Rectal cancer treatment of the elderly.

OBJECTIVE: Life expectancy and incidence of rectal cancer have been increasing. The purpose of this study was to evaluate rectal cancer treatment among very old patients. METHODS: This prospective national cohort study includes all 4875 rectal cancer patients in Norway aged over 65 years treated between November 1993 and December 2001. Patients aged 65-74, 75-79, 80-84 and over 85 years were compared for patient-, tumour- and treatment-characteristics and relative survival. Two thousand eight hundred and forty patients treated for cure with major surgery and TME technique were further evaluated for postoperative mortality, five-year local recurrence, distant metastasis and disease-free survival. RESULTS: There were more palliative surgery and local procedures and less surgery for cure (47%vs 77%, P < 0.001) for patients over 85 years compared to younger patients. Five-year relative survival was 36% for patients aged over 85 years compared to 49% for patients 80-84 years and 60% for patients 65-74 years. Among patients treated for cure with major surgery the rate of anterior resection decreased by age (67%vs 46%, P < 0.001). Postoperative mortality increased from 3% to 8% (P < 0.001). There were no significant differences in the rates of five-year local recurrence, distant metastasis or relative survival. CONCLUSION: Although a slight increase in postoperative mortality, major rectal cancer surgery can be performed in very old patients. These patients had similar rates of local recurrence, distant metastasis and relative survival as younger patients.

Association between transfusion of stored blood and infective bacterial complications after resection for colorectal cancer.

OBJECTIVE: To examine the association between blood transfusion and bacterial infective complications after resection for colorectal adenocarcinoma. DESIGN: Retrospective cohort study. SETTING: District hospital; Norway. SUBJECTS: 446 consecutive patients having resection of colorectal adenocarcinoma. MAIN OUTCOME MEASURES: Postoperative bacterial infective morbidity in hospital. RESULTS: 112 patients (25%) developed postoperative infections in hospital. Univariate analysis showed that the development of infection was significantly associated with increasing age (p=0.02), rectal compared with colonic cancer (p=0.002), preoperative radiotherapy (p=0.005), blood loss during operation (p=0.001), the extent of the primary tumour (T stage): T4 compared with T1-T3 (p=0.004), the presence of regional lymph node metastasis (N stage): N1-N3 compared with N0 (p=0.01), operating surgeon 1 (p=0.009), operating surgeon 2 (p=0.03), and blood transfusion (p < 0.001). Multivariate logistic regression analysis showed that the following variables were independent predictors of infection: age, rectal compared with colonic cancer, T stage, N stage, and blood transfusion. The corrected odds ratios for infection were 1.5 (95% CI 0.8 to 2.8) when 1-3 units of blood were given and 3.1 (95% CI 1.6 to 6.0) when more than three units were given. Storage time did not affect the rate of postoperative infections in patients given transfusions. CONCLUSION: Transfusion of non-filtered stored allogeneic blood suspended in saline-adenine-glucose-mannitol is an independent risk factor for the development of postoperative infections in hospital in patients having a resection of colorectal cancer.

Small bowel obstruction in patients previously operated on for colorectal cancer.

OBJECTIVE: To find out the incidence, aetiology, and outcome of patients operated on for small bowel obstruction after previous operation for colorectal cancer. DESIGN: Retrospective cohort study. SETTING: District hospital serving a defined population, Norway. SUBJECTS: 472 consecutive patients operated on for colorectal cancer, followed up for a median of 5.5 years (range 2.0-16.8) or until death; 351 had had a resection with curative intent, and 121 a palliative operation. MAIN OUTCOME MEASURES: Incidence and aetiology of small bowel obstruction, postoperative mortality, and long term survival. RESULTS: Small bowel obstruction necessitated operation in 36/351 (10%) after resection with curative intent, and in 5/121 (4%) after a palliative operation. The causes of obstruction were benign adhesions (n=21), local recurrence (n=17) and peritoneal carcinomatosis (n=3). One patient died of a myocardial infarction and six of cancer within 30 days of the operation for small bowel obstruction. The estimated median survival after the operation for small bowel benign obstruction was 1.9 years (SE=0.6) compared with 0.36 years (SE=0.04) for malignant obstruction (p=0.0007, logrank test). Late small bowel obstruction by adhesions was associated with higher blood loss during the primary operation (p=0.02). None of the 62 patients who took thiazide diuretics at the time of the primary operation later developed obstructive adhesions. CONCLUSION: 41/472 patients (9%) developed small bowel obstruction after the primary operation for colorectal cancer. The aetiology was benign in 21 and malignant in 20 patients. Survival after operation for the obstruction was far better with benign than with malignant obstruction.

Perioperative blood transfusions reduce long-term survival following surgery for colorectal cancer.

PURPOSE: The aim of the study contained herein was to investigate the association between blood transfusion and long-term outcome for patients treated for colorectal cancer, controlling for the effect of other prognostic factors. We also wanted to study whether blood storage time influenced the prognosis. METHODS: Cox's proportional hazards regression analysis was used to analyze data from 336 patients who survived resection with curative intent. Median follow-up was 5.8 (2-16.8) years or until death. RESULTS: Local recurrences and distant metastases were significantly more frequent when more than two units of blood had been transfused. In the multivariate Cox's analysis, with backward elimination of nonsignificant factors at the 10 percent level, the following risk factors were significantly related to death by colorectal cancer: tumor stage (T stage and N stage), perforation of tumor, age, and the need for a blood transfusion. Transfusions of more than two units of blood were independently and significantly associated with death from colorectal cancer (relative hazard, 2.7; 95 percent confidence intervals, 1.4-5.2). Time of blood storage had no effect on the prognoses. In patients dying from diseases unrelated to colorectal cancer, age and American Society of Anesthesiologists group were significantly related to death, whereas blood transfusion was not. CONCLUSION: We found an independent and significant association between perioperative blood transfusion and poor prognosis in colorectal cancer patients. Blood storage time was not a prognostic factor.

Colorectal cancer in patients over 80 years of age.

BACKGROUND/AIMS: The aim of the study was to compare the short- and long-term outcome of older and younger patients treated for colorectal cancer. We also wanted to study whether age was independently associated with post-operative mortality. METHODOLOGY: We conducted a retrospective study of 503 consecutive patients treated for colorectal cancer. One hundred and six (21%) were 80 years of age or older. The median follow-up was 5.5 years (2-16.8 years) or until death. RESULTS: Post-operative mortality was 6% (0.7% in patients less than 65 years and 16% in patients over 80 years). Multiple logistic regression analysis showed that age, emergency operation, advanced T-stage, and ASA-class were each independently related to post-operative mortality. The overall estimated 5-year survival rate was 59% in patients less than 65 years and 24% in patients over 80 years. The cancer specific 5-year survival was 62% in patients less than 65 years and 45% in patients over 80 years. CONCLUSIONS: The study demonstrated that age was an independent risk factor for post-operative mortality. In very old patients surviving the post-operative period, the long-term outcome was good. Advanced age alone should not be used as a criterion to deny surgery for colorectal cancer.

[Traditional surgical treatment of choledocholithiasis. An analysis of a 10-year material 1980-89]. / Tradisjonell kirurgisk behandling av choledochusstein. En analyse av et tiårsmateriale 1980-89.

During 1980-89, 224 patients, 129 women and 95 men, median age 72 years (18-96 years), were treated for common bile duct stones. 26 of the patients had remote cholecystectomy. 67 patients had additional acute cholecystitis, 37 acute cholangitis and 25 acute pancreatitis. 173 patients underwent a traditional open operation, 37 endoscopic papillotomy (EPT) and 14 were treated conservatively. No deaths occurred after elective operations in 52 patients, and one death occurred after early planned operation in 95 patients. Emergency operations and delayed operations for acute disease were encumbered with a lethality of 12%. During the last two years of the study, old septic patients were treated with papillotomy, and there was no mortality among the last 39 patients. The study shows that non-septic patients with common bile duct stones can be safely treated by open operation. Old patients with severe complicated gall stone disease should be treated by endoscopic papillotomy at an early stage.

[Early elective cholecystectomy in acute stone-related cholecystitis]. / Tidlig planlagt kolecystektomi ved akutt steinrelatert kolecystitt.

During the period 1980 to 1989, 342 patients with acute cholecystitis, 202 women and 140 men, with median age 71 (19-100) years, were admitted to our department. The treatment strategy during the period was early planned cholecystectomy in operable stabile patients with a duration of the disease of less than 7-8 days. Seven patients (2.0%) died, three after emergency operation, three after delayed operation when conservative treatment had failed, and one after medical treatment only. None of 192 patients treated with early planned operation died, and there was no lethality among the patients below the age of 75. The stay in hospital was reduced by 5.2 days after early planned operation. Early planned cholecystectomy for acute cholecystitis is a safe and cost-effective treatment.

[Can mortality in gallstone disease be reduced? An analysis of 1013 patients]. / Kan dødeligheten ved gallesteinssykdom reduseres? En analyse av 1013 pasienter.

A 10-year retrospective review of 1,013 patients with gallstone disease is analysed. The median age of the patients was 66 (18-100) years. 499 patients (49%) were admitted as emergencies. There was a significant relationship between the patient's age, complicated disease and lethality. The mortality was 1%. No patients below the age of 70 died. There was also a significant relationship between duration of the disease and mortality. Emergency operations and delayed operations for acute disease were encumbered with the highest lethality (7%), while early planned operation for acute disease and elective operations showed a lethality of 0.5 and 0.2% respectively. We advocate a more liberal attitude towards elective operations and early operative intervention in elderly patients who do not respond to medical treatment.

[Surgical treatment of carcinoid bronchial tumor]. / Kirurgisk behandling av karsinoid bronkialtumor.

During the period 1977-95, 20 patients underwent surgery for carcinoid tumour in the bronchus at the University Hospital of Trondheim (n = 16) and Innherred County Hospital (n = 4). All the tumours were typical carcinoid tumours. Median age of the patients was 41 years (range 16-78 years). The observation period averaged 7.5 years (0.5-18 years). The most common symptoms were cough, dyspnoea, wheezing and pneumonia. One patient had carcinoid syndrome. Chest X-ray were negative in three of the patients. Bronchoscopy was carried out in all the patients. Biopsies were taken in ten of them, and the diagnosis was conclusive in five cases. Lateral thoracotomy was performed in all the patients. The surgical procedures were lobectomy (15), segmental/wedge resection (3), bronchotomy with tumour resection (1) and sleeve resection (1). 19 patients were still alive at the time of follow-up, with no tumour recurrence. One patient died from cerebral stroke eight years after surgery. Good long-term results were found, and the study supports the use of limited lung resection or bronchoplasty operations to treat carcinoid tumour in the bronchus if the primary tumour is localised and there are no metastases.

Rectal cancer: the influence of type of operation on local recurrence and survival.

OBJECTIVE: To assess the results of standardised total mesorectal excision of rectal cancer with particular reference to local recurrence and survival. DESIGN: Prospective open study. SETTING: Central hospital, Norway. MAIN OUTCOME MEASURES: Local recurrence, survival. RESULTS: The resectability rate was 90% (107/118), of whom 81 (76%) underwent curative resection. The overall local recurrence rate in patients who underwent primary resection was 9% with an overall five-year survival rate of 53%. In patients who had had curative operations the local recurrence rate was 4% (3/81), with an overall five year survival of 65% and a cancer specific survival of 85%. None of the patients who had palliative treatment survived five years. In 12 patients whose tumours were thought to be unresectable but who were operated on, of whom nine were given additional radiotherapy (46 Gy), 5 (42%) developed local recurrences and the five year cancer free survival was 25%. CONCLUSION: Total mesorectal excision and strict adherence to the surgical principles of anatomical dissection in the pelvis and washing out of the rectal stump before anastomosis reduce local recurrences to a minimum. In patients with locally advanced, fixed cancers, preoperative irradiation with more than 46 Gy must precede operation to achieve local control.

[Diagnosis and treatment of gastrointestinal hemorrhage]. / Diagnostikk og behandling av gastrointestinale blødningstilstander.

The handling of gastrointestinal bleeding was discussed at a national expert symposium in February 1995. Internists are in charge of therapeutic endoscopy of upper gastrointestinal bleeding at the majority of Norwegian hospitals, but close collaboration with the surgeon on call is vital. The need for intensive care and monitoring may have been underestimated, since decompensation of co-existing diseases is a more frequent cause of death than the haemorrhage itself. Endoscopic treatment is the primary choice in all parts of the gut where endoscopy is possible, but surgery must be considered for patients who rebleed. Injection of sclerosering agents is the most prevalent mode of treatment for oesophageal varices and ulcers, but thermal probes and rubber band ligation are probably equally effective in experienced hands. Major lower bowel haemorrhage can render colonoscopy impossible, and emergency resections may be warranted, but preferably after angiography or peroperative endoscopic localisation of the area of bleeding.

[Administrative handling of gastrointestinal hemorrhage in Norway]. / Administrativ håndtering av gastrointestinale blødninger i Norge.

Rapid and adequate endoscopic treatment is a vital part of the initial handling of gastrointestinal haemorrhage. A national survey was carried out to study the logistics of the initial handling of these patients. Replies were received from 97% of the hospitals, each of which received an average of 11 patients per month with haematemesis/melena or rectal bleeding. Patients with haematemesis or melena were admitted primarily to medical departments or intensive care units, while patients with haematochezia were admitted most often to the surgical department. 47% of the hospitals performed emergency endoscopy as a routine on patients with red haematemesis, but even in this group of patients, endoscopy was postponed until the first working day in some instances, provided that the patient's condition was stable. The majority of emergency flexible endoscopies are performed by internists, but most hospitals describe close inter-departmental cooperation in the handling of these patients. The situation was deemed satisfactory at 91% of the hospitals.

[Treatment of fixed, primarily non-resected rectal cancer. Recommendations from Norwegian Gastrointestinal Cancer Group]. / Behandlingsopplegg ved fiksert, primaert ikke-resektabel rectumcancer. Anbefaling fra Norsk Gastrointestinal Cancer Gruppe.

In most cases (70%), fixed rectal cancers are primarily non-resectable, and of the ones that are resected, local recurrence will occur in 50-70%. The same trend, but less pronounced, is also seen for partly fixed or tethered tumours. High-dose irradiation (45-60 Gy) has been reported to yield resectability rates up to 70%, with 17% local recurrences and a 5-year disease-free survival of up to 60-70%. Combined chemotherapy and sequential radiation therapy, hyperthermia or addition of intra-operative radiotherapy, have shown promising results, but no randomized studies have been published comparing the different treatment modalities. Surgery should be performed 4-6 weeks after preoperative treatment. Resectability can only be determined by exploratory laparotomy and serious attempts to remove the tumour-bearing segment by anatomic dissection.

Prophylaxis of venographically diagnosed deep vein thrombosis in gastrointestinal surgery. Multicentre trials 20 mg and 40 mg enoxaparin versus dextran.

OBJECTIVE: To compare enoxaparin and dextran 70 for the prophylaxis of venographically diagnosed deep vein thrombosis (DVT) after gastrointestinal operations. DESIGN: Part 1: randomised double blind trial; Part 2: single blind study with historical controls. SETTING: Eight Norwegian hospitals. SUBJECTS: 381 Patients undergoing elective gastrointestinal operations. INTERVENTIONS: Part 1 (n = 329): enoxaparin 20 mg subcutaneously starting two hours before operation and continuing until the patient was fully mobilised or had had 10 injections and a placebo infusion of 0.9% sodium chloride, or dextran 70,500 ml at the start of the operation, on the evening of operation, and on the first, third, and fifth postoperative days and placebo subcutaneous injections. Part 2 (n = 52): enoxaparin 40 mg in the same regimen as part 1 (compared with 39 historical controls). Venograms 4-6 days post-operatively. MAIN OUTCOME MEASURE: Venographically confirmed DVT. RESULTS: Part 1: Because of the high overall incidence of DVT an interim analysis was done which showed 33/101 DVT (33%) among high risk patients in the enoxaparin 20 mg group and 33/107 (31%) in the dextran 70 group. The corresponding figures for patients at medium risk were 2/27 (7%) for enoxaparin 20 mg and 5/27 (19%) for dextran 70 (95% confidence interval (CI) for the difference--11.9 to 9.8). Part 2: the dose of enoxaparin was therefore increased to 40 mg and prophylaxis restricted to patients with cancer. There were 6/49 DVT (12%), which was compared with a random sample from the dextran 70 group from part 1 (historical controls) in which the incidence was 15/39 (38%, 95% CI of the difference 4.0 to 8.4). There were no pulmonary emboli, only 4 thrombi were above the knee and there were 4, 1 and 3 clinical DVT in the 20 mg and 40 mg enoxaparin, and dextran 70 groups, respectively. CONCLUSIONS: Enoxaparin 20 mg and dextran 70 are effective prophylaxis for patients at medium risk, but enoxaparin 40 mg is required for those at high risk.

Association between transfusion of stored blood and bacterial infective complications after biliary operations.

OBJECTIVE: To examine the association between blood transfusion and infective complications after biliary operations. DESIGN: Retrospective cohort study. SETTING: District hospital. SUBJECTS: 875 consecutive patients who required biliary operations. MAIN OUTCOME MEASURES: Postoperative infective morbidity in hospital. RESULTS: 73 patients (8%) developed postoperative infections in hospital. Univariate analysis showed that the development of infections was significantly associated with blood transfusion (p < 0.001), stones in the common bile duct (p < 0.001), operations on the common bile duct (p < 0.001), T-tube drainage (p < 0.001), duration of operation (p = 0.008), and age (p = 0.03). Multivariate logistic regression analysis showed that only blood transfusion and stones in the common bile duct were independent predictors of infection. The corrected odds ratios for infection were 4.7 (95% confidence interval (CI) 2.4 to 9.3) when 1-3 units of blood were given and 5.6 (95% CI 2.3 to 13.6) when more than three units were given. CONCLUSION: Transfusion is an independent risk factor in the development of postoperative infection in hospital in patients who have had biliary operations.

[Ulcer surgery and anti-ulcer agents. Changes in surgical activities and sale of anti-ulcer agents in Nord-Trøndelag 1975-89]. / Ulcuskirurgi og ulcusmidler. Endringer i operasjonsaktivitet og salg av ulcusmidler i Nord-Trøndelag 1975-89.

During recent decades the number of operations for peptic ulcer has decreased significantly. The incidence of operations for peptic ulcer or related complications during the period 1975-89 in persons older than 15 years was investigated in the Nord-Trøndelag region of Norway, with a population of approximately 100,000. The number of elective surgical procedures decreased by 72% from 1975 to 1989. The greatest reduction was found for duodenal ulcers. The incidence of acute operations decreased by 35%. The main reason was fewer surgical interventions in patients with haemorrhage, since the number of operations for perforation remained almost constant during the period of 15 years. The reduction in surgical treatment can be explained mainly by the introduction of new H2-antagonists in the seventies, leading to more successful pharmacological treatment of peptic ulcer.

[Medial femoral neck fractures treated with hip compression screw. A product control study]. / Mediale collumfrakturer behandlet med hoftekompresjonsskruen. En produktkontroll.

311 medial femoral neck fractures (213 of them displaced) treated with a hip compression screw were studied retrospectively. 90 patients were treated with a primary hemiprosthesis during the same period. Fixation was lost in the case of seven fractures within three months after the operation. Two patients developed pseudarthrosis and 53 late segmental collapse. 54 patients have been reoperated, and given an endoprosthesis. The radiographs of 176 patients (114 displaced fractures) who were accessible for follow-up until failure, or for at least three years, were analysed. The rates of late segmental collapse were particularly high for fractures with a postoperative anterior angulation exceeding 15 degrees. Displacement and time until operation were independently related to late segmental collapse.

Association between blood transfusion and infection in injured patients.

The association between red blood cell transfusions and infectious complications in 484 patients with acute injuries was studied in 1989. The median age was 62 years (0.5-97) and the median stay 7 days (3-141). Infectious complications developed in 46 (9.5%) patients. A number of potential risk factors, except blood transfusion, were analyzed in a logistic regression model to determine significant predictors of infectious complications. Blood transfusion as a cofactor was then added to this model. The final logistic regression analysis showed a relationship between blood transfusions and infectious morbidity that was independent of the other significant factors; Injury Severity Score, age, and surgical procedure. The corrected odds ratios for infection were 1.6 (95% confidence interval: 0.7-3.7) when 1-4 units of blood were given and 6.4 (95% CI: 2.3-18.3) when more than 4 units were used.

Long-term results after 'floppy' Nissen/Rossetti fundoplication for gastroesophageal reflux disease.

Eighty-two patients (median age, 51 years; range, 27-87 years) with refractory gastroesophageal reflux disease (GERD) underwent floppy Nissen/Rossetti fundoplication during the period 1980 to 1990. The median postoperative hospital stay was 5 days (3-16). Median follow-up was 72 months and included endoscopy and a clinical and a questionnaire assessment. Subjective symptoms of reflux were abolished in 98%, and 96% of the patients were satisfied with the results. Endoscopy showed healing of the esophagitis in 98%. There had been no disruption of the fundoplication. Twenty patients complained of gaseous distention and increased flatulence; only two of them had severe problems. Three patients were unable to belch. In conclusion, the floppy fundoplication has been an effective operation with no deaths, a low incidence of morbidity and adverse side effects, and without a tendency for late failure.

[Diagnosis-related groups and injuries. Is multiple trauma underrated?]. / Diagnoserelaterte grupper ved skader. Blir multitraume undervurdert?

A consecutive registration of all trauma patients admitted to the Department of Surgery, total 868, was made in 1989. Such patients constituted 20% of all surgical patients. The aim was to study the relation between the Norwegian Diagnosis-related group (DRG) cost weights and severity of injury and use of resources. The DRG system correlated reasonably well with the Injury Severity Score and use of resources, except in the case of serious multi-trauma, which seemed to be under-rated.