pinecone/core-2020-05-10-deduplication huggingface dataset:
Colorectal cancer : aspects of multidisciplinary treatment, metastatic disease and sexual function

More than 6000 people in Sweden are diagnosed with colorectal cancer annually. One out of
five patients already has metastases at diagnosis. However, the occurrences of metastases at
specific locations, e.g. peritoneal carcinomatosis and ovarian metastases, are not well known.
The development of surgical and oncological treatment strategies for primary tumours and
metastatic disease has led to a need to discuss colorectal cancer patients in a multidisciplinary
team (MDT). Although oncologic cure and overall survival are the main goals of treatment,
quality of life and functional results are becoming increasingly important with the prolonged
survival. While male sexual dysfunction after rectal cancer treatment has been well described,
considerably less data have been published about the impact on women. In addition to surgical
trauma, female androgen insufficiency could be a contributing factor to sexual dysfunction.
Radiotherapy for rectal cancer may increase the risk of reduced ovarian androgen production,
but there is scant information on this in the literature.



Papers I-III are large population-based cohort studies reporting on the effects of the development
and implementation of MDT-conferences in patients with metastatic disease (Paper I)
and the epidemiology of peritoneal carcinomatosis and ovarian metastases in colorectal cancer
patients (Papers II–III). MDT assessment and metastasis surgery were more common in rectal
cancer patients than in colon cancer patients, and the proportion increased over time. Peritoneal
carcinomatosis was common, and risk factors were colon cancer, advanced tumour and nodal
stage, fewer than 12 examined lymph nodes, emergency surgery, and a non-radical resection of
the primary tumour. Ovarian metastases were uncommon, especially in rectal cancer patients.



Paper IV  assesses feasibility and internal and external validity in a prospective, observational
cohort study on sexual function and androgen levels in women with rectal cancer. The methods
were workable and the patients’ compliance was good. Comparison of clinical data from the
study cohort with that of women who were eligible for inclusion but not included revealed a
selection bias. Having a partner and sexual activity was more common among women who
answered all questions in the questionnaires about sexual function compared with those who
did not. A power calculation based on data from the first included patients showed that a larger
sample size than initially planned for was needed.



In conclusion, an increasing proportion of patients with metastatic colorectal cancer were discussed
by the MDT. Predictors for and the occurrence of peritoneal carcinomatosis and ovarian
metastases were defined, which may help to decide on individual treatment and follow-up
regimens. The analysis of baseline data from the study on sexual function and androgen levels
in women with rectal cancer indicates feasible methods but a selection bias. Inclusion of new
patients in the study continues
Hepatectomy for recurrent colorectal liver metastases after radiofrequency ablation

Background:
The results of surgery for recurrent colorectal liver metastases (CLM) after radiofrequency ablation (RFA) have not been evaluated.

Methods:
From 1993 to 2009, data on patients who underwent resection or RFA for recurrent CLM were collected prospectively. Inclusion criteria for this study were RFA as initial treatment for CLM and resection of recurrent CLM after RFA. Postoperative results and oncological outcomes were analysed.

Results:
Twenty-eight patients (median number of tumours 1 (1–3), median size 2·8 (2·0–4·0) cm) met the inclusion criteria. Of these, 22 had recurrence at the site of RFA only, two developed new lesions, whereas four had both recurrent and de novo metastases. At the time of resection, patients had a median of 1 (1–13) CLM with a median maximum tumour diameter of 5·0 (1·8–11·0) cm, significantly larger than at the time of RFA (P = 0·021). Ninety-day postoperative morbidity and mortality rates were 46 per cent (13 of 28) and 7 per cent (2 of 28) respectively. After a median follow-up of 35 (0–70) months, 3-year overall and disease-free survival rates calculated by Kaplan–Meier analysis were 60 and 29 per cent respectively. Plasma carcinoembryonic antigen level over 5 ng/ml at the time of resection and a rectal primary tumour were associated with worse survival (P = 0·041 and P = 0·021 respectively).

Conclusion:
Resection for recurrence after RFA is associated with significant morbidity and modest long-term benefit. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.PublishedN/
Incidentally detected adrenal lesions - radiological aspects

Incidentally detected adrenal lesions (“adrenal incidentalomas”) have become a growing clinical problem due to increased and refined radiology methods. Autopsy studies show frequencies as high as 7-8% in the elderly. A large part of such lesions give no health problems but some can be related to hormone overproduction or malignant disease. Dedicated radiological imaging can often reveal whether the lesion is benign or malignant, based on e.g. its fat content and wash-out of contrast medium. Our first aim was to determine the frequency of adrenal lesions incidentally detected by radiological methods in a geographically defined region. Secondly, to characterize these lesions biochemically and radiologically in a 2-year follow-up study. Thirdly, the variability of adrenal lesion characterization was investigated. During 18 months all new cases of incidentally detected adrenal lesions were prospective reported from 19 radiology departments in Western Sweden. Included patients were examined with dedicated adrenal computed tomography (CT) and/or magnetic resonance imaging during 2 years follow-up. Biochemical and clinical examinations were performed at detection and after 2 years. To validate the frequency of submitted cases, a re-evaluation of 3.827 abdominal CT-examinations was performed. The characterization of adrenal lesions was validated by an interobserver analysis of 40 adrenal lesions and a phantom study of 8 different CT-machines. In total, 339 patients with adrenal lesions detected at CT were included. The re-evaluation showed that the CT frequency of adrenal lesions varied from 1.8 to 7.1% (mean 4.5%) between hospitals, while the initially reported mean frequency was 0.9%. Follow-up of patients with-out extra-adrenal malignant disease (n=226) revealed no primary adrenal malignancy. Fourteen patients (6.6%) were operated and benign hormone-producing tumours were verified in 3%. All were identified at first examination, and follow-up revealed no additional cases of hormone producing tumours. More than 80% of these patients had radiologically benign lesions. Benign adrenal lesions were found in 74% of patients with history of malignant disease, in 53% of those with concurrent malignancy and in 25% of those with metastatic disease. In patients with two or more adrenal CT-examinations performed over two years 20-25 % of adrenal lesions showed such variations in attenuation values that their classification as “benign” or “indeterminate” would change. Both interobserver analysis and phantom analysis showed some differences in attenuation measurements.
Adrenal lesions detected at radiological examinations are common and frequency figures approach those reported at autopsy. Dedicated imaging and biochemical testing is highly recommended early after detection and further follow-up is recommended for lesions that still are indeterminate after this process. Follow-up should preferably be done with the same CT equipment, including a calibration instrument and the same observer to minimize observer and inter-scanner variability
Management of penetrating neck injuries

Background: Routine surgical exploration after penetrating neck injury (PNI) leads to a large number of negative neck explorations and potential iatrogenic injury. Selective non-operative management (SNOM) of PNI is gaining favour. The present study assessed the feasibility of SNOM in PNI. Methods: Seventy-seven consecutive patients with PNI presenting to a tertiary trauma centre were included in this prospective study from September 2009 to December 2009. All patients were managed according to Advanced Trauma Life Support guidelines, and either underwent emergency surgery or were managed without surgery, based on clinical presentation and/or outcome of special investigations. Results: Eight patients (10 per cent) were haemodynamically unstable at presentation. Foley catheter balloon tamponade (FCBT) was successful in stopping active bleeding in six of these patients, and diagnostic angiography revealed an arterial injury in five. The remaining 69 patients were managed using SNOM. Angiography or computed tomography was done in 41 patients (53 per cent), and showed arterial injury in 15. These injuries were treated surgically (7 patients), radiologically (stenting in 3) or conservatively. Contrast swallow and/or endoscopy were performed in 37 patients (48 per cent) for suspected oesophageal injury, but yielded no positive results. During follow-up no missed injuries were detected. Conclusion: FCBT was useful in patients with PNI and active bleeding. Stable patients should undergo additional investigation based on clinical findings only. Copyrigh
Accuracy of an expanded early warning score for patients in general and trauma surgery wards

Background: Early warning scores (EWS) may aid the prediction of major adverse events in hospitalized patients. Recently, an expanded EWS was introduced in the Netherlands. The aim of this study was to assess the relationship between this EWS and the occurrence of major adverse clinical events during hospitalization of patients admitted to a general and trauma surgery ward. Methods: This was a prospective cohort study of consecutive patients admitted to the general and trauma surgery ward of a university medical centre (March-September 2009). Follow-up was limited to the time the patient was hospitalized. Logistic regression analysis was used to assess the relationship between the EWS and the occurrence of the composite endpoint consisting of death, reanimation, unexpected intensive care unit admission, emergency surgery and severe complications. Performance of the EWS was analysed using sensitivity, specificity, predictive values and receiver operating characteristic (ROC) curves. Results: A total of 572 patients were included. During a median follow-up of 4 days, 46 patients (8.0 per cent) reached the composite endpoint (two deaths, two reanimations, 17 intensive care unit admissions, 44 severe complications, one emergency operation). An EWS of at least 3, adjusted for baseline American Society of Anesthesiology classification, was associated with a significantly higher risk of reaching the composite endpoint (odds ratio 11·3, 95 per cent confidence interval (c.i.) 5·5 to 22·9). The area under the ROC curve was 0·87 (95 per cent c.i. 0·81 to 0·93). When considering an EWS of at least 3 to be a positive test result, sensitivity was 74 per cent and specificity was 82 per cent. Conclusion: An EWS of 3 or more is an independent predictor of major adverse events in patients admitted to a general and trauma surgery ward
Impact of participation in randomized trials on outcome following surgery for gastro-oesophageal reflux

Author version made available in accordance with the publisher's policy.Introduction\ud
Patients are unwilling to participate in clinical trials if they perceive risks. To identify how trial participation impacts on outcome, outcomes were evaluated following surgery for gastro-oesophageal reflux in patients recruited to randomised trials vs. patients not in trials.\ud
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Patients and Methods\ud
From 1994 to 2009, 417 patients entered 6 randomised trials evaluating surgery for reflux, and 980 underwent surgery outside the trials. The choice of procedure outside the trials was according to surgeon or patient preference. Clinical outcomes were determined 1 and 5 years after surgery using a standardised questionnaire, including analogue scales to assess heartburn and dysphagia, and overall satisfaction with the outcome. Subgroup analysis was undertaken for those aged < 75 yrs undergoing laparoscopic Nissen fundoplication.\ud
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Results\ud
The trial group contained a higher proportion of men, were younger, more likely to have Barrett’s oesophagus, and have undergone a Nissen fundoplication. Reoperations within 5 years were more common in the trials group. At one year patients in the trials had slightly lower heartburn scores, and less abdominal bloating, but otherwise similar outcomes to those not in the trials. At five years there were no differences except a slightly higher dysphagia score for liquids in the trials group. For the subgroup analysis demographic data were similar for both groups, and at one year there were no differences. At 5 yrs patients enrolled in the trials had higher scores for dysphagia for liquids. The magnitude of all statistically significant differences were unlikely to be clinically significant.\ud
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Conclusion\ud
Participation in a randomised trial assessing surgery for reflux does not impact outcomes
Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair

Background Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance. Methods Patients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6-18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks. Results Some 597 EVARs (71·1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47·6 per cent), moderate shrinkage (5-9 mm) in 142 (23·8 per cent) and major shrinkage (at least 10 mm) in 171 patients (28·6 per cent). Four years after the index imaging, the rate of freedom from complications was 84·3 (95 per cent confidence interval 78·7 to 89·8), 88·1 (80·6 to 95·5) and 94·4 (90·1 to 98·7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3·11; P < 0·001). Moderate compared with major shrinkage (HR 2·10; P = 0·022), early postoperative complications (HR 3·34; P < 0·001) and increasing abdominal aortic aneurysm baseline diameter (HR 1·02; P = 0·001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage. Conclusion Early change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance. Towards personalized surveillanc
Incorporation of apical lymph node status into the seventh edition of the TNM classification improves prediction of prognosis in stage III colonic cancer.

[Background]The node classification outlined in the seventh edition of the TNM classification is based solely on the number of metastasized lymph nodes. This study examined the prognostic value of apical lymph node (ALN) metastasis and the additional value of incorporating ALN status into a risk model based on the seventh edition. [Methods]This was a cohort study of patients with stage III colonic cancer who underwent tumour resection with dissection of regional (including apical) lymph nodes at 71 hospitals across Japan between 2000 and 2002. The main exposure was pathologically confirmed ALN metastasis, and the primary endpoint was cancer-specific death. [Results]ALN metastasis was present in 113 (8·3 per cent) of 1355 patients. During 5356 patient-years of follow-up (median 5·0 years), 221 instances (16·3 per cent) of cancer-specific death were observed. After adjustment for tumour and node classification (as described in the seventh edition of the TNM classification) and other prognostic factors, ALN metastasis was found to be independently associated with cancer-specific death (hazard ratio 2·29, 95 per cent confidence interval (c.i.) 1·49 to 3·52). Incorporation of ALN metastasis into the prognostic model based on the seventh edition of the TNM classification significantly improved discriminative performance for cancer-specific death (difference in concordance index 0·0146, 95 per cent c.i. 0·0030 to 0·0262) and risk reclassification for cancer-specific death at 5 years (category-free net reclassification improvement 19·4 (95 per cent c.i. 5·0 to 33·4) per cent). [Conclusion]Assessment of ALN metastasis provided independent prognostic information beyond that achievable with the seventh edition of the TNM classification in patients with stage III colonic cancer
Reductions in plasma endocannabinoids following bariatric surgery in morbidly obese females with impaired glucose homeostasis: a non-randomized prospective study

Reductions in plasma endocannabinoids following bariatric surgery in morbidly obese females with impaired glucose homeostasis: A non-randomized prospective study • Endocannabinoids (ECs) are bioactive lipid mediators − N-arachidonyl ethanolamine (AEA) − N-palmitoyl ethanolamine (PEA) − N-oleoyl ethanolamine (OEA) − related N-acylethanolamine (NAE) derivatives − 2-arachidonyl glycerol (2-AG) • Endocannabinoid system (ECS) plays a critical role in regulation of body weight and may have a role in aetiopathogenesis of Type 2 Diabetes (T2DM) • Elevated circulating levels of AEA and 2-AG in obese people compared to non-obese controls of both genders • Little information available on the effects of extreme weight loss associated with bariatric surgery in relation to the ECS
Variation in the risk of venous thromboembolism following colectomy

Background: Guidelines recommend extended thromboprophylaxis following colectomy for malignant disease, but not for non-malignant disease. The aim of this study was to determine absolute and relative rates of venous thromboembolism (VTE) following colectomy by indication, admission type and time after surgery.\ud
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Methods: A cohort study of patients undergoing colectomy in England was undertaken using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data (2001–2011). Crude rates and adjusted hazard ratios (HRs) were calculated for the risk of first VTE following colectomy using Cox regression analysis. \ud
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Results: Some 12 388 patients were identified; 312 (2·5 per cent) developed VTE after surgery, giving a rate of 29·59 (95 per cent c.i. 26·48 to 33·06) per 1000 person-years in the first year after surgery. Overall rates were 2·2-fold higher (adjusted HR 2·23, 95 per cent c.i. 1·76 to 2·50) for emergency compared with elective admissions (39·44 versus 25·78 per 1000 person-years respectively). Rates of VTE were 2·8-fold higher in patients with malignant disease versus those with non-malignant disease (adjusted HR 2·84, 2·04 to 3·94). The rate of VTE was highest in the first month after emergency surgery, and declined from 121·68 per 1000 person-years in the first month to 25·65 per 1000 person-years during the rest of the follow-up interval. Crude rates of VTE were similar for malignant and non-malignant disease (114·76 versus 120·98 per 1000 person-years respectively) during the first month after emergency surgery. \ud
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Conclusion: Patients undergoing emergency colectomy for non-malignant disease have a similar risk of VTE as patients with malignant disease in the first month after surgery
Impact of case-relevant and case-irrelevant communication within the surgical team on surgical-site infection

BACKGROUND\ud
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Surgical-site infections (SSIs) are the most common complications after surgery. An influence from talking and distractions during surgery on patient outcomes has been suggested, but there is limited evidence. The aim of this prospective observational study was to assess the relationship between intraoperative communication within the surgical team and SSI, and between intraoperative distractions and SSI.\ud
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METHODS\ud
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This prospective observational study included patients undergoing elective, open abdominal procedures. For each procedure, intraoperative case-relevant and case-irrelevant communication, and intraoperative distractions were observed continuously on site. The influence of communication and distractions on SSI after surgery was assessed using logistic regressions, adjusting for risk factors.\ud
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RESULTS\ud
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A total of 167 observed procedures were analysed; their mean(s.d.) duration was 4·6(2·1) h. A total of 24 SSIs (14·4 per cent) were diagnosed. Case-relevant communication during the procedure was independently associated with a reduced incidence of organ/space SSI (propensity score-adjusted odds ratio 0·86, 95 per cent c.i. 0·77 to 0·97; P = 0·014). Case-irrelevant communication during the closing phase of the procedure was independently associated with increased incidence of incisional SSI (propensity score-adjusted odds ratio 1·29, 1·08 to 1·55; P = 0·006). Distractions had no association with SSI.\ud
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CONCLUSION\ud
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More case-relevant communication was associated with fewer organ/space SSIs, and more case-irrelevant communication during wound closure was associated with incisional SSI
Development of incisional herniation after midline laparotomy

Background: Incisional herniation is a common complication after abdominal surgery associated with considerable morbidity. The aim of this study was to determine whether incisional hernia is an early complication, in order to understand better the aetiology of incisional hernia formation.\ud
Methods: This study involved the secondary analysis of a subset of patients included in a large RCT comparing small and large tissue bites (5 mm every 5 mm, or 1 cm every 1 cm) in patients scheduled to undergo elective abdominal surgery by midline laparotomy. The distance between the rectus abdominis muscles (RAM distance) was measured by standardized ultrasound imaging 1month and 1year after surgery. The relationship between the 1-year incidence of incisional hernia and the RAM distance at 1 month was investigated.\ud
Results: Some 219 patients were investigated, 113 in the small-bites and 106 in the large-bites group. At 1 month after surgery the RAM distance was smaller for small bites than for large bites (mean(s.d.) 1⋅90(1⋅18) versus 2⋅39(1⋅34)cm respectively; P=0⋅005). At 1year, patients with incisional hernia had a longer RAM distance at 1month than those with no incisional hernia (mean(s.d.) 2⋅43(1⋅48) versus 2⋅03(1⋅19) cm respectively; relative risk 1⋅14, 95 per cent c.i. 1⋅03 to 1⋅26, P = 0⋅015).\ud
Conclusion: A RAM distance greater than 2 cm at 1 month after midline laparotomy is associated with\ud
incisional hernia. Closure with small bites results in a smaller distance between the muscles