| 1. |
- Afshari, Kevin, et al.
(författare)
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Risk factors for developing Anorectal dysfunction after Anterior Resection
- 2021
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Ingår i: International Journal of Colorectal Disease. - : Springer Nature. - 0179-1958 .- 1432-1262. ; 36:12, s. 2697-2705
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Tidskriftsartikel (refereegranskat)abstract
- Anterior resection (AR) may result in defecatory dysfunction and the cause is multifactorial. The aim was to explore if dysfunction could be related to the part of the colon used for anastomosis (sigmoid or descending) and to identify other possible risk factors for bowel dysfunction after AR.This is a retrospective study based on prospectively registered data from a regional registry at the surgical department in Västmanland 1996–2019. Bowel function was registered at 1 year after AR or after stoma reversal. In total, 470 stage I–III rectal cancer patients had AR whereof 412 were included in this study.Clustering was seen in 57%, incontinence 29%, urgency 22%, and evacuatory dysfunction 16%. The part of the colon used for anastomosis, level of vascular tie, and gender were not significantly associated with defecatory dysfunction. The higher the anastomotic level, the lower the risk of incontinence (OR 0.75; CI 0.63–0.90; p < 0.001) and clustering (OR 0.78; CI 0.67–0.90; p < 0.001). Compared with patients without a loop-ileostomy, an increased risk of clustering (OR 1.89; 1.08–3.31; p = 0.03), incontinence (OR 2.48; 1.29–4.77; p < 0.01), and urgency (OR 4.61; CI 2.02–10.60; p < 0.001) was seen after loop-ileostomy closure. Preoperative radiotherapy had a negative impact on continence and clustering seen mainly in the unadjusted analysis.The part of the colon used for anastomosis was not a significantly associated functional outcome after anterior resection. Low anastomotic level and having had a diverting ileostomy were independent risk factors associated with negative functional outcomes.
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| 2. |
- Chabok, Abbas, 1964-
(författare)
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Colonic Diverticulitis : Diagnostic and Therapeutic Aspects
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aims of this thesis were to evaluate diagnostic and therapeutic aspects of colonic diverticulitis. In the first study, a systematic review of the literature was performed to evaluate radiological diagnostics for patients with acute left-sided diverticulitis. Forty-nine relevant articles were found and read in full and data were extracted or calculated. Twenty-nine of these were excluded. The best evidence for the diagnosis of diverticulitis in the literature was to be found with US. Only one small study of good quality was found for both CT and MRI. In the second paper, a prospective multicentre study was performed to determine the faecal carriage of antibiotic-resistant bacteria and antibiotic treatment in 208 surgical patients with acute intra-abdominal infections. The highest rates of resistance among Enterobacteriaceae were detected for ampicillin (54%), tetracycline (26%), cefuroxime (26%) and trimethoprim-sulfamethoxazole (20%). The prevalence of decreased susceptibility (I + R) for the other antibiotics tested was for ciprofloxacin 20%, piperacillin-tazobactam 17%, cefotaxime 14%, ertapenem 12%, gentamicin 3% and imipenem 0%. ESBL- and AmpC producing Enterobacteriaceae were found in samples from 13 patients (6.3%). We found high rates of resistance among Enterobacteriaceae against antibiotics which were commonly used in Sweden. In the third paper, a multicentre randomized study was performed to investigate the need of antibiotic treatment in acute uncomplicated diverticulitis. Six hundred and twenty-three patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics. Complications were found in six patients (1.9%) in the no antibiotic and three (1.0%) in the antibiotic group (p=0.302). The median hospital stay was three days in both groups. Recurrent diverticulitis follow-up was similar in both groups (16%, p=0.895). We conclude that antibiotic treatment for acute uncomplicated diverticulitis neither accelerated recovery nor prevented complications or recurrence. Based on the results, antibiotics should therefore be reserved mainly for the treatment of complicated diverticulitis. The fourth paper presents a prospective observational study performed in two centres to evaluate CT colonography in the follow-up of acute diverticulitis as regards patient acceptance and diagnostic accuracy in 108 patients. Patients experienced colonoscopy as more painful (p<0.001) and uncomfortable (p<0.001). Diverticulosis and polyps were detected in 94% and 20% with colonoscopy and in 94% and 29% with CTC, respectively. Sensitivity and specificity for CTC in the detection of diverticulosis was 99% and 67%, with a level of relatively good agreement (К= 0.71). Regarding detection of polyps, the sensitivity and specificity were 47% and 75%, with a poor agreement (К= 0.17). We concluded that CTC was less painful and unpleasant. CTC detected diverticulosis with good accuracy while the accuracy of detection of small polyps was poor. CTC could be an alternative, especially in cases of incomplete colonoscopy or in a situation with limited colonoscopy resources.
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| 3. |
- Chabok, Abbas, 1964-, et al.
(författare)
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CT-colonography in the follow-up of acute diverticulitis : patient acceptance and diagnostic accuracy
- 2013
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Ingår i: Scandinavian Journal of Gastroenterology. - : Informa UK Limited. - 0036-5521 .- 1502-7708. ; 48:8, s. 979-986
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Tidskriftsartikel (refereegranskat)abstract
- Objective. The aim of this study was to assess CT-colonography (CTC) in the follow-up of diverticulitis regarding patient acceptance and diagnostic accuracy for diverticular disease, adenomas and cancer, with colonoscopy as a reference standard. Methods. A prospective comparative study where half of the patients underwent colonoscopy first, followed immediately by CTC. The other half had the examinations in the reverse order. Patient experiences and findings were registered after every examination, blinded to the examiner. Results. Of a total of 110 consecutive patients, 108 were included in the study, with a median age of 56 years (range 27-84). The success rate was 91% for colonoscopy and 86% for CTC. Examination time was 25 mm for both methods. The mean time for CTC evaluation was 20 mm. Eighty-three per cent of the patients received sedation during colonoscopy. Despite this, patients experienced colonoscopy as more painful (p < 0.001) and uncomfortable (p < 0.001). Diverticulosis and polyps were detected in 94% and 20% with colonoscopy and in 94% and 29% with CTC, respectively. Sensitivity and specificity for CTC in the detection of diverticulosis was 99% and 67%, with a good agreement (kappa = 0.71). Regarding detection of polyps, the sensitivity and specificity were 47% and 75%, with a poor agreement (kappa = 0.17). No cancer was found. Conclusion. CTC was less painful and unpleasant and can be used for colonic investigation in the follow-up of diverticulitis. CTC detected diverticulosis with good accuracy while the detection accuracy of small polyps was poor. CTC is a viable alternative, especially in case of incomplete colonoscopy or in a situation with limited colonoscopy resources.
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| 4. |
- Collin, Åsa, et al.
(författare)
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The effect of local gentamicin-collagen on perineal wound complications and cancer recurrence after abdominoperineal resection : a multicentre randomised controlled trial
- 2013
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Ingår i: Colorectal Disease. - : Wiley. - 1462-8910 .- 1463-1318. ; 15:3, s. 341-346
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Tidskriftsartikel (refereegranskat)abstract
- Aim: Perineal wound sepsis is a common problem after abdominoperineal resection of the rectum (APR), with an reported incidence of 10-15% in previously non-radiated patients, 20-30% in patients given preoperative radiation, and 50% among patients submitted to preoperative radiation combined with chemotherapy. The local application of gentamicin-collagen was evaluated to determine whether its use in the perineal wound reduced the risk complications and had an effect on cancer recurrence.Method: In this prospective multicentre (7 hospitals) randomised controlled trial, 102 patients undergoing APR due to cancer or benign disease were randomised into two groups including surgery with gentamicin-collagen (GS+ n=52), or surgery without gentamicin-collagen (GS- n=50), Patients were followed at 7, 30 and 90 days and at one and five years.Results: There were no statistically significant differences between the two groups regarding perineal wound complications, infectious or non-infectious or cancer recurrence.Conclusion: There was no statistically significant effect on perineal wound complications or cancer recurrence following the local administration of gentamicin-collagen during APR.
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| 5. |
- Hosseinali Khani, Maziar, 1975-
(författare)
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Rectal Cancer : Surgical Strategies and Histopathological Aspects
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The management of rectal cancer has changed in many countries over the last two decades and resulted in improved survival for the majority of rectal cancer patients. In this thesis some surgical strategies and histopathological aspects to improve and clarify the management of rectal cancer patients are investigated. Even in the era of TME surgery and radiotherapy, a higher local recurrence rate and shorter survival for rectal cancer patients operated with abdominoperineal resection is reported. In the first paper we describe a new strategy with partial anterior en bloc resection of either the prostate or the vagina, resulting in very low local recurrence rates and excellent long-term survival. Histopathological examination of the specimen lays the foundation for decision making on oncological therapy. A positive circumferential resection margin (CRM) has, in previous papers, been related to a high risk of local recurrence. In the second paper we show that a CRM ≤ 1 mm was not correlated with an increased risk of local recurrence when patients were managed in a multidisciplinary setting with preoperative radiotherapy and optimal TME surgery. As the complexity of rectal cancer management is increasing, demands on organizational structure are growing. In paper three we could show that long-term survival was increased for all rectal cancer patients after the centralization to a single unit. Whether or not to resect the primary rectal tumour in patients with metastatic disease is an ongoing debate in the literature. In paper four, we studied the national management of rectal cancer patients with primary metastatic disease. Nineteen per cent of rectal cancer patients present with Stage IV disease and, at a national level, there is a clear shift to a more selective and restrictive approach. The 30-day mortality was low for patients that underwent a resectional surgery, for patients having an exploratory laparotomy, however, it was high. Overall survival was improved over time even though up to one fourth of patients received no surgical treatment.
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| 6. |
- Isacson, Daniel, et al.
(författare)
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No antibiotics in acute uncomplicated diverticulitis : does it work?
- 2014
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Ingår i: Scandinavian Journal of Gastroenterology. - : Informa UK Limited. - 0036-5521 .- 1502-7708. ; 49:12, s. 1441-1446
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Tidskriftsartikel (refereegranskat)abstract
- Background. The first randomized multicenter study evaluating the need for antibiotic treatment in patients with acute uncomplicated diverticulitis (AUD) could not demonstrate any benefit gained from antibiotic use. The aim of this study was to review the application of the no antibiotic policy and its consequences in regard to complications and recurrence. Methods. This retrospective population-based cohort study included all patients diagnosed with all types of colonic diverticulitis during the year 2011 at Vastmanland Hospital Vasteras, Sweden. All medical records were carefully reviewed. Primary outcomes were the types of treatment adopted for diverticulitis, complications and recurrence. Results. In total, 246 patients with computer tomography-verified diverticulitis were identified, 195 with primary AUD and 51 with acute complicated diverticulitis. Age, sex, and temperature at admission were similar between the groups but there was a significant difference in white blood cell count, C-reactive protein, and length of hospital stay. In the AUD group, 178 (91.3%) patients were not treated with antibiotics. In this group, there were six (3.4%) readmissions but only two developed an abscess. Of the remaining 17 patients (8.7%) who were treated with antibiotics in the AUD group, one developed an abscess. Twenty-five (12.8%) patients in the AUD group presented with a recurrence within 1 year. Conclusion. The no-antibiotic policy for AUD is safe and applicable in clinical practice. The previous results of a low complication and recurrence rate in AUD are confirmed. There is no need for antibiotic treatment for AUD. What does this paper add to the literature? Despite published papers with excellent results, there are still doubts about patient safety against the policy to not use antibiotics in acute uncomplicated diverticulitis. This is the first paper, in actual clinical practice, to confirm that the no antibiotic policy for acute uncomplicated diverticulitis is applicable and safe.
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| 7. |
- Jung, Bärbel, et al.
(författare)
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Mechanical bowel preparation does not affect the intramucosal bacterial colony count
- 2010
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Ingår i: International Journal of Colorectal Disease. - : Springer Science and Business Media LLC. - 0179-1958 .- 1432-1262. ; 25:4, s. 439-442
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: The aim of this study was to determine if mechanical bowel preparation (MBP) influences the intramucosal bacterial colony count in the colon. MATERIALS AND METHODS: Macroscopically normal colon mucosa was collected from 37 patients (20 with and 17 without MBP) who were undergoing elective colorectal surgery at three hospitals. The biopsies were processed and cultured in the same laboratory. Colony counts of the common pathogens Escherichia coli and Bacteroides as well as of total bacteria were conducted. The study groups were comparable with regard to age, gender, antibiotics use, diagnosis and type of resection. RESULTS: MBP did not influence the median colony count of E. coli, Bacteroides or total bacteria in our study. CONCLUSIONS: MBP did not affect the intramucosal bacterial count in this study. Further studies are suggested to confirm these findings.
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| 8. |
- Khani, M. Hosseinali, et al.
(författare)
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Is the circumferential resection margin a predictor of local recurrence after preoperative radiotherapy and optimal surgery for rectal carcinoma?
- 2007
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Ingår i: Colorectal Disease. - : Wiley. - 1462-8910 .- 1463-1318. ; 9:8, s. 706-712
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: Circumferential resection margin (CRM) involvement has been correlated with a high risk of developing local recurrence. The aim of this study was to examine the prognostic significance of the CRM involvement after curative resection of rectal cancer in patients treated with preoperative radiotherapy and postoperative chemotherapy where indicated. METHOD: All patients with rectal cancer treated in a regional central unit from 1996 to 2004 were identified. A surgical resection was performed on 257 patients, and in 229 of these this was assessed as potentially curative. The CRM was examined in all patients. A CRM of < or = 1 mm was considered positive. RESULTS: A positive margin was seen in 19 (8%) patients. At a median follow up of 40 months, only four (1.7%) patients had developed local recurrence, one of whom had a positive CRM. In the four patients the tumour was 5 cm or less from the anal verge. There were no significant differences regarding local recurrence and survival between CRM positive and negative tumours. CONCLUSION: Rectal cancer managed by combined radiochemotherapy and surgery resulted in a low positive CRM rate and a low local recurrence rate. An involved CRM was not a predictor of local recurrence.
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| 9. |
- Nikberg, Maziar, et al.
(författare)
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Circumferential Resection Margin as a Prognostic Marker in the Modern Multidisciplinary Management of Rectal Cancer
- 2015
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Ingår i: Diseases of the Colon & Rectum. - 0012-3706 .- 1530-0358. ; 58:3, s. 275-282
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: A positive circumferential resection margin has been associated with a high risk of local recurrence and a decrease in survival in patients who have rectal cancer.OBJECTIVE: The purpose of this study was to analyze the involvement of circumferential resection margin in local recurrence and survival in a multidisciplinary population-based setting by using tailored oncological therapy and surgery with total mesorectal excision.DESIGN: Data were collected in a prospective database and retrospectively analyzed. Between 1996 and 2009, 448 patients with rectal cancer underwent a curative bowel resection.SETTINGS: Population-based data were collected at a single institution in the county of Vastmanland, Sweden.RESULTS: Preoperative radiotherapy was delivered to 334 patients (74%); it was delivered to 35 patients (8%) concomitantly with preoperative chemotherapy. In 70 patients (16%), en bloc resections of the prostate and vagina were performed. Intraoperative perforations were seen in 7 patients (1.6%). The mesorectal fascia was assessed as complete in 117/118 cases. In 32 cases (7%), the circumferential resection margin was 1 mm or less. After a median follow-up of 68 months, 5 (1.1%) patients developed a local recurrence; one of them had circumferential resection margin involvement. The 5-year overall survival was 77%. In the multivariate analysis, the circumferential resection margin was not an independent factor for disease-free survival.LIMITATIONS: Mesorectal fascia was not assessed before 2007. The findings might be explained by a type II error but, from a clinical perspective, enough patients were included to motivate the conclusion of the study.CONCLUSIONS: Circumferential resection margin is an important measurement in rectal cancer pathology, but the correlation to local recurrence is much less than previously stated, probably because of oncological treatment and surgery that respects the mesorectal fascia and, when required, en bloc resections. Circumferential resection margin should not be used as a prognostic marker in the modern multidisciplinary management of rectal cancer.
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| 10. |
- Nikberg, Maziar, et al.
(författare)
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Prophylactic stoma mesh did not prevent parastomal hernias
- 2015
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Ingår i: International Journal of Colorectal Disease. - : Springer Science and Business Media LLC. - 0179-1958 .- 1432-1262. ; 30:9, s. 1217-1222
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Tidskriftsartikel (refereegranskat)abstract
- Parastomal herniation is reported in up to 50 % of patients with a colostomy. A prophylactic stoma mesh has been reported to reduce parastomal hernia rates. The aim of the study was to evaluate the rate of parastomal hernias in a population-based cohort of patients, operated with and without a prophylactic mesh at two different time periods. All rectal cancer patients operated with an abdominoperineal excision or Hartmann's procedure between 1996 and 2012 were included. From 2007, a prophylactic stoma mesh was placed in the retro-muscular plane. Patients were followed prospectively with clinical and computed tomography examinations. There were no differences with regard to age, gender, pre-operative albumin levels, ASA score, body mass index (BMI), smoking or type of surgical resection between patients with (n = 71) and without a stoma mesh (n = 135). After a minimum follow-up of 1 year, 187 (91 %) of the patients were alive and available for analysis. At clinical and computed tomography examinations, exactly the same parastomal hernia rates were found in the two groups, viz, 25 and 53 %, respectively (p = 0.95 and p = 0.18). The hernia sac contained omentum or intestinal loops in 26 (81 %) versus 26 (60 %) patients with and without a mesh, respectively (p = 0.155). In the multivariate analyses, high BMI was associated with parastomal hernia formation. A prophylactic stoma mesh did not reduce the rate of clinically or computed tomography-verified parastomal hernias. High BMI was associated with an increased risk of parastomal hernia formation regardless of prophylactic stoma mesh.
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