Cost-effectiveness of blood transfusion and white cell reduction in elective colorectal surgery.

BACKGROUND: The use of white cell (WBC)-reduced blood in elective colorectal surgery appears to reduce the frequency of postoperative infection. The question to be addressed is whether the cost:benefit ratio justifies the recommendation that WBC-reduced blood should be used for all colorectal surgery. STUDY DESIGN AND METHODS: Patients admitted for elective colorectal surgery (n = 197) were randomly assigned to receive transfusion consisting of whole blood or WBC-reduced whole blood. Postoperative complications, postoperative stay, and hospital charges were compared. RESULTS: Forty-eight patients received WBC-reduced whole blood, 56 received unfiltered whole blood, and 93 received no transfusion. Postoperative infections were significantly higher (p < 0.001) in the group that received unfiltered whole blood. That group also had longer hospital stays: 17 days as compared to stays of 10 and 11 days for the group receiving no transfusion and the group receiving filtered whole blood transfusions, respectively (p < 0.01). The total hospital cost per patient receiving unfiltered whole blood was $12,347, as compared to $7,867 for those who received WBC-reduced whole blood and $7,030 for those who received no transfusion. CONCLUSION: The use of WBC-reduced whole blood transfusions in elective colorectal surgery significantly reduces the frequency of postoperative infection, the length of hospital stay, and the total hospital charges for patients needing blood transfusion.

Pharmacological identification of different inhibitory mediators involved in the innervation of the internal anal sphincter.

1. Inhibitory non-adrenergic, non-cholinergic (NANC) responses were studied in isolated strips from the rabbit internal anal sphincter. 2. In the presence of atropine and guanethidine, transmural field stimulation induced frequency-dependent relaxations that reached a plateau at frequencies > or = 4 Hz. 3. These relaxations were inhibited by apamin (10(-6) M) and by N omega-nitro-L-arginine (L-NOARG, 10(-4) M). With these two substances in combination, relaxations were still seen in response to field stimulation, but only at frequencies > 2 Hz. 4. In the presence of both apamin (10(-6) M) and L-NOARG (10(-4) M), responses at high frequencies consisted of a fast relaxation followed by a slow return to prestimulus tension level. alpha-Chrymotrypsin hastens the return of tension to prestimulus level after high frequency stimulation. 5. Zinc-protoporphyrin IX, an inhibitor of haeme oxygenase, had a significant inhibitory effect on relaxations induced by transmural field stimulation. It was found, however, that responses to sodium nitroprusside and to isoprenaline (both 10(-9)-10(-4) M) were reduced comparably, indicating that the effect of zinc-protoporphyrin IX was unspecific. 6. It is concluded that pharmacological analysis allows identification of at least three distinguishable components of the inhibitory NANC innervation of the rabbit internal anal sphincter. The study does not allow conclusions about the role of carbon monoxide, a recently proposed mediator of NANC responses in opossum internal anal sphincter.

Postoperative infection and natural killer cell function following blood transfusion in patients undergoing elective colorectal surgery.

The frequency of infection in 197 patients undergoing elective colorectal surgery and having either no blood transfusion, transfusion with whole blood, or filtered blood free from leucocytes and platelets was investigated in a prospective randomized trial. Natural killer cell function was measured before operation and 3, 7 and 30 days after surgery in 60 consecutive patients. Of the patients 104 required blood transfusion; 48 received filtered blood and 56 underwent whole blood transfusion. Postoperative infections developed in 13 patients transfused with whole blood (23 per cent, 95 per cent confidence interval 13-32 per cent), in one patient transfused with blood free from leucocytes and platelets (2 per cent, 95 per cent confidence interval 0.05-11 per cent) and in two non-transfused patients (2 per cent, 95 per cent confidence interval 0.3-8 per cent) (P less than 0.01). Natural killer cell function was significantly (P less than 0.001) impaired up to 30 days after surgery in patients transfused with whole blood. These data provide a strong case against the use of whole blood transfusion in patients undergoing elective colorectal surgery.

Time to loco-regional recurrence after resection of Dukes' B and C colorectal cancer with or without adjuvant postoperative radiotherapy. A multivariate regression analysis.

Factors influencing time to loco-regional recurrence were identified in a multivariate regression analysis of data from a series of 468 radically operated patients (260 Dukes' B and 208 Dukes' C) with carcinoma of the rectum and the rectosigmoid. A number of clinical and pathological characteristics were prospectively collected and recorded. In addition, carcinoembryonic antigen (CEA) was measured within 1 week before surgery. The endpoint used was recurrence below the level of the umbilicus. All patients were followed for at least 5 years or until time of death. The two Dukes' stages B and C were analysed in two separate analyses using the Cox proportional hazards model. In patients with Dukes' B tumours, an increased risk of loco-regional recurrence was associated with perineural invasion, tumour located less than 10 cm from the anal verge, patient aged above 70 years, and small tumour size. In patients with Dukes' C tumours, the necessity to resect neighbour organs, perineural and venous invasion, tumour located less than 10 cm from the anal verge, and large tumour size were all associated with a poor loco-regional outcome. Postoperative radiotherapy was not a significant prognosticator for loco-regional control. An update of the 5-year results of the randomised study of post-operative radiotherapy (50 Gy with 2 Gy per fraction in an overall treatment time of 7 weeks) showed no survival benefit from adjuvant radiotherapy in either Dukes' category and no statistically significant improvement in the 5-year loco-regional control rate. However, when the comparison was restricted to a group of high-risk patients there was a statistically significant benefit from radiotherapy with respect to loco-regional control (P = 0.03) but not with respect to survival (P = 0.23). The potential advantage, in terms of the required number of patients, of restricting clinical trials of intensified loco-regional therapies to the high-risk patients, is illustrated.

Blood transfusion and prognosis in Dukes' B and C colorectal cancer.

To evaluate the prognostic influence of blood transfusion in cancer patients, transfusion data were reviewed on 468 radically operated patients (260 Dukes' B and 208 Dukes' C) with carcinoma of the rectum and the rectosigmoid. Data on whole blood and packed red blood cell transfusions were recorded together with a number of clinical, pathological and histochemical characteristics. The endpoint used was death with cancer. All patients were followed for 2-7 years or until time of death. Univariate statistical methods revealed a highly significant trend towards worsened prognosis with increasing volume of transfusion blood. However, this effect was insignificant when multivariate statistical methods were employed: patients receiving whole blood or packed red blood cell transfusions did no worse than expected from their clinico-pathological characteristics. It is concluded that in this series the observed association between transfusion status and prognosis is adequately explained by a multivariate prognostic model including well-established prognostic factors.

Controlled clinical trial with sucralfate in the treatment of macroscopic gastritis.

The efficacy of sucralfate in the treatment of patients with dyspepsia and macroscopic signs of gastritis was assessed in a double-blind, placebo-controlled study. Treatment was 2 g sucralfate or placebo taken 1/2 h before breakfast and at bedtime. Clinical and endoscopic examinations were performed after 6 weeks' treatment, and if mucosal changes and/or symptoms persisted, medication was continued for another 6 weeks. Cumulative healing rates at 6 and 12 weeks were 43% (13 of 30) and 62% (18 of 29) in the sucralfate group verus 37% (11 of 30) and 62% (18 of 29) in the placebo group. Corresponding rates for symptomatic improvement were 80% and 83% for those receiving sucralfate and 73% and 79% for placebo-treated patients. None of the differences between sucralfate and placebo were significant, and sucralfate does not seem to be superior to placebo in the treatment of macroscopic gastritis.

Omeprazole and ranitidine in treatment of reflux oesophagitis: double blind comparative trial.

One hundred and sixty two patients with endoscopically proved reflux oesophagitis stratified for severity, 66 with grade 1 disease (erythema and friability) and 96 with grade 2 or 3 disease (including erosions or ulcerations), were allocated at random to double blind treatment with omeprazole 40 mg in the morning or ranitidine 150 mg twice daily for up to 12 weeks. A patient could be evaluated sooner if symptomatic relief and endoscopically normal mucosa (grade 0) were noted after four to eight weeks' treatment. Patients treated with omeprazole responded significantly more rapidly than those treated with ranitidine (p less than 0.0001), cumulative healing rates at four, eight, and 12 weeks being 90%, 100%, and 100% respectively for those with grade 1 disease and 70%, 85%, and 91% respectively for those with grade 2 or 3 disease in the omeprazole group. Corresponding rates in the ranitidine group were 55%, 79%, and 88% (grade 1) and 26%, 44%, and 54% (grade 2 or 3). Relief of the major symptoms of heartburn, regurgitation, and dysphagia and improvements in the histological appearance of the mucosa occurred earlier and were again more pronounced during treatment with omeprazole than with ranitidine. This observed superiority of omeprazole 40 mg in the morning over ranitidine 150 mg twice daily in the short term treatment of reflux oesophagitis was obtained without major clinical or biochemical side effects, but further research is needed into longer term use of omeprazole and the effects of the acid inhibition it induces.

Major or local surgery for cure in early rectal and sigmoid carcinoma--a prospective evaluation.

The results of different types of treatment for early cancer in 158 out of 1,300 patients with rectal and sigmoid cancer were evaluated in a prospective study from 1979 to 1984. Radical surgery was performed in 121 patients (mean age 66 years) with cancer Dukes' A (median diameter 3 cm), while 37 patients (mean age 71) with smaller cancers (median 2 cm) had polypectomy or local excision. Post-operative complications were significantly more frequent in the first group. No patients in any of the two groups with carcinoma in pedunculated adenomas or within the upper half of the submucosa or above 9 cm from the anal verge had recurrent cancer. CEA-measurements had no prognostic value. No difference was found in crude or cancer-related death between the two groups. The overall results support the use of local treatment in elderly patients with complicating disease, having small cancers, not penetrating the tunica muscularis externa of the rectosigmoid wall.

Autologous splenic implantation in pigs. A comparison of two methods.

Two methods of autologous splenic implantation, with sliced or with minced splenic tissue, were compared in six pigs. The two procedures were carried out simultaneously in each pig and the splenic remnants were surgically removed three months later. These remnants were histomorphometrically quantified by point counting. Statistical analysis showed the mincing procedure to be significantly superior, since 33% of the originally implanted tissue remained, in contrast to 21% of sliced, implanted tissue. At microscopy the tissue remaining after both procedures was in all cases indistinguishable from normal pig spleen. No necrotic splenic tissue was found. The authors conclude that minced tissue and omental pouch technique are preferable for autologous splenic implantation.

Demonstration of splenic functions following splenectomy and autologous spleen implantation.

Autologous splenic tissue was implanted in 14 patients undergoing splenectomy for traumatic rupture or peroperatively arising lesion of the spleen. To demonstrate function of the implanted splenic tissue, spleen scintigraphy using 99mTc-labelled heat-damaged autologous erythrocytes, and percentage measurement of vacuolated erythrocytes in peripheral blood were performed one and three months after the splenectomy. The spleen scans were positive in eight patients after one month and in 12 patients after three months, demonstrating splenic phagocytic function. The numbers of vacuolated erythrocytes also indicated some restoration of the pitting function due to the implanted splenic tissue. No alterations were seen in serum immunoglobulins, but a moderate thrombocytosis still persisted after three months. The clinical significance of implantation of autologous splenic tissue is discussed.

A predictor analysis of patients' assessment of outcome after operation for duodenal ulcer. A one-year prospective study.

During a period of one year data were obtained concerning life events, non-specific psychological symptoms, individual social history and ulcer history in consecutive cases of patients about to undergo elective surgical treatment for duodenal ulcer. At a one-year follow-up, a blind clinical evaluation was performed, and information concerning the patients' assessment of outcome was obtained. Those patients who at the one-year follow-up stated no improvement due to the operation could be predicted to some extent from postoperative complications, partly from a long ulcer history. The patients who stated that the result did not come up to their expectations were predicted from older age, and from certain symptoms, especially severe headache. It is suggested that it is relevant to apply the patients' assessment of outcome for the purpose of evaluation, supplementing the clinical assessment of the more biomedical aspects of outcome.

Postoperative radiotherapy in rectosigmoid cancer Dukes' B and C: interim report from a randomized multicentre study.

The design, and complications seen during the first 2 years, of a randomized trial of postoperative radiotherapy for rectosigmoid cancer Dukes' B and C are presented and discussed. It is concluded that the present complication rate-below 10% in 221 patients-permits continuation of the intake, which is planned to include 550 patients, to demonstrate a possible increase in crude 5-year survival by 15% (60-75% in Dukes' B and 25-40% in Dukes' C), on the basis of a 0·01 significance level and a probability that the experiment will be successful of 0·90.

Renal function and cimetidine. Urinary albumin and beta 2-microglobulin excretion and creatine clearance during cimetidine treatment.

Urinary albumin and beta 2-microglobulin excretion and creatinine clearance were measured during 8 weeks' conventional cimetidine treatment in 13 ulcer patients without signs of renal disease. No changes were found in albumin or in beta 2-microglobulin excretion, indicating no changes in glomerular permeability and tubular reabsorption of proteins in the kidney. Creatinine clearance fell about 28 ml/min (26%) during cimetidine treatment but normalized after termination of medication. Concomitantly, serum creatinine increased by 22% during treatment and fell again after termination of treatment. The mechanism behind the changes in renal handling of creatinine during cimetidine was not clarified in the present study. It is concluded that the conventional 8 weeks' cimetidine treatment seems safe from the renal point of view, at least in patients without signs of renal disease.