Survival of patients with Stage III colon cancer is improved in hereditary non-polyposis colorectal cancer compared with sporadic cases. A Danish registry based study

AIM

Patients with hereditary non-polyposis colorectal cancer (HNPCC) seem to have a better prognosis than those with sporadic colorectal cancer (CRC). The aim was to compare survival after Stage III CC in patients with HNPCC with those having sporadic CC.

METHOD

A total of 230 patients with hereditary cancer from the Danish HNPCC Register and 3557 patients with sporadic CC from the Danish Colorectal Cancer Database, diagnosed during May 2001-December 2008, were included. HNPCC patients were classified according to mismatch repair mutation status and family pedigree. Sporadic cases had no known family history of cancer. Patient characteristics, geographical differences and survival data were analysed.

RESULTS

The overall survival (OS) was better in HNPCC patients compared with sporadic CC after stratification for sex and age (P = 0.02; CI 1.04-1.7). The 5-year survival was 70% in HNPCC patients compared with 56% in sporadic CC (P < 0.001). No survival difference was found between HNPCC subgroups but a tendency to better OS was seen in patients with Lynch syndrome. No geographical differences in OS were found. The median follow-up was 3.9 (0-9.5) years for HNPCC vs 3.2 (0-9.6) years for sporadic CC.

CONCLUSION

HNPCC patients with Stage III CC have a better OS compared with sporadic CC. No significant difference in OS was found within HNPCC subgroups.

Result of the implementation of multidisciplinary teams in rectal cancer

AIM

In 2003 colorectal multidisciplinary teams (MDTs) were established in all major Danish hospitals treating colorectal cancer. The aim was to improve the prognosis by multidisciplinary evaluation and decision about surgical and oncological treatment, based on medical history, clinical examination, imaging, histology and comorbidity. The present study evaluates the effect of the introduction of colorectal MDTs on 1 August 2004 in two Danish hospitals.

METHOD

A retrospective cohort study was conducted comparing the outcome during the last 3 years before introduction of MDTs with the first 2 years after (the MDT cohort). The national colorectal cancer database, with follow-up recorded by the National Patient Registry in September 2010 was used. The end-points included the incidence of preoperative radiochemotherapy offered according to the national guidelines, R0/R1/R2 resection, postoperative mortality, local recurrence, distant recurrence and over-all and disease-free survival.

RESULTS

Eight hundred and eleven patients were diagnosed with primary rectal cancer in Hvidovre and Bispebjerg hospitals between 1 May 2001 and 31 August 2006. The frequency of preoperative MRI scans increased in the MDT cohort and perioperative mortality decreased. More metachronous distant metastases were found in the MDT cohort but there was no difference in overall survival.

CONCLUSION

There was an improved postoperative mortality but no other potential benefits for the patients were seen after the implementation of colorectal MDTs.

Primary and secondary restorative proctocolectomy for familial adenomatous polyposis: complications and long-term bowel function

AIM

The aim of the study was to evaluate intra-operative difficulties, complications and long-term bowel function in polyposis patients undergoing conversion of an ileorectal anastomosis to an ileoanal pouch, compared with patients with a primary ileoanal pouch operation.

METHOD

A national register-based retrospective study was performed with clinical follow-up and a questionnaire on long-term bowel function.

RESULTS

There were 84 patients in the study: 59 (70%) had a primary pouch operation and in 25 (30%) a secondary pouch procedure was attempted. This was abandoned, in one case, leaving 24 patients who had a successful secondary restorative proctocolectomy. The median (range) follow-up was 123 (0-359) months. There were no intra-operative difficulties in the 59 primary operations, but intra-operative difficulties were reported in nine of 25 secondary operations (P < 0.001). Complications within 1 month of surgery occurred in six of 59 primary operations and in none of 24 secondary operations (P < 0.001); and late surgical complications occurred in eight of 55 primary operations and in eight of 24 secondary operations (P = 0.13). The only difference in bowel function was a lower frequency of nocturnal defaecation after secondary pouch formation (P = 0.02).

CONCLUSION

Reoperation with proctectomy after a previous ileorectal anastomosis and conversion to restorative proctocolectomy is feasible in polyposis patients, with morbidity and functional results similar to those seen after a primary pouch operation.

The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study

BACKGROUND

Transanal endoscopic microsurgery (TEM) allows locally complete resection of early rectal cancer as an alternative to conventional radical surgery. In case of unfavourable histology after TEM, or positive resection margins, salvage surgery can be performed. However, it is unclear if the results are equivalent to primary treatment with total mesorectal excision (TME). The aim of this retrospective study was to determine whether there is a difference in outcome between patients who underwent early salvage resection with TME after TEM, and those who underwent primary TME for rectal cancer.

METHODS

From 1997 to 2011, early salvage surgery with TME after TEM was performed in 25 patients in our institution. These patients were compared with 25 patients who underwent primary TME, matched according to gender, age (±2 years), cancer stage and operative procedure. Data were obtained from the patients' charts and reviewed retrospectively. No patients received preoperative chemotherapy. Perioperative data and oncological outcome were analysed. The Mann-Whitney U-test and Fisher's exact test were used to compare the results between the two groups.

RESULTS

There was no significant difference between the two groups in median operating time (P = 0.39), median blood loss (P = 0.19) or intraoperative complications (P = 1.00). The 30-day mortality was 8 % (n = 2) among patients who underwent salvage TME after TEM, and no patients died in the primary TME group (P = 0.49). There was no significant difference between two groups of patients in the median number of harvested lymph nodes (P = 0.34), median circumferential resection margin (CRM) (P = 0.99) or the completeness of the mesorectal fascia plane. No local recurrences occurred among the patients with salvage TME, and there were 2 patients (8 %) with local recurrences among the patients with primary TME (P = 0.49). Distant metastasis occurred in one patient (4 %) after salvage TME and in 3 patients (12 %) with primary TME (P = 0.61). The median follow-up time was 25 months (3-126) for patients who underwent salvage TME and 19 months (3-73) for patients after primary TME.

CONCLUSIONS

No difference was found in outcome between patients with rectal cancer undergoing salvage TME after TEM, those undergoing primary TME. In selected patients, TEM can therefore be chosen as a primary treatment, since failure of treatment and subsequent conventional resection appears not to compromise the outcome.

Duodenal surveillance improves the prognosis after duodenal cancer in familial adenomatous polyposis

AIM

Duodenal adenomatosis in familial adenomatous polyposis results in a cancer risk that increases with age. Endoscopic surveillance has been recommended, but the effect has not yet been documented. The aim of this study was to present the results of long-term duodenal surveillance and to evaluate the risk of cancer development.

METHOD

Follow up of patients in a previous study with gastroduodenoscopy in 1990-2010. Statistical analysis included the χ(2) test, actuarial method and Kaplan-Meier analysis.

RESULTS

Among 304 patients, 261 (86%) had more than one endoscopy. The median follow up was 14 (interquartile range, 9-17) years. The cumulative lifetime risk of duodenal adenomatosis was 88% (95% CI, 84-93), and of Spigelman stage IV was 35% (95% CI, 25-45). The Spigelman stage improved in 32 (12%) patients, remained unchanged in 88 (34%) and worsened in 116 (44%). Twenty (7%) patients had duodenal cancer at a median age of 56 (range, 44-82) years. The cumulative cancer incidence was 18% at 75 years of age (95% CI, 8-28) and increased with increasing Spigelman stage at the index endoscopy to 33% in Spigelman stage IV (P < 0.0001). The median overall survival was 6.4 years (95% CI, 1.7 to not estimated): 8 years after a screen-detected cancer vs 0.8 years (95% CI, 0.03-1.7) after a symptomatic cancer (P < 0.0001). The location of the mutation in the APC gene did not influence the risk of developing Spigelman stage IV (P = 0.46) or duodenal cancer (P = 0.83).

CONCLUSION

The risk of duodenal cancer in familial adenomatous polyposis is considerable, and regular surveillance and cancer prophylactic surgery result in a significantly improved prognosis.

Mucosectomy and stapled pouch-anal anastomosis in familial adenomatous polyposis

AIM

In familial adenomatous polyposis, a restorative proctocolectomy with an ileo-anal pouch may be performed either with a mucosectomy and a hand-sewn anastomosis or as a stapled anastomosis without a mucosectomy. The disadvantage of the former is suboptimal bowel function and the disadvantage of the latter is a high risk of recurrent adenomas in the rectal mucosal remnant.

METHOD

A procedure is presented that combines the advantages of mucosectomy and stapled ileo-anal anastomosis.

RESULTS

No severe complications were seen in 14 patients. After a median follow up of 29 (range 7-144) months, 13 (93%) patients were fully continent day and night with a median frequency of defecation of 5 (range 2-8)/24 h. No adenomas were found at the annual endoscopic follow up.

CONCLUSION

Mucosectomy with a stapled ileo-anal pouch has few complications. Short-term results show good function and a very low risk of recurrent adenoma development.

Intra-operative perforation is an important predictor of local recurrence and impaired survival after abdominoperineal resection for rectal cancer

AIM

Abdominoperineal resection for rectal cancer is associated with higher rates of local recurrence and poorer survival than anterior resection. The aim of this study was to evaluate the outcome of conventional abdominoperineal resection in a large national series.

METHOD

The study was based on the Danish National Colorectal Cancer Database and included patients treated with abdominoperineal resection between 1 May 2001 and 31 December 2006. Follow up in the departments was supplemented with vital status in the Civil Registration System. The analysis included actuarial local and distant recurrence, and overall and cancer-specific survival. Risk factors for local recurrence, distant metastases, overall survival and cancer-specific survival were identified using multivariate analyses.

RESULTS

A total of 1125 patients were followed up for a median of 57 (25-93) months. Intra-operative perforation was reported in 108 (10%) patients. The cumulative 5-year local recurrence rate was 11% [95% confidence interval (CI), 7-13)], overall survival was 56% (95% CI, 53-60) and cancer-specific survival was 68% (95% CI, 65-71). Multivariate analysis showed that perforation, tumour stage and nonradical surgery were independent risk factors for local recurrence; tumour fixation to other organs, perforation and tumour stage were independent risk factors for distant metastases; and risk factors for impaired overall survival and cancer-specific survival were age, tumour perforation, tumour stage, lymph node metastases and nonradical surgery.

CONCLUSION

Intra-operative perforation is a major risk factor for local and distant recurrence and survival and therefore should be avoided.

Attenuated familial adenomatous polyposis: results from an international collaborative study

AIM

The study aimed to describe genetical and clinical features of attenuated familial adenomatous polyposis (AFAP) and to propose clinical criteria and guidelines for treatment and surveillance.

METHOD

A questionnaire study was carried out of polyposis registries with data on patients with presumed AFAP, defined as having ≤ 100 colorectal adenomas at age ≥ 25.

RESULTS

One hundred and ninety-six patients were included. The median number of adenomas was 25 (0-100) with a uniform distribution of colorectal adenomas and carcinomas (CRC). Age at CRC diagnosis was delayed by 15 years compared with classic FAP. Eighty-two patients had a colectomy and an ileorectal anastomosis and 5/82 (6%) had a secondary proctectomy. The location of the mutation in the APC gene was known in 69/171 (40%) tested patients. Only 15/29 (52%) of mutations in APC were found in parts of the gene usually associated with AFAP (the 5' end, exon 9 and 3' end).

CONCLUSIONS

A subset of FAP patients with a milder phenotype does exist and treatment and surveillance had to be modified accordingly. The mutation detection rate is lower than in classic FAP and mutations in AFAP patients are located throughout the APC gene. We propose the following clinical diagnostic criteria for AFAP: a dominant mode of inheritance of colorectal adenomatosis and <100 colorectal adenomas at age 25 or older. Colonoscopy had to be preferred to sigmoidoscopy and surveillance had to be life-long. In the majority of patients, prophylactic colectomy and ileorectal anastomosis are recommended at the age of 20-25 years.

Improved survival after rectal cancer in Denmark

OBJECTIVE

In 1995, an analysis showed an inferior prognosis after rectal cancer in Denmark compared with the other Scandinavian countries. The Danish Colorectal Cancer Group (DCCG) was established with the aim of improving the prognosis, and in this study we present a survival analysis of patients treated from 1994 to 2006.

METHOD

The study was based on the National Rectal Cancer Registry and the National Colorectal Cancer Database, supplemented with data from the Central Population Registry. The analysis included actuarial overall and relative survival.

RESULTS

A total of 10 632 patients were operated on. The overall 5-year survival increased from 0.37 in 1994 to 0.51% in 2006; the improvement was greater in men (20% points) than in women (10% points), and greatest in stage III (20% points). The relative 5-year survival increased from 0.46 to 0.62, including an improvement of 23% points in men and 9% points in women and the greatest in stage III (22% points).

CONCLUSIONS

The prognosis has improved substantially, probably mainly because of initiatives taken by the DCCG, among which implementation of total mesorectal excision, improved staging and centralized treatment are considered most important.

Peutz-Jeghers syndrome: a systematic review and recommendations for management

Peutz-Jeghers syndrome (PJS, MIM175200) is an autosomal dominant condition defined by the development of characteristic polyps throughout the gastrointestinal tract and mucocutaneous pigmentation. The majority of patients that meet the clinical diagnostic criteria have a causative mutation in the STK11 gene, which is located at 19p13.3. The cancer risks in this condition are substantial, particularly for breast and gastrointestinal cancer, although ascertainment and publication bias may have led to overestimates in some publications. Current surveillance protocols are controversial and not evidence-based, due to the relative rarity of the condition. Initially, endoscopies are more likely to be done to detect polyps that may be a risk for future intussusception or obstruction rather than cancers, but surveillance for the various cancers for which these patients are susceptible is an important part of their later management. This review assesses the current literature on the clinical features and management of the condition, genotype-phenotype studies, and suggested guidelines for surveillance and management of individuals with PJS. The proposed guidelines contained in this article have been produced as a consensus statement on behalf of a group of European experts who met in Mallorca in 2007 and who have produced guidelines on the clinical management of Lynch syndrome and familial adenomatous polyposis.

A national cohort study of long-course preoperative radiotherapy in primary fixed rectal cancer in Denmark

OBJECTIVE

Preoperative radiotherapy has been shown to enable a fixed rectal cancer to become resectable which in turn may result in long-time survival. In this study, we analysed the outcome of long-course preoperative radiotherapy in fixed rectal cancer in a national cohort including all Danish patients registered with primary inoperable rectal cancer and treated in the period May 2001 to December 2005.

METHOD

The study was based on surgical and demographic data from a continuously updated and validated national database. In addition, retrospective data were retrieved from all departments of radiotherapy concerning technique of radiotherapy, dose and fractionation and use of concomitant chemotherapy. Outcome was determined by actuarial analysis of local control, disease-free survival and overall survival.

RESULTS

A total of 258 patients with fixed rectal cancer received long-course radiotherapy (> 45 Gy). The median age at diagnosis was 66 years (range: 32-85) and 185 (72%) patients were male. The resectability rate was 80%, and a R0 resection was obtained in 148 patients (57% of all patients and 61% of those operated). The 5-year local recurrence rate for all patients was 5% (95% CI: 3-7%), and the actuarial distant recurrence rate was 41% (95% CI: 35-47%). The cumulative 5-year disease-free survival was 27% (95% CI: 22-32%) and overall 5-year survival was 34% (95% CI: 29-39%).

CONCLUSIONS

This study is the first population-based report on outcome of preoperative long-course radiotherapy in a large unselected patient group with clinically fixed rectal cancer. Most patients could be resected with the intention of cure and one in three was alive after 5 years.

Clinical outcome in 520 consecutive Danish rectal cancer patients treated with short course preoperative radiotherapy

AIM

The purpose of this study was to analyse the results of preoperative short course radiotherapy in a consecutive, national cohort of patients with rectal cancer.

METHODS

Through a validated, prospective national database we identified 520 Danish patients who presented with high-risk mobile tumours in the lower two thirds of the rectum and were referred for preoperative radiotherapy with 5 x 5 Gy. The inclusion period was 56 months. Radiotherapy data was retrospectively collected.

RESULTS

Of the 520 patients, 514 completed radiotherapy and 506 had surgery. Surgery was considered curative in 439 patients. The 3-year local recurrence rate was 4.0% (95% CI 2.5-6.5%) and the distant recurrence rate at 3 years was 18.7% (95% CI 15.4-22.5%). The 5-year disease free survival rate was 40.2% (95% CI 27.0-53.1%) and overall survival 50.4% (95% CI 36.1-63.1%). Most tumours (61%) were classified as T3 or T4 and 41% of the local recurrences occurred in patients with a fixed tumour at surgery.

CONCLUSION

This study confirms data from randomised studies that the short course 5 x 5 Gy regime is a feasible treatment for locally advanced rectal cancer even when applied in a population outside clinical trials.

Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer

BACKGROUND

Only a few small studies have evaluated risk factors related to early death following emergency surgery for colonic cancer. The aim of this study was to identify risk factors for death within 30 days after such surgery.

METHODS

Some 2157 patients who underwent emergency treatment for colonic cancer from May 2001 to December 2005 were identified from the national colorectal cancer registry. Thirty-day mortality rates were calculated and risk factors for early death were identified using logistic regression analysis.

RESULTS

The overall 30-day mortality rate was 22.1 per cent. The strongest risk factor for early death was postoperative medical complications (cardiopulmonary, renal, thromboembolic and infectious), with an odds ratio of 11.7 (95 per cent confidence interval 8.8 to 15.5). Such complications occurred in 24.4 per cent of patients, of whom 57.8 per cent died. Other independent risk factors were age at least 71 years, male sex, American Society of Anesthesiologists grade III or more, palliative outcome, tumour perforation, splenectomy and adverse intraoperative surgical events. Postoperative surgical complications were noted in 20.4 per cent of the patients but had no statistically significant influence on mortality.

CONCLUSION

Emergency surgery for colonic cancer is still associated with an increased risk of death. There is a need for a system providing increased safety in the perioperative period.

Guidelines for the clinical management of familial adenomatous polyposis (FAP)

Familial adenomatous polyposis (FAP) is a well-described inherited syndrome, which is responsible for <1% of all colorectal cancer (CRC) cases. The syndrome is characterised by the development of hundreds to thousands of adenomas in the colorectum. Almost all patients will develop CRC if they are not identified and treated at an early stage. The syndrome is inherited as an autosomal dominant trait and caused by mutations in the APC gene. Recently, a second gene has been identified that also gives rise to colonic adenomatous polyposis, although the phenotype is less severe than typical FAP. The gene is the MUTYH gene and the inheritance is autosomal recessive. In April 2006 and February 2007, a workshop was organised in Mallorca by European experts on hereditary gastrointestinal cancer aiming to establish guidelines for the clinical management of FAP and to initiate collaborative studies. Thirty-one experts from nine European countries participated in these workshops. Prior to the meeting, various participants examined the most important management issues according to the latest publications. A systematic literature search using Pubmed and reference lists of retrieved articles, and manual searches of relevant articles, was performed. During the workshop, all recommendations were discussed in detail. Because most of the studies that form the basis for the recommendations were descriptive and/or retrospective in nature, many of them were based on expert opinion. The guidelines described herein may be helpful in the appropriate management of FAP families. In order to improve the care of these families further, prospective controlled studies should be undertaken.

Transanal stent in anterior resection does not prevent anastomotic leakage

OBJECTIVE

A defunctioning transanal stent may theoretically reduce the leakage rate after anterior rectal resection. We present a randomized open study with the aim of comparing the leakage rate after anterior resection with a loop ileostomy, a transanal stent, both or neither.

PATIENTS AND METHODS

Randomized open trial of 194 patients operated in 11 hospitals during September 2000 to September 2003 with anterior resection for a mobile rectal tumour, 115 men and 79 women, median age 68 years (range 37-90 years). The surgeon decided upon the use of a protective ileostomy, and after completion of the operation the patients were randomized in two groups with and without a transanal stent.

RESULTS

A clinically significant leakage was diagnosed in 25 patients (13%). No significant difference was found 17 of 98 patients with a stent and 8 of 96 without (P = 0.09), or in 9 of 44 ileostomy patients with a stent and in 3 of 45 without (P = 0.07). Several leaks over a short time led to an interim analysis after inclusion of 194 of 448 planned patients. The analysis showed no significant protective effect of the stent, and more leakages in the stent group, although not statistically significant. On this basis it was decided to discontinue the study prematurely for ethical reasons.

CONCLUSION

Decompression of the anastomosis with a transanal stent does not reduce the risk of anastomotic leakage after anterior resection.

Hospital volume and outcome of rectal cancer surgery in Denmark 1994-99

OBJECTIVE

The association between hospital volumen and outcome of major cancer surgery is being debated at present. We analysed the outcome of rectal cancer surgery in Denmark during the period 1994-99.

METHODS

All patients with a first-time rectal cancer were registered in a national database during the 5-year period. In this observational cohort study, the influence of hospital case volume on resectional procedure, complications, 30-day mortality and 5-year mortality was analysed.

RESULTS

The register comprised 5021 patients. Surgery was performed in 27 hospitals with <15 operations per year, 15 hospitals with 15-30 operations per year and 11 hospitals with >30 operations per year. In a multivariate model, the risk of permanent colostomy was significantly increased in the group of low-volume hospitals. On the contrary, volume did not influence the risk of anastomotic leakage, 30-day mortality and 5-year mortality. However, a large variation in 5-year mortality was observed particularly within the low-volume group of hospitals.

CONCLUSIONS

In this study, only risk of having a permanent colostomy during surgery for rectal cancer was significantly related to hospital case volume. When individual hospitals were analysed, a large variation in 5-year mortality was observed within the low-volume group of hospitals.

Blood loss and transfusion after total mesorectal excision and conventional rectal cancer surgery

OBJECTIVES

A recent study showed less bleeding and need of transfusion after total mesorectal excision (TME) compared with conventional rectal cancer surgery. The aim of this study was to evaluate this result in more details.

PATIENTS AND METHODS

Comparison of transfusion history in rectal cancer resections in two different multicentre-studies. Two hundred and forty-six patients were operated in the period 1991-93 with a conventional technique and 311 patients were operated with TME-technique in the period 1996-98. Peri-operative data, including blood transfusion from one month before until one month after the operation, was recorded prospectively.

RESULTS

The median intra-operative blood loss was 1000 ml, range 50-6000 ml, before, and 550 ml, range 10-6000 ml (P < 0.001) after introduction of TME. The overall peri-operative transfusion rate was reduced from 73% to 43% (P < 0.001). When adjusted for blood loss, age, gender, weight, and type of resection, TME significantly reduced the risk of receiving intra or postoperative blood transfusion by 0.4 (CI: 0.3-0.6). The variability in blood loss among 12 TME-centres was more than 400% and not correlated with transfusion requirements within the centres.

CONCLUSION

TME results in a reduced blood loss and a reduction of blood transfusion, but additional factors others than blood loss seems to influence the decision of transfusion.

Survival of rectal cancer patients in Denmark during 1994-99

OBJECTIVE

As survival from rectal cancer in Denmark is below the European average, we analysed survival during the period of 1994-99 focusing upon improvement strategies.

METHOD

All patients with a first-time rectal cancer were registered in a national database during this 5-year period. In the observational cohort study, data on patient age and gender, tumour stage, surgical procedures, adjuvant radiotherapy, anastomotic leakage, 30-day mortality and long-term survival were evaluated.

RESULTS

The database comprised 5021 patients. Sixty-four percent had a localized tumour. Less than a third of patients with fixed tumours had pre-operative radiotherapy and curative surgery was achieved in 70%. Anastomotic leakage occurred in 13%, and 30-day mortality was 4% following abdominoperineal or anterior resection and 11% following a Hartmann's procedure. The relative 5-year survival in the entire series was 39% in males and 47% in females, respectively. Following curative surgery the relative 5-year survival was 55% in males and 63% in females, respectively. Survival was 71% in the subset of patients receiving curative total mesorectal excision.

CONCLUSION

The average tumour stage upon diagnosis was probably more advanced compared to the other Nordic countries and pre-operative radiotherapy was administered to a minority of patients with fixed tumours. The anastomotic leakage rate was relatively high, whereas the 30-day mortality was comparable to other studies. Survival from rectal cancer in Denmark is still less favourable compared to the other Nordic and several European countries but improved from 1996 and onwards.

Duodenal adenomatosis in familial adenomatous polyposis

BACKGROUND

The prevalence of duodenal carcinoma is much higher in familial adenomatous polyposis (FAP) than in the background population, and duodenal adenomatosis is found in most polyposis patients.

AIMS

To describe the long term natural history of duodenal adenomatosis in FAP and evaluate if cancer prophylactic surveillance of the duodenum is indicated.

METHODS

A prospective five nation study was carried out in the Nordic countries and the Netherlands.

PATIENTS

A total of 368 patients were examined by gastroduodenoscopy at two year intervals during the period 1990-2001.

RESULTS

At the first endoscopy, 238 (65%) patients had duodenal adenomas at a median age of 38 years. Median follow up was 7.6 years. The cumulative incidence of adenomatosis at age 70 years was 90% (95% confidence interval (CI) 79-100%), and of Spigelman stage IV 52% (95% CI 28-76%). The probability of an advanced Spigelman score increased during the study period (p<0.0001) due to an increasing number and size of adenomas. Two patients had asymptomatic duodenal carcinoma at their first endoscopy while four developed carcinoma during the study at a median age of 52 years (range 26-58). The cumulative incidence rate of cancer was 4.5% at age 57 years (95% CI 0.1-8.9%) and the risk was higher in patients with Spigelman stage IV at their first endoscopy than in those with stages 0-III (p<0.01).

CONCLUSIONS

The natural course of duodenal adenomatosis has now been described in detail. The high incidence and increasing severity of duodenal adenomatosis with age justifies prophylactic examination, and a programme is presented for upper gastrointestinal endoscopic surveillance.

Familial adenomatous polyposis patients without an identified APC germline mutation have a severe phenotype

BACKGROUND

Development of more than 100 colorectal adenomas is diagnostic of the dominantly inherited autosomal disease familial adenomatous polyposis (FAP). Germline mutations can be identified in the adenomatous polyposis coli (APC) gene in approximately 80% of patients. The APC protein comprises several regions and domains for interaction with other proteins, and specific clinical manifestations are associated with the mutation assignment to one of these regions or domains.

AIMS

The phenotype in patients without an identified causative APC mutation was compared with the phenotype in patients with a known APC mutation and with the phenotypes characteristic of patients with mutations in specific APC regions and domains.

PATIENTS

Data on 121 FAP probands and 149 call up patients from 70 different families were extracted from the Danish Polyposis register.

METHODS

Differences in 16 clinical manifestations were analysed according to the patient's mutational status. Two sided independent t sample test, two sided chi(2) test, and odds ratios were calculated.

RESULTS

Patients without identified APC mutations had a unique and severe phenotype, which was roughly described as: young age at diagnosis and subsequent death in spite of development of few colorectal adenomas; low risk of involvement of the upper gastrointestinal tract, as reflected by a low mean Spigelman stage, and a low risk of fundic gland polyposis. Finally, they had significantly fewer affected family members, although they do not themselves more often represent an isolated case.

CONCLUSIONS

The severe phenotype should be considered when counselling FAP families in which attenuated FAP is excluded and in which a causative APC mutation has not been identified.

Desmoid tumour in familial adenomatous polyposis. A review of literature

Desmoid tumours (DT) are rare benign tumours that do not metastasise, but tend to invade locally. DT are frequently seen in patients with familial adenomatous polyposis (FAP), and diagnosis and treatment are often difficult. Surgical trauma, genetic predisposition and hormonal factors are considered to be correlated with the development and growth of DT. In patients with FAP, 50% of the tumours are localised intra-abdominally, and 85-100% of these are mesenteric. DT frequently present as non- tender, slowly growing masses. The symptoms are abdominal pain, vomiting, diarrhoea or haematochezia. Mesenteric DT can cause small bowel obstruction or ischaemia, hydronephrosis or form fistulas. Diagnosis is obtained through biopsy and the extension is determined by a CT-scan. Surgical excision is recommended in patients with DT in the abdominal wall. First line treatment of mesenteric DT is a NSAID in combination with tamoxifen. Surgery may be considered in case of a small and well-defined DT with no signs of invasion of vital structures, and in cases of imminent bowel ischaemia or obstruction. The prognosis in mesenteric DT is serious, and improvement of the therapeutic strategy awaits current international studies.

Recurrence and survival after mesorectal excision for rectal cancer

BACKGROUND

Mesorectal excision for rectal cancer has resulted in local recurrence rates of 3-11 per cent compared with up to 38 per cent after conventional methods. The results of a prospective Danish study with a historical control group are presented.

METHODS

Three hundred and eleven patients with a mobile rectal cancer had mesorectal excision with curative intent performed by certified surgeons and were followed for 3 years. Demographic, perioperative and follow-up data were recorded prospectively. A series of patients who had conventional operations for rectal cancer served as a control group.

RESULTS

The cumulative 3-year local recurrence rate was 11 per cent after mesorectal excision compared with 30 per cent after conventional surgery (hazard ratio (HR) 0.33 (95 per cent confidence interval (c.i.) 0.21 to 0.52); P < 0.001). Multivariate regression analysis showed that only advanced age (HR 0.97 (95 per cent c.i. 0.94 to 1.00); P = 0.048) and tumour in the lower third of the rectum (HR 0.21 (95 per cent c.i. 0.04 to 1.97); P = 0.075) were marginal independent predictors of local recurrence after mesorectal excision. The cumulative crude 3-year survival rate was 77 per cent after mesorectal excision and 62 per cent after conventional surgery (HR 0.58 (95 per cent c.i. 0.43 to 0.77); P < 0.001). Age was the only independent predictor of death after mesorectal excision (HR 1.04 (95 per cent c.i. 1.02 to 1.07); P = 0.001).

CONCLUSION

Mesorectal excision is associated with a considerably lower risk of local recurrence and a better survival rate than conventional surgery, and is the optimum method for rectal cancer resection.

Results of national registration of familial adenomatous polyposis

BACKGROUND AND AIMS

The Danish Polyposis Register was established in 1971 with the aim of improving the poor prognosis of familial adenomatous polyposis (FAP), and in 1975 the register became national. The aim of the present study was to evaluate the prevalence of colorectal cancer and survival rate in FAP patients before and after the establishment of the Danish Polyposis Register.

PATIENTS AND METHODS

The Danish Polyposis Register was established by collecting information on probands and construction of their pedigrees. Family members at risk were offered prophylactic endoscopic and molecular genetic examination, and affected individuals were treated by colectomy.

RESULTS

At the end of 2001, the Danish Polyposis Register included 434 patients from 165 families. The incidence rate was 1.90x10(-6) and the prevalence rate 4.65x10(-5). Colorectal cancer on the basis of FAP constituted 0.07% of all colorectal cancers in the 1990s. Colorectal cancer was diagnosed in 170/252 probands (67%) and in 5/182 call-up patients (3%) (p<0.001). The cumulative crude survival was 94% in call-up patients compared with 44% in probands (p<0.0001). A comparison of two periods, 1900-1975 and 1976-2001, demonstrated a decreased prevalence of colorectal cancer from 60% to 27% (p<0.0001), and an increased use of colectomy from 52% to 93% (p<0.00001). The cumulative crude survival in FAP showed substantial improvement with time (p<0.00001).

CONCLUSION

Since the establishment of the Danish Polyposis Register, the prevalence of colorectal cancer has decreased considerably and the prognosis has improved substantially. The work of the Danish Polyposis Register is probably the main cause of this improvement.

CT- and MR colonography

BACKGROUND

Colorectal cancer is the second most frequent cancer and adenomas are widely accepted as precursors to colorectal cancer. Diagnosis and removal of adenomas are recommended to reduce cancer incidence and mortality. The current diagnostic methods include sigmoidoscopy and colonoscopy. Lately, CT- and MR colonography have emerged as non-invasive methods for colon imaging.

METHODS

At present, CTC and MRC require bowel preparation. However, preliminary studies have been carried out without colon preparation. After the colon has been filled with air or contrast, the patient is scanned in the supine and prone positions. Data are then downloaded to a workstation for post processing and image-analysis.

RESULTS

Results have shown a high sensitivity and specificity for polyps > or = 10 mm, comparable to the sensitivity of conventional colonoscopy and superior to double contrast barium enema.

CONCLUSIONS

With the exponential development in computer processing power, CT- and MR colonography holds the promise for future colon examination with the advantages of non-invasiveness, no need for sedation, and probably no bowel preparation. A major disadvantage, however, is the radiation dose during CT colonography. Future developments with the use of "intelligent" computers, better resolution and faster examinations will make CT and/or MR colonography realistic options to replace conventional diagnostic colonoscopy.

Female fecundity before and after operation for familial adenomatous polyposis

BACKGROUND

Knowledge about the fertility of women suffering from familial adenomatous polyposis (FAP) is scarce and inconclusive. The purpose of this study was to investigate the fecundity of women with FAP before and after operation, and to compare the findings with those of a general population database and women with ulcerative colitis.

METHODS

A questionnaire concerning reproductive experiences and waiting times to pregnancy was sent to all 230 women on the polyposis registers in Denmark, Finland, Sweden and Norway in whom primary surgery had consisted of ileorectal anastomosis or ileal pouch-anal anastomosis. Data on the general population and women with ulcerative colitis came from an existing database. Cox regression and Kaplan-Meier plots were used for analysis.

RESULTS

The fecundity of women with FAP before operation and after colectomy with ileorectal anastomosis was similar to that of the general population. However, fecundity dropped to 54 per cent (P = 0.015) following proctocolectomy with ileal pouch-anal anastomosis, although it was greater than the postoperative fecundity of women with ulcerative colitis.

CONCLUSION

The significant reduction in female fecundity after ileal pouch-anal anastomosis should be communicated to young women with FAP before it is decided which surgical option to follow.

[Sigmoidoscopy as primary examination in patients with bowel symptoms]

INTRODUCTION

Flexible sigmoidoscopy is recommended in the literature and is now officially recommended as the primary diagnostic method in patients with symptoms consistent with colorectal cancer. Sigmoidoscopy can detect two-thirds of all colorectal cancers.

MATERIAL AND METHODS

We carried out a retrospective analysis of prospective data on symptoms and findings at FS in 682 patients, above the age of 40 years, referred to a private specialist for rectal bleeding, change in bowel habits, or unspecific abdominal symptoms. The chi 2-test and logistic multivariate regression analysis were used to estimate the predictive value of symptoms for neoplasia.

RESULTS

Carcinoma was found in 31 (5%) and adenoma in 76 (11%), i.e., neoplasia in 16%. Logistic multivariate regression showed that bleeding in or on the faeces (p < 0.0001, OR 10.6 and 11.6), mucous discharge (p = 0.02, OR 3.0), and change in bowel habits (p = 0.02, OR 3.0) were independent risk factors of cancer, and bleeding on the faeces (p = 0.0002, OR 3.2) or in the faeces (p = 0.02, OR 2.7) were independent risk factors of adenoma.

DISCUSSION

On the basis of the literature and the present results, we conclude that sigmoidoscopy is a suitable primary diagnostic method for the detection of neoplasia in the rectum and left colon in patients with bowel symptoms. Bleeding, mucous discharge, and change in bowel habits are independent risk factors for carcinoma and bleeding for adenoma.

Decision analysis in the surgical treatment of patients with familial adenomatous polyposis: a Dutch-Scandinavian collaborative study including 659 patients

BACKGROUND AND AIMS

The choice of colorectal surgery in patients with familial adenomatous polyposis lies between the morbidity of proctocolectomy and ileum-pouch-anal anastomosis (IPAA) and the mortality from rectal cancer after total colectomy and ileorectal anastomosis (IRA). The aims of the present study were: (1) to assess the risk of dying from rectal cancer after IRA, (2) to compare the life expectancy between patients with an IRA and those with an IPAA, and (3) to investigate whether regular endoscopic examination of the rectum leads to detection of cancer at an earlier stage.

METHODS

Clinical and pathological data on 659 patients who underwent colectomy and ileorectal anastomosis were collected from four national polyposis registries-that is, in Denmark, Finland, Sweden, and the Netherlands. Data were analysed using survival analysis methods. Decision analysis was used to compare the life expectancy between patients with an IRA and those with an IPAA.

RESULTS

A total of 47 patients developed rectal cancer after IRA. The risk of dying from rectal cancer was 12.5% (95% confidence interval 7.1--17.9%) by age 65. Compared with IRA, IPAA would lead to an increase in life expectancy of 1.8 years. Seventy five per cent of patients with rectal cancer had a negative rectoscopy within 12 months before the diagnosis.

CONCLUSION

IRA is associated with substantial mortality due to rectal cancer. Follow up examinations of the rectum does not have sufficient preventive effect on morbidity and mortality of rectal cancer.

[Recurrence and survival after conventional low anterior resection for rectal cancer]

INTRODUCTION

The aim of the study was to evaluate the incidence of recurrence of local cancer, distant metastases and survival after conventional low anterior resection for cure in patients with rectal carcinoma, on the basis of the poor prognosis after colorectal cancer in Denmark.

MATERIAL AND METHODS

Consecutive patients operated on in the nine Danish departments of surgical gastroenterology in 1992-1993. Retrospective collection of data on recurrence of local cancer, distant metastases, and over-all survival at the end of 1996.

RESULTS

Of 268 patients, 77 (29%) developed recurrent local cancer and/or distant metastases. Forty-eight (18%) had local recurrence with a cumulative 5-year rate of 39%. Distant metastases were seen in 54 (20%). The local recurrence rate increased with increasing Dukes' tumour stage and was higher after operation by a non-specialist (30%) than by a consultant, another specialist, or a surgeon under training and supervised by a consultant (15-17%) (p = 0.04). Multiple regression showed that the recurrence rate was independent of tumour localisation, blood loss, transfusion, anastomotic leakage, and status of the surgeon. The cumulative crude 5-year survival was 50% and independent of the status of the surgeon.

DISCUSSION

Our relatively high local recurrence rate and the results in the literature after total mesorectal excision (TME) indicate that the conventional technique should be replaced by TME, which has become the recommended method in recent years. Furthermore, we propose a changed strategy in the treatment of rectal cancer. The patients should be treated in fewer departments with established teams of rectal cancer specialists taking part in all operations for rectal cancer.

[Changed working plans can improve medical training]

INTRODUCTION

The quality of clinical medical training in Denmark has been closely debated and criticised in recent years. Reorganisation of the daily working plans is one of the recommendations for improvement.

METHOD

In the Department of Gastrointestinal Surgery, we made changes in the daily working plans in order to improve supervision and training. These changes included firmer attachment of the young residents to specialised medical teams in the department and the creation of more supervised working situations. The morning rounds were done by all the senior and junior doctors in the team together, which meant that the rounds could be completed in half-an-hour and consequently more senior doctors were available for supervision during the rest of the day. This was adopted by the outpatient clinic, the endoscopy unit, and the operating rooms, where activities did not start until after the rounds.

RESULTS

The changes led to a considerable increase in the number of working situations with supervision. Assessment by a questionnaire showed that residents also found significant improvements in supervision during all clinical activities. Overall satisfaction with the department and working conditions increased.

CONCLUSION

Many different aspects must be considered if clinical medical training is to improve. One key factor is a thorough revision of the daily working plans, so as to establish as many supervised teaching situations as possible.

[Coloanal pouch in surgery of rectal neoplasms]

BACKGROUND

The aim of this study was to evaluate the rate of complications and the functional result after construction of a coloanal J pouch during low anterior resection of the rectum for cancer.

DESIGN

A retrospective study of medical records and interviews with patients at follow-up.

RESULTS

32 patients were followed-up for a median of 28 months (range 12-82 months). Two patients (6%) developed anastomotic leakage, one of whom died. Two patients developed rectovaginal fistula, one of whom was given a permanent colostomy. One patient died from complications after closure of the diverting ileostomy. In two patients, local cancer recurred and four died from distant metastases. At follow-up, the frequency of bowel movements was median 2/24 h (range 0.3-4). Three of 29 (10%) experienced intermittent incontinence, whereas none complained of evacuation problems.

DISCUSSION

The complication rate was as expected after low anterior rectal resection, but there were unexpected severe complications after closure of the diverting stoma. The functional results were satisfactory and the construction of a colonic J pouch is recommended during low rectal resection, if the defecation pattern and the quality of life is to improve, especially within the first postoperative year.

Ileorectal anastomosis is appropriate for a subset of patients with familial adenomatous polyposis

BACKGROUND & AIMS

This study reevaluates the risk of rectal cancer and the frequency of subsequent proctectomy for nonmalignant causes in patients with familial adenomatous polyposis (FAP) who have undergone colectomy with ileorectal anastomosis (IRA). Potential risk factors for rectal cancer in this setting are also examined, and recommendations for the choice of surgical procedure are made.

METHODS

The national polyposis registries in Denmark, Finland, The Netherlands, and Sweden included 659 patients undergoing surgery with IRA in 1940-1997. Kaplan-Meier analysis and Cox regression analysis were performed to evaluate cumulative risk, survival, and predictive risk factors.

RESULTS

Rectal carcinoma was diagnosed in 47 patients, with a cumulative 40-year risk of 0.32. The cumulative risk according to chronologic age was 0.30 at age 60, and higher in patients undergoing surgery above age 25 (P = 0.0016). Chronologic age was the only independent risk factor (P = 0.0016). The cumulative 5-year survival rate after rectal carcinoma was 0.60. The apc mutation was known in 167 patients, of whom 7 had rectal cancer. The cumulative 40-year risk of secondary proctectomy was 0.70, and higher in patients with a mutation in codon 1250-1500 than outside this region (P = 0.005). However, all 7 rectal cancers were found in the latter group. None of the 18 patients with attenuated FAP (mutation in codon 0-200 or >1500) had a secondary proctectomy.

CONCLUSIONS

IRA is recommended in (1) young patients with few rectal adenomas and a family history of a mild phenotype and (2) patients with attenuated FAP (a mutation in codon 0-200 or >1500), provided there is acceptance of life-long rectal surveillance. Patients with many rectal polyps and/or a family history of severe polyposis should be offered a restorative proctocolectomy with an ileal pouch-anal anastomosis.

[Desmoid tumor in familial adenomatous polyposis]

INTRODUCTION

Desmoid tumors (DT) are rare benign tumors that do not metastasize, but tend to invade locally. DT are frequently seen in patients with familial adenomatous polyposis (FAP), and diagnosis and treatment are often difficult.

METHOD

The article presents the clinical picture, diagnosis and treatment of DT in patients registered in the Danish Polyposis Register by the end of 1999.

RESULTS

Twenty-seven of 486 patients (6%) had DT. Eighteen patients were alive at the time of evaluation. DT were found in the mesentery in 42%, in the abdominal wall in 40%, in the retroperitoneum in 8% and only 10% on the extremities. Fifty percent of the patients had complications (intestinal obstruction, hydronephrosis or fistulas), and 2/9 deaths were caused by DT. Ninety-three percent were treated with surgery, NSAIDs, antioestogenic drugs, chemotherapy or radiotherapy, but all modalities proved disappointing, except for treatment with a combination of the NSAID sulindac and tamoxifen. Five patients treated with this combination showed extensive and long lasting response.

DISCUSSION

Surgical excision is recommended in patients with DT in the abdominal wall. First line treatment of mesenteric DT is Clinoril in combination with tamoxifen. Elective surgery may be considered in patients with a small well-defined DT with no signs of invasion of vital structures, and in patients with imminent bowel ischaemia or obstruction. The prognosis for mesenteric DT is grave, and improvement of the therapeutic strategy awaits current international studies.

Asthma mortality in Danish children and young adults, 1973-1994: epidemiology and validity of death certificates

Several reports indicate that asthma mortality has increased during the last few decades. International comparisons reveal some striking differences in the pattern of asthma mortality. The authors investigated the asthma mortality rate in the Danish child and youth population 1973-1994 and studied the validity of death certificates. The authors reviewed all death certificates coded as asthma death in the International Classification of Diseases (ICD 8-ICD 10 (1994)) and adjacent respiratory code numbers for the age group 1-19 yrs. Hospital records and autopsy reports were assessed to validate the cause of death. Age-standardized and age-specific mortality rates were calculated. From 1973 to 1987 there was a significant upward trend in the mortality. On subdivision, this trend was limited to the age group 15-19 yrs. Generally the mortality rate decreased from 1988 to 1994. Four per cent coded as asthma were false positive. Twelve per cent were false negative asthma deaths, wrongly coded as due to other causes. Only 62% of all true positive death caused by asthma were appropriately coded. The number of false negative certifications increased with increasing autopsy frequency. Asthma mortality rates in Denmark increased in adolescents during 1973-1987 and decreased from 1988 to 1994. A possible explanation may be an increased awareness of asthma symptoms combined with a steadily improved treatment of asthma. Even in children and young adults under the age of 20 yrs, validity problems still make comparisons between countries difficult; even interpretation of national trends requires caution.

Causes of death in familial adenomatous polyposis

BACKGROUND

The prognosis in familial adenomatous polyposis (FAP) has improved over the past decades owing to a reduction in the prevalence of colorectal cancer, resulting from effective early screening. During the same period several polyposis registers have recorded an increasing number of deaths due to duodenal/periampullary cancer and desmoid tumours. The aim of this study was to examine the causes of death with special emphasis on duodenal/periampullary cancer.

METHODS

The material consisted of 328 patients (144 females and 184 males) registered from I January 1943 to 31 December 1992 in the Danish Polyposis Register. The standard mortality rate (SMR) was calculated for known major causes of death, using the entire Danish population as background population. The attributable risk was also calculated for selected death causes.

RESULTS

One hundred and thirty-three patients had died, SMR being 4.98 (95% confidence limits, 4.17-5.90). There were significantly lower SMRs in the call-up group than in the proband group. The late cohort (1943-1992) had lower SMRs than the early group (1889-1942). SMR was significantly increased for death due to colorectal cancer (145), duodenal cancer (214), and ovarian cancer (30). No deaths due to desmoids were observed in the examination period. The attributable risk for colorectal cancer was 29% and for duodenal cancer only 0.6%.

CONCLUSION

Colorectal cancer is the most frequent cause of death in polyposis patients, followed by duodenal/periampullary cancer, but the latter is still a rare cause of death in FAP.

Cumulative risk of developing polyps or malignancy at the ileal pouch-anal anastomosis in patients with familial adenomatous polyposis

Restorative proctocolectomy with an ileal pouch-anal anastomosis is performed in an increasing number of patients with familial adenomatous polyposis (FAP). Two techniques are currently used to construct an ileal pouch-anal anastomosis: (1) a double-stapled anastomosis between the pouch and the anal canal and (2) mucosectomy with a hand-sewn ileoanal anastomosis at the dentate line. Although this procedure is thought to abolish the risk of colorectal adenoma, an increasing number of case reports have been published concerning the development of adenoma at the anastomotic site. The purpose of this study was to evaluate the overall cumulative risk of developing adenomatous polyps after ileal pouch-anal anastomosis and to compare the cumulative risk after either anastomotic technique. A total of 126 consecutive FAP patients undergoing a restorative proctocolectomy were identified from polyposis registries in The Netherlands, Denmark, Italy, Germany, and New York. Life-table analysis was used to calculate the cumulative risk of developing polyps in 97 patients with at least 1 year of endoscopic follow-up (median 66 months, range 12 to 188 months). A double-stapled anastomosis was used in 35 patients, whereas in 62 patients a hand-sewn anastomosis with a mucosectomy was performed. In 13 patients polyps developed at the anastomotic site, four with severe and four with moderate dysplasia. None of the patients developed a carcinoma at the anastomotic site. The cumulative risk of developing a polyp at the anastomotic site was 8% (95% confidence interval 2% to 14%) at 3.5 years and 18% (95% confidence interval 8% to 28%) at 7 years, respectively. The risk of developing a polyp at the anastomotic site within 7 years was 31% for patients with a double-stapled vs. 10% for patients with a hand-sewn anastomosis with mucosectomy (P = 0.03 [log-rank test]). Because FAP patients undergoing a restorative proctocolectomy with either a double-stapled or hand-sewn anastomosis have a substantial risk of developing adenomatous polyps at the anastomotic site, lifelong endoscopic surveillance is mandatory in both groups.

[Carcinoid tumors of the colon and rectum]

The article gives a review of the literature concerning carcinoid tumours of the colon and rectum. Carcinoid tumours of the rectum are more common than of the colon, although these tumours are rarities. The carcinoid tumour grows slowly and the patients can survive for years with the disease. Treatment of the rectal carcinoid depends on the size and invasiveness of the primary tumour, as a non-invasive tumour less than 2 cm in diameter can be locally excised. For carcinoids of the colon, the treatment of tumours of less than 2 cm and without invasion will be local excision. For larger and/or invasive tumours in both colon and rectum the treatment is resection. The prognosis for colonic carcinoids is worse than for rectal carcinoids. Adjuvant treatment forms are briefly described. Follow-up programmes for these patients are generally long (over five years) and include recto-/colonoscopy, and search for metastatic spread.

[Local recurrence after low anterior resection of rectal cancer]

Among 75 consecutive patients operated upon with anterior resection for rectal adenocarcinoma during a five year period, 29 (39%) developed local cancer recurrence. The total cumulative five-year survival was 49%, but only 17% in those with a local cancer recurrence. The most important risk factors for development of local recurrence were tumour fixation, intraoperative blood transfusion and surgical routine. Local recurrence was seen in 4/23 (17%) after operation performed by a consultant, 1/5 (20%) after a consultant-supervised operation and 24/47 (51%) after operation by a senior registrar (p < 0.02). As a consequence we recommend that operation for rectal cancer should only be performed or supervised by a few specialists in colorectal surgery.

Hereditary non-polyposis colorectal cancer: clinical features and survival. Results from the Danish HNPCC register

BACKGROUND

Hereditary non-polyposis colorectal cancer (HNPCC) is a dominantly inherited syndrome characterized by the development of colorectal cancer (CRC) and other carcinomas. Our aim was to evaluate tumour parameters and survival in HNPCC.

METHODS

One hundred and eight Danish HNPCC patients were compared with 870 patients with sporadic colorectal cancer.

RESULTS

The median age at CRC diagnosis was 41 years in the HNPCC group. HNPCC patients had significantly more carcinomas located to the right colon (68% against 49% in controls), more synchromous tumours (7% versus 1%), more metachronous CRC after 10 years (29% versus 5%), more localized carcinomas (62% versus 39%), and significantly higher crude cumulative 5-year survival (56% versus 30%).

CONCLUSIONS

CRC in HNPCC behaves differently compared to sporadic cases concerning age of onset, frequency of multiple lesions, and location. The metastatic tendency is less than in sporadic CRC and the survival is better.

Decision analysis in the management of duodenal adenomatosis in familial adenomatous polyposis

BACKGROUND

Patients with familial adenomatous polyposis are not only at high risk of developing adenomas in the colorectum but a substantial number of patients also develop polyps in the duodenum. Because treatment of duodenal polyps is extremely difficult and it is unknown how many patients ultimately develop duodenal cancer, the value of surveillance of the upper digestive tract is uncertain.

AIMS

(1) To assess the cumulative risk of duodenal cancer in a large series of polyposis patients. (2) To develop a decision model to establish whether surveillance would lead to increased life expectancy.

METHODS

Risk analysis was performed in 155 Dutch polyposis families including 601 polyposis patients, and 142 Danish families including 376 patients. Observation time was from birth until date of last contact, death, diagnosis of duodenal cancer, or closing date of the study.

RESULTS

Seven Dutch and five Danish patients developed duodenal cancer. The lifetime risk of developing this cancer by the age of 70 was 4% (95% confidence interval 1-7%) in the Dutch series and 3% (95% confidence interval 0-6%) in the Danish series. Decision analysis showed that surveillance led to an increase in life expectancy by seven months.

CONCLUSIONS

Surveillance of the upper digestive tract led to a moderate gain in life expectancy. Future studies should evaluate whether this increase in life expectancy outweighs the morbidity of endoscopic examination and proximal pancreaticoduodenectomy.

[Patients' perception of symptoms in colorectal cancer. A cause of delay in diagnosis and treatment]

A questionnaire was given to a series of 50 patients referred for colorectal cancer to the Department of Surgical Gastroenterology at Hvidovre Hospital, Copenhangen. The patients were asked about the length of the period from debut of symptoms to the first visit to their family doctor (patient's delay), detailed symptoms and their views and attitudes towards the significance of these symptoms. More than half of the patients first saw their own doctor more than three months after the first symptom: 17/33 (52%) with a change in bowel habits, 12/28 (43%) with rectal bleeding, 11/19 (58%) with abdominal pain and 4/6 (67%) with a palpable mass. Only 7/44 (15%) thought that cancer was the cause of their symptoms, and a similar minority was afraid of an operation or an ostomy. We conclude that the main cause of patient's delay is a lack of knowledge among the patients about the significance of bowel symptoms, rather than fear of cancer, operation or an ostomy. On this basis we recommend that an information campaign about cancer-related bowel symptoms (bleeding, change of bowel habits) should be carried out with the aim of reducing patient's delay and thereby possibly also improving the prognosis through an early diagnosis.

[Anastomotic leakage after low anterior resection for rectal cancer]

A series of 377 consecutive patients were operated upon with low anterior resection for rectal cancer in the nine Danish departments of surgical gastroenterology during 1992-1993. A retrospective analysis was carried out to calculate the frequency of anastomotic leakage and to evaluate factors of potential influence on the development of leakage according to the literature. Sixty-three patients (17%) developed leakage, which was followed by an increased mortality within the first three postoperative months. Only two variables significantly influenced the leakage rate: male gender was associated with a higher leakage rate (p = 0.02), whereas departments with a low number of rectal cancer surgeons had a low rate of anastomotic leakage (p = 0.02). In conclusion, the rather high frequency of anastomotic leakage calls for further clinical and pathogenetic research in this field. Until then, we recommend the routine use of a peroperative leakage test and selective use of prophylactic ostomy in cases of unsatisfactory anastomosis. Furthermore, it is recommended that low anterior resection for rectal cancer is limited to few surgeons in each department in order to ensure a uniform quality and hopefully also thereby reduce the rate of anastomotic leakage.

Is screening for thyroid carcinoma indicated in familial adenomatous polyposis? The Leeds Castle Polyposis Group

Forty-five polyposis patients with thyroid carcinoma constituted 1.2% of the patients in the Leeds Castle Polyposis Group database. The patients were diagnosed during 1959-1995; 44 were females at a median age of 25 years (range 10-40) and 37 (82%) had papillary carcinoma. At the end of 1995 only one patient (9%) had died from thyroid carcinoma, and the ten-year cumulative survival was 84% (95% confidence limits 72-97). Due to the low incidence of thyroid carcinoma in FAP and the good prognosis we do not recommend a regular thyroid screening in polyposis, as this is unlikely to result in a reduction of the mortality, but will only aggravate existing cancrophobia in these strained patients.

[Prognosis in familial adenomatous polyposis. Results from the Polyposis Registry]

Regional and national polyposis registries have been established all over the world over last decades, with the aim to improve survival in patients with familial adenomatous polyposis (FAP). The Danish Polyposis Register was founded in 1971 and coordinates screening and prophylactic treatment. At the end of 1992 the register included 321 histologically verified FAP patients: 142/205 probands (69%) had colorectal cancer at the time of diagnosis of FAP versus only 2/116 call-up cases (2%). The 10-year cumulative crude survival was 94% among call-up cases versus only 41% among probands (p < 0.00001), and the survival increased significantly after establishment of the Polyposis Register in 1971. We conclude that centralized registration with identification and prophylactic examination of relatives at risk results in a substantial improvement of the prognosis.

[Surgery for ulcerative colitis. Treatment with proctocolectomy, stapled ileum-J-pouch, stapled pouch-anal anastomosis and temporary ileostomy]

Thirty-two patients with ulcerative colitis, median age 29 (range 14-49), were submitted to restorative proctocolectomy. Twenty-five patients had a three-stage procedure and seven had a two-stage procedure. A stapled J-pouch was formed, and a pouch-anal anastomosis was created by the double stapling technique. A temporary end ileostomy was closed through peristomal incision after three months. There were no pouch failures and no cases of pouch-anal anastomosis leakage. In one patient secondary mucosectomy and neo-anastomosis became necessary due to severe inflammation of remnant rectal mucosa. Five patients were operated for small bowel obstruction, and two had to have a dilatation of a slight stricture of the pouch-anal anastomosis. In two patients the final diagnosis was verified or probable Crohns disease, of whom one developed recurrence of a previous rectovaginal fistula. Twenty-seven patients have had the ileostomy closed for more than one month, 25 of these (93%) were fully continent three months after ileostomy closure and later on. After one year the patients had median five (range 3-9) bowel movements per day. It is concluded that restorative proctocolectomy with a stapled J-pouch-anal anastomosis and a temporary end ileostomy for ulcerative colitis carries few complications and provides a good functional result.