The remaining colon after radical surgery for colorectal cancer

This study investigates the possible gain and limitation by performing colonoscopy and double-contrast enema immediately after, and every six months after, radical surgery for colorectal cancer. It was possible to perform a complete colonoscopy within three months of surgery in 80 per cent of the 239 patients and at the follow-up time in 90 per cent. Incompleteness was related to insufficient bowel preparation, narrow anastomosis, and long transverse colon. Five patients had synchronous cancers, and 64 had adenomas at the time of surgery. The risk of recurrent adenomas in the latter was higher (17/64) than in those without adenomas (15/175). The adenomas were located above the rectum in 57 of 80 patients who had polypectomy. Four patients with metachronous cancer and one of five patients with local recurrence had another radical operation, while this was possible in none of 40 patients with recurrence diagnosed by other means than colonoscopy and enema. Radical colorectal surgery should be followed by colonoscopy and double-contrast enema, but how often and for how long remains to be established.     

Gastric acid secretion and risk of recurrence of duodenal ulcer within six to eight years after truncal vagotomy and drainage

The value of insulin and augmented histamine tests in predicting recurrence of duodenal ulcer within six to eight years after truncal vagotomy and drainage was assessed in a series of 500 consecutively and electively operated patients. Criteria of recurrence were established by a discriminative analysis of gastric acid secretion parameters. Recurrence was predicted with a probability of about 75% in patients with dyspepsia, the proportion between recurrences and dyspeptic nonrecurrences being 1:1. The discriminatory ability of the insulin test was no better than that of the postoperative histamine test. Men with a preoperative PAO > 46.1 m-equiv/h had a risk of recurrence of 21%, women with a PAO > 41.5 m-equiv/h, 28%. Below these levels the risk was 5 and 1% respectively, demonstrating that recurrence after vagotomy is related to the number of parietal cells before vagotomy. A rationale is provided for antrectomy and vagotomy in duodenal ulcer patients with a high number of parietal cells.     

Repeated screening for colorectal cancer with fecal occult blood test. A prospective randomized study at Funen, Denmark

Two screenings with Hemoccult-II were performed in a randomized study, allocating 30,970 persons to screening and 30,968 as controls in a population of 140,000 between 45 and 74 years old on the island of Funen, Denmark. The test was completed in 20,672 initially and in 18,779 of these during rescreening 2 years later. Positive H-II tests were found in 215 and 159 persons during the two screenings, respectively. A total colonoscopy was performed in 187 and 144, and cancer was detected in 37 and 13 and adenomata in 86 and 76, respectively. Interval cancers had developed in 40 persons at the end of the second screening, and 39 non-responders had developed cancer. Cancer was diagnosed in 115 controls and an adenoma in 100 during the same period. Interval cancers presented as rectal cancers more frequently than those detected by screening. Early cancers were more frequent in the screening group, and, accordingly, more patients had curative and also less extensive surgery, with a low postoperative mortality. The total number of deaths from colorectal cancer was 37 in the screening group, including interval cancers and cancers in non-responders and persons who developed cancer before they could be invited, which suggests a reduction in mortality of 27% (51 deaths among controls, compared with 37). The reduction is as yet not statistically significant, and final evaluation must await at least one more screening, ending in 1990, and a follow-up of some years. Removal of more large adenomas during screening makes it possible that the incidence of cancer will decrease.     

Rectal prolapse and anal incontinence treated with a modified Roscoe Graham operation

The results of abdominal mobilization of the rectum and repair of the pelvic floor behind the anorectal junction are reported in 23 patients with rectal prolapse, being accompanied by some form of anal incontinence in 12. Within 20 months, on the average, three patients had recurrent prolapse. Two thirds of the patients with incontinence for solid and/or fluid feces were cured for prolapse as well as incontinence. Seven became constipated, while 14 were fully satisfied. Seven of eight patients with a highly reduced tone of the external sphincter before surgery had a marked improvement after surgery. The results do not differ greatly from those after the suspension operation or repair of the pelvic floor in front of the rectum, despite being more physiologic, but suggest that simultaneous suspension and abdominal repair of the pelvic floor may avoid the need for a secondary postanal repair from below in patients with persistent incontinence after suspension surgery. A controlled, randomized trial is advocated.     

Hepatocellular carcinoma in a patient with sarcoidosis-associated chronic active hepatitis and the MZ alpha-1-antitrypsin phenotype

A case of primary hepatocellular carcinoma is described in a patient with long-standing sarcoidosis of the liver associated with chronic active hepatitis, and the MZ alpha-1-antitrypsin phenotype. This association appears to be unique. The respective roles of alpha-1-antitrypsin deficiency, sarcoidosis and chronic active hepatitis in the development of hepatocellular carcinoma in this case are uncertain.     

Acute obstruction from tumour in the left colon without spread

Staged resection (group T) versus acute resection (group R) for cure was compared in a randomized study of 121 patients presenting with signs of leftsided obstructive colorectal tumours during emergency surgery from 1978 to 1993. Patients with distant spread were excluded. Transverse colostomy was done in 58 and resection without immediate anastomosis in 56. Duration of energency surgery was shorter, bloodtransfusions less and wound infections less frequent in T compared to R, but postoperative mortality was similar (8 patients in each group). The diagnosis of tumour was wrong in 11 patients in T and 6 in R. The proportion of patients surviving the second stage curative resection in T without a permanent colostomy (32/35) was higher than after acute resection (36/50) in spite of 6 patients having anastomotic surgery (Coloshield) at the time of acute resection in R. Days spent in hospital were less in R. Overall recurrence rates and survival rates were similar in T and R. No major advantage besides shorter hospital stay could be demonstrated by acute resection without simultaneous anastomosis compared with the traditional three state procedure, which on the other hand carried a much smaller risk of a permanent colostomy. The latter should therefore serve as a control in a prospective evaluation of emergency resection with simultaneous anastomosis.

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Résumé La résection différée (groupe T) a été comparée à la résection en urgence (groupe R) chez 121 patients randomisés présentant les signes d'une occulusion colo-rectale gauche d'origine tumorale opérée en urgence entre 1978 et 1993. Les patients porteurs de métastases ont été exclus. Une colostomie transverse a été réalisée chez 58 malades et une résection sans anastomose chez 56. Dans le groupe T, la durée de l'intervention chirurgicale était plus courte, le nombre de transfusions sanguines nécessaires inférieur et le taux de surinfection de plaie inférieur à celui observé dans le groupe R mais la mortalité post-opératoire était identique dans les deux groupes (8 patients dans chaque collectif). Le diagnostic de tumeur était erroné chez 11 patients du groupe T et 6 patients du groupe R. La proportion de patients vivant après la résection curative du deuxième temps opératoire dans le groupe T sans colostomie (32/35) était plus élevée qu'après la résection en urgence (36/50) bien que 6 patients aient eu un rétablissement de la continuité avec un coloshield au moment de la résection en urgence dans le groupe R. La durée du séjour hospitalier était inférieure dans le groupe R. L'incidence globale des récidives et le taux de survie étaient similaires dans les groupes T et R. Aucun avantage majeur en dehors de la durée plus brève du séjour hospitalier n'a pu être démontrée en comparant la résection en urgence sans anastomose et la technique en trois temps opératoires qui comporte, par ailleurs, un risque plus réduit de devoir laisser une stomie permanente. Cette dernière doit donc servir de contrôle dans une évaluation prospective de la résection en urgence avec anastomose simultanée.

     

Causes of death among Danish HIV patients compared with population controls in the period 1995–2008

Purpose

To compare the mortality and causes of death in human immunodeficiency syndrome (HIV) patients with the background population.

Methods

All adult HIV patients treated in Danish HIV centers from 1995 to 2008 and 14 controls for each HIV patient were included. Age-adjusted mortality rates (MR) and mortality rate ratios (MRR) were estimated using direct standardization and Poisson regression analyses. Up to four contributory causes of death for each person were included in analyses of cause-specific MR.

Results

A total of 5,137 HIV patients and 71,918 controls were followed for 37,838 and 671,339 person-years (PY), respectively. Among non-injection drug use (IDU) HIV patients, the acquired immune deficiency syndrome (AIDS)-related MR/1,000 PY declined dramatically from 122.9 [95?% confidence interval (CI) 106.8?C141.4] in 1995 to 5.0 (95?% CI 3.1?C8.1) in 2008. The non-AIDS-related MR did not change substantially from 6.9 (95?% CI 3.8?C12.5) to 5.6 (95?% CI 3.6?C8.8). The MR of unnatural causes declined from 6.9 (95?% CI 3.8?C12.5) to 2.7 (95?% CI 1.4?C5.1). The MRR of infections declined from 46.6 (95?% CI 19.6?C110.9) to 3.3 (95?% CI 1.6?C6.6). The MRR of other natural causes of death remained constant.

Conclusions

After the introduction of highly active antiretroviral therapy (HAART), the AIDS-related mortality has decreased substantially, but the long-term exposure to HIV and HAART has not translated into increasing mortality from malignancy, cardiovascular, and hepatic diseases.     

Sulindac and indomethacin suppress the diuretic action of furosemide in patients with cirrhosis and ascites: evidence that sulindac affects renal prostaglandins

Nonsteroidal anti-inflammatory drugs (NSAID) suppress prostaglandin-dependent renal blood flow and furosemide-induced diuresis in patients with cirrhosis and ascites. Since sulindac may selectively spare inhibition of renal prostaglandins, we evaluated the interactions of acute administration of sulindac or indomethacin with furosemide in 15 patients with cirrhosis and ascites. Prior to furosemide, indomethacin reduced creatinine clearance (by 55%), urinary volume (by 82%), sodium (by 93%), and prostaglandin E2 (by 87%) (all P less than 0.05), whereas sulindac had no effect. However, both drugs reduced furosemide-induced diuresis. Indomethacin appeared slightly more potent in reducing the diuresis (55% v 38%), natriuresis (67% v 52%), and prostaglandin E2 (PGE2) release (81% v 74%). In a similar protocol in healthy subjects, furosemide-induced diuresis and natriuresis were also blunted by both drugs. Thus, under conditions of enhanced prostaglandin activity from furosemide, sulindac does affect renal function. These data suggest that renal function should be monitored in patients with cirrhosis and ascites who receive sulindac as well as other NSAID.     

Therapeutic trial of thromboxane synthesis inhibition in the hepatorenal syndrome

Urinary excretion of the vasoconstrictor metabolite thromboxane B2 is increased in some patients with the hepatorenal syndrome. To define the role of thromboxanes in this syndrome and to evaluate a potential treatment for the renal impairment, we administered the thromboxane synthetase inhibitor dazoxiben to 5 patients with alcoholic hepatitis and rapidly progressive renal failure. Dazoxiben 200 mg/day followed by 400 mg/day reduced urinary thromboxane B2 by approximately 50% without altering prostaglandin E2 or 6-keto prostaglandin F1 alpha and without improving creatinine clearance (6 +/- 2 to 6 +/- 3 ml/min). In 3 additional patients, a higher dose of dazoxiben of 600 mg/day reduced thromboxane B2 by approximately 75% without consistent improvement in renal function. Thus, as judged by selective thromboxane inhibition with dazoxiben, thromboxanes are unlikely to be the key renal vasoconstrictor factor in the hepatorenal syndrome.