| 1. |
- Azhar, Najia, et al.
(författare)
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Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial
- 2021
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Ingår i: JAMA Surgery. - Chicago, IL, United States : American Medical Association. - 2168-6254 .- 2168-6262. ; 156:2, s. 121-127
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Tidskriftsartikel (refereegranskat)abstract
- IMPORTANCE Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available.OBJECTIVE To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis.DESIGN, SETTING, AND PARTICIPANTS This international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-upwas conducted between March 2018 and November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need and computed tomography-verified free air, were eligible. Those available for trial intervention (Hinchey stagesINTERVENTIONS Patients were assigned to undergo laparoscopic peritoneal lavage or colon resection based on computer-generated, center-stratified block randomization.MAIN OUTCOMES AND MEASURES The primary outcome was severe complications within 5 years. Secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life.RESULTS Of 199 randomized patients, 101were assigned to undergo laparoscopic peritoneal lavage and 98were assigned to colon resection. At the time of surgery, perforated purulent diverticulitiswas confirmed in 145 patients randomized to lavage (n = 74) and resection (n = 71). The median follow-upwas 59 (interquartile range, 51-78; full range, 0-110) months, and 3 patientswere lost to follow-up, leaving a final analysis of 73 patients who had had laparoscopic lavage (mean [SD] age, 66.4 [13] years; 39 men [53%]) and 69 who had received a resection (mean [SD] age, 63.5 [14] years; 36 men [52%]). Severe complications occurred in 36%(n = 26) in the laparoscopic lavage group and 35%(n = 24) in the resection group (P = .92). Overall mortalitywas 32%(n = 23) in the laparoscopic lavage group and 25%(n = 17) in the resection group (P = .36). The stoma prevalencewas 8%(n = 4) in the laparoscopic lavage group vs 33% (n = 17; P =.002) in the resection group among patients who remained alive, and secondary operations, including stoma reversal, were performed in 36%(n = 26) vs 35%(n = 24; P = .92), respectively. Recurrence of diverticulitiswas higher following laparoscopic lavage (21% [n = 15] vs 4%[n = 3]; P = .004). In the laparoscopic lavage group, 30%(n = 21) underwent a sigmoid resection. Therewere no significant differences in the EuroQoL-5Dquestionnaire or Cleveland Global Quality of Life scores between the groups.CONCLUSIONS AND RELEVANCE Long-term follow-up showed no differences in severe complications. Recurrence of diverticulitis after laparoscopic lavage was more common, often leading to sigmoid resection. This must be weighed against the lower stoma prevalence in this group. Shared decision-making considering both short-term and long-term consequences is encouraged.
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| 2. |
- Collin, Åsa
(författare)
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Colorectal cancer : Aspects of staging, treatment, recurrence and survival
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Colorectal cancer is the third most common malignancy in the world, and major breakthroughs have been made regarding both surgical and oncological treatment. Still, postoperative complications, such as perineal infections after abdominoperineal resection (APR), are a major cause of morbidity, and distant recurrence rate is nearly 20%. In this thesis, means to improve postoperative infection rates, nodal staging in rectal cancer (and resulting overtreatment through (chemo)radiotherapy), cancer recurrence rates and survival, were investigated. In Paper I, the effects on complication rates, recurrence rates and survival of antibiotics applied locally after an APR, by means of a gentamicin-collagen sponge in the perineal wound, were analysed in a randomized setting. No difference was seen regarding any of the endpoints. The results suggest that local antibiotics can safely be omitted in APRs. Paper II investigated the effects of mechanical bowel preparation (MBP) on cancer recurrence and survival, among colon cancer patients undergoing a colon resection. Data from the Swedish randomized MBP trial were used. After follow-up, no improvement in recurrence rates or overall survival was seen, but cancer-specific survival was improved in the MBP group. In conclusion, MBP might be a prognostic favourable factor for outcome in colon cancer patients. In Paper III, the effect of new national guideline criteria for MRI nodal staging in rectal cancer was assessed, regarding the proportion of clinically positive nodes and staging accuracy, and resulting effects on preoperative (chemo)radiotherapy use. Comparing the two years prior to guideline implementation with the two years after implementation revealed a significant decrease in the proportion clinically positive nodes, but staging accuracy remained low, and (chemo)radiotherapy rates decreased with seemingly no correlation to guidelines. Thus, new guidelines decreased the rate of clinically positive nodes, but nodal accuracy remained poor and nodal staging should perhaps not be a criterion in preoperative treatment decisions. Paper IV investigated the impact of the total mesorectal excision quality, by means of the three Quirke grades, mesorectal (best quality), intramesorectal and muscularis propria (worst quality), on recurrence and survival, and assessed risk factors for intramesorectal or muscularis propria resection. Muscularis propria grade was associated with a higher local recurrence rate, but not with distant recurrence or survival. Several factors were associated with intramesorectal and muscularis propria grade, and more caution is warranted in these patients. In conclusion, this thesis provides insight into treatment choice, and the association of day-to-day treatment details with postoperative complications, recurrence and survival rates, as well as the challenges of nodal staging.
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| 3. |
- Enblad, Malin, et al.
(författare)
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Mucinous rectal cancers : clinical features and prognosis in a population-based cohort
- 2022
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Ingår i: BJS Open. - : Oxford University Press (OUP). - 2474-9842. ; 6:2
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Tidskriftsartikel (refereegranskat)abstract
- Purpose Mucinous rectal cancers are generally associated with poor prognosis. This study aimed to clinically characterize mucinous rectal cancers in a defined region of Sweden. Methods All patients with rectal cancer in Uppsala and Dalarna, Sweden, between 2010 and 2018, were identified using the Swedish Colorectal Cancer Registry. Data were verified and updated by way of medical, radiology, and histopathology reports. Patients were selected if magnetic resonance imaging, biopsy, and/or surgical specimen were mucinous. Primary outcomes were overall survival (OS), time to recurrence (TTR), pattern of metastatization, and downstaging. Risk factors for recurrence were analysed with univariable and multivariable analyses. Results Of 1220 patients with rectal cancer, 263 (22 per cent) had a mucinous specimen, median (interquartile range; i.q.r.) age was 71 (63-77) years, and 152 (58 per cent) were men. Most were localized in the low-middle rectum (76 per cent) and were stage III (53 per cent), or stage IV (28 per cent). The 5-year OS was 55 per cent (95 per cent c.i. 49 to 62); after total mesorectal excision (n = 164), 5-year OS was 75 per cent (95 per cent c.i. 68 to 83), and 5-year TTR was 68 per cent (95 per cent c.i. 60 to 77). In those with complete response (pCR), pStage I, pStage II, and pStage III, 5-year TTR was 93 per cent, 85 per cent, 74 per cent, and 44 per cent respectively. Synchronous metastasis was most common in the liver (64 per cent) and metachronous in the lungs (58 per cent). pCR was achieved in 14 patients, (13 per cent); whereas T and N category downstaging was achieved in 31 (28 per cent) and 67 patients (61 per cent) respectively. Perineural invasion had the strongest association with recurrence (hazard ratio 6.34, 95 per cent c.i. 2.50 to 16.10). Conclusion Mucinous rectal cancers have high recurrence rates, but pCR rate is more than 10 per cent. Perineural invasion is the main feature associated with recurrence. Mucinous rectal has been associated with a more aggressive disease course and this study aimed to clinically characterize all mucinous rectal cancers in a defined region of Sweden. Primary outcomes were overall survival, time to recurrence, pattern of metastatization, and downstaging; mucinous rectal cancer was found to have higher recurrence rates than rectal cancer in general, but complete responses were uncommon. Perineural invasion was associated with recurrence, which most commonly occurs in the lungs, whereas synchronous metastases are most common in the liver.
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| 4. |
- Enblad, Malin, et al.
(författare)
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Signet Ring Cell Colorectal and Appendiceal Cancer : A Small Signet Ring Cell Component Is Also Associated with Poor Outcome
- 2023
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Ingår i: Cancers. - : MDPI. - 2072-6694. ; 15:9
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Tidskriftsartikel (refereegranskat)abstract
- Background: Colorectal signet ring cell (SRC) carcinoma with ≥50% SRCs (SRC ≥ 50) has a poor prognosis, but the prognostic role of SRCs < 50% (SRC < 50) is unclear. The aim of this study was to provide a clinicopathological characterization of SRC colorectal and appendiceal tumours and analyse the importance of the SRC component size.Methods: All patients in the Swedish Colorectal Cancer Registry diagnosed with colorectal or appendiceal cancer in 2009–2020 at Uppsala University Hospital, Sweden, were included. The SRCs were verified, and the components estimated by a gastrointestinal pathologist.Results: Of the 2229 colorectal cancers, 51 (2.3%) had SRCs, with a median component size of 30% (interquartile range of 12.5–40) and 10 (0.45%) had SRC ≥ 50. The SRC tumours were primarily localized in the right colon (59%) and appendix (16%). No patients with SRCs had stage I disease, and 26 (51%) had stage IV, of whom, 18 (69%) had peritoneal metastases. The SRC tumours were often high grade with perineural and vascular invasion. The 5-year overall survival (OS) rate for patients with SRC ≥ 50 were 20% (95% confidence interval (CI) 6–70), for SRC < 50, 39% (95% CI 24–61); and for non-SRCs, 55% (95% CI 55–60). Among the patients with SRC < 50 and <50% extracellular mucin, the 5-year OS was 34% (95% CI 19–61), while those with ≥50% extracellular mucin had an OS of 50% (95% CI 25–99). The 5-year recurrence-free survival rates were 51% (95% CI 13–83) for patients with SRC tumours, as compared to 83% (95% CI 77–89) and 81% (95% CI 79–84) for mucinous and non-mucinous adenocarcinoma, respectively.Conclusions: The presence of SRCs was strongly associated with aggressive clinicopathological features, peritoneal metastases, and poor prognosis, also when they make up <50% of a tumour.Simple SummarySignet ring cell (SRC) carcinoma of colorectal and appendiceal cancer is rare but is recognized as the histopathological subtype with the poorest prognosis. However, the prognostic relevance of a SRC component <50% is unclear. The aim of this study was to provide a clinicopathological characterization of all SRC-containing colorectal and appendiceal cancers, including those with <50% SRCs. The results showed that SRCs, both ≥50% and <50%, were associated with aggressive histopathological features, advanced stages, and, particularly, peritoneal metastases. Information about the presence of SRCs in tumour tissue, not only in the case of ≥50% SRCs, should be routinely registered in pathology reports and clinical registers to enable larger studies that can aid our understanding of SRCs in colorectal and appendiceal cancers.
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