Local resection of rectal tumors by transanal endoscopic microsurgery: experience with the first 70 cases.

BACKGROUND: Transanal endoscopic microsurgery (TEM) can access the whole rectum up to 20 cm from the anal verge. Due to its excellent view and accurate dissection, TEM is useful for the removal of adenoma and selected low risk cancers of the rectum. We report our experience with the first 70 patients presenting. METHODS: A prospective descriptive study of 70 patients treated for rectal tumor with TEM from December 99 until October 2002 at Haukeland University Hospital. RESULTS: TEM was performed in 37 men and 33 women, median age 70.5 (19-90) years, for anticipated adenoma (n = 64), adenocarcinoma (n = 3), rectal ulcer (n = 1), and re-resection after snare resection of rectal polyp with adenocarcinoma (n = 1) and carcinoid tumor (n = 1). The median observation time was 12 (1-33) months. The distance from the anal verge to the lower tumor border was 5.5 (2.5-14) cm. The median resected area was 15.4 (1.5-132) cm(2). 56 of the 64 anticipated adenomas were true adenoma, resected without recurrences; 8 (12.5%) were unexpected adenocarcinoma. Three of these underwent a secondary rectal resection and 5 patients have been observed without recurrence. Of the 3 patients with known adenocarcinoma, there was one recurrence which was treated with a secondary curative rectal resection. CONCLUSIONS: TEM can access tumors in the whole rectum. Large tumors may be removed with low frequency of per- and postoperative complications and short hospital stay. TEM is highly useful for removal of rectal adenoma. A role for primary treatment of selected low-risk rectal cancers may emerge.

Proton nuclear magnetic resonance spectroscopy of serum from patients with colorectal neoplasia.

Proton nuclear magnetic resonance (NMR) spectra of serum have been recorded from patients with colorectal neoplastic polyps, before and after treatment of colorectal cancer, in patients with advanced lung cancer, and also from healthy controls. Digitally defined NMR profiles of the methyl and methylene peaks were used as input for supervised principal component modelling. An unknown sample was classified according to its residual, i.e. the difference between the spectral pattern of the unknown and control group. There was a statistically significant difference between the mean residual in the untreated colorectal cancer group and in controls (P = 0.003). The sensitivity of detecting untreated colorectal cancer was only 20%. There were no stage-dependent differences between the residuals within the untreated colorectal cancer group. After curative surgery, four patients had recurrence of malignant disease without an increase in residual prior to recurrence. Patients with advanced malignant disease (lung cancer WHO stage IIIB and IV) had a highly significant difference in mean residual from that of controls, with a sensitivity of detecting cancer of 87.5%. This increase in residual could not be explained by increase in the level of serum triglyceride. NMR spectroscopy was not a useful diagnostic tool in patients with colorectal neoplastic polyps and cancer.

[Determination of the activated proto-oncogene (Ki-ras) in feces. A new laboratory analysis for early diagnosis of colorectal cancer]. / Påvisning av aktivert protoonkogen (Ki-ras) i avføringsprøver. Ny laboratorieanalyse for tidlig diagnostikk av kolorektal cancer.

Colorectal cancer is one of the most common malignancies in Norway. Many cases of the disease are detected at a stage where surgery is unlikely to result in cure. Currently used screening tests based on faecal occult blood and other tumour markers are poor indicators of colorectal neoplasia. Multiple gene alterations are associated with colorectal carcinogenesis. Mutations in the Ki-ras oncogene occur in 50% of colorectal carcinomas and also in 50% of the precursor lesions, the adenomas. These mutations have proved to be detectable in the faeces of patients with colorectal tumours, but the techniques used so far have been impractical for screening purposes. We have developed a rapid and simple laboratory technique, based on the polymerase chain reaction, for detecting mutated Ki-ras in the faeces. In eight of 12 patients with mutated Ki-ras in adenomas or carcinomas we found the corresponding mutations in stool samples. Our results represent a significant progression towards a simple and effective DNA-based screening strategy for early detection of curable colorectal cancer.

[Colonoscopy. In investigation, treatment and control of gastrointestinal diseases]. / Kolodkopi. I utredning, behandling og kontroll av gastrointestinale sykdommer.

Colonoscopy is the initial examination for patients with manifest or occult rectal bleeding, inflammatory bowel disease and colorectal polyps. In addition to polypectomy, colonoscopy is useful in decompression of adynamic colonileus and laser palliation of intractable tumours. In adenoma patients controls should be limited to high risk patients, i.e. those with large and multiple tubular adenomas, villous adenomas, multiple hyperplastic polyps (> 30), and first degree relatives of patients with colorectal carcinomas. Control after radical surgical treatment of colorectal cancer is offered during the first two years after the operation and to persons younger than 40 years. The efficacy of control programmes for hereditary nonpolyposis colorectal cancer families have to be evaluated in controlled series. Rectosigmoidoscopies could probably replace some total colonoscopies to examine ulcerative colitis patients for cancer, since cancer usually occurs in the distal colon. Complications are rare after diagnostic and therapeutic colonoscopies, but perforation, bleeding and injury to surrounding organs can be experienced.

Ischaemic necrosis of lesser curve of stomach after proximal gastric vagotomy.

Of 483 patients treated by proximal gastric vagotomy (PGV) between 1972 and 1986 four (0.8%) developed lesser curve necrosis with perforation and one died of diffuse peritonitis. Gastroscopy 3-6 days after PGV in 26 patients between November 1985 and May 1987 showed that five had developed ischemic ulcers on the lesser curve (19%). One further patient developed lesser curve necrosis with perforation before endoscopy, giving a total of six lesser curve lesions after 26 vagotomies (23%). Endoscopy also showed that most patients had some gastric retention. Ulcers with maximal diameters of 0.4-2 cm were asymptomatic. One patient with a large ischaemic ulcer (3 cm) had an abrupt fall in haemoglobin concentration (from 148 to 73 g/l) as did two patients who developed lesser curve necrosis with perforation and peritonitis (143 to 93, and 159 to 71, respectively). We conclude that ischemic ulcers are relatively common after PGV, that small ulcers are asymptomatic and do not perforate, and that an upper GI bleeding after PGV strongly suggests that lesser curve necrosis has developed.

Reperitonealization of the lesser curve in proximal gastric vagotomy for duodenal ulcer.

Ninety-six consecutive patients were operated upon with proximal gastric vagotomy for duodenal ulcer at our department during the two year period 1976 to 1978. These patients were prospectively randomized into two groups, one of which (45 patients) had reperitonealization of the lesser curve. These two groups are compared herein. Reperitonealization of the lesser curve was without benefit on long term clinical results, ulcer recurrence rate and gastric acid secretion. None of the patients had perforation of the lesser curve.

Low-dose preoperative radiation postpones recurrences in operable rectal cancer. Results of a randomized multicenter trial in western Norway.

A randomized, multicenter clinical trial was conducted in Western Norway to study the effectiveness of preoperative radiation therapy in operable rectal cancer, given at a dosage of 3150 cGy in 18 fractions, 2 to 3 weeks before radical surgery. Three hundred nine patients were entered into the trial between May 1976 and December 1985. After radiation no tumor was seen in 4.5% of the patients. There was no increased morbidity or mortality at surgery. The 5-year survival for evaluable patients was 57.5% in the control group and 56.7% in the radiotherapy group. For patients operated on for cure the 5-year survival was 60.9% and 64.2% in the control group and radiotherapy group, respectively. Radiation significantly delayed both local and distant recurrences in patients in the radiation group who had curative resection from 13.3 months in controls to 27.1 months. The local recurrence rate in the corresponding groups was 21.1% and 13.7%, respectively. We conclude that higher preoperative radiation doses should be used in new trials as a higher dosage may transform the observed positive effects into a survival benefit.

Preoperative radiotherapy in operable rectal cancer.

The effect of preoperative radiotherapy (31.5 Gy in 3.5 weeks) in operable rectal cancer was examined with respect to resectability and prognosis after two surgical procedures, abdominoperineal resection, or low anterior resection. Preoperative radiation did not influence the surgeon's selection of low anterior resection, which was similar (40 percent) in each group. Radiation improved five-year survival probability and decreased the incidence of local recurrence significantly after low anterior resection. In contrast, no improvement of treatment results was found in patients treated by abdominoperineal resection after radiotherapy.

Volvulus of the caecum. An evaluation of various surgical procedures.

To evaluate the various operations for caecal volvulus we reviewed 48 patients who were treated between 1948 and 1989. Six were treated conservatively (the volvulus resolved before operation), and the remaining 42 patients (43 operations) were treated by untwisting (n = 14, 2 early deaths); caecopexy (n = 13, no deaths); caecostomy (n = 3, 2 early deaths); or resection (n = 13, one early death). At follow up a mean of 11.8 years later (range 0.4 to 34) the numbers of patients who had remained free of symptoms were 6, 5, 1 and 9, respectively. We conclude that resection gives the best long term results with acceptable mortality and morbidity and should be the treatment of choice for caecal volvulus.

Epidemiology of Crohn's disease in western Norway. Study group of Inflammatory Bowel Disease in Western Norway.

The incidence of Crohn's disease in western Norway was estimated in a prospective epidemiologic study during the years 1984 and 1985. The total population in the area was 807,000. Both inpatients and outpatients were included. Five hundred and fifty general practitioners and 12 hospitals participated in the study. A total of 86 patients were diagnosed, giving a mean annual incidence of 5.3 per 100,000. For patients between 15 and 19 years of age-specific incidence rate was 16.0 The M/F sex ratio was 0.9. In the same period 240 patients with ulcerative colitis were diagnosed (mean annual incidence, 14.8 per 100,000), giving a ratio of 2.8 between ulcerative colitis and Crohn's disease and an annual incidence of 20.1 per 100,000 for inflammatory bowel disease. Familial occurrence of IBD was found for 12% of the patients.

Transanal extirpation for early rectal cancer.

Transanal extirpation was performed in 38 patients with adenocarcinoma of the rectum. In 17 patients (group I) the tumor extended into the submucosa only, and in 14 patients (group II) tumors extended into, but not through, the muscularis propria. There was a significant difference in local recurrence between groups I and II. None of the patients in group I and six of the patients (42.6 percent) in group II developed local recurrences (P = 0.02). The 5-year actuarial survival probability was 100 and 82.6 percent, respectively. Transanal extirpation is an alternative to transsphincteric and abdominoperineal resection in the treatment of early well or moderately well-differentiated cancer of the rectum. The surgical procedure is simple and has few complications; however, only tumors extending no deeper than the submucosa are suitable for this treatment. The operation should be followed by frequent sigmoidoscopies and rectal palpation. The procedure should be defined as an excisional biopsy until results from the histologic examination are presented.

Epidemiology of ulcerative colitis in western Norway.

The incidence of ulcerative colitis (UC) in the three counties that compose Western Norway was registered in a prospective study during the years 1984 and 1985. Both inpatients and outpatients were included. Five hundred and fifty general practitioners and 12 hospitals participated in the study. A total of 239 patients were diagnosed in this area with 807,000 inhabitants, giving a mean annual incidence of 14.8 per 100,000. For patients between 30 and 35 years of age the age-specific incidence rate was 31.2. The M/F sex ratio was 1.10. Familial occurrence of inflammatory bowel disease was found in 11% of the patients. Patients with rectal involvement only constituted 35% of the patients.

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.

Improved diagnosis of primary hyperparathyroidism by defining the inverse relationship between serum immunoreactive parathyroid hormone and calcium.

Serum concentrations of immunoreactive parathyroid hormone (iPTH) measured with a mid-region specific radioimmunoassay and total calcium were correlated in 300 healthy subjects and 158 patients with surgically verified primary hyperparathyroidism (HPT). All the healthy individuals could be separated from the patients by a monoexponential declining curve in which iPTH at concentrations of 0.60 micrograms/l and 0.33 micrograms/l corresponded to calcium concentrations of 2.20 mmol/l and 2.60 mmol/l, respectively. In 22 patients more than one sample was analysed and serum iPTH and calcium were inversely correlated. In contrast, three patients with parathyroid carcinoma showed no reciprocal fluctuations between serum iPTH and calcium. Of 75 patients with hypercalcaemia due to malignant diseases (metastatic mammary carcinoma, bronchial carcinoma, renal carcinoma, myelomatosis), 62 had a normal iPTH/calcium relationship. Two patients with myelomatosis had a temporary elevation of serum iPTH and calcium due to renal impairment. One patient with bronchial carcinoma probably had ectopic production of iPTH. The remaining 10 patients (six mammary carcinomas and four bronchial carcinomas) were found in the pathological iPTH/calcium range. In conclusion, we have demonstrated that an inverse relationship exists between serum iPTH and calcium in patients with non-malignant, primary HPT. Evaluation of iPTH and calcium in the same serum sample gave a correct diagnosis in more than 90% of patients with primary HPT.

Temporary ischaemia of a large bowel segment induced by degradable starch microspheres in man.

Degradable starch microspheres were used to induce temporary ischaemia measured by electromagnetic flowmetry in colon segments during bowel resection. Severe reversible ischaemia free from unwanted side effects was induced in eight of nine patients. In one of the five patients where the tumour was included in the microsphere-embolised tissue volume no reduction in blood flow was seen. Segmental enteric ischaemia induced by degradable starch microspheres in man seems safe and may be useful for radioprotective purposes in clinical radiation therapy.

Budd-Chiari syndrome with obstruction of the inferior caval vein: successful treatment by cavosplenoatrial shunt.

A 27-year-old man had a 10-month history of recurrent ascites, massive edema, and extreme fatigue. The diagnosis of Budd-Chiari syndrome with severe stenosis of the retrohepatic part of the inferior caval vein had been established. Medical treatment had failed to prevent further deterioration. A single 14 mm Gore-Tex graft (W.L. Gore & Associates, Inc. Elkton, Md.) was used to establish a cavosplenoatrial shunt. The postoperative recovery was uneventful. All signs of ascites and edema disappeared within 8 weeks after surgery. In connection with repair of a ventral hernia 8 months later, a liver biopsy specimen revealed partial normalization of liver histology and an angiography demonstrated a patent shunt. Two and a half years after the initial operation he developed a bleeding peptic ulcer demanding emergency surgery. The shunt was again found patent. Three years after the first operation the patient is free of symptoms and working full time.

Time-dependent changes in the axillary nodes in breast cancer: nodal area.

This paper reports a difference in the lymphoid tissue area in the axilla of node-negative breast cancer patients in the first versus the second half of the year, the area being greater in the latter. This observations is new. It is based on data from 72 patients derived over 25 consecutive months and is in keeping with previous reports of a proliferative histological picture in the nodes at this time. The findings were less marked in the node-positive cases (23), and were not accompanied by an increase in nodal number. No such difference was seen in 80 specimens from noncancer autopsy controls. A total of 1,868 nodes were evaluated. The possibility that light-mediated reactions may be involved is discussed briefly, as is the role of this proliferative reaction and its probable mediation relative to the parallel histological changes reported in primary breast carcinomas at this time.