The role of surgery in weaning patients from home parenteral support - A cohort study.

AIM: Some patients with intestinal failure requiring home parenteral support (HPS) may be weaned. This study considered all abdominal surgery in a cohort of HPS patients over a 25-year period. Our aim was to identify how many patients can be weaned from HPS and by what means, and to identify what makes weaning more likely. METHOD: A prospectively collected database of HPS patients to December 2018 was analysed for outcomes of care. RESULTS: At 5 years 56% of 205 patients remained on HPS. Fifty eight patients (28%), who had 68 operations, stopped HPS after surgery. Patients stopping HPS had a longer median final small bowel length (155 cm, range 45-350 cm) and were more likely to have colon in circuit (84%) than patients who had reconstructive surgery but did not stop HPS (median small bowel length 50 cm, range 15-135 cm; 50% colon in circuit). The median period between HPS discharge and reconstructive surgery was 238 days. There were no deaths, but 18 Clavien-Dindo grade 3-4 complications occurred within 30 days. Ninety per cent of patients who stopped HPS survived for 5 years from the start of HPS in comparison with 53% of those who remained on HPS. CONCLUSIONS: No previous study has examined surgery in an entire cohort of HPS patients. More than a quarter of HPS patients can be weaned after reconstructive surgery. The length of bowel available for recruitment at surgery is the main determinant of the ability to stop HPS. The possibility of reconstruction should be considered, since patients who stop HPS appear to have a survival advantage.

Changes in adult home parenteral nutrition practice over 25 years.

BACKGROUND AND AIMS: Home Parenteral Nutrition (HPN) is the established treatment of intestinal failure. This study considers the changes in practice in a single UK centre over the past twenty-five years. METHODS: Data was culled from a database used for clinical care and maintained prospectively. RESULTS: Two hundred and five patients were included from 1993 to 2018. Patient numbers increased from 22 during 1999-2003 to 158 during 2014-2018. The median age at discharge increased from 52 years during 1999-2003 to 59 years during 2014-2018. Thirty percent of patients discharged during 1999-2003 had Crohn's disease, reducing to 14% during 2014-2018. Fifteen percent of patients discharged during 1999-2003 had small bowel fistula or obstruction in comparison to 44% during 2014-2018. Only 18 patients were treated with palliative intent, the majority in recent years. An increasing number of patients required help with HPN care over the years. Survival in non-palliative patients was 85% at 1 year, 67% at 3 years, 53% at 5 years and 42% at 10 years. The majority of deaths were due to underlying disease and only 5 of 55 deaths were attributed to HPN alone. HPN dependence in non-palliative patients was 73% at 1 year, 59% at 3 years, 56% at 5 years and 43% at 10 years. Fifty eight patients stopped HPN after reconstructive surgery. Patients experienced 5.1 admissions/1000 HPN days (64.7 admission days/1000 HPN days). Admission rate did not change over the years though the percentage due to catheter problems fell from 52% to 40% while the percentage due to underlying disease or unrelated cause rose. CONCLUSIONS: The increase in numbers, age and dependency of HPN patients requires increasing resource and consideration of new models of service. Many patients with short bowel syndrome now survive to old age and the care needs of the HPN patient who has become elderly can be complex. A significant proportion of patients are being referred for HPN as a bridge to reconstructive surgery after surgical complication and this requires close involvement of gastrointestinal surgeons in HPN teams. The need for hospital admissions remains a burden for HPN patients and there is scope for changes in service provision to try to reduce hospital days.

Multidisciplinary management of anal intraepithelial neoplasia and rate of progression to cancer: A retrospective cohort study.

PURPOSE: To describe the regional burden of AIN and rate of progression to cancer in patients managed in specialist and non-specialist clinic settings. METHODS: Patients with a histopathological diagnosis of AIN between 1994 and 2018 were retrospectively identified. Clinicopathological characteristics including high-risk status (chronic immunosuppressant use or HIV positive), number and type of biopsy (punch/excision) and histopathological findings were recorded. The relationship between clinicopathological characteristics and progression to cancer was assessed using logistic regression. RESULTS: Of 250 patients identified, 207 were eligible for inclusion: 144 from the specialist and 63 from the non-specialist clinic. Patients in the specialist clinic were younger (<40 years 31% vs 19%, p = 0.007), more likely to be male (34% vs 16%, p = 0.008) and HIV positive (15% vs 2%, p = 0.012). Patients in the non-specialist clinic were less likely to have AIN3 on initial pathology (68% vs 79%, p = 0.074) and were more often followed up for less than 36 months (46% vs 28%, p = 0.134). The rate of progression to cancer was 17% in the whole cohort (20% vs 10%, p = 0.061). On multivariate analysis, increasing age (OR 3.02, 95%CI 1.58-5.78, p < 0.001), high risk status (OR 3.53, 95% CI 1.43-8.74, p = 0.006) and increasing number of excisions (OR 4.88, 95%CI 2.15-11.07, p < 0.001) were related to progression to cancer. CONCLUSION: The specialist clinic provides a structured approach to the follow up of high-risk status patients with AIN. Frequent monitoring with specialist assessments including high resolution anoscopy in a higher volume clinic are required due to the increased risk of progression to anal cancer.

Management of Enterocutaneous Fistula: Outcomes in 276 Patients.

OBJECTIVE: To assess the outcomes of patients with type II intestinal failure due to enterocutaneous fistulae in a tertiary referral centre over a 15 year period. Intestinal failure secondary to enterocutaneous fistula (ECF) requires multidisciplinary management at significant cost. Mortality and morbidity are high. METHODS: Patients were identified from a prospectively collected database of patients requiring inpatient parenteral nutrition (1998-2013). Data collected included: demographics, mode of admission, pathological grouping and outcome. RESULTS: A total of 286 ECF were identified in 278 patients, mean age 64 years (20-96 years) with an equal gender distribution. In total, 112 fistulas developed following an emergency admission, 89 fistulas following an elective admission, and the remainder 85 were transferred from outlying district hospitals. In total, 246 ECF were as a result of previous surgery, 11 occurred following endoscopic procedures, with the remainder occurring spontaneously. All patients received parenteral nutrition (PN). Forty-seven patients overall died from sepsis/multiorgan failure. A total of 154 ECF resolved with aggressive non-operative management and 46 died prior to resolution of their fistula or surgery. 74.8% of patients with ECF proximal to the duodenal-jejunal flexure closed without surgery compared to 35.4% with disease distal to the flexure (p = 0.001). Nineteen early operations were performed, with 51 patients undergoing definitive surgery. In-hospital mortality was 19.1% (53/278), with 30-day post-operative mortality from definitive surgery being 9.8% (5/51). CONCLUSION: Mortality remains high and is associated with sepsis. Fistulas proximal to the duodeno-jejunal flexure are more likely to close spontaneously. If the fistula fails to close spontaneously care is often prolonged and complex, requiring a dedicated nutrition team. In this series, spontaneous closure was more common in upper GI fistulas. Patients who are not able to be discharged in the interval between fistula formation and definitive surgery have a higher mortality risk.

Analysis of lesion localisation at colonoscopy: outcomes from a multi-centre U.K. study.

BACKGROUND: Colonoscopy is currently the gold standard for detection of colorectal lesions, but may be limited in anatomically localising lesions. This audit aimed to determine the accuracy of colonoscopy lesion localisation, any subsequent changes in surgical management and any potentially influencing factors. METHODS: Patients undergoing colonoscopy prior to elective curative surgery for colorectal lesion/s were included from 8 registered U.K. sites (2012-2014). Three sets of data were recorded: patient factors (age, sex, BMI, screener vs. symptomatic, previous abdominal surgery); colonoscopy factors (caecal intubation, scope guide used, colonoscopist accreditation) and imaging modality. Lesion localisation was standardised with intra-operative location taken as the gold standard. Changes to surgical management were recorded. RESULTS: 364 cases were included; majority of lesions were colonic, solitary, malignant and in symptomatic referrals. 82% patients had their lesion/s correctly located at colonoscopy. Pre-operative CT visualised lesion/s in only 73% of cases with a reduction in screening patients (64 vs. 77%; p = 0.008). 5.2% incorrectly located cases at colonoscopy underwent altered surgical management, including conversion to open. Univariate analysis found colonoscopy accreditation, scope guide use, incomplete colonoscopy and previous abdominal surgery significantly influenced lesion localisation. On multi-variate analysis, caecal intubation and scope guide use remained significant (HR 0.35, 0.20-0.60 95% CI and 0.47; 0.25-0.88, respectively). CONCLUSION: Lesion localisation at colonoscopy is incorrect in 18% of cases leading to potentially significant surgical management alterations. As part of accreditation, colonoscopists need lesion localisation training and awareness of when inaccuracies can occur.

C-reactive protein as a predictor of postoperative infective complications after curative resection in patients with colorectal cancer.

BACKGROUND: Infective complications particularly in the form of surgical site infections including anastomotic leak represent a serious morbidity after colorectal cancer surgery. Systemic inflammation markers, including C-reactive protein (CRP) and white cell count, have been reported to provide early detection. However, their relative predictive value is unclear. The aim of the present study was to examine the diagnostic accuracy of serial postoperative WCC, albumin and CRP in detecting infective complications. METHODS: White cell count, albumin and CRP were measured postoperatively for 7 days in 454 consecutive patients undergoing surgery for colorectal cancer. All postoperative complications were recorded. The diagnostic accuracy of the white cell count, albumin and CRP values were analyzed by receiver operating characteristics curve analysis with surgical site infective complications as outcome measures. RESULTS: One hundred four patients (23 %) developed infective complications, and 26 of them developed an anastomotic leak. CRP was most sensitive to the development of an infective complication, surgical site or at a remote site. On postoperative day 3 CRP the area under the receiver operating characteristic curve was 0.80 (p < 0.001) and the optimal cutoff value was 170 mg/L. This threshold was also associated with an increase in the length of hospital stay (p < 0.001), 30 day mortality (p < 0.05) and 12 month mortality (p < 0.10). CONCLUSIONS: Postoperative CRP measurement on day 3 postoperatively is clinically useful in predicting surgical site infective complications, including an anastomotic leak, in patients undergoing surgery for colorectal cancer.

The relationships between plasma and red cell vitamin B2 and B6 concentrations and the systemic and local inflammatory responses in patients with colorectal cancer.

B vitamins have been implicated in cancer pathogenesis. It is therefore of interest that plasma B6 falls as part of the systemic inflammatory response (SIR), whereas red cell concentrations do not. The modified Glasgow Prognostic Score (mGPS) is a validated inflammation-based prognostic score that consists of a combination of albumin and C-reactive protein concentrations. The aim of this study was to examine the relationships between the concentrations of plasma and red cell vitamin B concentrations, the local and systemic inflammatory response in patients with colorectal cancer. Preoperative venous blood of 108 patients with colorectal cancer were analyzed for C-reactive protein, albumin, flavin adenine dinucleotide (FAD), and pyridoxal phosphate (PLP), and lymphocyte counts. Pathological slides were retrieved for assessment of inflammatory cell infiltration. Increasing mGPS was associated with lower plasma PLP concentrations (P < 0.01) but not plasma and red cell FAD and red cell PLP concentrations. Increasing tumor stage was associated with the presence of venous invasion (P < 0.01) and low-grade inflammatory cell infiltrate (P < 0.05) but not the SIR, FAD, or PLP concentrations. A low-grade inflammatory cell infiltrate was not significantly associated with any other parameter. The presence of a SIR was associated with lower concentrations of plasma PLP but not red cell PLP concentrations in patients with colorectal cancer. Neither FAD and PLP were associated with the tumor inflammatory cell infiltrate.

Improvement of parenteral nutrition-associated cholestasis in an adult using fish oil-based parenteral nutrition.

Parenteral nutrition-associated cholestasis (PNAC) is a severe complication of parenteral nutrition. Standard feed preparations contain soybean and olive oil that are rich in ω-6 polyunsaturated fats, and which studies suggest can be hepatotoxic. Preparations containing fish oil, rich in ω-3 polyunsaturated fats, may be hepatoprotective and have been used in the critical care setting as immunotherapy. A case demonstrating dramatic improvement in liver function and overall clinical condition in an adult with PNAC and intestinal failure within 8 weeks of changing to a fish oil-based parenteral feed is reported. As far as is known, this is the first report of an adult patient whose parenteral nutrition-associated liver disease resolved after a parenteral nutrition lipid emulsion was changed to the fish oil-containing emulsion, SMOFlipid.

The revised ACPGBI model is a simple and accurate predictor of operative mortality after potentially curative resection of colorectal cancer.

BACKGROUND: The Association of Coloproctology of Great Britain and Ireland (ACPGBI) risk-adjustment model for colorectal cancer surgery has been recently revised. The aim of the present study was to compare the performance of the revised ACPGBI model, the original ACPGBI model, P-POSSUM, and CR-POSSUM, in the prediction of operative mortality after resection of colorectal cancer. METHODS: A total of 423 patients who underwent potentially curative resection of colorectal cancer at a single institution (1997-2007) were included. Data used in the construction of the ACPGBI model was collected prospectively. The models were compared by examining observed to expected (O:E) ratios, the Hosmer-Lemeshow (H-L) goodness-of-fit test, and area under the receiver operator characteristic curve (AUC) analysis. RESULTS: The 30-day mortality rate was 4%. The performance of the models was as follows: revised ACPGBI model (O:E ratio = 1.05, AUC = 0.73, H-L = 11.02), original ACPGBI model (O:E ratio = 0.58, AUC = 0.76, H-L = 14.23), P-POSSUM (O:E ratio = 0.87, AUC = 0.79, H-L = 10.63), and CR-POSSUM (O:E ratio = 0.63, AUC = 0.84, H-L = 15.84). In subgroup analysis, the revised ACPGBI model performed well in both elective cases (O:E ratio = 1.06) and emergency cases (O:E ratio = 0.91). CONCLUSIONS: The revised ACPGBI model is simple to construct and accurately predicts operative mortality after potentially curative resection of colorectal cancer.

The impact of perioperative risk, tumor pathology and surgical complications on disease recurrence following potentially curative resection of colorectal cancer.

OBJECTIVE: The objective of the study was to identify determinants of disease recurrence after potentially curative resection of colorectal cancer. SUMMARY BACKGROUND DATA: The identification of patients at increased risk of disease recurrence is currently based on pathological factors. Recently, there has been considerable interest in the potential impact of perioperative factors on long-term colorectal cancer outcome. Few studies have examined pre-, intra-, and postoperative variables in a single cohort. METHODS: Four hundred and twenty-three patients with histologically confirmed colorectal cancer who underwent surgery with curative intent between 1997 and 2007 were included. Pre-, intra-, and postoperative variables were recorded. Logistic and Cox regression analyses were performed to identify predictors of surgical complications and disease recurrence, respectively. RESULTS: The postoperative mortality rate was 4% and the morbidity rate 34%. The most important predictors of complications were smoking (odd ratio [OR] 1.32), ASA grade (OR 1.90) and POSSUM operative score (OR 1.32). During follow up (median 80 months), 35% of patients developed disease recurrence. Predictors of recurrence, independent of tumor stage, were POSSUM physiology score (hazard ratio [HR] 1.31) and systemic inflammatory response (HR 1.31). CONCLUSIONS: Preoperative risk factors, but not postoperative complications, are associated with early disease recurrence after potentially curative resection of colorectal cancer.

Elastica staining for venous invasion results in superior prediction of cancer-specific survival in colorectal cancer.

OBJECTIVE: To examine the prognostic implications of routine elastica staining for venous invasion on prediction of cancer-specific survival in colorectal cancer. SUMMARY BACKGROUND DATA: Venous invasion is an important high risk feature in colorectal cancer, although prevalence in published studies ranges from 10% to 90%. To resolve the disparity, elastica stains have been used in our institution to provide a more objective judgment since 2002. METHODS: The study included 419 patients undergoing curative elective colorectal cancer resection between 1997 and 2006. Patients were grouped prior to (1997-2001 [cohort 1]) and following the introduction of elastica staining (2003-2006 [cohort 2]). FINDINGS: Clinicopathologic characteristics and 3-year survival rates were similar in both groups. Rate of detected venous invasion increased from 18% to 58% following introduction of elastica staining (P < 0.001). The 3-year cancer-specific survival rate associated with the absence of venous invasion was 84% in cohort 1, compared with 96% in cohort 2 (P < 0.01). Elastica staining improved the prognostic value of venous invasion, showing the area under the receiver operator curve rising from 0.59 (P = 0.040; 1997-2001) to 0.68 (P < 0.001; 2003-2006), using cancer mortality as an end point. A direct comparison between H&E alone and elastica Hematoxylin and Eosin (H&E) was made in 53 patients. The area under the receiver operator curve increased from 0.58, P = 0.293 (H&E alone) to 0.74, P = 0.003 for venous invasion detected using the elastica method. CONCLUSIONS: Increased detection of venous invasion with elastica staining, compared with H&E staining, provides superior prediction of cancer survival in colorectal cancer. This relationship was seen in the comparison of 2 consecutive cohorts and in a direct comparison in a single cohort. Based on these results, elastica staining should be incorporated into the routine pathologic assessment of venous invasion in colorectal cancer.

Surgical pathology is a predictor of outcome in post-operative lymph leakage.

BACKGROUND: Post-operative lymph leak is a potentially serious complication which may contribute to fluid and electrolyte imbalance, malnutrition and an increase risk of sepsis and mortality. We aimed to study the use of TPN in the treatment of post-operative lymph leak. METHODS: Retrospective review of prospectively collected clinical database comprising patients with post-operative lymph leak treated with TPN collected over 1998-2006. An analysis of morbidity and mortality was performed. RESULTS: 36 patients developed lymph leak following radical neck dissection (n = 10), Whipples procedure (n = 13), oesophagectomy (n = 10) and pulmonary/vascular/retroperitoneal (n = 3) surgery. The survival to discharge was 89%. The mortality rate in patients with chylothorax following oesophagectomy was 30% (three out of ten). The majority of patients (67%, 24 out of 36) with lymph leak settled on TPN alone. The overall re-intervention rate was 20%. Of the seven survivors after oesophagectomy, five underwent re-intervention thoracic surgery (two also had ischaemic perforation of gastric remnant needing revision surgery). Overall, the re-intervention rate in all patients undergoing oesophageal surgery is 60%. CONCLUSION: Most patients with post-operative lymph leak receiving TPN alone survived. It is rare for re-operation to be necessary in patients who have lymph leaks in the neck or retroperitoneum. Re-operative intervention is more commonly performed in lymph leak after oesophagectomy.

Home parenteral nutrition in Scotland: frequency of monitoring, adequacy of review and consequence for complication rates.

BACKGROUND AND AIMS: Home parenteral nutrition (HPN) has been a major advance in the management of patients with gastrointestinal failure. It demands regular monitoring to ensure optimal intake, assess treatment response, and minimize complications. The Scottish Home Parenteral Nutrition Managed Clinical Network (MCN) produced a guideline advising three-monthly monitoring of biochemistry, micronutrients, vitamins, weight, and anthropometry. This study assesses the frequency and adequacy of monitoring of these complex patients and investigates any effect of this on complication rate. METHODS: All patients receiving HPN funded by the National Health Service in Scotland are known to the MCN via the National Contract for provision of HPN. Data are collected in an MS Access database; 2006 data is extracted. RESULTS: There were 141 HPN clinic assessments for 53 patients. Sixteen (30%) were seen every 100 d as recommended by the guideline. Sixty percent of reviews were within 100 d of the previous appointment. Duration of HPN treatment inversely correlated with frequency of review. Bloods were checked at 93% of reviews, weight at 86%, anthropometry at 24%, and vitamins and micronutrients measurement at 62% of clinics. No difference in complication rates was found between those reviewed within the recommended time periods and those reviewed less often. CONCLUSIONS: Less than one-third of patients met the current recommended review frequency. Routine bloods and weight measurements were good, micronutrients less so; anthropometry is poorly monitored. Complication rates were not increased in HPN patients reviewed less often.

Abnormal colonic motility: a possible association with urge fecal incontinence.

PURPOSE: Fecal incontinence is a distressing condition affecting up to 7% of the population. Severe urgency is a symptom associated with hypersensitivity of the rectum, a common finding in both fecal incontinence and irritable bowel syndrome. The purpose of this study was to investigate whether patients with fecal incontinence, urgency, and rectal hypersensitivity have abnormal hindgut motility, suggestive of a more generalized motility problem. METHODS: Eleven females with urgency-associated incontinence and without anal sphincter injury were compared with 5 controls. After full clinical, ultrasonographic, and physiological assessment, patients underwent prolonged colonic manometry studies. Motility patterns were recorded and, in particular, the response to a standard gastrocolic reflex was noted. RESULTS: Rectal sensation values in patients were as follows: first sensation, 22 (range, 5-58) mls; desire to defecate, 31 (range, 13-166) mls; and maximum tolerated volume, 64 (range, 21-254) mls. Compared with controls, patients had significantly higher numbers of 1) low amplitude waves (>5 mmHg) in both the sigmoid colon (101 vs 46.5; P = .028) and the descending colon (101.5 vs 41; P = .036) in the hour before the meal stimulus, and 2) high amplitude waves (>50 mmHg) in the sigmoid colon (2 vs 0; P = .006) in the fasting state. CONCLUSION: Patients with fecal incontinence associated with severe urgency may have rectal hypersensitivity and a more global colonic motility problem similar to irritable bowel syndrome.

Relationship between emergency presentation, systemic inflammatory response, and cancer-specific survival in patients undergoing potentially curative surgery for colon cancer.

BACKGROUND: Emergency presentation is recognized to be associated with poorer cancer-specific survival following curative resection for colorectal cancer. The present study examined the hypothesis that an enhanced systemic inflammatory response, prior to surgery, might explain the impact of emergency presentation on survival. METHODS: In all, 188 patients undergoing potentially curative resection for colorectal cancer were studied. Of these, 55 (29%) presented as emergencies. The systemic inflammatory response was assessed using the Glasgow Prognostic Score (mGPS), which is the combination of an elevated C-reactive protein (>10 mg/L) and hypoalbuminemia (<35 g/L). RESULTS: In the emergency group, tumor stage was greater (P < 0.01), more patients received adjuvant therapy (P < 0.01) more patients had an elevated mGPS (P < 0.01), and more patients died of their disease (P < 0.05). The minimum follow-up was 12 months; the median follow-up of the survivors was 48 months. Emergency presentation was associated with poorer 3-year cancer-specific survival in those patients aged 65 to 74 years (P < 0.01), in both males and females (P < 0.05), in the deprived (P < 0.01), in patients with tumor-node-metastasis (TNM) stage II disease (P < 0.01), in those who received no adjuvant therapy (P < 0.01), and in the mGPS 0 and 1 groups (P < 0.05) groups. On multivariate survival analysis of patients undergoing potentially curative surgery for TNM stage II colon cancer, emergency presentation (P < 0.05) and mGPS (P < 0.05) were independently associated with cancer-specific survival. CONCLUSIONS: These results suggest that emergency presentation and the presence of systemic inflammatory response prior to surgery are linked and account for poorer cancer-specific survival in patients undergoing potentially curative surgery for colon cancer. Both emergency presentation and an elevated mGPS should be taken into account when assessing the likely outcome of these patients.

Benchmarking home parenteral nutrition in Scotland and New Zealand: disparities revealed.

AIM: Home parenteral nutrition (HPN) remains the treatment of choice for severe intestinal failure. These patients are few in number but consume significant resource in funding and personnel. Patients receiving HPN in Scotland and New Zealand (NZ) are both tracked through HPN registers which enable clinical audit for identifying important variations in practice. Scotland and NZ have similar demographics, healthcare systems, and populations (Scotland 5.1 million, NZ 4.1 million). METHODS: The HPN registers for Scotland and New Zealand for 2005 were examined for patients who received HPN during 2005 together with the diagnostic category identified (ICD-10) that resulted in provision of HPN. RESULTS: The diagnostic categories for the 2005 HPN patients were similar in both countries but rates of provision were much higher in Scotland (71 patients vs 14 patients). CONCLUSIONS: Despite similar demographics, healthcare systems, and population size, HPN is utilised to a significantly lesser extent in NZ. The reasons for this are not clear. However, it is possible that there is a lack of recognition of the need for HPN and/or under provision of HPN, which may lead to poorer treatment outcomes.

Vitamin antioxidants, lipid peroxidation, tumour stage, the systemic inflammatory response and survival in patients with colorectal cancer.

Both the tumour growth and progression and the systemic inflammatory response have the potential to increase oxidative stress. We therefore examined the relationship between lipid-soluble antioxidant vitamins, lipid peroxidation, the systemic inflammatory response and survival in patients with primary operable (n = 53) and advanced inoperable (n = 53) colorectal cancer. Compared with those patients with primary operable colorectal cancer, patients with unresectable liver disease had significantly lower median concentrations of alpha-tocopherol (p < 0.001), lutein (p < 0.001), lycopene (p < 0.001), alpha-carotene (p < 0.01) and beta-carotene (p < 0.001) and higher malondialdehyde concentrations. An elevated systemic inflammatory response (Glasgow prognostic score, mGPS) was associated with a greater proportion of females (p < 0.05) and more advanced tumour stage (p < 0.05), lower circulating levels of retinol (p < 0.01), lutein (p < 0.01), lycopene (p < 0.01) and alpha- (p < 0.01) and beta-carotene but not MDA (p = 0.633). In the liver metastases group 41 patients died of their cancer and a further 1 patient died of intercurrent disease on follow-up. On univariate survival analysis, mGPS (p < 0.01), retinol (p < 0.001), alpha-tocopherol (p < 0.05) and alpha-carotene (p < 0.05) were associated significantly with cancer-specific survival. On multivariate survival analysis of these significant variables, only mGPS (p < 0.01) and retinol (p < 0.001) were independently associated with cancer-specific survival. The results of the present study showed that the systemic inflammatory response was associated with a reduction of lipid-soluble antioxidant vitamins, whereas advanced tumour stage was associated with increased lipid peroxidation in patients with colorectal cancer. Of the antioxidant vitamins measured, only retinol was independently associated with cancer-specific survival.

Tumor size is associated with the systemic inflammatory response but not survival in patients with primary operable colorectal cancer.

AIM: To examine the relationship between tumor diameter, C-reactive protein concentrations and survival in patients undergoing surgery for colorectal cancer. METHOD: Tumor diameter and pathological characteristics of the resected specimen were assessed in 227 patients. Circulating concentrations of C-reactive protein were measured prior to surgery. RESULTS: Ninety-six patients had an elevated C-reactive protein concentration (>10 mg/L) prior to surgery. Tumor size was associated with an elevated C-reactive protein concentration (P < 0.001). C-reactive protein concentrations (P < 0.001) were associated with poorer cancer-specific survival. CONCLUSION: Prior to surgery, the maximal tumor diameter is associated with an elevated preoperative C-reactive protein concentration but not survival in patients with primary operable colorectal cancer.