Quality of life and functional outcomes after transanal total mesorectal excision for rectal cancer-results from the implementation period in Denmark.

BACKGROUND: The standard operation for mid- and low rectal cancer total mesorectal excision (TME) is routinely performed as minimally invasive surgery. TME is associated with temporary or permanent functional impairment of pelvic organs, causing reduced quality of life (QoL). Concerns have been raised that the newest minimally invasive approach, transanal TME (TaTME), may further reduce urogenital and anorectal functions. OBJECTIVE: To determine if functional outcomes affecting QoL are altered after TaTME. Primary end-point is the impact of TaTME on QoL and functional outcomes. Secondary end-point is assessing differences in QoL and functional outcomes after TME surgery from below (TaTME) or above (transabdominal TME). DESIGN, SETTING, AND PARTICIPANTS: Observational study consisting of prospectively registered self-reported questionnaire data collected at baseline and follow-ups after TaTME. All patients who underwent TaTME during the Danish national implementation phase were included. Central surveillance of the implementation included questionnaires concerning QoL and functional outcomes. Analyses of functional results from the Danish cohort of the ROLARR trial (Jayne et al. in JAMA 318:1569-1580, (2017) are reported separately for perspective, representing the transabdominal approach to TME, i.e., laparoscopic- or robotic-assisted TME (LaTME/RoTME). Applied questionnaires include EORTC QLQ-C30, SF-36, LARS, ICIQ-MLUTS, ICIQ-FLUTS, IPSS, IIEF, SVQ, and FSFI. RESULTS: A total of 115 TaTME procedures were registered August 2016 to April 2019. LaTME/RoTME patients (n = 92) were operated on January 2011 to September 2014. A temporary postoperative decrease of QoL (global health status and functional scales) was observed, yet long-term results were unaffected by surgery in both groups. In TaTME patients, the anorectal dysfunction increased significantly (p < 0.001) from preoperative baseline to 13.5 months follow-up, where 67.5% (n = 52) reported major LARS symptoms. Urinary function was not significantly impaired after TME regardless of technique. The paucity of responses concerning sexual function precludes conclusions. CONCLUSIONS: Although an initial reduction in QoL after TME occurs, it normalizes within the first year postoperatively. In concurrence with international results, we found that significant anorectal dysfunction is common after TaTME. No data on anorectal function was available for LaTME/RoTME patients for comparison. We found no indications that transanal TME is inferior to transabdominal TME surgery concerning urogenital functions or health-related QoL.

Quality of life in a randomized trial of early closure of temporary ileostomy after rectal resection for cancer (EASY trial).

BACKGROUND: A temporary ileostomy may reduce symptoms from anastomotic leakage after rectal cancer resection. Earlier results of the EASY trial showed that early closure of the temporary ileostomy was associated with significantly fewer postoperative complications. The aim of the present study was to compare health-related quality of life (HRQOL) following early versus late closure of a temporary ileostomy. METHODS: Early closure of a temporary ileostomy (at 8-13 days) was compared with late closure (at more than 12 weeks) in a multicentre RCT (EASY) that included patients who underwent rectal resection for cancer. Inclusion of participants was made after index surgery. Exclusion criteria were signs of anastomotic leakage, diabetes mellitus, steroid treatment, and signs of postoperative complications at clinical evaluation 1-4 days after rectal resection. HRQOL was evaluated at 3, 6 and 12 months after resection using the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires QLQ-C30 and QLQ-CR29 and Short Form 36 (SF-36®). RESULTS: There were 112 patients available for analysis. Response rates of the questionnaires were 82-95 per cent, except for EORTC QLQ-C30 at 12 months, to which only 54-55 per cent of the patients responded owing to an error in questionnaire distribution. There were no clinically significant differences in any questionnaire scores between the groups at 3, 6 or 12 months. CONCLUSION: Although the randomized study found that early closure of the temporary ileostomy was associated with significantly fewer complications, this clinical advantage had no effect on the patients' HRQOL. Registration number: NCT01287637 (https://www.clinicaltrials.gov).

Short-term outcomes after complete mesocolic excision compared with 'conventional' colonic cancer surgery.

BACKGROUND: Complete mesocolic excision (CME) seems to be associated with improved oncological outcomes compared with 'conventional' surgery, but there is a potential for higher morbidity. METHODS: Data for patients after elective resection at the four centres in the Capital Region of Denmark (June 2008 to December 2013) were retrieved from the Danish Colorectal Cancer Group database and medical charts. Approval from a Danish ethics committee was not required (retrospective study). RESULTS: Some 529 patients who underwent CME surgery at one centre were compared with 1701 patients undergoing 'conventional' resection at the other three hospitals. Laparoscopic CME was performed in 258 (48·8 per cent) and laparoscopic 'conventional' resection in 1172 (68·9 per cent). More extended right colectomy procedures were done in the CME group (17·4 versus 3·6 per cent). The 90-day mortality rate in the CME group was 6·2 per cent versus 4·9 per cent in the 'conventional' group (P = 0·219), with a propensity score-adjusted logistic regression odds ratio (OR) of 1·22 (95 per cent c.i. 0·79 to 1·87). Laparoscopic surgery was associated with a lower risk of mortality at 90 days (OR 0·63, 0·42 to 0·95). Intraoperative injury to other organs was more common in CME operations (9·1 per cent versus 3·6 per cent for 'conventional' resection; P < 0·001), including more splenic (3·2 versus 1·2 per cent; P = 0·004) and superior mesenteric vein (1·7 versus 0·2 per cent; P < 0·001) injuries. Rates of sepsis with vasopressor requirement (6·6 versus 3·2 per cent; P = 0·001) and postoperative respiratory failure (8·1 versus 3·4 per cent; P < 0·001) were higher in the CME group. CONCLUSION: CME is associated with more intraoperative organ injuries and severe non-surgical complications than 'conventional' resection for colonic cancer.

Can the quality of colonic surgery be improved by standardization of surgical technique with complete mesocolic excision?

AIM: we analysed the influence of standardization of colon cancer surgery with complete mesocolic excision (CME) on the quality of surgery measured by the pathological end-points of number of harvested lymph nodes, high tie of supplying vessels, plane of mesocolic resection and rate of R0 resection. METHOD: One hundred and ninety-eight patients with colonic carcinoma who underwent radical surgery between September 2007 and February 2009 were divided into two groups, including those undergoing surgery before (93) or after (105) 1 June 2008, when complete mesocolic excision (CME) was introduced as standard in our hospital. RESULTS: The overall mean high tie increased from 7.1 (CI, 6.5-7.6) to 9.6 (8.9-10.3) cm (P<0.0001) and the mean number of harvested lymph nodes from 24.5 (22.8-26.2) to 26.7 (24.6-28.8) (P=0.0095). There were no significant increases in these end-points in open right hemicolectomy, and in laparoscopic sigmoid resection the number of lymph nodes did not increase significantly. The plane of mesocolic resection, the rate of R0 resection and the risk of complications did not change significantly. The median (range) length of hospital stay increased from 4 (2-62) to 5 (2-71) days (P=0.04). CONCLUSION: Standardization of colonic cancer surgery with CME seems to improve the quality of surgery without increasing the risk of complications.

The influence of wire localisation for non-palpable breast lesions on visualisation of the sentinel node.

PURPOSE: In our clinic, patients with occult breast lesions are treated with a sentinel node biopsy combined with wire-guided tumour excision. The aim of this retrospective study was to determine the influence of the sequence of wire localisation and sentinel node procedure on visualisation of the sentinel node. METHODS: A total of 136 patients had a wire-guided tumour excision combined with a sentinel node procedure. Sixty-six patients had guide wire localisation prior to the sentinel node procedure. Seventy patients had sentinel node visualisation before insertion of the guide wire. RESULTS: The sentinel node was visualised in 41 (62%) of the patients who first underwent guide wire localisation. In the group of patients who underwent visualisation of the sentinel node before placement of the guide wire, the sentinel node was visualised in 62 (89%). This is a significant difference in visualisation (p<0.001). CONCLUSION: This study shows that guide wire localisation prior to the sentinel node procedure negatively influences visualisation of the sentinel node.

[Pneumothorax during laparoscopic cholecystectomy]. / Pneumothorax opstået under laparoskopisk kolecystektomi.

One patient developed pneumothorax during laparoscopic cholecystectomy. The pneumothorax was immediately drained with an intercostal canula. A diaphragmatic lesion caused by the electrocoagulator was identified and closed, surgery was completed, and the patient was not seriously affected by the complication. Laparoscopic cholecystectomy has gained enormous popularity. Pneumothorax is a rare, but potentially fatal complication. Immediate treatment is essential and easy. This report should make anaesthetists and surgeons aware of the possibility of gas insufflated during laparoscopy producing a pneumothorax, particularly with the increased use of the technique for major upper abdominal procedures.

Evaluation of the E-test for susceptibility testing of the Bacteroides fragilis group. Danish study group.

The susceptibilities of 100 clinical isolates belonging to the Bacteroides fragilis group to 9 antibiotics, i.e. ampicillin, piperacillin, ceftriaxone, cefotaxime, cefoxitin, imipenem, erythromycin, clindamycin, and metronidazole, were tested using a standard agar dilution method and the E-test. Overall, 81% of the E-test MICs were within one log2 dilution step of the agar dilution MICs and 95% were within two log2 dilution steps. The E-test showed significantly lower MIC values than the agar dilution method for ampicillin, cefotaxime, and imipenem, and significantly higher MIC values for piperacillin, ceftriaxone, erythromycin, clindamycin, and metronidazole. However, this only resulted in minor discrepancies that did not change the susceptibility status. The E-test is easy to perform and read, and the MIC values correlated well with the MICs obtained by the agar dilution method when testing susceptibility of the Bacteroides fragilis group.

Antibiotic sensitivity of the Bacteroides fragilis group in Denmark. Danish Study Group.

Resistance rates to 9 antibiotics were determined for 370 isolates of the Bacteroides fragilis group submitted during a 5-month period in 1990-91 from 6 laboratories in Denmark. There was no resistance to imipenem (MIC > 8 mg/l) or metronidazole (MIC > 16 mg/l), while resistance to ampicillin was the rule (97% at > 4 mg/l) and to ceftriaxone rather common (19% at > 32 mg/l). Resistance was uncommon to cefoxitin (0.5% at > 32 mg/l), cefotaxime (6% at > 32 mg/l), piperacillin (7% at > 64 mg/l), ampicillin/sulbactam (1% at > 16 mg/l), and clindamycin (3% at > 4 mg/l). Two hundred and thirty-nine strains were Bacteroides fragilis. The 131 other strains were generally more resistant than the Bacteroides fragilis strains. For 5 antibiotics the Bacteroides fragilis had a significantly lower MIC in western than in eastern laboratories. For the group with other strains there was no significant difference.

A retrospective evaluation of 691 ureteroscopies: indications, procedures, success rate and complications.

In the period of 1983-1990, a total of 691 ureteroscopies were performed in 480 patients. The main indications for ureteroscopy were stones, stenoses or making a diagnosis. In one third of the cases, pathology was suspected in the renal pelvis or at the ureteropelvic junction, in one third in the distal third of the ureter, and in the remaining cases, in either the upper or the middle part of the ureter. The most frequent ureteroscopic procedures were diagnostic examination or surveillance and procedures involving treatment of stones. In the 1st attempt, the ureteroscope was introduced to the suspected pathology in 79.9% of all cases, and the main objective was achieved in 76.6%. The success of stone manipulation has increased from 74% in the 1st to 92% in the last part of the period. More than half the procedures involving a ureteral stenosis were not completed satisfactorily. The location of suspected pathology did not influence the results. Complications occurred in 23% of the ureteroscopies, and the relative number of major complications decreased continuously. We conclude that ureteroscopy is appropriate at any location of pathology and that efforts must be made to minimize both major and minor complications.

Susceptibility testing of anaerobic bacteria. Regression lines for six antibiotics determined with and without prediffusion.

The relationship between susceptibility testing by an agar dilution test and a tablet diffusion test was studied for 60 anaerobic bacteria (20 B. fragilis, 20 anaerobic cocci, 20 Clostridium species). For cefoxitin, no prediffusion and prediffusion times of one h, three h, 12 h, 24 h and 48 h were examined. For metronidazole, erythromycin, clindamycin, penicillin and imipenem, only 24 h prediffusion and no prediffusion were studied. Measurements were made after incubation for 24 h and 48 h. Prediffusion improved the correlation for all antibiotics tested, and 24 h prediffusion gave the best results. The slope of the regression line increased and the influence of the individual growth parameters on zone size was reduced. Prediction of susceptibility based on three zone breakpoints to estimate MIC was also better with 24 h prediffusion. However, the variation about the regression line for many of the antibiotics was still extremely high. Measurements after 24 h and 48 h incubation times showed almost identical regression equations, except for erythromycin, where the regression lines differed.

Effect of doxapram on postoperative pulmonary complications after upper abdominal surgery in high-risk patients.

In a double-blind randomised trial an infusion of doxapram, 2 mg per min for 6 h immediately after surgery and repeated on the first postoperative day, or the same volume of saline, was given to 39 patients who underwent upper abdominal surgery and who were at high risk of postoperative day, or the same volume of saline, was given to 39 patients who underwent upper abdominal surgery and who were at high risk of postoperative pulmonary complications. The patients were assessed pre-operatively and during the first 5 postoperative days by physical examination, spirometry, blood-gas analysis, and chest radiography. Postoperative pulmonary complications were defined as temperature over 38 degrees C for 2 days, abnormal auscultation, pathological radiography, and/or productive cough. Data from 16 patients per group were analysed. Significantly more patients in the placebo group had three criteria of postoperative pulmonary complication compared with the doxapram group (63% vs 19%). The doxapram group also had higher PaO2 postoperatively.

[Cyproterone acetate in the treatment of post-orchiectomy flushing]. / Cyproteronacetat i behandling af postorkiektomi-flushing.

Out of 17 patients who had been submitted to subcapsular orchidectomy as the primary treatment of cancer of the prostate, postorchiectomy flushing was found in eight, corresponding to 47%. Six of the patients were treated with cyproterone acetate in a dosage of 50-100 mg daily. In all of these clinically significant reduction in the frequency and duration of the flushing was found. In four out of five patients with possible recurrent flushing after withdrawal of cyproterone acetate, recommencement of the treatment proved necessary. Administration of cyproterone acetate appears to be equally effective in a dosage of 100 mg daily as in a dosage of 300 mg daily and this reduces the side effects and expenses considerably. If it is possible to obtain a more extensive patient material without hormone treatment, a placebo-controlled investigation with the reduced dosage is desirable.

Determination of susceptibility of anaerobic bacteria to beta-lactam antibiotics by a tablet diffusion test.

A standardized tablet diffusion test and a reference agar dilution test was evaluated for susceptibility testing of anaerobic bacteria to beta-lactam antibiotics. 74 freshly isolated anaerobic bacteria and three control strains (Cl. perfringens ATCC 13124 B. fragilis ATCC 25285, B. thetaiotaomicron ATCC 29741) were tested. The in vitro activities of 7 beta-lactam antibiotics were compared with metronidazole and clindamycin. Most active were metronidazole and clindamycin. Cefoxitin had the best activity of the beta-lactam antibiotics, whereas piperacillin and carbenicillin had good activities. High resistance rates were found for penicillin, ampicillin, cefuroxime and cefotaxime. MIC on control strains fell well within range set by the National Committee for Clinical Laboratory Standards (NCCLS). Correlation between MIC and inhibition zone diameters was generally good. Tablet diffusion can be used to divide anaerobic bacteria into three susceptibility categories. In addition all bacterial strains were tested for production of beta-lactamase by a nitrocefin tube test. Beta-lactamase production by the nitrocefin test indicated reduced sensitivity to beta-lactam antibiotics.

Acute spontaneous streptococcal myositis. Case report.

Streptococcal myositis of the acute spontaneous type is extremely rare. To the best of our knowledge, this report describes the first case in which a patient has survived, and reviews the differential diagnosis. The treatment is primarily surgical.

Susceptibility testing of 7 antibiotics against anaerobic bacteria: comparison of 2 different media and carbon dioxide concentrations.

Anaerobic agar (AA) and Danish Blood agar (DBA) were evaluated by a standardized agar diffusion and agar dilution test in 5% CO2. The activity of seven antibiotics (tetracycline, clindamycin, metronidazole, rifamycin, chloramphenicol, penicillin, erythromycin) was tested against 40 anaerobic bacteria, including 3 control strains (Cl.perfringens ATCC 13124, B.fragilis ATCC 25285, B.thetaiotaomicron ATCC 29741). 70% of the strains were resistant to erythromycin in 10% CO2, only 30% in 5% CO2. No evident CO2-effect could be seen with the other antibiotics. Mean MIC for tetracycline was twice as great on AA than DBA. In spite of that, tablet sensitivity testing with tetracycline on AA proved to be more accurate and completely separated the resistant and susceptible strains. For penicillin, the mean MIC was one dilution step higher on AA. No major differences could be seen with the other antibiotics. AA was superior to DBA in providing growth of anaerobes. Measurement on AA was easier, and it was more precise. Except for tetracycline. MIC on control strains fell well within range set by The National Committee for Clinical Laboratory Standards (NCCLS) on AA. Acceptable correlation coefficients were recorded between agar diffusion and agar dilution. Prediction of susceptibility based on zone diameter measurements was very good on AA. Only one discrepancy that could cause change of susceptibility status occurred on AA, while there were 12 on DBA. On DBA, there was poor correlation between MIC, compared with earlier results on the same agar. The 50% inhibitory concentration (IC50) was also measured, but offered no advantage over MIC.

Effect of culture medium and carbon dioxide concentration on growth of anaerobic bacteria and medium pH.

Two Danish agars, Danish Blood Agar (D.B.A.) and Anaerobic Agar (A.A.), were evaluated for their ability to support growth of 47 clinically isolated anaerobic strains in 5 different CO2-concentrations ranging from 0-10% CO2. CO2 and the use of an enriched medium (A.A.) are essential for satisfactory recovery of anaerobes. No gain could be seen when raising the CO2-concentration above 5%. The surface pH of the agars was measured both on non-inoculated and inoculated plates at room temperature and anaerobic incubation in the 5 different CO2-concentrations at 37 degrees C. Temperature change from room temperature to 37 degrees C resulted in a pH decrease of 0.1 units. There was a CO2-mediated decrease in pH (approximately 0.05 units/pr. CO2%) on non-inoculated media. On inoculated plates there was a minor additional fall in pH, which increased with time of incubation, but first became significant when the plates were incubated for more than 24 h. The use of 5% CO2 and A.A. is recommended for antimicrobial susceptibility studies on solid media.