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Gölz L, Pannetier P, Fagundes T, Knörr S, Behnstedt L, Coordes S, Matthiessen P, Morthorst J, Vergauwen L, Knapen D, Holbech H, Braunbeck T, Baumann L. Development of the integrated fish endocrine disruptor test-Part B: Implementation of thyroid-related endpoints. Integr Environ Assess Manag 2024; 20:830-845. [PMID: 37578010 DOI: 10.1002/ieam.4828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/21/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
Given the vital role of thyroid hormones (THs) in vertebrate development, it is essential to identify chemicals that interfere with the TH system. Whereas, among nonmammalian laboratory animals, fish are the most frequently utilized test species in endocrine disruptor research, for example, in guidelines for the detection of effects on the sex hormone system, there is no test guideline (TG) using fish as models for thyroid-related effects; rather, amphibians are used. Therefore, the objective of the present project was to integrate thyroid-related endpoints for fish into a test protocol combining OECD TGs 229 (Fish Short-Term Reproduction Assay) and 234 (Fish Sexual Development Test). The resulting integrated Fish Endocrine Disruption Test (iFEDT) was designed as a comprehensive approach to covering sexual differentiation, early development, and reproduction and to identifying disruption not only of the sexual and/or reproductive system but also the TH system. Two 85-day exposure tests were performed using different well-studied endocrine disruptors: 6-propyl-2-thiouracil (PTU) and 17α-ethinylestradiol (EE2). Whereas the companion Part A of this study presents the findings on effects by PTU and EE2 on endpoints established in existing TGs, the present Part B discusses effects on novel thyroid-related endpoints such as TH levels, thyroid follicle histopathology, and eye development. 6-Propyl-2-thiouracil induced a massive proliferation of thyroid follicles in any life stage, and histopathological changes in the eyes proved to be highly sensitive for TH system disruption especially in younger life stages. For measurement of THs, further methodological development is required. 17-α-Ethinylestradiol demonstrated not only the well-known disruption of the hypothalamic-pituitary-gonadal axis, but also induced effects on thyroid follicles in adult zebrafish (Danio rerio) exposed to higher EE2 concentrations, suggesting crosstalk between endocrine axes. The novel iFEDT has thus proven capable of simultaneously capturing endocrine disruption of both the steroid and thyroid endocrine systems. Integr Environ Assess Manag 2024;20:830-845. © 2023 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).
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Affiliation(s)
- Lisa Gölz
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | - Pauline Pannetier
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
- Laboratoire de Ploufragan-Plouzané-Niort, Site de Plouzané, Agence nationale de sécurité sanitaire de l'alimentation, de l'environnement et du travail, Plouzané, France
| | - Teresa Fagundes
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | - Susanne Knörr
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | - Laura Behnstedt
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | - Sara Coordes
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | | | - Jane Morthorst
- Department of Biology, University of Southern Denmark, Odense, Denmark
| | - Lucia Vergauwen
- Department of Veterinary Sciences, Veterinary Physiology and Biochemistry, Zebrafishlab, University of Antwerp, Wilrijk, Belgium
| | - Dries Knapen
- Department of Veterinary Sciences, Veterinary Physiology and Biochemistry, Zebrafishlab, University of Antwerp, Wilrijk, Belgium
| | - Henrik Holbech
- Department of Biology, University of Southern Denmark, Odense, Denmark
| | - Thomas Braunbeck
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | - Lisa Baumann
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
- Amsterdam Institute for Life and Environment (A-LIFE), Section Environmental Health & Toxicology, Vrije Universiteit Amsterdam, HV Amsterdam, The Netherlands
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Pannetier P, Gölz L, Pissarreira Mendes Fagundes MT, Knörr S, Behnstedt L, Coordes S, Matthiessen P, Morthorst JE, Vergauwen L, Knapen D, Holbech H, Braunbeck T, Baumann L. Development of the integrated fish endocrine disruptor test (iFEDT)-Part A: Merging of existing fish test guidelines. Integr Environ Assess Manag 2024; 20:817-829. [PMID: 37483114 DOI: 10.1002/ieam.4819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/21/2023] [Accepted: 07/20/2023] [Indexed: 07/25/2023]
Abstract
There has been increasing interest in endocrine-disrupting chemicals (EDCs) among scientists and public authorities over the last 30 years, notably because of their wide use and the increasing evidence of detrimental effects on humans and the environment. However, test systems for the detection of potential EDCs as well as testing strategies still require optimization. Thus, the aim of the present project was the development of an integrated test protocol that merges the existing OECD test guidelines (TGs) 229 (fish short-term reproduction assay) and 234 (fish sexual development test) and implements thyroid-related endpoints for fish. The integrated fish endocrine disruptor test (iFEDT) represents a comprehensive approach for fish testing, which covers reproduction, early development, and sexual differentiation, and will thus allow the identification of multiple endocrine-disruptive effects in fish. Using zebrafish (Danio rerio) as a model organism, two exposure tests were performed with well-studied EDCs: 6-propyl-2-thiouracil (PTU), an inhibitor of thyroid hormone synthesis, and 17α-ethinylestradiol (EE2), an estrogen receptor agonist. In part A of this article, the effects of PTU and EE2 on established endpoints of the two existing TGs are reported, whereas part B focuses on the novel thyroid-related endpoints. Results of part A document that, as expected, both PTU and EE2 had strong effects on various endocrine-related endpoints in zebrafish and their offspring. Merging of TGs 229 and 234 proved feasible, and all established biomarkers and endpoints were responsive as expected, including reproductive and morphometric changes (PTU and EE2), vitellogenin levels, sex ratio, gonad maturation, and histopathology (only for EE2) of different life stages. A validation of the iFEDT with other well-known EDCs will allow verification of the sensitivity and usability and confirm its capacity to improve the existing testing strategy for EDCs in fish. Integr Environ Assess Manag 2024;20:817-829. © 2023 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).
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Affiliation(s)
- Pauline Pannetier
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
- Laboratoire de Ploufragan-Plouzané-Niort, Site de Plouzané, Agence nationale de sécurité sanitaire de l'alimentation, de l'environnement et du travail, Plouzané, France
| | - Lisa Gölz
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | | | - Susanne Knörr
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | - Laura Behnstedt
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | - Sara Coordes
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | | | - Jane E Morthorst
- Department of Biology, University of Southern Denmark, Odense, Denmark
| | - Lucia Vergauwen
- Department of Veterinary Sciences, Veterinary Physiology and Biochemistry, Zebrafishlab, University of Antwerp, Wilrijk, Belgium
| | - Dries Knapen
- Department of Veterinary Sciences, Veterinary Physiology and Biochemistry, Zebrafishlab, University of Antwerp, Wilrijk, Belgium
| | - Henrik Holbech
- Department of Biology, University of Southern Denmark, Odense, Denmark
| | - Thomas Braunbeck
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
| | - Lisa Baumann
- Aquatic Ecology and Toxicology Section, Centre for Organismal Studies, University of Heidelberg, Heidelberg, Germany
- Amsterdam Institute for Life and Environment (A-LIFE), Section Environmental Health and Toxicology, Vrije Universiteit Amsterdam, HV Amsterdam, The Netherlands
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Gerdin A, Park J, Häggström J, Segelman J, Matthiessen P, Lydrup ML, Rutegård M. Preoperative beta blockers and other drugs in relation to anastomotic leakage after anterior resection for rectal cancer. Colorectal Dis 2024. [PMID: 38462750 DOI: 10.1111/codi.16933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 03/12/2024]
Abstract
AIM Previous research has indicated that preoperative beta blocker therapy is associated with a decreased risk of complications after surgery for rectal cancer. This is thought to arise because of the anti-inflammatory activity of the drug. These results need to be reproduced and analyses extended to other drugs with such properties, as this information might be useful in clinical decision-making. The main aim of this work was to replicate previous findings of beta blocker use as a prognostic marker for postoperative leakage. We also investigated whether drug exposure might induce anastomotic leaks. METHOD This is a retrospective multicentre cohort study, comprising 1126 patients who underwent anterior resection for rectal cancer between 2014 and 2018. The use of any preoperative beta blocker was treated as the primary exposure, while anastomotic leakage within 12 months of surgery was the outcome. Secondary exposures comprised angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins and metformin. Using multivariable regression, we performed a replication analysis with a predictive aim for beta blockers only, while adjustment for confounding was done in more causally oriented analyses for all drugs. We estimated incidence rate ratio (IRR) and relative risk (RR) with 95% confidence intervals (CIs). RESULTS Anastomotic leakage occurred in 20.6% of patients. Preoperative beta blockers were used by 22.7% of the cohort, while the leak distribution was almost identical between exposure groups. In the main replication analysis, no association could be detected (IRR 0.95, 95% CI 0.68-1.33). In the causally oriented analyses, only metformin affected the risk of leakage (RR 1.59, 95% Cl 1.31-1.92). CONCLUSION While previous research has suggested that preoperative beta blocker use could be prognostic of anastomotic leakage, this study could not detect any such association. On the contrary, our results indicate that preoperative beta blocker use neither predicts nor causes anastomotic leakage after anterior resection for rectal cancer.
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Affiliation(s)
- Anders Gerdin
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Jennifer Park
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jenny Häggström
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Josefin Segelman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
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Rutegård M, Svensson J, Segelman J, Matthiessen P, Lydrup ML, Park JM. Anastomotic Leakage in Relation to Type of Mesorectal Excision and Defunctioning Stoma Use in Anterior Resection for Rectal Cancer. Dis Colon Rectum 2024; 67:398-405. [PMID: 37994449 DOI: 10.1097/dcr.0000000000003050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND Anastomotic leakage after anterior resection for rectal cancer is more common after total mesorectal excision compared to partial mesorectal excision but might be mitigated by a defunctioning stoma. OBJECTIVE The aim is to assess how anastomotic leakage is affected by type of mesorectal excision and defunctioning stoma use. DESIGN This is a retrospective multicenter cohort study evaluating anastomotic leakage after anterior resection. Multivariable Cox regression with HRs and 95% CIs was used to contrast mesorectal excision types and defunctioning stoma use with respect to anastomotic leakage, with adjustment for confounding. SETTINGS This multicenter study included patients from 11 Swedish hospitals between 2014 and 2018. PATIENTS Patients who underwent anterior resection for rectal cancer were included. MAIN OUTCOMES MEASURES Anastomotic leakage rates within and after 30 days of surgery are described up to 1 year after surgery. RESULTS Anastomotic leakage occurred in 24.2% and 9.0% of 1126 patients operated with total and partial mesorectal excision, respectively. Partial compared to total mesorectal excision was associated with a reduction in leakage, with an adjusted HR of 0.46 (95% CI, 0.29-0.74). Early leak rates within 30 days were 14.9% with and 12.5% without a stoma, whereas late leak rates after 30 days were 7.5% with and 1.9% without a stoma. After adjustment, defunctioning stoma was associated with a lower early leak rate (HR 0.47; 95% CI, 0.28-0.77). However, the late leak rate was nonsignificantly higher in patients with defunctioning stomas (HR 1.69; 95% CI, 0.59-4.85). LIMITATIONS This study was limited by its retrospective observational study design. CONCLUSIONS Anastomotic leakage is common up to 1 year after anterior resection for rectal cancer, where partial mesorectal excision is associated with a lower leak rate. Defunctioning stomas seem to decrease the occurrence of leakage, although partially by only delaying the diagnosis. See Video Abstract . FUGA ANASTOMTICA SEGN EL TIPO DE EXCISIN MESORRECTAL Y LA CONFECCIN DE OSTOMA DE PROTECCIN EN LA RESECCIN ANTERIOR POR CNCER DE RECTO ANTECEDENTES:La fuga anastomótica después de una resección anterior por cáncer de recto es más frecuente después de la excisión total del mesorrecto comparada con la excisión parcial del mismo, pero podría mitigarse con la confección de ostomías de protección.OBJETIVO:El objetivo es evaluar cómo la fuga anastomótica se ve afectada según el tipo de excisión mesorrectal y la confección de una ostomía de protección.DISEÑO:Estudio de cohortes multicéntrico y retrospectivo que evalúa la fuga anastomótica después de la resección anterior. Se aplicó la regresión multivariada de Cox con los índices de riesgo (HR) y los intervalos de confianza (IC) al 95% para contrastar los tipos de excisión mesorrectal y el uso de otomías de protección con respecto a la fuga anastomótica, realizando ajustes respecto a las variables de confusión.AJUSTES:El presente estudio multicéntrico incluyó pacientes de 11 hospitales suecos entre 2014 y 2018.PACIENTES:Se incluyeron todos aquellos sometidos a resección anterior por cáncer de recto.PRINCIPALES MEDIDAS DE RESULTADOS:Las tasas de fuga anastomótica dentro y después de los 30 días de la cirugía fueron descritos hasta un año mas tarde al acto quirúrgico.RESULTADOS:La fuga anastomótica ocurrió en el 24,2% y el 9,0% de 1126 pacientes operados por excisión total y parcial del mesorrecto respectivamente.La excisión parcial del mesorrecto en comparación con la total se asoció con una reducción de la fuga, HR ajustado de 0,46 (IC del 95 %: 0,29 a 0,74). Las tasas de fuga temprana dentro de los 30 días fueron del 14,9 % con y el 12,5 % sin estoma, mientras que las tasas de fuga tardía después de 30 días fueron del 7,5 % con y el 1,9 % sin estoma.Después del ajuste de variables de confusión, las ostomías de protección se asociaron con una tasa de fuga temprana más baja (HR 0,47; IC 95 %: 0,28-0,77). Sin embargo, la tasa de fuga tardía no fue significativamente mayor en pacientes ostomizados (HR 1,69; IC 95%: 0,59-4,85).LIMITACIONES:Las limitaciones del presente estudio estuvieron vinculadas con el diseño de tipo observacional y retrospectivo.CONCLUSIONES:La fuga anastomótica es común hasta un año después de la resección anterior por cáncer de recto, donde la excisión parcial del mesorrecto se asocia con una menor tasa de fuga. La confección de ostomías de protección parece disminuir la aparición de fuga anastomótica, aunque en parte sólo retrasen el diagnóstico. (Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Johan Svensson
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Josefin Segelman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - Jennifer M Park
- Department of Surgery, Scandinavian Surgical Outcomes Research Group (SSORG), Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Petersson J, Matthiessen P, Jadid KD, Bock D, Angenete E. Short-term results in a population based study indicate advantage for minimally invasive rectal cancer surgery versus open. BMC Surg 2024; 24:52. [PMID: 38341534 PMCID: PMC10858513 DOI: 10.1186/s12893-024-02336-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The aim of this study was to determine if minimally invasive surgery (MIS) for rectal cancer is non-inferior to open surgery (OPEN) regarding adequacy of cancer resection in a population based setting. METHODS All 9,464 patients diagnosed with rectal cancer 2012-2018 who underwent curative surgery were included from the Swedish Colorectal Cancer Registry. PRIMARY OUTCOMES Positive circumferential resection margin (CRM < 1 mm) and positive resection margin (R1). Non-inferiority margins used were 2.4% and 4%. SECONDARY OUTCOMES 30- and 90-day mortality, clinical anastomotic leak, re-operation < 30 days, 30- and 90-day re-admission, length of stay (LOS), distal resection margin < 1 mm and < 12 resected lymph nodes. Analyses were performed by intention-to-treat using unweighted and weighted multiple regression analyses. RESULTS The CRM was positive in 3.8% of the MIS group and 5.4% of the OPEN group, risk difference -1.6% (95% CI -1.623, -1.622). R1 was recorded in 2.8% of patients in the MIS group and in 4.4% of patients in the OPEN group, risk difference -1.6% (95% CI -1.649, -1.633). There were no differences between the groups in adjusted unweighted and weighted analyses. All analyses demonstrated decreased mortality and re-admissions at 30 and 90 days as well as shorter LOS following MIS. CONCLUSIONS In this population based setting MIS for rectal cancer was non-inferior to OPEN regarding adequacy of cancer resection with favorable short-term outcomes.
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Affiliation(s)
- Josefin Petersson
- Department of Surgery, SSORG Sahlgrenska University Hospital/Östra, 416 85, Göteborg, Sweden.
- Sunshine Coast University Hospital, Britinya, QLD, Australia.
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health Sciences, Örebro University, Örebro, Sweden
| | - Kaveh Dehlaghi Jadid
- Department of Surgery, Faculty of Medicine and Health Sciences, Örebro University, Örebro, Sweden
| | - David Bock
- Department of Surgery, SSORG Sahlgrenska University Hospital/Östra, 416 85, Göteborg, Sweden
| | - Eva Angenete
- Department of Surgery, SSORG Sahlgrenska University Hospital/Östra, 416 85, Göteborg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Göteborg, Sweden
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Sijmons JML, Dekker JWT, Tuynman JB, Mohan HM, Smart P, Heriot AG, Walker K, Kuryba A, Matthiessen P, Tanis PJ. Correction to: Evolution of surgical approach to rectal cancer resection: A multinational registry assessment. Int J Colorectal Dis 2024; 39:25. [PMID: 38329560 PMCID: PMC10853313 DOI: 10.1007/s00384-024-04599-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Affiliation(s)
| | | | | | - Helen M Mohan
- Bowel Cancer Outcomes Registry (BCOR), Melbourne, Australia
| | - Philip Smart
- Bowel Cancer Outcomes Registry (BCOR), Melbourne, Australia
| | | | - Kate Walker
- National Bowel Cancer Audit (NBOCA), Leeds, UK
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Sijmons JML, Dekker JWT, Tuynman JB, Mohan HM, Smart P, Heriot AG, Walker K, Kuryba A, Matthiessen P, Tanis PJ. Evolution of surgical approach to rectal cancer resection: A multinational registry assessment. Int J Colorectal Dis 2024; 39:15. [PMID: 38183451 DOI: 10.1007/s00384-023-04578-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE Surgical approach to rectal cancer has evolved in recent decades, with introduction of minimally invasive surgery (MIS) techniques and local excision. Since implementation might differ internationally, this study is aimed at evaluating trends in surgical approach to rectal cancer across different countries over the last 10 years and to gain insight into patient, tumour and treatment characteristics. METHODS Pseudo-anonymised data of patients undergoing resection for rectal cancer between 2010 and 2019 were extracted from clinical audits in the Netherlands (NL), Sweden (SE), England-Wales (EW) and Australia-New Zealand (AZ). RESULTS Ninety-nine thousand five hundred ninety-seven patients were included (38,413 open, 55,155 MIS and 5416 local excision). An overall increase in MIS was observed from 29.9% in 2010 to 72.1% in 2019, with decreasing conversion rates (17.5-9.0%). The MIS proportion was highly variable between countries in the period 2010-2014 (54.4% NL, 45.3% EW, 39.8% AZ, 14.1% SE, P < 0.001), but variation reduced over time (2015-2019 78.8% NL, 66.3% EW, 64.3% AZ, 53.2% SE, P < 0.001). The proportion of local excision for the two periods was highly variable between countries: 4.7% and 11.8% in NL, 3.9% and 7.4% in EW, 4.7% and 4.6% in AZ, 6.0% and 2.9% in SE. CONCLUSIONS Application and speed of implementation of MIS were highly variable between countries, but each registry demonstrated a significant increase over time. Local excision revealed inconsistent trends over time.
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Affiliation(s)
| | | | | | - Helen M Mohan
- Bowel Cancer Outcomes Registry (BCOR), Melbourne, Australia
| | - Philip Smart
- Bowel Cancer Outcomes Registry (BCOR), Melbourne, Australia
| | | | - Kate Walker
- National Bowel Cancer Audit (NBOCA), Leeds, UK
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Rutegård M, Svensson J, Segelman J, Matthiessen P, Lydrup ML, Park J. Splenic flexure mobilization and anastomotic leakage in anterior resection for rectal cancer: A multicentre cohort study. Scand J Surg 2023; 112:246-255. [PMID: 37675547 DOI: 10.1177/14574969231181222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Some colorectal surgeons advocate routine splenic flexure mobilization (SFM) when performing anterior resection for rectal cancer to ensure a tension-free anastomosis. Meta-analyses of smaller studies suggest that this approach does not influence anastomotic leakage rates, but larger multicentre studies are needed to confirm the safety of a selective strategy. The aim of this study is to evaluate the impact of SFM on anastomotic leakage. METHODS This is a retrospective multicentre cohort study, comprising 1109 patients operated with anterior resection for rectal cancer in 2014-2018. Exposure was SFM, while anastomotic leakage within a year constituted the outcome. Stratified analyses were performed for type of mesorectal excision and surgical approach, as well as sensitivity analysis considering vascular tie placement. Multivariable Cox regression with hazard ratios (HRs) and 95% confidence intervals (CIs) was employed to adjust for confounding, while multiple imputation was used for missing data. RESULTS SFM was performed in 381 patients (34.4%). Anastomotic leakage occurred in 83 (21.8%) and 123 (20.3%) patients operated with and without SFM, respectively. SFM was neither clearly detrimental nor beneficial regarding anastomotic leakage (adjusted HR = 0.82; 95% CI: 0.59-1.15), with no apparent differences for total or partial mesorectal excision and minimally invasive or open surgery. Concurrent high vascular ligation did not impact these results, and there was no evidence of interaction from centers with a more common use of SFM. CONCLUSIONS SFM did not seem to influence the risk of anastomotic leakage after anterior resection for rectal cancer, regardless of type of mesorectal excision, use of minimally invasive surgery, or high vascular ligation.
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Affiliation(s)
- Martin Rutegård
- Department of Surgical and Perioperative Sciences, SurgeryUmeå UniversitySE-901 85 UmeåSwedenWallenberg Centre for Molecular MedicineUmeå UniversityUmeåSweden
| | - Johan Svensson
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Josefin Segelman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, SwedenDepartment of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital and Lund University, Lund, Sweden
| | - Jennifer Park
- Department of Surgery, Scandinavian Surgical Outcomes Research Group (SSORG), Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Golshani P, Park J, Häggström J, Segelman J, Matthiessen P, Lydrup ML, Rutegård M. The modified Glasgow Prognostic Score indicates an increased risk of anastomotic leakage after anterior resection for rectal cancer. Int J Colorectal Dis 2023; 38:200. [PMID: 37470911 PMCID: PMC10359376 DOI: 10.1007/s00384-023-04496-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Preoperative inflammation might cause and also be a marker for anastomotic leakage after anterior resection for rectal cancer. Available biomarker indices such as the modified Glasgow Prognostic Score (mGPS) or the C-reactive protein-to-albumin ratio (CAR) may be clinically useful for leakage assessment. METHODS Patients who underwent anterior resection for rectal cancer during 2014-2018 from a multicentre retrospective cohort were included. Data from the Swedish Colorectal Cancer registry and chart review at each hospital were collected. In a subset of patients, preoperative laboratory assessments were available, constituting the exposures mGPS and CAR. Anastomotic leakage within 12 months was the outcome. Causally oriented analyses were conducted with adjustment for confounding, as well as predictive models. RESULTS A total of 418 patients were eligible for analysis. Most patients had mGPS = 0 (84.7%), while mGPS = 1 (10.8%) and mGPS = 2 (4.5%) were less common. mGPS = 2 (OR: 4.11; 95% CI: 1.69-10.03) seemed to confer anastomotic leakage, while this was not seen for mGPS = 1 (OR 1.09; 95% CI: 0.53-2.25). A cut off point of CAR > 0.36 might be indicative of leakage (OR 2.25; 95% CI: 1.21-4.19). Predictive modelling using mGPS rendered an area-under-the-curve of 0.73 (95% CI: 0.67-0.79) at most. DISCUSSION Preoperative inflammation seems to be involved in the development of anastomotic leakage after anterior resection for cancer. Inclusion into prediction models did not result in accurate leakage prediction, but high degrees of systemic inflammation might still be important in clinical decision-making.
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Affiliation(s)
- Parisa Golshani
- Department of Surgery, Regional Council of Gävleborg, Gävle, Sweden
| | - Jennifer Park
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jenny Häggström
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Josefin Segelman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Ersta Hospital, Stockholm, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, SE-901 85, Umeå, Sweden.
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
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10
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Rutegård M, Häggström J, Back E, Holmgren K, Wixner J, Rutegård J, Matthiessen P, Sjöström O. Defunctioning loop ileostomy in anterior resection for rectal cancer and subsequent renal failure: nationwide population-based study. BJS Open 2023; 7:7158799. [PMID: 37161674 PMCID: PMC10170252 DOI: 10.1093/bjsopen/zrad010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/29/2022] [Accepted: 01/06/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Electrolyte disturbances and dehydration are common after anterior resection for rectal cancer with a defunctioning loop ileostomy. High-quality population-based studies on the impact of a defunctioning loop ileostomy on renal failure are lacking. METHODS This was a nationwide observational study, based on the Swedish Colorectal Cancer Registry of patients undergoing anterior resection for rectal cancer between 2008 and 2016, with follow-up until 2017. Patients with severe co-morbidity, with age greater than 80 years, and with pre-existing renal failure were excluded. Loop ileostomy at index surgery constituted exposure, while a diagnosis of renal failure was the outcome. Acute and chronic events were analysed separately. Inverse probability weighting with adjustment for confounding derived from a causal diagram was employed. Hazards ratios (HRs) with 95 per cent c.i. are reported. RESULTS A total of 5355 patients were eligible for analysis. At 5-year follow-up, all renal failure events (acute and chronic) were 7.2 per cent and 3.3 per cent in the defunctioning stoma and no stoma groups respectively. In the weighted analysis, a HR of 11.59 (95 per cent c.i. 5.68 to 23.65) for renal failure in ostomates was detected at 1 year, with the largest effect from acute renal failure (HR 24.04 (95 per cent c.i. 8.38 to 68.93)). Later follow-up demonstrated a similar pattern, but with smaller effect sizes. CONCLUSION Patients having a loop ileostomy in combination with anterior resection for rectal cancer are more likely to have renal failure, especially early after surgery. Strategies are needed, such as careful fluid management protocols, and further research into alternative stoma types or reduction in stoma formation.
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Affiliation(s)
- Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Jenny Häggström
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Erik Back
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Klas Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Jonas Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Olle Sjöström
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
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11
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Weibull CE, Boman SE, Glimelius B, Syk I, Matthiessen P, Smedby KE, Nordenvall C, Martling A. CRCBaSe: a Swedish register-based resource for colorectal adenocarcinoma research. Acta Oncol 2023; 62:342-349. [PMID: 37029990 DOI: 10.1080/0284186x.2023.2197121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2023]
Abstract
OBJECTIVES To facilitate high-quality register-based research on colorectal cancer (CRC) in Sweden by constructing a database consisting of CRC patients, matched comparators, and relatives. MATERIAL AND METHODS Patients with adenocarcinoma in the colon and/or rectum were identified in the Swedish Colorectal Cancer Register, a nationwide quality-of-care register. For each patient, six comparators from the general population were matched on birth year, sex, year of CRC diagnosis, and county. Comparators were free from CRC at the time of matching, but could later become cases. For both patients and comparators, first-degree relatives (parents, siblings, and children) were identified. Information from nationwide population-based registers was retrieved and linked to each individual in the database using the personal identification number unique to all Swedish residents. RESULTS A total of 76,831 CRC patients diagnosed between 1995 and 2016 were identified (51% colon, 49% rectal; before 2007 only rectal cancer patients were included). Among all patients, 37% were stage I-II, 22% stage III, and 22% stage IV. The median follow-up time was 11.9 years (inter-quartile range, IQR: 8.6-15.3). Together with comparators and relatives, the database contains 2,413,139 individuals with information on demographics, dates and causes of death, in- and outpatient healthcare records, cancer diagnoses, prescribed and dispensed drugs, childbirths (among women), and social security information (such as sick leave and early retirement). CONCLUSION The Colorectal Cancer Database Sweden (CRCBaSe) is a large and unique register-based data research platform, which opens up for clinically important, large epidemiological studies with innovative design in the field of colorectal adenocarcinoma.
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Affiliation(s)
- Caroline E Weibull
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Sol Erika Boman
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Ingvar Syk
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Karin E Smedby
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, GI Oncology and Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, GI Oncology and Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
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12
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Green C, Bilyanska A, Bradley M, Dinsdale J, Hutt L, Backhaus T, Boons F, Bott D, Collins C, Cornell SE, Craig M, Depledge M, Diderich B, Fuller R, Galloway TS, Hutchison GR, Ingrey N, Johnson AC, Kupka R, Matthiessen P, Oliver R, Owen S, Owens S, Pickett J, Robinson S, Sims K, Smith P, Sumpter JP, Tretsiakova-McNally S, Wang M, Welton T, Willis KJ, Lynch I. A Horizon Scan to Support Chemical Pollution-Related Policymaking for Sustainable and Climate-Resilient Economies. Environ Toxicol Chem 2023; 42:1212-1228. [PMID: 36971460 DOI: 10.1002/etc.5620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/13/2023] [Accepted: 03/21/2023] [Indexed: 05/10/2023]
Abstract
While chemicals are vital to modern society through materials, agriculture, textiles, new technology, medicines, and consumer goods, their use is not without risks. Unfortunately, our resources seem inadequate to address the breadth of chemical challenges to the environment and human health. Therefore, it is important we use our intelligence and knowledge wisely to prepare for what lies ahead. The present study used a Delphi-style approach to horizon-scan future chemical threats that need to be considered in the setting of chemicals and environmental policy, which involved a multidisciplinary, multisectoral, and multinational panel of 25 scientists and practitioners (mainly from the United Kingdom, Europe, and other industrialized nations) in a three-stage process. Fifteen issues were shortlisted (from a nominated list of 48), considered by the panel to hold global relevance. The issues span from the need for new chemical manufacturing (including transitioning to non-fossil-fuel feedstocks); challenges from novel materials, food imports, landfills, and tire wear; and opportunities from artificial intelligence, greater data transparency, and the weight-of-evidence approach. The 15 issues can be divided into three classes: new perspectives on historic but insufficiently appreciated chemicals/issues, new or relatively new products and their associated industries, and thinking through approaches we can use to meet these challenges. Chemicals are one threat among many that influence the environment and human health, and interlinkages with wider issues such as climate change and how we mitigate these were clear in this exercise. The horizon scan highlights the value of thinking broadly and consulting widely, considering systems approaches to ensure that interventions appreciate synergies and avoid harmful trade-offs in other areas. We recommend further collaboration between researchers, industry, regulators, and policymakers to perform horizon scanning to inform policymaking, to develop our ability to meet these challenges, and especially to extend the approach to consider also concerns from countries with developing economies. Environ Toxicol Chem 2023;00:1-17. © 2023 Crown copyright and The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC. This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.
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Affiliation(s)
- Christopher Green
- Department for Environment Food and Rural Affairs, Chemicals, Pesticides and Hazardous Wastes Team, London, United Kingdom
| | - Antoaneta Bilyanska
- Department for Environment Food and Rural Affairs, Chemicals, Pesticides and Hazardous Wastes Team, London, United Kingdom
| | - Mags Bradley
- Department for Environment Food and Rural Affairs, Chemicals, Pesticides and Hazardous Wastes Team, London, United Kingdom
| | - Jason Dinsdale
- Horizon Scanning & Futures Team, Environment Agency, Horizon House, Bristol, United Kingdom
| | - Lorraine Hutt
- Environment Agency, Horizon House, Bristol, United Kingdom
| | - Thomas Backhaus
- Department of Biological and Environmental Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Frank Boons
- IMP Innovation, Strategy and Sustainability, University of Manchester, Manchester, United Kingdom
| | - David Bott
- Head of Innovation, SCI, London, United Kingdom
| | - Chris Collins
- Department of Geography and Environmental Science, Soil Research Centre, University of Reading, Reading, United Kingdom
| | - Sarah E Cornell
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
| | - Mark Craig
- Severn Trent Water, Darlington, United Kingdom
| | - Michael Depledge
- European Centre for Environment and Human Health, University of Exeter Medical School, Royal Cornwall Hospital, Truro, Cornwall, United Kingdom
| | - Bob Diderich
- Organisation for Economic Co-operation and Development, Paris, France
| | | | - Tamara S Galloway
- College of Life and Environmental Sciences: Biosciences, University of Exeter, Exeter, United Kingdom
| | - Gary R Hutchison
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Nicola Ingrey
- Landfill and Resources from Waste Team, Environment Agency, Bristol, United Kingdom
| | | | - Rachael Kupka
- The Global Alliance on Health and Pollution, Geneva, Switzerland
| | | | - Robin Oliver
- Syngenta Crop Protection, Jealotts Hill Research Station, Bracknell, United Kingdom
| | - Stewart Owen
- AstraZeneca, Global Sustainability, Brixham, Devon, United Kingdom
| | - Susan Owens
- Newnham College, Cambridge University, Cambridge, United Kingdom
| | - John Pickett
- School of Chemistry, Cardiff University, Cardiff, United Kingdom
| | - Sam Robinson
- School of History, University of Kent, Canterbury, United Kingdom
| | - Kerry Sims
- Chemical Strategic & Regulatory Planning Team, Environment Agency, Bristol, United Kingdom
| | - Pete Smith
- Institute of Biological and Environmental Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - John P Sumpter
- Institute of Environment, Health and Societies, Brunel University, London, United Kingdom
| | | | - Mengjiao Wang
- Greenpeace Research Laboratories, Innovation Centre Phase 2, University of Exeter, Exeter, United Kingdom
| | - Tom Welton
- Department of Chemistry, Imperial College London, London, United Kingdom
| | - Katherine J Willis
- Department of Zoology, Long-Term Ecology Laboratory, University of Oxford, Oxford, United Kingdom
| | - Iseult Lynch
- School of Geography, Earth and Environmental Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
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13
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Jadid KD, Cao Y, Petersson J, Sjövall A, Angenete E, Matthiessen P. Long-term oncological outcomes for minimally invasive surgery versus open surgery for colon cancer-a population-based nationwide study with a non-inferiority design. Colorectal Dis 2023; 25:954-963. [PMID: 36762443 DOI: 10.1111/codi.16512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/20/2023] [Accepted: 01/29/2023] [Indexed: 02/11/2023]
Abstract
AIM The study aimed to compare 5-year overall survival in a national cohort of patients undergoing curative abdominal resection for colon cancer by minimally invasive surgery (MIS) or by the open (OPEN) technique. METHODS All patients diagnosed between 2010 and 2016 in Sweden with pathological Union International Contre le Cancer Stages I-III colon cancer localized in the caecum, ascending colon, hepatic flexure or sigmoid colon and those who underwent curative right sided hemicolectomy, sigmoid resection or high anterior resection by MIS or OPEN were included. Patients were identified in the Swedish Colorectal Cancer Registry from which all data were retrieved. The analyses were performed as intention-to-treat and the relationship between surgical technique (MIS or OPEN) and overall mortality within 5 years was analysed. For the primary research question a non-inferiority hypothesis was assumed with a statistical power of 90%, a one-side type I error of 2.5% and a non-inferiority margin of 2%. For the secondary analyses, multilevel survival regression models with the patients matched by propensity scores were employed, adjusted for patient- and tumour-related variables. RESULTS A total of 11 605 pathological Union International Contre le Cancer Stages I-III patients were included with 3297 MIS (28.4%) and 8308 OPEN (71.6%) and were followed until 31 December 2020. The primary analysis demonstrated superiority for MIS compared to OPEN. The multilevel survival regression analyses confirmed that 5-year overall survival was higher in MIS with a hazard ratio of 0.874 (95% confidence interval 0.791-0.965), and if excluding pT4 the outcome was similar, with a hazard ratio of 0.847 (95% confidence interval 0.756-0.948). CONCLUSION This observational study demonstrated that MIS was favourable to OPEN with regard to 5-year overall survival. These results support the use of laparoscopic colon cancer surgery in routine practice.
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Affiliation(s)
- Kaveh Dehlaghi Jadid
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Josefin Petersson
- SSORG-Scandinavian Surgical Outcomes Research Group, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annika Sjövall
- Gastrointestinal Oncology and Colorectal Surgery Unit, Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Angenete
- SSORG-Scandinavian Surgical Outcomes Research Group, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Matthiessen
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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14
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Morthorst JE, Holbech H, De Crozé N, Matthiessen P, LeBlanc GA. Thyroid-like hormone signaling in invertebrates and its potential role in initial screening of thyroid hormone system disrupting chemicals. Integr Environ Assess Manag 2023; 19:63-82. [PMID: 35581168 PMCID: PMC10083991 DOI: 10.1002/ieam.4632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/30/2022] [Accepted: 05/12/2022] [Indexed: 05/07/2023]
Abstract
This review examines the presence and evolution of thyroid-like systems in selected aquatic invertebrates to determine the potential use of these organisms in screens for vertebrate thyroid hormone axis disrupting chemicals (THADCs). Such a screen might support the phasing out of some vertebrate testing. Although arthropods including crustaceans do not contain a functional thyroid signaling system, elements of such a system exist in the aquatic phyla mollusks, echinoderms, tunicates, and cephalochordates. These phyla can synthesize thyroid hormone, which has been demonstrated in some groups to induce the nuclear thyroid hormone receptor (THR). Thyroid hormone may act in these phyla through interaction with a membrane integrin receptor. Thyroid hormone regulates inter alia metamorphosis but, unlike in vertebrates, this does not occur via receptor activation by the ligands triiodothyronine (T3) and thyroxine (T4). Instead, the unliganded nuclear receptor itself controls metamorphosis in mollusks, echinoderms, and tunicates, whereas the T3 derivative tri-iodothyroacetic acid (TRIAC) acts as a THR ligand in cephalochordates. In view of this, it may be possible to develop an invertebrate-based screen that is sensitive to vertebrate THADCs that interfere with thyroid hormone synthesis or metabolism along with interaction with membrane receptors. The review makes some recommendations for the need to develop an appropriate test method. Integr Environ Assess Manag 2023;19:63-82. © 2022 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).
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Affiliation(s)
| | - Henrik Holbech
- Department of BiologyUniversity of Southern DenmarkOdense MDenmark
| | - Noémie De Crozé
- Laboratoire Recherche Environnementale, L'ORÉAL Recherche & InnovationAulnay‐sous‐BoisFrance
| | | | - Gerald A. LeBlanc
- Department of Biological SciencesNorth Carolina State UniversityRaleighNorth CarolinaUSA
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15
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Dehlaghi Jadid K, Cao Y, Petersson J, Angenete E, Matthiessen P. Long term oncological outcomes for laparoscopic versus open surgery for rectal cancer - A population-based nationwide noninferiority study. Colorectal Dis 2022; 24:1308-1317. [PMID: 35656573 PMCID: PMC9796648 DOI: 10.1111/codi.16204] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/12/2022] [Accepted: 05/22/2022] [Indexed: 01/01/2023]
Abstract
AIM The aim of this work was to compare the 5-year overall survival in a national cohort of patients undergoing curative abdominal resection for rectal cancer by laparoscopic (LAP) or open (OPEN) surgery. METHOD All patients diagnosed with clinical Stage I-III rectal cancer and who underwent LAP or OPEN abdominal curative surgery in Sweden between 2010 and 2016 were retrieved from the Swedish Colorectal Cancer Registry. A noninferiority study design was employed with a statistical power of 90%, a one-side type I error of 2.5% and a noninferiority margin of 2%. The analyses were performed as intention-to-treat and the relationship between surgical technique and overall mortality within 5 years was analysed. Multilevel regression models with the patients matched by propensity scores adjusted for patient- and tumour-related variables were used. RESULTS A total of 8410 Stage I-III cancer patients were included. This group underwent 2094 LAP (24.9%) and 6316 OPEN (75.1%) procedures and were followed until 31 December 2020. Multivariable Cox regression demonstrated that 5-year overall survival was higher in the LAP group [hazard ratio (HR) 0.877; 95% CI 0.775-0.993]. [Correction added on 21 November 2022, after first online publication: In the preceding sentence, the CI value for LAP group has been corrected from "0.877" to "0.775" in this version.] The outcome was similar when multiple imputation and propensity score matching were employed. When cT4 patients were excluded there was no difference (HR 0.885; 95% CI 0.790-1.033). At 5-years' follow-up local recurrence was not different, at 2.9% for the LAP group and 3.6% for the OPEN group (p = 0.075), while metastatic disease was more frequent in the OPEN group (19.6% compared with 15.6% for LAP; p < 0.001). CONCLUSION This study demonstrated that the LAP technique was not inferior to OPEN surgery with regard to overall 5-year survival. These results support the use of laparoscopic surgery.
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Affiliation(s)
- Kaveh Dehlaghi Jadid
- Department of SurgeryÖrebro University HospitalÖrebroSweden,Department of Surgery, Faculty of Medicine and HealthÖrebro UniversityÖrebroSweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical SciencesÖrebro UniversityÖrebroSweden
| | - Josefin Petersson
- SSORG – Scandinavian Surgical Outcomes Research Group, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Region Västra Götaland, Department of SurgerySahlgrenska University HospitalGothenburgSweden
| | - Eva Angenete
- SSORG – Scandinavian Surgical Outcomes Research Group, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Region Västra Götaland, Department of SurgerySahlgrenska University HospitalGothenburgSweden
| | - Peter Matthiessen
- Department of SurgeryÖrebro University HospitalÖrebroSweden,Department of Surgery, Faculty of Medicine and HealthÖrebro UniversityÖrebroSweden
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16
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Grahn O, Lundin M, Chapman SJ, Rutegård J, Matthiessen P, Rutegård M. Concerning our paper on the possible relation of postoperative non-steroidal anti-inflammatory drugs to anastomotic leakage and cancer recurrence. Colorectal Dis 2022; 24:1245. [PMID: 35349193 DOI: 10.1111/codi.16130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 03/19/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Oskar Grahn
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Mathias Lundin
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Department of Statistics, Umeå School of Business and Economics, Umeå University, Umeå, Sweden
| | - Stephen J Chapman
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
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17
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Grahn O, Lundin M, Chapman SJ, Rutegård J, Matthiessen P, Rutegård M. Postoperative nonsteroidal anti-inflammatory drugs in relation to recurrence, survival and anastomotic leakage after surgery for colorectal cancer. Colorectal Dis 2022; 24:933-942. [PMID: 35108455 PMCID: PMC9541253 DOI: 10.1111/codi.16074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/07/2021] [Accepted: 01/21/2022] [Indexed: 12/23/2022]
Abstract
AIM The aim of this work was to investigate whether nonsteroidal anti-inflammatory drugs (NSAIDs) could be beneficial or harmful when used perioperatively for colorectal cancer patients, as inflammation may affect occult disease and anastomotic healing. METHOD This is a protocol-based retrospective cohort study on colorectal cancer patients operated on between 2007 and 2012 at 21 hospitals in Sweden. NSAID exposure was retrieved from postoperative analgesia protocols, while outcomes and patient data were retrieved from the Swedish Colorectal Cancer Registry. Older or severely comorbid patients, as well as those with disseminated or nonradically operated tumours were excluded. Multivariable regression with adjustment for confounders was performed, estimating hazard ratios (HRs) for long-term outcomes and odds ratios (ORs) for short-term outcomes, including 95% confidence intervals (CIs). RESULTS Some 6945 patients remained after exclusion, of whom 3996 were treated at hospitals where a NSAID protocol was in place. No association was seen between NSAIDs and recurrence-free survival (HR 0.97, 95% CI 0.87-1.09). However, a reduction in cancer recurrence was detected (HR 0.83, 95% CI 0.72-0.95), which remained significant when stratifying into locoregional (HR 0.68, 95% CI 0.48-0.97) and distant recurrences (HR 0.85, 95% CI 0.74-0.98). Anastomotic leakage was less frequent (HR 0.69%, 95% CI 0.51-0.94) in the NSAID-exposed, mainly due to a risk reduction in colo-rectal and ileo-rectal anastomoses (HR 0.47, 95% CI 0.33-0.68). CONCLUSION There was no association between NSAID exposure and recurrence-free survival, but an association with reduced cancer recurrence and the rate of anastomotic leakage was detected, which may depend on tumour site and anastomotic location.
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Affiliation(s)
- Oskar Grahn
- Department of Surgical and Perioperative Sciences, SurgeryUmeå UniversityUmeåSweden
| | - Mathias Lundin
- Department of Surgical and Perioperative Sciences, SurgeryUmeå UniversityUmeåSweden
- Department of StatisticsUmeå School of Business and EconomicsUmeå UniversityUmeåSweden
| | - Stephen J. Chapman
- Leeds Institute of Medical Research at St James'sUniversity of LeedsLeedsUK
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, SurgeryUmeå UniversityUmeåSweden
| | - Peter Matthiessen
- Department of SurgeryFaculty of Medicine and HealthÖrebro UniversityÖrebroSweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, SurgeryUmeå UniversityUmeåSweden
- Wallenberg Centre for Molecular MedicineUmeå UniversityUmeåSweden
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18
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Shahrivar M, Weibull CE, Ekström Smedby K, Glimelius B, Syk I, Matthiessen P, Nordenvall C, Martling A. Low-dose aspirin use and colorectal cancer survival in 32,195 patients-A national cohort study. Cancer Med 2022; 12:315-324. [PMID: 35717628 PMCID: PMC9844641 DOI: 10.1002/cam4.4859] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 04/28/2022] [Accepted: 05/17/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Results from previous studies indicate that use of aspirin may improve colorectal cancer (CRC) survival. The aim of this study was to assess whether use of aspirin influences overall survival or CRC-specific survival in an unselected cohort of patients diagnosed with CRC. METHODS The study was performed using the Colorectal Cancer Data Base Sweden (CRCBaSe), a mega-linkage originating from the Swedish Colorectal Cancer Register, with additional linkages to other national health care registers. All patients diagnosed with primary CRC stage I-III treated with curative surgery, aged 18-85 years at diagnosis, from 2007 through 2016 were identified. Information on low-dose aspirin use was extracted from the Swedish Prescribed Drug Register. Exposure was defined as dispensed prescription for at least 6 months. Aspirin exposure was analyzed at the time of surgery (yes/no) and as a time-varying exposure during follow-up. Follow-up was restricted to a maximum 6 years, to model 5-year survival. Cox regression models were fitted to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). Adjustments were performed for sex, age, year of diagnosis, Charlson comorbidity index, hypertension, and ASA score as potential confounders. RESULTS A total of 32,195 patients diagnosed with CRC were included. 6764 (21%) were exposed to aspirin at the time of CRC surgery. The median time of follow-up was 4.2 years. Aspirin use at the time of surgery was not associated with all-cause (adjusted HR = 1.03, 95% CI: 0.97-1.08) nor CRC-specific mortality (adjusted HR = 0.99, 95% CI: 0.91-1.07). Aspirin use during follow-up was associated with increased all-cause (adjusted HR = 1.09, 95% CI: 1.04-1.15) but not CRC-specific mortality (adjusted HR = 0.98, 95% CI: 0.91-1.06). A CRC-specific effect associated with aspirin was noted from approximately 3 years following surgery. CONCLUSIONS In this large nation-wide cohort study there was no convincing association between aspirin use after CRC and OS or CRC-specific survival.
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Affiliation(s)
- Mehrnoosh Shahrivar
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Caroline E. Weibull
- Department of Medicine Solna, Clinical Epidemiology DivisionKarolinska InstitutetStockholmSweden
| | - Karin Ekström Smedby
- Department of Medicine Solna, Clinical Epidemiology DivisionKarolinska InstitutetStockholmSweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and PathologyUppsala UniversityUppsalaSweden
| | - Ingvar Syk
- Department of SurgerySkåne University HospitalMalmöSweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and HealthÖrebro UniversityÖrebroSweden
| | - Caroline Nordenvall
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden,Department of Pelvic Cancer, GI oncology and colorectal surgery unitKarolinska University HospitalStockholmSweden
| | - Anna Martling
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden,Department of Pelvic Cancer, GI oncology and colorectal surgery unitKarolinska University HospitalStockholmSweden
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19
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Warps AK, Saraste D, Westerterp M, Detering R, Sjövall A, Martling A, Dekker JWT, Tollenaar RAEM, Matthiessen P, Tanis PJ. National differences in implementation of minimally invasive surgery for colorectal cancer and the influence on short-term outcomes. Surg Endosc 2022; 36:5986-6001. [PMID: 35258664 PMCID: PMC9283170 DOI: 10.1007/s00464-021-08974-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 12/31/2021] [Indexed: 12/24/2022]
Abstract
Background The timing and degree of implementation of minimally invasive surgery (MIS) for colorectal cancer vary among countries. Insights in national differences regarding implementation of new surgical techniques and the effect on postoperative outcomes are important for quality assurance, can show potential areas for country-specific improvement, and might be illustrative and supportive for similar implementation programs in other countries. Therefore, this study aimed to evaluate differences in patient selection, applied techniques, and results of minimal invasive surgery for colorectal cancer between the Netherlands and Sweden. Methods Patients who underwent elective minimally invasive surgery for T1-3 colon or rectal cancer (2012–2018) registered in the Dutch ColoRectal Audit or Swedish ColoRectal Cancer Registry were included. Time trends in the application of MIS were determined. Outcomes were compared for time periods with a similar level of MIS implementation (Netherlands 2012–2013 versus Sweden 2017–2018). Multilevel analyses were performed to identify factors associated with adverse short-term outcomes. Results A total of 46,095 Dutch and 8,819 Swedish patients undergoing MIS for colorectal cancer were included. In Sweden, MIS implementation was approximately 5 years later than in the Netherlands, with more robotic surgery and lower volumes per hospital. Although conversion rates were higher in Sweden, oncological and surgical outcomes were comparable. MIS in the Netherlands for the years 2012–2013 resulted in a higher reoperation rate for colon cancer and a higher readmission rate but lower non-surgical complication rates for rectal cancer if compared with MIS in Sweden during 2017–2018. Conclusion This study showed that the implementation of MIS for colorectal cancer occurred later in Sweden than the Netherlands, with comparable outcomes despite lower volumes. Our study demonstrates that new surgical techniques can be implemented at a national level in a controlled and safe way, with thorough quality assurance. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08974-1.
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Affiliation(s)
- A K Warps
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, Netherlands.,Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA, Leiden, Netherlands
| | - D Saraste
- Department of Surgery, Södersjukhuset, 118 83, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Insitutet, 171 76, Stockholm, Sweden
| | - M Westerterp
- Department of Surgery, Haagland Medisch Centrum, Lijnbaan 32, 2512 VA, Den Haag, Netherlands
| | - R Detering
- Department of Surgery, Amsterdam University Medical Centres, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands
| | - A Sjövall
- Department of Molecular Medicine and Surgery, Karolinska Insitutet, 171 76, Stockholm, Sweden.,Department of Surgery, Karolinska University Hospital, Anna Steckséns gata 53, 171 64, Solna, Sweden
| | - A Martling
- Department of Molecular Medicine and Surgery, Karolinska Insitutet, 171 76, Stockholm, Sweden.,Department of Surgery, Karolinska University Hospital, Anna Steckséns gata 53, 171 64, Solna, Sweden
| | - J W T Dekker
- Department of Surgery, Reinier de Graaf Groep, Reinier de Graafweg 5, 2625 AD, Delft, Netherlands
| | - R A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, Netherlands.,Dutch Institute for Clinical Auditing, Rijnsburgerweg 10, 2333 AA, Leiden, Netherlands
| | - P Matthiessen
- Department of Surgery, Örebro University Hospital, von Rosens väg 1, 70185, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health Sciences, Örebro University, 70182, Örebro, Sweden
| | - P J Tanis
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam University Medical Centres, University of Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, Netherlands.
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20
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Rutegård M, Holmgren K, Häggström J, Haapamäki MM, Matthiessen P, Rutegård J. The right kind of rectal cancer operation for the right patient requires information on all relevant outcomes. Colorectal Dis 2022; 24:136-137. [PMID: 34913581 DOI: 10.1111/codi.16020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Klas Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Jenny Häggström
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Markku M Haapamäki
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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21
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Holmgren K, Jonsson P, Lundin C, Matthiessen P, Rutegård J, Sund M, Rutegård M. OUP accepted manuscript. BJS Open 2022; 6:6598239. [PMID: 35652588 PMCID: PMC9161645 DOI: 10.1093/bjsopen/zrac072] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/09/2022] [Accepted: 04/19/2022] [Indexed: 11/12/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Klas Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Correspondence to: Klas Holmgren, Department of Surgical and Perioperative Sciences, Umeå University, Umeå University Hospital, SE-901 85 Umeå, Sweden (e-mail: )
| | - Pär Jonsson
- Department of Chemistry, Umeå University, Umeå, Sweden
| | - Christina Lundin
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Malin Sund
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
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22
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Back E, Häggström J, Holmgren K, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. Author response to: Permanent stoma prediction after anterior resection for rectal cancer: risk prediction scoring using preoperative variables. Br J Surg 2021; 109:e40. [PMID: 34734222 DOI: 10.1093/bjs/znab386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Erik Back
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Jenny Häggström
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Klas Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Markku M Haapamäki
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
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23
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Holmgren K, Häggström J, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. Defunctioning stomas may reduce chances of a stoma-free outcome after anterior resection for rectal cancer. Colorectal Dis 2021; 23:2859-2869. [PMID: 34310840 DOI: 10.1111/codi.15836] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/28/2021] [Accepted: 07/19/2021] [Indexed: 12/30/2022]
Abstract
AIM To investigate the conflicting consequences of faecal diversion on stoma outcomes and anastomotic leakage in anterior resection for rectal cancer, including interaction effects determined by the extent of mesorectal excision. METHOD Anterior resections between 2007 and 2016 were identified using the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine stoma outcome 2 years after surgery. Tumour distance from the anal verge constituted a proxy for extent of mesorectal excision [total mesorectal excision (TME): ≤10 cm; partial mesorectal excision (PME): 13-15 cm]. With confounder-adjusted probit regression, the total effect of defunctioning stoma on permanent stoma, and the interaction effect of extent of mesorectal excision, were estimated together with the indirect effect through anastomotic leakage. Baseline risks, risk differences (RDs) and relative risks (RRs) were reported. RESULTS The main study cohort included 4529 patients. Defunctioning stomas influenced the absolute permanent stoma risk (TME: RD 0.11 [95% CI 0.09-0.13]; PME: RD 0.15 [95% CI 0.13-0.16]). The baseline risk was higher in TME, with a resulting greater RR in PME (2.23 [95% CI 1.43-3.02] vs 4.36 [95% CI 3.05-5.68]). The indirect reduction in permanent stoma rates, due to the alleviating effect of faecal diversion on anastomotic leakage, was small (TME: 0.89 [95% CI 0.81-0.96]; PME: 0.96 [95% CI 0.91-1.00]). CONCLUSION In anterior resection for rectal cancer, defunctioning stomas may reduce chances of a stoma-free outcome. Considering leakage reduction benefits, consequences of routine diversion in TME might be fairly balanced, while this seems questionable in PME.
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Affiliation(s)
- Klas Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Jenny Häggström
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Markku M Haapamäki
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
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24
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Hulme RA, Forssten MP, Pourlotfi A, Cao Y, Bass GA, Matthiessen P, Mohseni S. The Association Between Revised Cardiac Risk Index and Postoperative Mortality Following Elective Colon Cancer Surgery: A Retrospective Nationwide Cohort Study. Scand J Surg 2021; 111:14574969211037588. [PMID: 34605315 DOI: 10.1177/14574969211037588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Despite improvements in the perioperative care during the last decades for oncologic colon resection, there is still a substantial risk for postoperative complications and mortality. Opportunities exist for improvement in preoperative risk stratification in this patient population. We hypothesize that the Revised Cardiac Risk Index, a user-friendly tool, could better identify patients with high postoperative mortality risks. METHODS A retrospective analysis of operated patients between the years 2007 and 2017 was undertaken, using the prospectively recorded Swedish Colorectal Cancer Registry, which has a 99.5% national coverage for all cases of colon cancer. Patients were cross-referenced with the Swedish National Board of Health and Welfare dataset, a government registry of mortality and comorbidity data. Revised Cardiac Risk Index (RCRI) scores were calculated for each patient and stratified into four groups (RCRI 1, 2, 3, ⩾ 4). A Poisson regression model with robust standard errors of variance was employed to correlate the 90-day postoperative survival with each level of the Revised Cardiac Risk Index. RESULTS A total of 24,198 patients met the study inclusion criteria. 90-day postoperative mortality increased from 2.4% in patients with RCRI 1 to 10.1% in patients with RCRI ⩾ 4 (p < 0.001). Adjusted 90-day postoperative mortality increased linearly with an increasing RCRI, where an RCRI of 2, 3, and ≥ 4 respectively led to a 46%, 80%, and 167% increased risk of mortality compared to RCRI 1 (p < 0.001). CONCLUSIONS A strong association between an increasing Revised Cardiac Risk Index score and increased 90-day postoperative mortality risk was detected. The Revised Cardiac Risk Index may facilitate risk stratification of patients undergoing elective colon cancer surgery.
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Affiliation(s)
- Rebecka Ahl Hulme
- School of Medical Sciences, Örebro University, Örebro, Sweden Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Arvid Pourlotfi
- Department of Surgery, Örebro University Hospital, Örebro, Sweden School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Örebro University, Örebro, Sweden Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Peter Matthiessen
- School of Medical Sciences, Örebro University, Örebro, Sweden Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, 701 85 Örebro, Sweden
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25
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Back E, Häggström J, Holmgren K, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. Permanent stoma rates after anterior resection for rectal cancer: risk prediction scoring using preoperative variables. Br J Surg 2021; 108:1388-1395. [PMID: 34508549 PMCID: PMC10364873 DOI: 10.1093/bjs/znab260] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 05/03/2021] [Accepted: 06/20/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND A permanent stoma after anterior resection for rectal cancer is common. Preoperative counselling could be improved by providing individualized accurate prediction modelling. METHODS Patients who underwent anterior resection between 2007 and 2015 were identified from the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine presence of a stoma 2 years after surgery. A training set based on the years 2007-2013 was employed in an ensemble of prediction models. Judged by the area under the receiving operating characteristic curve (AUROC), data from the years 2014-2015 were used to evaluate the predictive ability of all models. The best performing model was subsequently implemented in typical clinical scenarios and in an online calculator to predict the permanent stoma risk. RESULTS Patients in the training set (n = 3512) and the test set (n = 1136) had similar permanent stoma rates (13.6 and 15.2 per cent). The logistic regression model with a forward/backward procedure was the most parsimonious among several similarly performing models (AUROC 0.67, 95 per cent c.i. 0.63 to 0.72). Key predictors included co-morbidity, local tumour category, presence of metastasis, neoadjuvant therapy, defunctioning stoma use, tumour height, and hospital volume; the interaction between age and metastasis was also predictive. CONCLUSION Using routinely available preoperative data, the stoma outcome at 2 years after anterior resection for rectal cancer can be predicted fairly accurately.
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Affiliation(s)
- E Back
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - J Häggström
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - K Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M M Haapamäki
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - J Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
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26
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Pourlotfi A, Bass GA, Ahl Hulme R, Forssten MP, Sjolin G, Cao Y, Matthiessen P, Mohseni S. Statin Use and Long-Term Mortality after Rectal Cancer Surgery. Cancers (Basel) 2021; 13:4288. [PMID: 34503098 PMCID: PMC8428352 DOI: 10.3390/cancers13174288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/03/2021] [Accepted: 08/20/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The current study aimed to assess the association between regular statin therapy and postoperative long-term all-cause and cancer-specific mortality following curative surgery for rectal cancer. The hypothesis was that statin exposure would be associated with better survival. METHODS Patients with stage I-III rectal cancer undergoing surgical resection with curative intent were extracted from the nationwide, prospectively collected, Swedish Colorectal Cancer Register (SCRCR) for the period from January 2007 and October 2016. Patients were defined as having ongoing statin therapy if they had filled a statin prescription within 12 months before and after surgery. Cox proportional hazards models were employed to investigate the association between statin use and postoperative five-year all-cause and cancer-specific mortality. RESULTS The cohort consisted of 10,743 patients who underwent a surgical resection with curative intent for rectal cancer. Twenty-six percent (n = 2797) were classified as having ongoing statin therapy. Statin users had a considerably decreased risk of all-cause (adjusted hazard ratio (HR) 0.66, 95% confidence interval (CI): 0.60-0.73, p < 0.001) and cancer-specific (adjusted HR 0.60, 95% CI: 0.47-0.75, p < 0.001) mortality up to five years following surgery. CONCLUSIONS Statin use was associated with a lower risk of both all-cause and rectal cancer-specific mortality following curative surgical resections for rectal cancer. The findings should be confirmed in future prospective clinical trials.
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Affiliation(s)
- Arvid Pourlotfi
- Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden; (M.P.F.); (G.S.); (P.M.)
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
- Division of Traumatology, Emergency Surgery & Surgical Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rebecka Ahl Hulme
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
- Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52 Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden; (M.P.F.); (G.S.); (P.M.)
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
| | - Gabriel Sjolin
- Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden; (M.P.F.); (G.S.); (P.M.)
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, 701 82 Orebro, Sweden;
| | - Peter Matthiessen
- Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden; (M.P.F.); (G.S.); (P.M.)
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
| | - Shahin Mohseni
- Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden; (M.P.F.); (G.S.); (P.M.)
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
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27
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Bass GA, Forssten M, Pourlotfi A, Ahl Hulme R, Cao Y, Matthiessen P, Mohseni S. Cardiac risk stratification in emergency resection for colonic tumours. BJS Open 2021; 5:6316195. [PMID: 34228103 PMCID: PMC8259498 DOI: 10.1093/bjsopen/zrab057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/18/2021] [Indexed: 12/12/2022] Open
Abstract
Background Despite advances in perioperative care, the postoperative mortality rate after emergency oncological colonic resection remains high. Risk stratification may allow targeted perioperative optimization and cardiac risk stratification. This study aimed to test the hypothesis that the Revised Cardiac Risk Index (RCRI), a user-friendly tool, could identify patients who would benefit most from perioperative cardiac risk mitigation. Methods Patients who underwent emergency resection for colonic cancer from 2007 to 2017 and registered in the Swedish Colorectal Cancer Registry (SCRCR) were analysed retrospectively. These patients were cross-referenced by social security number to the Swedish National Board of Health and Welfare data set, a government registry of mortality, and co-morbidity data. RCRI scores were calculated for each patient and correlated with 90-day postoperative mortality risk, using Poisson regression with robust error of variance. Results Some 5703 patients met the study inclusion criteria. A linear increase in crude 90-day postoperative mortality was detected with increasing RCRI score (37.3 versus 11.3 per cent for RCRI 4 or more versus RCRI 1; P < 0.001). The adjusted 90-day all-cause mortality risk was also significantly increased (RCRI 4 or more versus RCRI 1: adjusted incidence rate ratio 2.07, 95 per cent c.i. 1.49 to 2.89; P < 0.001). Conclusion This study documented an association between increasing cardiac risk and 90-day postoperative mortality. Those undergoing emergency colorectal surgery for cancer with a raised RCRI score should be considered high-risk patients who would most likely benefit from enhanced postoperative monitoring and critical care expertise.
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Affiliation(s)
- G A Bass
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - M Forssten
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - A Pourlotfi
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - R Ahl Hulme
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Y Cao
- Department of Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - P Matthiessen
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - S Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
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Falk W, Gupta A, Forssten MP, Hjelmqvist H, Bass GA, Matthiessen P, Mohseni S. Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study. Ann Med Surg (Lond) 2021; 66:102414. [PMID: 34113442 PMCID: PMC8170121 DOI: 10.1016/j.amsu.2021.102414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/16/2021] [Accepted: 05/16/2021] [Indexed: 12/01/2022] Open
Abstract
Background Epidural analgesia (EA) has been the standard of care after major abdominal surgery for many years. This study aimed to correlate EA with postoperative complications, short- and long-term mortality in patients with and without EA after open surgery (OS) and minimally invasive surgery (MIS) for colorectal cancer. Methods Patient, clinical and outcome data were obtained from the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry. All adult patients diagnosed with colorectal cancer without metastases who underwent elective curative MIS or OS for colorectal cancer between January 2016 and December 2018 and who had data recorded in both registries, were included in the study. Data were analyzed for OS and MIS procedures separately. A Poisson regression model was used to investigate the association between EA and the outcomes of interest. Results Five thousand seven hundred sixty-two patients were included in the study, 2712 in the MIS and 3050 patients in the OS group. After adjusting for patient specific and clinically relevant variables in the regression model, no statistically significant difference in risk for complications; 30-day, 90-day, and up to 3-year mortality following either MIS or OS could be detected between the EA+ and EA-cohorts. Conclusions In this large study cohort, EA as part of the comprehensive care provided was not associated with a reduction in postoperative complications risk or improved 30-day, 90-day, or 3-year survival after MIS or OS for colorectal cancer. No reduction in postoperative complications with epidural analgesia. No reduction in short-term mortality with epidural analgesia after colorectal surgery. No reduction in long-term mortality with epidural analgesia in colorectal cancer.
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Affiliation(s)
- Wiebke Falk
- Department of Anesthesiology and Intensive Care, Orebro University Hospital, 701 85, Orebro, Sweden.,School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Anil Gupta
- Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, 171 77, Stockholm, Sweden
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Hans Hjelmqvist
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Department of Anesthesiology and Intensive Care, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA
| | - Peter Matthiessen
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Department of Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
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Falk W, Magnuson A, Eintrei C, Henningsson R, Myrelid P, Matthiessen P, Gupta A. Comparison between epidural and intravenous analgesia effects on disease-free survival after colorectal cancer surgery: a randomised multicentre controlled trial. Br J Anaesth 2021; 127:65-74. [PMID: 33966891 PMCID: PMC8258969 DOI: 10.1016/j.bja.2021.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 03/30/2021] [Accepted: 04/04/2021] [Indexed: 02/06/2023] Open
Abstract
Background Thoracic epidural analgesia (TEA) has been suggested to improve survival after curative surgery for colorectal cancer compared with systemic opioid analgesia. The evidence, exclusively based on retrospective studies, is contradictory. Methods In this prospective, multicentre study, patients scheduled for elective colorectal cancer surgery between June 2011 and May 2017 were randomised to TEA or patient-controlled i.v. analgesia (PCA) with morphine. The primary endpoint was disease-free survival at 5 yr after surgery. Secondary outcomes were postoperative pain, complications, length of stay (LOS) at the hospital, and first return to intended oncologic therapy (RIOT). Results We enrolled 221 (110 TEA and 111 PCA) patients in the study, and 180 (89 TEA and 91 PCA) were included in the primary outcome. Disease-free survival at 5 yr was 76% in the TEA group and 69% in the PCA group; unadjusted hazard ratio (HR): 1.31 (95% confidence interval [CI]: 0.74–2.32), P=0.35; adjusted HR: 1.19 (95% CI: 0.61–2.31), P=0.61. Patients in the TEA group had significantly better pain relief during the first 24 h, but not thereafter, in open and minimally invasive procedures. There were no differences in postoperative complications, LOS, or RIOT between the groups. Conclusions There was no significant difference between the TEA and PCA groups in disease-free survival at 5 yr in patients undergoing surgery for colorectal cancer. Other than a reduction in postoperative pain during the first 24 h after surgery, no other differences were found between TEA compared with i.v. PCA with morphine.
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Affiliation(s)
- Wiebke Falk
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Örebro University, Örebro, Sweden.
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Christina Eintrei
- Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden
| | - Ragnar Henningsson
- Department of Anaesthesiology and Intensive Care, Central Hospital Karlstad, Karlstad, Sweden
| | - Pär Myrelid
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - Peter Matthiessen
- Department of Surgery, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Anil Gupta
- Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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30
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Wikner F, Matthiessen P, Sörelius K, Legrell P, Rutegård M. Discrepancy between surgeon and radiological assessment of ligation level of the inferior mesenteric artery in patients operated for rectal cancer-impacting registry-based research and surgical practice. World J Surg Oncol 2021; 19:115. [PMID: 33849560 PMCID: PMC8045315 DOI: 10.1186/s12957-021-02222-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/31/2021] [Indexed: 12/12/2022] Open
Abstract
Background The reliability of the registered ligation level of the inferior mesenteric artery (IMA) in the Swedish Colorectal Cancer Registry has been questioned. The primary aim of this study was to evaluate this parameter in the registry by comparing the registered ligation levels with a postoperative computed tomography angiography (CT-angiography) in patients operated for rectal cancer. Methods Patients operated for rectal cancer at two Swedish university hospitals were prospectively included between December 2016 and December 2019. At the 1-year postoperative follow-up, an additional CT-angiography was performed and independently examined by two radiologists. The radiological assessment of the ligation level was compared to registry data, using different measures of agreement. Results A total of 94 patients were included, 55 (59%) were men and 39 (41%) women. All patients underwent abdominal resection: conventional or robot-assisted laparoscopic surgery, n=56 (60%), or open resection, n=38 (40%). The ligation level as assessed on CT-angiography was high in 29 (31%) patients and low in 65 (69%). The registered level of ligation of the IMA and the radiological assessment of the CT-angiographies were consistent in 77/94 cases, demonstrating an 82% agreement and a sensitivity and specificity of 86% and 72%, respectively. The estimated Kappa value was 0.58, reaching 0.64 after prevalence bias adjustment. Conclusion This study showed that CT-angiography can be used to evaluate the reliability of the registered ligation level in the Swedish Colorectal Cancer Registry. The demonstrated agreement between the registry and postoperative CT-angiography was moderate to good. This discrepancy impacts registry-based research using IMA ligation data and may ultimately influence surgical practice. Trial registration Clinical Trials identifier NCT03875612 Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02222-5.
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Affiliation(s)
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Karl Sörelius
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Petter Legrell
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden. .,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
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Pourlotfi A, Ahl R, Sjolin G, Forssten MP, Bass GA, Cao Y, Matthiessen P, Mohseni S. Statin therapy and postoperative short-term mortality after rectal cancer surgery. Colorectal Dis 2021; 23:875-881. [PMID: 33305498 PMCID: PMC8246857 DOI: 10.1111/codi.15481] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 12/13/2022]
Abstract
AIM This study aimed to assess the correlation between regular statin therapy and postoperative mortality following surgical resection for rectal cancer. METHOD This retrospective cohort study included all adult patients undergoing abdominal rectal cancer surgery in Sweden between January 2007 and September 2016. Data were gathered from the Swedish Colorectal Cancer Registry, a large population-based prospectively collected registry. Statin users were defined as patients with one or more collected prescriptions of a statin within 12 months before the date of surgery. The statin-positive and statin-negative cohorts were matched by propensity scores based on baseline demographics. RESULTS A total of 11 966 patients underwent surgical resection for rectal cancer, of whom 3019 (25%) were identified as statin users. After applying propensity score matching (1:1), 3017 pairs were available for comparison. In the matched groups, statin users demonstrated reduced 90-day all-cause mortality (0.7% vs. 5.5%, p < 0.001) and also showed significantly reduced cause-specific mortality due to cardiovascular and respiratory events, as well as sepsis and multiorgan failure. The significant postoperative survival benefit of statin users was seen despite a higher rate of cardiovascular comorbidity. CONCLUSION Preoperative statin therapy displays a strong association with reduced postoperative mortality following surgical resection for rectal cancer. The results from the current study warrant further investigation to determine whether a causal relationship exists.
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Affiliation(s)
- Arvid Pourlotfi
- Division of Trauma & Emergency Surgery, Department of SurgeryOrebro University HospitalOrebroSweden,School of Medical SciencesOrebro UniversityOrebroSweden
| | - Rebecka Ahl
- School of Medical SciencesOrebro UniversityOrebroSweden,Division of SurgeryDepartment of Clinical Science, Intervention and TechnologyKarolinska InstitutetStockholmSweden
| | - Gabriel Sjolin
- Division of Trauma & Emergency Surgery, Department of SurgeryOrebro University HospitalOrebroSweden,School of Medical SciencesOrebro UniversityOrebroSweden
| | - Maximilian Peter Forssten
- Division of Trauma & Emergency Surgery, Department of SurgeryOrebro University HospitalOrebroSweden,School of Medical SciencesOrebro UniversityOrebroSweden
| | - Gary A. Bass
- School of Medical SciencesOrebro UniversityOrebroSweden,Surgical Critical Care and Emergency SurgeryPenn MedicinePenn Presbyterian Medical CenterPAUSA
| | - Yang Cao
- Clinical Epidemiology and BiostatisticsSchool of Medical SciencesOrebro UniversityOrebroSweden
| | - Peter Matthiessen
- Division of Trauma & Emergency Surgery, Department of SurgeryOrebro University HospitalOrebroSweden,School of Medical SciencesOrebro UniversityOrebroSweden
| | - Shahin Mohseni
- Division of Trauma & Emergency Surgery, Department of SurgeryOrebro University HospitalOrebroSweden,School of Medical SciencesOrebro UniversityOrebroSweden
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32
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Lillo-Felipe M, Ahl Hulme R, Sjolin G, Cao Y, Bass GA, Matthiessen P, Mohseni S. Hospital academic status is associated with failure-to-rescue after colorectal cancer surgery. Surgery 2021; 170:863-869. [PMID: 33707039 DOI: 10.1016/j.surg.2021.01.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Failure-to-rescue is a quality indicator measuring the response to postoperative complications. The current study aims to compare failure-to-rescue in patients suffering severe complications after surgery for colorectal cancer between hospitals based on their university status. METHODS Patients undergoing colorectal cancer surgery from January 2015 to January 2020 in Sweden were included through the Swedish Colorectal Cancer Registry in the current study. Severe postoperative complications were defined as Clavien-Dindo ≥3. Failure-to-rescue incidence rate ratios were calculated comparing university versus nonuniversity hospitals. RESULTS A total of 23,351 patients were included in this study, of whom 2,964 suffered severe postoperative complication(s). University hospitals had lower failure-to-rescue rates with an incidence rate ratios of 0.62 (0.46-0.84, P = .002) compared with nonuniversity hospitals. There were significantly lower failure-to-rescue rates in almost all types of severe postoperative complications at university than nonuniversity hospitals. CONCLUSION University hospitals have a lower risk for failure-to-rescue compared with nonuniversity hospitals. The exact mechanisms behind this finding are unknown and warrant further investigation to identify possible improvements that can be applied to all hospitals.
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Affiliation(s)
| | - Rebecka Ahl Hulme
- Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; School of Medical Sciences, Orebro University, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Gabriel Sjolin
- Department of Surgery, Orebro University Hospital, Orebro, Sweden; School of Medical Sciences, Orebro University, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Sweden
| | - Gary A Bass
- School of Medical Sciences, Orebro University, Sweden; Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Peter Matthiessen
- Department of Surgery, Orebro University Hospital, Orebro, Sweden; School of Medical Sciences, Orebro University, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Sweden.
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Gadan S, Floodeen H, Lindgren R, Rutegård M, Matthiessen P. What is the risk of permanent stoma beyond 5 years after low anterior resection for rectal cancer? A 15-year follow-up of a randomized trial. Colorectal Dis 2020; 22:2098-2104. [PMID: 32931137 DOI: 10.1111/codi.15364] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022]
Abstract
AIM Low anterior resection of the rectum for cancer (LAR) entails a risk of symptomatic anastomotic leakage as well as impaired anorectal function, both of which may eventually result in the need for a permanent stoma (PS). The aim was to investigate the incidence of and risk factors for PS beyond 5 years following LAR. METHODS Patients undergoing LAR and included in a multicentre trial with randomization to defunctioning stoma or not were followed for a median of 15 years. The reasons for a PS up to 5 years (PS ≤ 5 years) and beyond 5 years (PS > 5 years) were identified and compared. Risk factors for PS were analysed. RESULTS Of all patients, 25% (57/232) had a PS. PS ≤ 5 years occurred in 19% (44/232) at a median of 12.5 months and PS > 5 years in 6% (13/232) at a median of 118 months following LAR. The main reason for PS ≤ 5 years was impaired anorectal function in 55% (24/44) and the main reason for PS > 5 years was pelvic sepsis related to the colorectal anastomosis in 46% (6/13). The major risk factor for PS was symptomatic anastomotic leakage, which occurred in 56% (32/57) of patients with PS and 10% (17/175) of patients without PS (P < 0.001). CONCLUSION One-fourth of the patients who ended up with a PS had it fashioned beyond 5 years at a median of 10 years following LAR. Symptomatic anastomotic leakage was the major risk factor for PS, and impaired anorectal function was the main overall reason for a PS.
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Affiliation(s)
- S Gadan
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - H Floodeen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - R Lindgren
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Sandberg S, Asplund D, Bisgaard T, Bock D, González E, Karlsson L, Matthiessen P, Ohlsson B, Park J, Rosenberg J, Skullman S, Sörensson M, Angenete E. Low anterior resection syndrome in a Scandinavian population of patients with rectal cancer: a longitudinal follow-up within the QoLiRECT study. Colorectal Dis 2020; 22:1367-1378. [PMID: 32346917 DOI: 10.1111/codi.15095] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/25/2020] [Indexed: 12/12/2022]
Abstract
AIM Low anterior resection syndrome (LARS) is common after low anterior resection. Our aim was to evaluate the prevalence and 'bother' (subjective, symptom-associated distress) of major LARS after 1 and 2 years, identify possible risk factors and relate the bowel function to a reference population. METHOD The QoLiRECT (Quality of Life in RECTal cancer) study is a Scandinavian prospective multicentre study including 1248 patients with rectal cancer, of whom 552 had an anterior resection. Patient questionnaires were distributed at diagnosis and after 1, 2 and 5 years. Data from the baseline and at 1- and 2-year follow-up were included in this study. RESULTS The LARS score was calculated for 309 patients at 1 year and 334 patients at 2 years. Prevalence was assessed by a generalized linear mixed effects model. Major LARS was found in 63% at 1 year and 56% at 2 years. Bother was evident in 55% at 1 year, decreasing to 46% at 2 years. Major LARS was most common among younger women (69%). Among younger patients, only marginal improvement was seen over time (63-59%), for older patients there was more improvement (62-52%). In the reference population, the highest prevalence of major LARS-like symptoms was noted in older women (12%). Preoperative radiotherapy, defunctioning stoma and tumour height were found to be associated with major LARS. CONCLUSION Major LARS is common and possibly persistent over time. Younger patients, especially women, are more affected, and perhaps these patients should be prioritized for early stoma closure to improve the chance of a more normal bowel function.
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Affiliation(s)
- S Sandberg
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - D Asplund
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - T Bisgaard
- Department of Surgery, Centre for Surgical Science, University Hospital of Zealand, Køge, Denmark
| | - D Bock
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - E González
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - L Karlsson
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - B Ohlsson
- Department of Surgery, Blekinge Hospital, Karlshamn, Sweden
| | - J Park
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - J Rosenberg
- Department of Surgery, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - S Skullman
- Department of Surgery, Skaraborgs Hospital Skövde, Skövde, Sweden
| | - M Sörensson
- Department of Surgery, Karlstad Hospital, Karlstad, Sweden
| | - E Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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Ahl R, Matthiessen P, Sjölin G, Cao Y, Wallin G, Ljungqvist O, Mohseni S. Effects of beta-blocker therapy on mortality after elective colon cancer surgery: a Swedish nationwide cohort study. BMJ Open 2020; 10:e036164. [PMID: 32641361 PMCID: PMC7342478 DOI: 10.1136/bmjopen-2019-036164] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/14/2020] [Accepted: 05/28/2020] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Colon cancer surgery remains associated with substantial postoperative morbidity and mortality despite advances in surgical techniques and care. The trauma of surgery triggers adrenergic hyperactivation which drives adverse stress responses. We hypothesised that outcome benefits are gained by reducing the effects of hyperadrenergic activity with beta-blocker therapy in patients undergoing colon cancer surgery. This study aims to test this hypothesis. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS This is a nationwide study which includes all adult patients undergoing elective colon cancer surgery in Sweden over 10 years. Patient data were collected from the Swedish Colorectal Cancer Registry. The national drugs registry was used to obtain information about beta-blocker use. Patients were subdivided into exposed and unexposed groups. The association between beta-blockade, short-term and long-term mortality was evaluated using Poisson regression, Kaplan-Meier curves and Cox regression. PRIMARY AND SECONDARY OUTCOMES Primary outcome of interest was 1-year all-cause mortality. Secondary outcomes included 90-day all-cause and 5-year cancer-specific mortality. RESULTS The study included 22 337 patients of whom 36.1% were prescribed preoperative beta-blockers. Survival was higher in patients on beta-blockers up to 1 year after surgery despite this group being significantly older and of higher comorbidity. Regression analysis demonstrated significant reductions in 90-day deaths (IRR 0.29, 95% CI 0.24 to 0.35, p<0.001) and a 43% risk reduction in 1-year all-cause mortality (adjusted HR 0.57, 95% CI 0.52 to 0.63, p<0.001) in beta-blocked patients. In addition, cancer-specific mortality up to 5 years after surgery was reduced in beta-blocked patients (adjusted HR 0.80, 95% CI 0.73 to 0.88, p<0.001). CONCLUSION Preoperative beta-blockade is associated with significant reductions in postoperative short-term and long-term mortality following elective colon cancer surgery. Its potential prophylactic effect warrants further interventional studies to determine whether beta-blockade can be used as a way of improving outcomes for this patient group.
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Affiliation(s)
- Rebecka Ahl
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Matthiessen
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Gabriel Sjölin
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Yang Cao
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Göran Wallin
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Olle Ljungqvist
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Shahin Mohseni
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
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Sörensson M, Asplund D, Matthiessen P, Rosenberg J, Hallgren T, Rosander C, González E, Bock D, Angenete E. Self-reported sexual dysfunction in patients with rectal cancer. Colorectal Dis 2020; 22:500-512. [PMID: 31713295 PMCID: PMC7317395 DOI: 10.1111/codi.14907] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/21/2019] [Indexed: 01/04/2023]
Abstract
AIM Patients with rectal cancer often experience sexual dysfunction after treatment. The aim of this study was to evaluate sexual function in a prospective cohort of patients regardless of treatment and tumour stage and explore what factors might affect sexual activity 1 year after diagnosis. METHOD The QoLiRECT study (Quality of Life in RECTal cancer) is a prospective study on the health-related quality of life in patients with rectal cancer in Denmark and Sweden. Questionnaires were completed at diagnosis and 1 year. Clinical data were retrieved from national quality registries. RESULTS Questionnaire data were available from 1085 patients at diagnosis and 920 patients at 1 year. Median age was 69 years (range 25-100). At diagnosis, 29% of the women and 41% of the men were sexually active, which was lower than an age-matched reference population. This was further reduced to 25% and 34% at 1 year. Risk factors for sexual inactivity were absence of sexual activity prior to the diagnosis and the presence of a stoma. Women experienced reduced lubrication and more dyspareunia at 1 year compared with the time of diagnosis. In men, erectile dysfunction increased from 46% to 55% at 1 year. CONCLUSION Sexual activity in patients with rectal cancer is lower at diagnosis compared with the population norm and is further reduced at 1 year. The presence of a stoma contributed to reduced sexual activity after operation. Sexual dysfunction was difficult to evaluate due to low sexual activity in the cohort. In men, erectile dysfunction is common.
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Affiliation(s)
- M. Sörensson
- Department of SurgeryKarlstad HospitalKarlstadSweden
| | - D. Asplund
- Department of SurgerySSORG – Scandinavian Surgical Outcomes Research GroupInstitute of Clinical SciencesSahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of SurgeryRegion Västra GötalandSahlgrenska University HospitalGothenburgSweden
| | - P. Matthiessen
- Department of SurgeryFaculty of Medicine and HealthÖrebro UniversityÖrebroSweden
| | - J. Rosenberg
- Department of SurgeryHerlev HospitalUniversity of CopenhagenHerlevDenmark
| | - T. Hallgren
- Department of SurgeryKarlstad HospitalKarlstadSweden
| | - C. Rosander
- Department of SurgerySSORG – Scandinavian Surgical Outcomes Research GroupInstitute of Clinical SciencesSahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of SurgeryRegion Västra GötalandSahlgrenska University HospitalGothenburgSweden
| | - E. González
- Department of SurgerySSORG – Scandinavian Surgical Outcomes Research GroupInstitute of Clinical SciencesSahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of SurgeryRegion Västra GötalandSahlgrenska University HospitalGothenburgSweden
| | - D. Bock
- Department of SurgerySSORG – Scandinavian Surgical Outcomes Research GroupInstitute of Clinical SciencesSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - E. Angenete
- Department of SurgerySSORG – Scandinavian Surgical Outcomes Research GroupInstitute of Clinical SciencesSahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of SurgeryRegion Västra GötalandSahlgrenska University HospitalGothenburgSweden
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Kverneng Hultberg D, Svensson J, Jutesten H, Rutegård J, Matthiessen P, Lydrup ML, Rutegård M. The Impact of Anastomotic Leakage on Long-term Function After Anterior Resection for Rectal Cancer. Dis Colon Rectum 2020; 63:619-628. [PMID: 32032197 DOI: 10.1097/dcr.0000000000001613] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is still not clear whether anastomotic leakage after anterior resection for rectal cancer affects long-term functional outcome. OBJECTIVE This study aimed to evaluate how anastomotic leakage following anterior resection for rectal cancer influences defecatory, urinary, and sexual function. DESIGN In this retrospective population-based cohort study, patients were identified through the Swedish Colorectal Cancer Registry, which was also used for information on the exposure variable anastomotic leakage and covariates. SETTINGS A nationwide register was used for including patients. PATIENTS All patients undergoing anterior resection for rectal cancer in Sweden from April 2011 to June 2013 were included. MAIN OUTCOME MEASURES Outcome was any defecatory, sexual, or urinary dysfunction, assessed 2 years after surgery by a postal questionnaire. The association between anastomotic leakage and function was assessed in multivariable logistic and linear regression models, with adjustment for confounding. RESULTS Response rate was 82%, resulting in 1180 included patients. Anastomotic leakage occurred in 7.5%. A permanent stoma was more common among patients with leakage (44% vs 9%; p < 0.001). Patients with leakage had an increased risk of aid use for fecal incontinence (OR, 2.27; 95% CI, 1.20-4.30) and reduced sexual activity (90% vs 82%; p = 0.003), whereas the risk of urinary incontinence was decreased (OR, 0.53; 95% CI, 0.31-0.90). A sensitivity analysis assuming that a permanent stoma was created because of anorectal dysfunction strengthened the negative impact of leakage on defecatory dysfunction. LIMITATIONS Limitations include the use of a questionnaire that had not been previously validated, underreporting of anastomotic leakage in the register, and small patient numbers in the analysis of sexual symptoms. CONCLUSIONS Anastomotic leakage was found to statistically significantly increase the risk of aid use due to fecal incontinence and reduced sexual activity, although the impact on defecatory dysfunction might be underestimated, because permanent stomas are sometimes fashioned because of anorectal dysfunction. Further research is warranted, especially regarding urogenital function. See Video Abstract at http://links.lww.com/DCR/B157. EL IMPACTO DE LA FUGA ANASTOMÓTICA EN LA FUNCIÓN A LARGO PLAZO DESPUÉS DE LA RESECCIÓN ANTERIOR POR CÁNCER RECTAL: Todavía no está claro si la fuga anastomótica después de la resección anterior por cáncer rectal afecta el resultado funcional a largo plazo.Evaluar cómo la fuga anastomótica después de la resección anterior para el cáncer rectal influye en la función defecatoria, urinaria y sexual.En este estudio de cohorte retrospectivo basado en la población, los pacientes fueron identificados a través del Registro Sueco de cáncer colorrectal, que también se utilizó para obtener información sobre la variable de exposición de fuga anastomótica y las covariables.Se utilizó un registro nacional para incluir pacientes.Se incluyeron todos los pacientes sometidos a resección anterior por cáncer de recto en Suecia desde abril de 2011 hasta junio de 2013.El resultado fue cualquier disfunción defecatoria, sexual o urinaria, evaluada dos años después de la cirugía mediante un cuestionario postal. La asociación entre la fuga anastomótica y la función se evaluó en modelos logísticos multivariables y de regresión lineal, con ajuste por confusión.La tasa de respuesta fue del 82%, lo que resultó en 1180 pacientes incluidos. La fuga anastomótica ocurrió en el 7,5%. Un estoma permanente fue más común entre los pacientes con fugas (44% vs. 9%; p <0.001). Los pacientes con fugas tenían un mayor riesgo de uso de ayuda para la incontinencia fecal (OR 2.27; IC 95% 1.20-4.30) y una menor actividad sexual (90% vs. 82%; p = 0.003), mientras que el riesgo de incontinencia urinaria disminuyó (OR 0.53; IC 95% 0.31-0.90). Un análisis de sensibilidad que supone que se creaba un estoma permanente debido a una disfunción anorrectal fortaleció el impacto negativo de la fuga en la disfunción defecatoria.Las limitaciones incluyen el cuestionario utilizado que no ha sido validado previamente, el subregistro de fugas anastomóticas en el registro y el pequeño número de pacientes en el análisis de síntomas sexuales.Se descubrió que la fuga anastomótica aumentaba estadísticamente de manera significativa el riesgo de uso de ayuda debido a la incontinencia fecal y la actividad sexual reducida, aunque el impacto en la disfunción defecatoria podría estar subestimada, ya que a veces los estomas permanentes se forman debido a la disfunción anorrectal. Se justifica la investigación adicional, especialmente con respecto a la función urogenital. Consulte Video Resumen en http://links.lww.com/DCR/B157. (Traducción-Dr. Gonzalo Hagerman).
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Affiliation(s)
| | - Johan Svensson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Henrik Jutesten
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå
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Collins C, Depledge M, Fraser R, Johnson A, Hutchison G, Matthiessen P, Murphy R, Owens S, Sumpter J. Key actions for a sustainable chemicals policy. Environ Int 2020; 137:105463. [PMID: 32086074 DOI: 10.1016/j.envint.2020.105463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 01/02/2020] [Accepted: 01/02/2020] [Indexed: 06/10/2023]
Abstract
Chemicals policies have spawned a wide range of regulations aimed at limiting damage to the environment and human health. Most instruments are reactive and fragmented. We propose a simple underpinning philosophy, "Do no harm", to ensure a more sustainable, safe "chemical environment" for the future.
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Affiliation(s)
- Chris Collins
- Soil Research Centre, Department Geography and Environmental Science, University of Reading, Reading RG6 6DW, UK.
| | - Mike Depledge
- European Centre for Environment and Human Health, University of Exeter Medical School, Heavitree Road, Exeter EX1 2LU, UK
| | - Robert Fraser
- School of Economics, Kennedy Building, Park Wood Road, Canterbury, Kent CT2 7FS, UK
| | - Andrew Johnson
- UK Centre for Ecology & Hydrology, Crowmarsh Gifford, Wallingford, Oxfordshire OX10 8BB, UK
| | - Gary Hutchison
- School of Applied Sciences, Edinburgh Napier University, Sighthill Campus, Edinburgh EH11 4BN, UK
| | | | - Richard Murphy
- Centre for Environment and Sustainability, University of Surrey, Guildford GU2 7XH, UK
| | - Susan Owens
- Newnham College, Sidgwick Avenue, Cambridge CB3 9DF, UK
| | - John Sumpter
- Institute of Environment, Brunel University, Middlesex UB8 3PH, UK
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Ahl R, Matthiessen P, Cao Y, Sjolin G, Ljungqvist O, Mohseni S. The Relationship Between Severe Complications, Beta-Blocker Therapy and Long-Term Survival Following Emergency Surgery for Colon Cancer. World J Surg 2019; 43:2527-2535. [PMID: 31214833 DOI: 10.1007/s00268-019-05058-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Emergency surgery for colon cancer carries significant morbidity, and studies show more than doubled mortality when comparing elective to emergency surgery. The relationship between postoperative complications and survival has been outlined. Beta-blocker therapy has been linked to improved postoperative outcomes. This study aims to assess the impact of postoperative complications on long-term survival following emergency surgery for colon cancer and to determine whether beta-blockade can reduce complications. STUDY DESIGN This cohort study utilized the prospective Swedish Colorectal Cancer Registry to identify adults undergoing emergency colon cancer surgery between 2011 and 2016. Prescription data for preoperative beta-blocker therapy were collected from the national drug registry. Cox regression was used to evaluate the effect of beta-blocker exposure and complications on 1-year mortality, and Poisson regression was used to evaluate beta-blocker exposure in patients with major complications. RESULTS A total of 3139 patients were included with a mean age of 73.1 [12.4] of which 671 (21.4%) were prescribed beta-blockers prior to surgery. Major complications occurred in 375 (11.9%) patients. Those suffering major complications showed a threefold increase in 1-year mortality (adjusted HR = 3.29; 95% CI 2.75-3.94; p < 0.001). Beta-blocker use was linked to a 60% risk reduction in 1-year mortality (adjusted HR = 0.40; 95% CI 0.26-0.62; p < 0.001) but did not show a statistically significant association with reductions in major complications (adjusted IRR = 0.77; 95% CI 0.59-1.00; p = 0.055). CONCLUSION The development of major complications after emergency colon cancer surgery is associated with increased mortality during one year after surgery. Beta-blocker therapy may protect against postoperative complications.
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Affiliation(s)
- Rebecka Ahl
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Peter Matthiessen
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Gabriel Sjolin
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Örebro University, Örebro, Sweden.
- Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
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40
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Maghami S, Cao Y, Ahl R, Detlofsson E, Matthiessen P, Sarani B, Mohseni S. Beta-blocker Therapy is Associated with Decreased 1-year Mortality After Emergency Laparotomy in Geriatric Patients. Scand J Surg 2019; 110:37-43. [DOI: 10.1177/1457496919877582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background and Aims: Emergency laparotomy is associated with a great risk of mortality in the elderly. The hyperadrenergic state induced by surgical trauma may play an important role in the pathophysiology of this increased risk. Studies have shown that beta-blocker exposure may be associated with decreased morbidity and mortality in the perioperative period. We aimed to study the effect of beta-blocker on mortality in geriatric patients undergoing emergency laparotomy. Material and Methods: This is a retrospective study of patients who underwent emergency laparotomy between 1 January 2015 and 31 December 2016 at a single institution. The outcomes of interest were the association between post-operative complications and in-hospital and 1-year mortality in patients on beta-blocker therapy (BB(+)) and those who were not (BB(−)). The Poisson regression analysis was used to evaluate the association. Results: A total of 192 patients were included of whom 62 (32.2%) had pre-operative beta-blocker therapy with continued exposure during their hospital stay. The in-hospital mortality was 17.7% in the BB(+) and 23.8% in the BB(−) cohorts ( p = 0.441). One-year mortality was significantly lower in the BB(+) group compared to the BB(−) group (30.6% versus 47.7%; p = 0.038). After adjusting for confounders, the incidence of deaths during 1 year post-operatively decreased by 35% in the BB(+) group (incidence rate ratio = 0.65, p = 0.004). No significant differences in the incidence of post-operative complications between the two groups could be measured. Conclusion: Beta-blocker therapy may be associated with reduced 1-year mortality following emergency laparotomy in geriatric patients.
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Affiliation(s)
- S. Maghami
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Y. Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - R. Ahl
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - E. Detlofsson
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - P. Matthiessen
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - B. Sarani
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - S. Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
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41
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Sörelius K, Svensson J, Matthiessen P, Rutegård J, Rutegård M. A nationwide study on the incidence of mesenteric ischaemia after surgery for rectal cancer demonstrates an association with high arterial ligation. Colorectal Dis 2019; 21:925-931. [PMID: 31062468 DOI: 10.1111/codi.14674] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
AIM The incidence of mesenteric ischaemia after resection for rectal cancer has not been investigated in a population-based setting. The use of high ligation of the inferior mesenteric artery might cause such ischaemia, as the bowel left in situ depends on collateral blood supply after a high tie. METHOD The Swedish Colorectal Cancer Registry was used to identify all patients subjected to an abdominal resection for rectal cancer during the years 2007-2017 inclusive. Mesenteric ischaemia within the first 30 postoperative days was recorded, classified as either stoma necrosis or colonic necrosis. Multivariable logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for mesenteric ischaemia in relation to high tie, with adjustment for confounding. RESULTS Some 14 657 patients were included, of whom 59 (0.40%) had a reoperation for any type of mesenteric ischaemia, divided into 34 and 25 cases of stoma necrosis and colonic necrosis, respectively. Compared with patients who did not require reoperation for mesenteric ischaemia following rectal cancer surgery, the proportion having high tie was greater (54.2% vs 38.5%; P = 0.032). The adjusted OR for reoperation due to any mesenteric ischaemia with high tie was 2.26 (95% CI 1.34-3.79), while the corresponding estimates for stoma and colonic necrosis, respectively, were 1.60 (95% CI 0.81-3.17) and 3.69 (95% CI 1.57-8.66). CONCLUSION The incidence of reoperation for mesenteric ischaemia after abdominal resection for rectal cancer is low, but the use of a high tie might increase the risk of colonic necrosis demanding surgery.
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Affiliation(s)
- K Sörelius
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - J Svensson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - J Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
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Rottensteiner H, Kaufmann S, Rathgeb A, Kink B, Plaimauer B, Matthiessen P, Hann S, Scheiflinger F. Temperature-dependent irreversible conformational change of recombinant ADAMTS13 upon metal ion chelation. J Thromb Haemost 2019; 17:995-1002. [PMID: 31006963 PMCID: PMC6850365 DOI: 10.1111/jth.14440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/20/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND The catalytic domain of ADAMTS13 possesses one Zn2+ and up to three putative Ca2+ binding sites and can be inactivated by chelating agents. Although replenishment with an appropriate metallic cation is thought to restore the enzyme's proteolytic activity fully, ADAMTS13 stability in a metal ion-depleting environment has not been explored. OBJECTIVES To address the stability of ADAMTS13 in citrated human plasma. METHODS ADAMTS13 activity was measured using the FRETS-VWF73 fluorogenic assay. The molar ratio of metals bound to ADAMTS13 was determined by size exclusion chromatography inductively coupled plasma mass spectrometry (SEC-ICP-MS). Higher-order structural changes were analyzed using Fourier-transformed infrared spectroscopy and dynamic light scattering. RESULTS ADAMTS13 was stable at room temperature for up to 24 hours irrespective of the presence of citrate (0.38%). However, at 37°C, citrate caused a time-dependent activity decrease. No ADAMTS13 activity decrease was seen in heparinized plasma, but the addition of citrate again caused ADAMTS13 instability at 37°C. Scavenging of citrate by the addition of Ca2+ or Zn2+ prior to but not postincubation prevented the activity decrease of the enzyme. The SEC-ICP-MS analyses showed that ADAMTS13 only bound Zn2+ and that its reduced activity correlated with a gradual loss of bound Zn2+ . Concomitant higher-order structural analyses demonstrated structural changes in ADAMTS13 that are typical of less-ordered protein structures. CONCLUSIONS Zn2+ is required to stabilize ADAMTS13 structure at physiologic temperature, thereby preventing irreversible loss of enzyme activity. This finding is particularly important to consider when using citrated human plasma as a source of ADAMTS13 in clinical settings.
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Affiliation(s)
| | - Stefan Kaufmann
- Baxalta Innovations GmbH, a member of the Takeda group of companiesViennaAustria
| | - Anna Rathgeb
- Department of ChemistryUniversity of Natural Resources and Life Sciences (BOKU)ViennaAustria
| | - Barbara Kink
- Baxalta Innovations GmbH, a member of the Takeda group of companiesViennaAustria
| | - Barbara Plaimauer
- Baxalta Innovations GmbH, a member of the Takeda group of companiesViennaAustria
| | - Peter Matthiessen
- Baxalta Innovations GmbH, a member of the Takeda group of companiesViennaAustria
| | - Stephan Hann
- Department of ChemistryUniversity of Natural Resources and Life Sciences (BOKU)ViennaAustria
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Godfray HCJ, Stephens AEA, Jepson PD, Jobling S, Johnson AC, Matthiessen P, Sumpter JP, Tyler CR, McLean AR. A restatement of the natural science evidence base on the effects of endocrine disrupting chemicals on wildlife. Proc Biol Sci 2019; 286:20182416. [PMID: 30963852 PMCID: PMC6408895 DOI: 10.1098/rspb.2018.2416] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/08/2019] [Indexed: 12/24/2022] Open
Abstract
Endocrine disrupting chemicals (EDCs) are substances that alter the function of the endocrine system and consequently cause adverse effects to humans or wildlife. The release of particular EDCs into the environment has been shown to negatively affect certain wildlife populations and has led to restrictions on the use of some EDCs. Current chemical regulations aim to balance the industrial, agricultural and/or pharmaceutical benefits of using these substances with their demonstrated or potential harm to human health or the environment. A summary is provided of the natural science evidence base informing the regulation of chemicals released into the environment that may have endocrine disrupting effects on wildlife. This summary is in a format (a 'restatement') intended to be policy-neutral and accessible to informed, but not expert, policy-makers and stakeholders.
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Affiliation(s)
- H. Charles J. Godfray
- Oxford Martin School and Department of Zoology, University of Oxford, 34 Broad St, Oxford OX1 3BD, UK
| | - Andrea E. A. Stephens
- Oxford Martin School and Department of Zoology, University of Oxford, 34 Broad St, Oxford OX1 3BD, UK
| | - Paul D. Jepson
- Institute of Zoology, Zoological Society of London, Regent's Park, London NW1 4RY, UK
| | - Susan Jobling
- Institute of Environment, Health and Societies, Brunel University London, Uxbridge UB8 3PH, UK
| | - Andrew C. Johnson
- Centre for Ecology and Hydrology, Wallingford, Oxfordshire OX10 8BB, UK
| | | | - John P. Sumpter
- Institute of Environment, Health and Societies, Brunel University London, Uxbridge UB8 3PH, UK
| | - Charles R. Tyler
- Biosciences, College of Life and Environmental Sciences, University of Exeter, Exeter EX4 4QD, UK
| | - Angela R. McLean
- Oxford Martin School and Department of Zoology, University of Oxford, 34 Broad St, Oxford OX1 3BD, UK
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Gadan S, Lindgren R, Floodeen H, Matthiessen P. Reversal of defunctioning stoma following rectal cancer surgery: are we getting better? A population-based single centre experience. ANZ J Surg 2019; 89:403-407. [PMID: 30806006 DOI: 10.1111/ans.14990] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/28/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND The aim was to assess factors influencing the timing of defunctioning stoma (DS) reversal following low anterior resection of rectum for cancer (LAR). METHODS All patients operated with LAR and a primary DS during a 9-year period were included. Reversal later than 120 days after LAR was considered as delayed. A DS not reversed within 2 years was considered as permanent. RESULTS In the present study, median age at LAR was 67 years, 45% were females, median body mass index was 25, 87% had American Society of Anesthesiologists class I or II, 64% had pre-operative radiotherapy, and 3% had cancer stage IV. A total of 79% (92/116) underwent stoma reversal, whereof 25% (23/92) were reversed within 120 days. The most common health-related reasons for delayed stoma reversal were adjuvant chemotherapy in 38%, symptomatic anastomotic leakage in 16% and other post-operative adverse events in 13%. In 35% delayed stoma reversal was because of low priority within the healthcare system. A total of 18% (20/110) never had their DS reversed (n = 11) or had their DS converted to a permanent end colostomy (n = 9). Major risk factors for permanent stoma were stage IV cancer in 55%, and symptomatic anastomotic leakage in 30%. CONCLUSION One fourth of the patients had their defunctioning stoma reversed within 120 days. The most common identifiable medical reasons for delayed stoma reversal were adjuvant chemotherapy and symptomatic anastomotic leakage, while in one out of three patients it was because of low priority by the healthcare provider.
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Affiliation(s)
- Soran Gadan
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Rickard Lindgren
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Hannah Floodeen
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Peter Matthiessen
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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Holmgren K, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. Anterior resection for rectal cancer in Sweden: validation of a registry-based method to determine long-term stoma outcome. Acta Oncol 2018; 57:1631-1638. [PMID: 30306825 DOI: 10.1080/0284186x.2018.1521988] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND A permanent stoma after anterior resection for rectal cancer is common. Nationwide registries provide sufficient power to evaluate factors influencing this phenomenon, but validation is required to ensure the quality of registry-based stoma outcomes. METHODS Patients who underwent anterior resection for rectal cancer in the Northern healthcare region of Sweden between 1 January 2007 and 31 December 2013 were reviewed by medical records and followed until 31 December 2014 with regard to stoma outcome. A registry-based method to determine nationwide long-term stoma outcomes, using data from the National Patient Registry and the Swedish Colorectal Cancer Registry, was developed and internally validated using the chart reviewed reference cohort. Accuracy was evaluated with positive and negative predictive values and Kappa values. Following validation, the stoma outcome in all patients treated with an anterior resection for rectal cancer in Sweden during the study period was estimated. Possible regional differences in determined stoma outcomes between the six Swedish healthcare regions were subsequently evaluated with the χ2 test. RESULTS With 312 chart reviewed patients as reference, stoma outcome was accurately predicted through the registry-based method in 299 cases (95.8%), with a positive predictive value of 85.1% (95% CI 75.8%-91.8%), and a negative predictive value of 100.0% (95% CI 98.4%-100.0%), while the Kappa value was 0.89 (95% CI 0.82-0.95). In Sweden, 4768 patients underwent anterior resection during the study period, of which 942 (19.8%) were determined to have a permanent stoma. The stoma rate varied regionally between 17.8-29.2%, to a statistically significant degree (p = .001). CONCLUSION Using data from two national registries to determine long-term stoma outcome after anterior resection for rectal cancer proved to be reliable in comparison to chart review. Permanent stoma prevalence after such surgery remains at a significant level, while stoma outcomes vary substantially between different healthcare regions in Sweden.
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Affiliation(s)
- Klas Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Markku M. Haapamäki
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
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Ellebæk MB, Daams F, Jansson K, Matthiessen P, Cosse C, Fristrup C, Ellebæk SB, Sabroe JE, Qvist N. Peritoneal microdialysis as a tool for detecting anastomotic leakage in patients after left-side colon and rectal resection. A systematic review. Scand J Gastroenterol 2018; 53:1625-1632. [PMID: 30457391 DOI: 10.1080/00365521.2018.1533033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective was to evaluate peritoneal microdialysis in the detection of clinical anastomotic leakage after left-sided colon and rectal resection through a systematic review. METHODS A systematic review (PRISMA guidelines) based on a systematic search through PubMed, Cochrane Library, and EMBASE (1 February 2017) was performed. Methodological index of non-randomised studies score was selected to assess the methodological quality. Patient demographics and raw data for intraperitoneal microdialysis concentrations of glucose, lactate, glycerol and pyruvate for 5 d postoperative were obtained from the respective study groups. RESULTS Ten studies with a total of 128 patients were included. Thirty (23%) patients developed clinical anastomotic leakage. The area under the curve for intraperitoneal lactate concentration was significant higher in patients with anastomotic leakage (58.2; 95% CI 39.2, 77.2) compared with the no leakage group (41.0; 95% CI 35.2, 46.1; p = .007). Receiver operating characteristic curve analysis of the maximum measured lactate concentration demonstrated 25% sensitivity, 88% specificity and 74% accuracy for AL at a cut-off value of 9.8 mmol/L. The odds ratio for a 5 mmol/L increase in lactate in relation to the risk of AL was 2.9 (CI 1.1, 8.0). CONCLUSIONS Increased intraperitoneal lactate concentration within the first 5 d postoperative was significantly associated with clinical anastomotic leakage, but with low predictive values. The microdialysis method is not yet ready for clinical implication before large prospective studies have defined cut off values for a biologic marker in the setting of a clear definitions of leakage.
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Affiliation(s)
| | - Freek Daams
- b Erasmus Medical Centre, Surgery's Gravendijkwal , Rotterdam , Netherlands
| | - Kjell Jansson
- c Department of Surgery, Faculty of Medicine and Health , Örebro University , Örebro , Sweden
| | - Peter Matthiessen
- c Department of Surgery, Faculty of Medicine and Health , Örebro University , Örebro , Sweden
| | - Cyril Cosse
- d Department of Digestive Surgery , Amiens University Hospital , Amiens Cedex , France
| | - Claus Fristrup
- a Department of Surgery , Odense University Hospital , Odense , Denmark
| | | | - Jonas Emil Sabroe
- a Department of Surgery , Odense University Hospital , Odense , Denmark
| | - Niels Qvist
- a Department of Surgery , Odense University Hospital , Odense , Denmark
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Popiolek M, Dehlaghi K, Gadan S, Baban B, Matthiessen P. Total Mesorectal Excision for Mid-Rectal Cancer Without Anastomosis: Low Hartmann’s Operation or Intersphincteric Abdomino-Perineal Excision? Scand J Surg 2018; 108:233-240. [DOI: 10.1177/1457496918812219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background and Aims: In mid-rectal cancer, the low colorectal anastomosis is, although feasible, sometimes avoided. The aim was to compare low Hartmann’s procedure with intersphincteric abdomino-perineal excision of the rectum, in patients operated with total mesorectal excision for mid-rectal cancer in whom the low anastomosis was technically feasible but for patient-related reasons undesired. Material and Methods: A total of 64 consecutive patients with mid-rectal cancer who underwent low Hartmann’s procedure (n = 34) or intersphincteric abdomino-perineal excision (n = 30) at one colorectal unit were compared regarding patient demography, short-term oncology, surgical outcome at 3 and 24 months, and long-term overall survival. Results: There were no significant differences between intersphincteric abdomino-perineal excision and Hartmann’s procedure regarding age, gender distribution, body mass index, preoperative radiotherapy, tumor level, or cancer stages. Operation time was shorter in Hartmann’s procedure as compared with intersphincteric abdomino-perineal excision, median 174 and 256 min, (P < 0.001), and intraoperative blood loss was increased, 600 and 500 mL, respectively (P = 0.045). Number of lymph nodes and circumferential resection margin were comparable. In Hartmann’s procedure compared with intersphincteric abdomino-perineal excision, the need for reoperation was 24% and 3%, (P = 0.020), complications classified as Clavien–Dindo 3–4 occurred in 32% and 10%, (P = 0.031), pelvic abscess in 21% and 10%, (P = 0.313), and mortality within 90 days was 3% and 0%, respectively, (P = 0.938). In intersphincteric abdomino-perineal excision, the perineal wound was not healed at 3 months in 13%, and in Hartmann’s procedure 15% had chronic secretion from the anorectal remnant at 2 years postoperatively. Conclusion: The results from this study suggest that intersphincteric abdomino-perineal excision might be an alternative to Hartmann’s procedure in patients with mid-rectal cancer, in whom a low colorectal anastomosis is undesired.
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Affiliation(s)
- M. Popiolek
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
- Department of Urology, Örebro University Hospital, Örebro, Sweden
| | - K. Dehlaghi
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - S. Gadan
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
- Department of Surgery, Schools of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - B. Baban
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
- Department of Surgery, Schools of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - P. Matthiessen
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
- Department of Surgery, Schools of Health and Medical Sciences, Örebro University, Örebro, Sweden
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48
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Boström P, Haapamäki MM, Rutegård J, Matthiessen P, Rutegård M. Population-based cohort study of the impact on postoperative mortality of anastomotic leakage after anterior resection for rectal cancer. BJS Open 2018; 3:106-111. [PMID: 30734021 PMCID: PMC6354192 DOI: 10.1002/bjs5.50106] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 08/22/2018] [Indexed: 12/19/2022] Open
Abstract
Background Anastomotic leakage following anterior resection for rectal cancer may result in death. The aim of this study was to yield an updated, population‐based estimate of postoperative mortality and evaluate possible interacting factors. Methods This was a retrospective national cohort study of patients who underwent anterior resection between 2007 and 2016. Data were retrieved from a prospectively developed database. Anastomotic leakage constituted exposure, whereas outcome was defined as death within 90 days of surgery. Logistic regression analyses, using directed acyclic graphs to evaluate possible confounders, were performed, including interaction analyses. Results Of 6948 patients, 693 (10·0 per cent) experienced anastomotic leakage and 294 (4·2 per cent) underwent reintervention due to leakage. The mortality rate was 1·5 per cent in patients without leakage and 3·9 per cent in those with leakage. In multivariable analysis, leakage was associated with increased mortality only when a reintervention was performed (odds ratio (OR) 5·57, 95 per cent c.i. 3·29 to 9·44). Leaks not necessitating reintervention did not result in increased mortality (OR 0·70, 0·25 to 1·96). There was evidence of interaction between leakage and age on a multiplicative scale (P = 0·007), leading to a substantial mortality increase in elderly patients with leakage. Conclusion Anastomotic leakage, in particular severe leakage, led to a significant increase in 90‐day mortality, with a more pronounced risk of death in the elderly.
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Affiliation(s)
- P Boström
- Surgery Unit, Department of Surgical and Perioperative Sciences Umeå University Umeå Sweden
| | - M M Haapamäki
- Surgery Unit, Department of Surgical and Perioperative Sciences Umeå University Umeå Sweden
| | - J Rutegård
- Surgery Unit, Department of Surgical and Perioperative Sciences Umeå University Umeå Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences Örebro University Örebro Sweden
| | - M Rutegård
- Surgery Unit, Department of Surgical and Perioperative Sciences Umeå University Umeå Sweden
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49
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Ahl R, Matthiessen P, Fang X, Cao Y, Sjolin G, Lindgren R, Ljungqvist O, Mohseni S. Effect of beta-blocker therapy on early mortality after emergency colonic cancer surgery. Br J Surg 2018; 106:477-483. [DOI: 10.1002/bjs.10988] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/18/2018] [Accepted: 07/28/2018] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Emergency colorectal cancer surgery is associated with significant mortality. Induced adrenergic hyperactivity is thought to be an important contributor. Downregulating the effects of circulating catecholamines may reduce the risk of adverse outcomes. This study assessed whether regular preoperative beta-blockade reduced mortality after emergency colonic cancer surgery.
Methods
This cohort study used the prospectively collected Swedish Colorectal Cancer Registry to recruit all adult patients requiring emergency colonic cancer surgery between 2011 and 2016. Patients were subdivided into those receiving regular beta-blocker therapy before surgery and those who were not (control). Demographics and clinical outcomes were compared. Risk factors for 30-day mortality were evaluated using Poisson regression analysis.
Results
A total of 3187 patients were included, of whom 685 (21·5 per cent) used regular beta-blocker therapy before surgery. The overall 30-day mortality rate was significantly reduced in the beta-blocker group compared with controls: 3·1 (95 per cent c.i. 1·9 to 4·7) versus 8·6 (7·6 to 9·8) per cent respectively (P < 0·001). Beta-blocker therapy was the only modifiable protective factor identified in multivariable analysis of 30-day all-cause mortality (incidence rate ratio 0·31, 95 per cent c.i. 0·20 to 0·47; P < 0·001) and was associated with a significant reduction in death of cardiovascular, respiratory, sepsis and multiple organ failure origin.
Conclusion
Preoperative beta-blocker therapy may be associated with a reduction in 30-day mortality following emergency colonic cancer surgery.
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Affiliation(s)
- R Ahl
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - P Matthiessen
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - X Fang
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Y Cao
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - G Sjolin
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - R Lindgren
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - O Ljungqvist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - S Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
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50
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Segelman J, Buchli C, Svanström Röjvall A, Matthiessen P, Arver S, Bottai M, Ahlberg M, Jasuja R, Flöter-Rådestad A, Martling A. Effect of radiotherapy for rectal cancer on ovarian androgen production. Br J Surg 2018; 106:267-275. [PMID: 30277569 DOI: 10.1002/bjs.10980] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/26/2018] [Accepted: 07/14/2018] [Indexed: 01/13/2023]
Abstract
Abstract
Background
The impact of radiotherapy (RT) for rectal cancer on ovarian androgen production is unknown. The aim was to examine the effect of RT for rectal cancer on androgen levels in non-oophorectomized women and the association with female sexual desire.
Methods
This prospective cohort study included women who had surgery for rectal cancer with or without RT. Serum testosterone, free testosterone, androstenedione and dehydroepiandrosterone sulphate (DHEA-S) levels were assessed at baseline, after RT and 1 year after surgery. Sexual desire was assessed by means of the Female Sexual Function Index.
Results
Twenty-seven participants had surgery alone (RT– group) and 98 had preoperative RT and surgery (RT+ group). During the first year after surgery, median serum testosterone and free testosterone levels decreased from 0·6 (range 0·1–3·6) to 0·5 (0·1–2·3) nmol/l (P < 0·001) and from 9·1 (1·6–45·8) to 7·9 (1·4–22·7) pmol/l (P < 0·001) respectively in the RT+ group, but did not change in the RT– group. Longitudinal regression analysis confirmed a decrease in testosterone and free testosterone after RT. The adjusted change in androstenedione and DHEA-S was not significant in any group. The mean change in testosterone (odds ratio (OR) 2·74, 95 per cent c.i. 1·06 to 7·11; P = 0·038), free testosterone (OR 1·08, 1·02 to 1·15; P = 0·011), androstenedione (OR 1·52, 1·07 to 2·16; P = 0·019) and DHEA-S (OR 0·49, 0·27 to 0·89; P = 0·019) was related to change in sexual desire.
Conclusion
RT decreased levels of androgens predominantly derived from the ovaries, whereas androgens of mainly adrenal origin remained unchanged. Reduction in ovarian androgens may be associated with reduced sexual desire.
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Affiliation(s)
- J Segelman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - C Buchli
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - A Svanström Röjvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, St Göran Hospital, Stockholm, Sweden
| | - P Matthiessen
- Department of Surgery, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - S Arver
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Andrology and Sexual Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - M Bottai
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - M Ahlberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - R Jasuja
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, and Function Promoting Therapies, Weston, Massachusetts, USA
| | - A Flöter-Rådestad
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Division of Obstetrics and Gynaecology, Karolinska University Hospital, Stockholm, Sweden
| | - A Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
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