[Laparoscopic surgery--evidence-based ?]. / Laparoskopisk kirurgi--hur evidensbaserad är den?

The literature has been searched for current results in laparoscopic cholecystectomy, hernia repair, appendectomy and fundoplication. This was performed as a systematic review. Laparoscopic cholecystectomy was judged to be safe and cost/effective, with good patient acceptability. However a need for further studies is indicated. Laparoscopic technique in hernia repair has a longer learning curve and is more expensive than open repair, with no major difference in recurrence rates. It is preferable in bilateral repairs. Laparoscopic appendectomy in the hands of experienced surgeons is cost/effective. Time to recovery is shorter and the rate of infectious complications is lower than in conventional procedures. There are still too few results reported from laparoscopic fundoplication to permit reliable conclusions.

Influence of hospital- and surgeon-related factors on outcome after treatment of rectal cancer with or without preoperative radiotherapy.

BACKGROUND: Preoperative radiotherapy reduces recurrence rates after surgery for rectal cancer but other variables may also affect outcome. The Stockholm Rectal Cancer Study Group has conducted two prospective randomized trials on preoperative radiotherapy in rectal cancer. METHODS: This study analysed postoperative morbidity and mortality, local recurrence rate and death from rectal cancer in 1399 patients, according to different hospital- and surgeon-related factors. RESULTS: Patients operated on by surgeons who were certified specialists for at least 10 years had a lower risk of local recurrence (relative risk 0.8 (95 per cent confidence interval (c.i.) 0.6-1.0)) and death from rectal cancer (relative risk 0.8 (95 per cent c.i. 0.7-0.9)). The risk was also lower for patients operated on in university hospitals (relative risk of local recurrence 0.7 (95 per cent c.i. 0.5-0.9), relative risk of death from rectal cancer 0.8 (95 per cent c.i. 0.7-1.0)) compared with community hospitals, although the results in some community hospitals were similar to those in university hospitals. The proportional reduction of local recurrence rate after preoperative radiotherapy was not significantly different for the studied institutions and surgeons. CONCLUSION: There was a significant surgeon-related variation in patient outcome, which is probably related to the surgical technique. Although improved technique may reduce the local recurrence rate, preoperative radiotherapy is still beneficial concerning local control and survival.

Risk of relapse in new cases of ulcerative colitis and indeterminate colitis.

PURPOSE: Changes in morbidity pattern of ulcerative colitis have created a need to update understanding of the course of the disease. METHOD: A follow-up study was done of relapse rates and progression of inflammation in 571 non-selected patients with ulcerative and indeterminate colitis. RESULTS: Relapse rate ten years after diagnosis was 70 percent in definite ulcerative colitis, 22 percent in probable ulcerative colitis, and 77 percent in indeterminate colitis. During the study period, there was no change in the relapse rate. In relapsing proctitis, 52 percent developed more extensive inflammation. Fifty-four percent of patients with only one attack of colitis had persistent signs of inflammatory bowel disease. CONCLUSIONS: Shift in morbidity pattern to a greater proportion of patients with proctitis at diagnosis and a shorter time from onset of symptoms to diagnosis had no influence on the relapse rate. Indeterminate colitis has a worse prognosis than definite ulcerative colitis. Considering the documented efficacy of sulfasalazine, the high relapse rate calls for studies of the effectiveness of such treatment in everyday practice.

Operations in unselected patients with ulcerative colitis and indeterminate colitis. A long-term follow-up study.

OBJECTIVE: To assess the need for operative treatment for ulcerative colitis and indeterminate colitis. DESIGN: Retrospective study. SETTING: University Hospital, Sweden. SUBJECT: All patients diagnosed from 1958 to 1982, in Malmö, Sweden-ulcerative colitis (n = 471) and indeterminate colitis (n = 100). MAIN OUTCOME MEASURES: Incidence of colectomy. RESULTS: The mean follow-up was 15 years. The incidence of colectomy was 7.51, 1.90 and 36.13/1000 person years for definite ulcerative colitis, probable ulcerative colitis and indeterminate colitis, respectively. The incidence of colectomy in patients with definite ulcerative colitis in the present study was low compared with other studies. In contrast to other reports, men had a threefold risk while extent of inflammation did not influence the incidence. Patients with indeterminate colitis were a high risk group with a high incidence of colectomy. The high incidence among patients with indeterminate colitis compared with that in patients with definite ulcerative colitis was also seen in subgroups such as patients with total colitis at diagnosis, in patients in remission after the first attack, and in patients with a severe attack. CONCLUSION: As patients with indeterminate colitis seem to be at increased risk of colectomy it could be important to distinguish them from those with ulcerative colitis. Today, however, it is not possible to identify all patients with indeterminate colitis early in the course of the disease.

Ulcerative colitis and indeterminate colitis in the city of Malmö, Sweden. A 25-year incidence study.

BACKGROUND: This study was designed to assess time trends in the incidence of ulcerative colitis and indeterminate colitis in an urban population. METHODS: Medical records of in- and out-patients with inflammatory bowel disease were reviewed by a panel to establish the diagnosis. All histopathologic specimens and almost all radiographs were re-examined. RESULTS: During the time period 1958 to 1982 there were 354 new cases of definite ulcerative colitis, 117 of probable ulcerative colitis, and 100 of indeterminate colitis. This corresponds to an average annual incidence per 100,000 of 5.5, 1.8, and 1.6, respectively. The incidence was higher in men than in women. Peak incidence was between 20 and 29 years, but indeterminate colitis was most common in 10- to 19-year-old males. The incidence was stable from 1958 to 1972 but then increased in almost all age groups in both sexes. The increase in annual incidence of definite ulcerative colitis from 4.2 to 9.4/10(5) corresponds to an average annual increase of about 5% (p < 0.001). The increase in the incidence of definite ulcerative colitis was due to an increased proportion of patients with proctitis. CONCLUSIONS: This study has shown an increased incidence of ulcerative colitis and indeterminate colitis, and we have found no reason to believe that this is a spurious finding.

Incidence of colorectal cancer and all cause mortality in non-selected patients with ulcerative colitis and indeterminate colitis in Malmö, Sweden.

Cancer morbidity and all cause mortality were studied prospectively in all patients with definite and probable ulcerative colitis and indeterminate colitis diagnosed from 1958 to 1982, in the city of Malmö, Sweden. The follow-up to Jan. 1, 1990 was complete for all but ten patients. Nine of the 471 patients with ulcerative colitis and three of the 100 patients with indeterminate colitis developed colo-rectal cancer. The incidence of colorectal cancer in ulcerative colitis was 1.4 per 1000 person-years. The observed number of cases was 2.1 times higher than expected; (95% C.I. 1.0-4.1), based on the age- and sex-specific cancer incidence in the city during the study period. Indeterminate colitis was associated with a higher colorectal cancer risk than ulcerative colitis; 2.4 per 1000 person-years; (SMR 8.6, 95% C.I. 1.8-25.1). Both conditions were associated with a slight increased mortality rate, for ulcerative colitis 12.6 per 1000 person-years; (SMR 1.3, 95% C.I. 1.0-1.5), and for indeterminate colitis 11.7 per 1000 person-years; (SMR 2.7, 95% C.I. 1.6-4.4). Complications of colitis were the main cause of death in both groups. The cancer risk was related to extent of disease, duration of disease and female gender. Ten out of the 12 cases with cancer had or developed total colitis. However, only seven of the 134 cases with total ulcerative colitis and two of 87 cases with total indeterminate colitis developed cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Compartment syndrome after prolonged surgery with leg supports.

Compartment syndrome has been reported in a few cases after prolonged surgery with patients in leg supports. A recent case in our hospital (57-year-old man undergoing cystourethrectomy because of cancer) made us interested in the problem. This case together with six from the literature are analysed. Moreover, the first 11 cases operated on with a pelvic pouch and ileoanal anastomosis at our department were reviewed. They had been in the leg support position for a median duration of 6.4 (5.8-8) h. In four of them leg pain and swelling developed within 12 h. Three showed regression within a few days, one after a week. In one patient with swelling compartment pressure was measured with a transducer tipped catheter. Intermittently the pressure was up to 50 mm Hg. There was an obvious decrease in pressure on knee bending. Also, in a patient without swelling large pressure variations were seen but not to critical levels.

The adenoma-carcinoma sequence in rectal adenomas. Support by the expression of blood group substances and carcinoma antigens.

The reaction patterns of eight antibodies directed against blood group substances A, B, and H and against Lewis B antigen, difucosylated carbohydrate antigens (DFCA), gastrointestinal cancer antigen (GICA) CA 19-9, carcinoma-associated antigen CA-50, and carcinoembryonic antigen (CEA) were studied in mucosa and adenomas of the rectum. Antigenic heterogeneity was a common feature of rectal mucosa and was observed to a considerable degree in adenomas. In general, the rectal mucosa expressed only a few antigens and to a limited extent. The adenomas were more extensively stained than the rectal mucosa. The proportion of positive cells increased with the grade of dysplasia but was relatively unrelated to the histologic type. The proportion of individual antigens expressed and the number of antigens extensively expressed increased between rectal mucosa, benign adenomas, and adenomas with early invasive carcinoma. These findings support the concept of an adenoma (dysplasia)-carcinoma sequence.

Treatment of colorectal cancer--techniques for local excision.

Local excision of rectal carcinomas may be performed in selected cases with well differentiated, small "early" carcinomas or as a compromise operation in patients too frail for a major surgical procedure.

Perianal Paget's disease.

A case of extramammary, perianal Paget's disease with underlying rectal carcinoma is presented. The importance of awareness of the condition is stressed and the diagnosis and treatment are commented upon.

Surgical treatment of inflammatory bowel disease--a review of some current opinions and controversies.

There are many controversial issues regarding the treatment of patients with inflammatory bowel disease. From this review we have concluded that the longer surgery for Crohn's disease is delayed, the higher the rate is of pre- and postoperative complications. A plea is thus made for relatively early surgical intervention. For Crohn's disease, the general policy today is to perform resections, even if relatively limited ones, rather than to perform by-passes of the macroscopically involved intestine. Indeterminate colitis, as well as self-limiting colitis, are differential diagnoses that the surgeon must be aware of, especially when selecting the appropriate operative method. Due to the existent risk of cancer in ulcerative colitis, some authors advocate prophylactic colectomy after 10 to 15 years, but the most current policy seems to be one of close surveillance, with surgery only in the cases of severe dysplasia or if a so called dysplasia associated lesion or mass (DALM) is diagnosed. Coloproctectomy has been the standard procedure for patients with ulcerative colitis, however, good or even excellent results are often seen after ileorectal anastomosis and pelvic pouch operations. Although all patients cannot benefit from the latter operation it is likely that it will become the principal operation for patients with ulcerative colitis.

Upper gastrointestinal carcinoma in familial polyposis. Case report.

In three siblings with familial polyposis coli, adenocarcinoma of the upper gastrointestinal tract appeared many years after colectomy. The risk of extracolonic lesions occurring in familial polyposis underlines the need for regular upper gastrointestinal surveillance after colectomy.

Recurrence rates after curative surgery for rectal carcinoma, with special reference to their accuracy.

Is the observed recurrence rate after curative surgery for rectal cancer always a good measure of therapeutic improvements? In an attempt to answer this question, the rates of local and distant recurrences were studied in two complete series of patients operated on for cure for rectal carcinoma. One hundred one consecutive patients were followed for five years in one series and 231 were followed for at least 18 years in the other series. The recurrence rate in the first series was 39 percent and in the second, with the longer observation time, 54 percent. The local recurrence rates were 24 and 38 percent, respectively. Both local and total recurrence rates increased with the length of the follow-up period. This was especially true for patients with combined local and distant disease. Autopsy sometimes demonstrated recurrences, clinically undiscovered. It is concluded that completeness, long follow-up, and intensive search for recurrence, including a high autopsy rate, are factors that raise both total and local recurrence rates. All these factors are important to consider when comparing results of different treatment modalities.