaticography (ERCP) in patients with suspected common bile duct (CBD) stone disease. MATERIAL AND METHODS: Fifty consecutive patients with suspected CBD disease underwent MRCP and then ERCP within 12 h of each other. The result of the MRCP was blinded to the reader of the ERCP. The MRCP was done using a superconducting 1.0 T unit with a heavily T2-weighted breath-hold technique. The ERCP was done in the fluoroscopy suite by one of the clinicians and was evaluated by one of the radiologists who had not read the MRCP examinations. RESULTS: There were 28 true-positives, 17 true-negatives, 1 false-positive, and 4 false-negatives. The sensitivity was 87.5% and the specificity 94.4%, respectively. The positive predictive value was 96.6% and the negative predictive value was 81.1%. CONCLUSION: MRCP was shown to be good enough to replace ERCP as a diagnostic method in patients with suspected CBD disease. MRCP is now our modality of choice after ultrasound in the diagnostic evaluation of these patients.

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.

Serum carcinoembryonic antigen in relation to survival, DNA ploidy pattern, and recurrent disease in 406 colorectal carcinoma patients

Serum carcinoembryonic antigen (CEA) levels in relation to survival, flow cytometric DNA ploidy pattern, Dukes stage, and recurrent disease was prospectively evaluated in 406 patients with colorectal carcinoma. In 246 patients (61%) the carcinomas were DNA aneuploid. Increased preoperative CEA levels (> 5 micrograms/l) were found in 151 of 363 evaluable patients (42%). Dukes stage-B patients with preoperative CEA elevation showed significantly poorer prognosis than those with normal CEA values (p = 0.001). A weak but significant correlation was found between preoperative CEA level and Dukes stage (Kendalls tau = 0.25, p < 0.01). Of 50 evaluable patients with clinical recurrence and postoperative normal or normalized CEA levels, 28 (56%) had a rise in CEA before or at the time of clinical recurrence. The sensitivity of the CEA test for primary and for recurrent disease was not significantly different in the DNA aneuploid and the DNA near-diploid groups.

Dissolution of cholesterol gallbladder stones with methyl tert-butyl ether in patients with increased surgical risk

The safety and efficacy of methyl tert-butyl ether (MTBE) dissolution of cholesterol gallbladder stones were evaluated in 25 patients with increased risk for surgery. Two patients were treated twice. The MTBE was infused and aspirated manually through a percutaneous transhepatic catheter to the gallbladder. The placement of the catheter failed in three patients (11%). In 19 of 24 patients (79%) there was complete dissolution of stones after a mean treatment time of 12.2 h (range, 4.3-19.5 h). In five patients treatment was discontinued before complete dissolution owing to technical problems or side effects. Side effects were nausea, pain, vasovagal reaction, and fever. Fifteen patients were followed up for a mean of 15.7 months after dissolution. Stone recurrence was found in eight patients, five of whom suffered symptomatic relapse. We conclude that dissolution therapy with MTBE is a safe and adequate alternative to surgery in selected high-risk patients.