ProtSeq: Toward high-throughput, single-molecule protein sequencing via amino acid conversion into DNA barcodes

We demonstrate early progress toward constructing a high-throughput, single-molecule protein sequencing technology utilizing barcoded DNA aptamers (binders) to recognize terminal amino acids of peptides (targets) tethered on a next-generation sequencing chip. DNA binders deposit unique, amino acid-identifying barcodes on the chip. The end goal is that, over multiple binding cycles, a sequential chain of DNA barcodes will identify the amino acid sequence of a peptide. Toward this, we demonstrate successful target identification with two sets of target-binder pairs: DNA-DNA and Peptide-Protein. For DNA-DNA binding, we show assembly and sequencing of DNA barcodes over six consecutive binding cycles. Intriguingly, our computational simulation predicts that a small set of semi-selective DNA binders offers significant coverage of the human proteome. Toward this end, we introduce a binder discovery pipeline that ultimately could merge with the chip assay into a technology called ProtSeq, for future high-throughput, single-molecule protein sequencing.

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Designed ProtSeq protein sequencing method compatible with widely used NGS technology

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Built Target-Switch SELEX to isolate aptamers specific to N-terminal amino acids (AAs)

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Showed binding, ligation, cleavage, and NGS of six DNA binders in ordered barcode chain

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Developed pipeline to deconvolve AAs from DNA barcodes to identify putative proteins

Genomic alterations accompanying tumour evolution in colorectal cancer: tracking the differences between primary tumours and synchronous liver metastases by whole-exome sequencing

BACKGROUND

Colorectal cancer (CRC) patients with metastatic disease can become cured if neoadjuvant treatment can enable a resection. The search for predictive biomarkers is often performed on primary tumours tissue. In order to assess the effectiveness of tailored treatment in regard to the primary tumour the differences in the genomic profile needs to be clarified.

METHODS

Fresh-frozen tissue from primary tumours, synchronous liver metastases and adjacent normal liver was collected from 21 patients and analysed by whole-exome sequencing on the Illumina HiSeq 2500 platform. Gene variants designated as 'damaging' or 'potentially damaging' by Ingenuity software were used for the subsequent comparative analysis. BAM files were used as the input for the analysis of CNAs using NEXUS software.

RESULTS

Shared mutations between the primary tumours and the synchronous liver metastases varied from 50 to 96%. Mutations in APC, KRAS, NRAS, TP53 or BRAF were concordant between the primary tumours and the metastases. Among the private mutations were well-known driver genes such as PIK3CA and SMAD4. The number of mutations was significantly higher in patients with right- compared to left-sided tumours (102 vs. 66, p = 0.004). Furthermore, right- compared to left-sided tumours had a significantly higher frequency of private mutations (p = 0.023). Similarly, CNAs differed between the primary tumours and the metastases. The difference was mostly comprised of numerical and segmental aberrations. However, novel CNAs were rarely observed in specific CRC-relevant genes.

CONCLUSION

The examined primary colorectal tumours and synchronous liver metastases had multiple private mutations, indicating a high degree of inter-tumour heterogeneity in the individual patient. Moreover, the acquirement of novel CNAs from primary tumours to metastases substantiates the need for genomic profiling of metastases in order to tailor metastatic CRC therapies. As for the mutational status of the KRAS, NRAS and BRAF genes, no discordance was observed between the primary tumours and the metastases.

The Reliability of Medical History and Physical Examination in Patients with Acute Abdominal Pain

The reliability of medical record information is of fundamental importance to the certainty with which a diagnosis can be made. 40 patients were chosen at random and each was examined by four clinicians. The information and a tentative diagnosis were written on a special record form. The results were judged by means of the coefficient kappa. The clinicians disagreed more on symptoms than on diagnoses. The diagnoses made by an automatic diagnosis system showed lower precision and lower accuracy than the clinicians’ diagnoses. The results of the study might explain why computer assistance in diagnostics is of limited value.

Reoperation risk following the first operation for internal herniation in patients with laparoscopic Roux-en-Y gastric bypass

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most commonly used surgical procedure in the treatment of morbid obesity in Denmark. Internal herniation (IH) and intermittent internal herniation (IIH) are probably the most common late complications in patients with LRYGB. The aim of this study was to investigate a possible increased risk of subsequent operations after an initial IH or IIH event.

Methods

This long-term follow-up study of patients who had surgery for an initial IH or IIH event in 2006–2011, based on the Danish National Patient Registry (NPR), was performed to 2013. During this period, mesenteric defects were not closed routinely during LRYGB.

Results

Data were retrieved from 12 221 patients with LRYGB from the NPR. A total of 383 patients had surgery for an initial IH or IIH event. Some 102 patients (26·6 (95 per cent c.i. 22·5 to 31·3) per cent) had a second operation. Twenty-seven (26·5 (18·9 to 35·8) per cent) of these 102 patients had a third operation, and five (19 (8 to 37) per cent) of the 27 had a fourth operation. Of the 383 patients diagnosed with an initial IH or IIH event, 72 (18·8 per cent) had a second IH/IIH event, 14 (3·7 per cent) had a third event, and three (0·8 per cent) a fourth event requiring surgery.

Conclusion

Patients who have surgery for IH or IIH have a substantial risk of needing further operations.

The prognostic value of lymph node ratio in a national cohort of rectal cancer patients

OBJECTIVE

To analyze the prognostic implications of the lymph node ratio (LNR) in curative resected rectal cancer.

SUMMARY BACKGROUND DATA

It has been proposed that the LNR has a high prognostic impact in colorectal cancer, but the lymph node ratio has not been evaluated exclusively for rectal cancer in a large national cohort study.

METHODS

All 6793 patients in Denmark diagnosed with stage I to III adenocarcinoma of the rectum, and so treated in the period from 2003 to 2011, were included in the analysis. The cohort was divided into two groups according to whether or not neo-adjuvant treatment had been given.

RESULTS

In a multivariate analysis the pN status, ypN status and lymph node yield were found to be independent prognostic factors for overall survival, irrespective of neo-adjuvant therapy. The LNR was also found to be a significant prognostic factor with a Hazard Ratio ranging from 1.154 (95% CI: 0.930-1.432) (LNR: 0.01-0.08) to 2.974 (95% CI: 2.452-3.606) (LNR > 0.5) in the group of patients who had surgery to begin with and from 1.381 (95% CI: 0.891-2.139) (LNR: 0.01-0.08) to 2.915 (95% CI: 2.244-3.787) (LNR > 0.5) in the group of patients who had neo-adjuvant treatment.

CONCLUSIONS

The LNR reflects the influence on survival from N-status and the lymph node yield and since LNR was shown to be a significant prognostic predictor for overall survival in patients with curatively resected stage III rectal cancer irrespective of neo-adjuvant therapy we recommend that the introduction of LNR should be considered for rectal cancer in a revised TNM classification.

CDX2 downregulation is associated with poor differentiation and MMR deficiency in colon cancer

BACKGROUND

Homeobox genes are often deregulated in cancer and can have both oncogenic and tumor-suppressing potential. The Caudal-related homeobox transcription factor 2 (CDX2) is an intestine-specific transcription factor. CDX2 has been implicated in differentiation, proliferation, cell adhesion, and migration. In this study, we investigated CDX2 mRNA and protein expression in relation to the clinicopathological characteristics of colon cancer, including mismatch repair status and recurrence risk.

METHODS

Tumor samples were obtained from colon cancer patients. Biopsies from tumor tissue and normal adjacent tissue were fixed in liquid nitrogen for RNA extraction or in formalin and paraffin embedded (FFPE) for immunohistochemical staining. CDX2 mRNA expression was evaluated by RT-qPCR. FFPE sections were stained for MLH1, MSH2, MSH6, PMS2, and CDX2.

RESULTS

A total of 191 patient samples were included in the study and analyzed by immunohistochemistry. Of these samples, 97 were further evaluated by RT-qPCR. There was no significant difference in CDX2 mRNA expression between tumor and normal tissues. CDX2 mRNA expression was significantly lower in right-sided tumors (p<0.05), poorly differentiated tumors (p<0.05), and MMR-deficient tumors (p<0.05). Similarly, CDX2 protein expression was more often low or absent in right-sided tumors (p<0.01), poorly differentiated tumors (p<0.001), and MMR-deficient tumors (p<0.001). Low CDX2 protein or mRNA expression was not associated with recurrence risk.

CONCLUSION

We found that CDX2 downregulation is associated with MMR deficiency, right-sided tumors, and poor differentiation at both the mRNA and protein level. Whether CDX2 plays an active role in tumor progression in MSI/MMR-deficient tumors remains to be elucidated.

Control of protein function through optochemical translocation

Controlled manipulation of proteins and their function is important in almost all biological disciplines. Here, we demonstrate control of protein activity with light. We present two different applications—light-triggered transcription and light-triggered protease cleavage—both based on the same concept of protein mislocation, followed by optochemically triggered translocation to an active cellular compartment. In our approach, we genetically encode a photocaged lysine into the nuclear localization signal (NLS) of the transcription factor SATB1. This blocks nuclear import of the protein until illumination induces caging group removal and release of the protein into the nucleus. In the first application, prepending this NLS to the transcription factor FOXO3 allows us to optochemically switch on its transcription activity. The second application uses the developed light-activated NLS to control nuclear import of TEV protease and subsequent cleavage of nuclear proteins containing TEV cleavage sites. The small size of the light-controlled NLS (only 20 amino acids) minimizes impact of its insertion on protein function and promises a general approach to a wide range of optochemical applications. Since the light-activated NLS is genetically encoded and optically triggered, it will prove useful to address a variety of problems requiring spatial and temporal control of protein function, for example, in stem-cell, developmental, and cancer biology.

The clinical perspectives of CDX2 expression in colorectal cancer: a qualitative systematic review

INTRODUCTION

Homeobox genes are often deregulated in cancer. They can have both oncogenic and tumor-suppressing potential. The Caudal-related homeobox transcription factor 2 (CDX2) is an intestine-specific transcription factor. It is implicated in differentiation, proliferation, cell-adhesion, and migration. CDX2 has been proposed as a tumor suppressor in colorectal cancer but its role is still controversial. This systematic review were undertaken in order to clarify CDX2s role in colorectal cancer.

METHODS

A literature search was performed in the MEDLINE database from 1966 to February 2014. Only studies in which all or a part of the experimental design were performed on human colorectal cancer tissue were included. Thus, studies solely performed in cell-lines or animal models were excluded.

RESULTS

Fifty-two articles of relevance were identified. CDX2 expression was rarely lost in colorectal cancers, however the expression pattern may often be heterogeneous within the tumor and can be selectively down regulated at the invasive front and in tumor buddings. Loss of CDX2 expression is probably correlated to tumor grade, stage, right-sided tumor location, MMR-deficiency, CIMP, and BRAF mutations. The CDX2 gene is rarely mutated but the locus harboring the gene is often amplified and may suggest CDX2 as a linage-survival oncogene. CDX2 might be implicated in cell proliferation and migration through cross-talk with the Wnt-signaling pathway, tumor-stroma proteins, and inflammatory cytokines.

CONCLUSION

A clear role for CDX2 expression in colorectal cancer remains to be elucidated, and it might differ in relation to the underlying molecular pathways leading to the cancer formation.

Health-related quality of life after surgery for advanced and recurrent rectal cancer: a nationwide prospective study

AIM

Advances in the treatment of rectal cancer have made it possible to perform complex rectal cancer surgery (COMP-RCS) in patients with primary advanced rectal cancer penetrating beyond the total mesorectal excision planes and in patients with locally recurrent rectal cancer. The aim of this study was to examine health-related quality of life (HRQoL) before and during the first 2 years after COMP-RCS.

METHOD

Between 2001 and 2008, 180 patients were treated with COMP-RCS at Aarhus University Hospital. HRQoL was assessed preoperatively and 3, 6, 12, 18 and 24 months after surgery using three questionnaires. The results were compared with those for patients treated with standard rectal cancer surgery (STAN-RCS) and with data from the general Danish population (NORM-data).

RESULTS

One hundred and twenty-two (68%) patients responded to the questionnaires. Of these 80 (66%) with disease-free survival for 2 years after surgery were included in the main analysis. The lowest level of functioning and the highest degree of symptoms were reported preoperatively. The majority of the HRQoL scales improved or remained stable during the first postoperative year; a decrease was observed for body image only. One year after surgery, HRQoL in patients treated with COMP-RSC was comparable to that for patients treated with STAN-RCS. Lower levels were found for physical and emotional role functioning, compared with NORM-data.

CONCLUSION

Patients treated with COMP-RCS experienced improvement in HRQoL in the first year after surgery. One year after surgery, HRQoL was similar to that of patients treated with STAN-RCS. Compared with NORM-data, lower levels were found for physical and emotional role functioning.

Patient-reported genitourinary dysfunction after laparoscopic and open rectal cancer surgery in a randomized trial (COLOR II)

BACKGROUND

This article reports on patient-reported sexual dysfunction and micturition symptoms following a randomized trial of laparoscopic and open surgery for rectal cancer.

METHODS

Patients in the COLOR II randomized trial, comparing laparoscopic and open surgery for rectal cancer, completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-CR38 questionnaire before surgery, and after 4 weeks, 6, 12 and 24 months. Adjusted mean differences on a 100-point scale were calculated using changes from baseline value at the various time points in the domains of sexual functioning, sexual enjoyment, male and female sexual problems, and micturition symptoms.

RESULTS

Of 617 randomized patients, 385 completed this phase of the trial. Their mean age was 67·1 years. Surgery caused an anticipated reduction in genitourinary function after 4 weeks, with no significant differences between laparoscopic and open approaches. An improvement in sexual dysfunction was seen in the first year, but some male sexual problems persisted. Before operation 64·5 per cent of men in the laparoscopic group and 55·6 per cent in the open group reported some degree of erectile dysfunction. This increased to 81·1 and 80·5 per cent respectively 4 weeks after surgery, and 76·3 versus 75·5 per cent at 12 months, with no significant differences between groups. Micturition symptoms were less affected than sexual function and gradually improved to preoperative levels by 6 months. Adjusting for confounders, including radiotherapy, did not change these results.

CONCLUSION

Sexual dysfunction is common in patients with rectal cancer, and treatment (including surgery) increases the proportion of patients affected. A laparoscopic approach does not change this.

REGISTRATION NUMBER

NCT00297791 (http://www.clinicaltrials.gov).

Tumour stage and preoperative chemoradiotherapy influence the lymph node yield in stages I-III rectal cancer: results from a prospective nationwide cohort study

AIM

The study aimed to determine whether the lymph node yield (LNY) in rectal cancer is influenced by patient-related and histopathological factors and the use of preoperative chemoradiotherapy (CRT).

METHOD

An analysis was carried out of the LNY in a nationwide Danish cohort of 7950 patients, treated by curative resection of Stage I-III rectal cancer during the period 2001-2011. The impact of year of diagnosis, age, gender, pathological stage of the tumour (pT-stage) and preoperative CRT on LNY was analysed.

RESULTS

Twenty-nine per cent of the patients received preoperative CRT. The median LNY was 13 [interquartile range (IQR): 8-19]. A total of 43.4% of the patients had an LNY of < 12. The median LNY increased from 8 (IQR: 5-12) to 20 (IQR: 13-28) LNs over the years of the study period (P < 0.0001). Gender and body mass index (BMI) had no impact on the median LNY. Age had a minor impact, with a range of 12 (IQR: 8-18) to 13 (IQR: 9-20) (P < 0.0001). The LNY ranged from 9 (IQR: 6-14) to 16 (IQR: 10-26), according to pT-stage (pT0-pT4) (P < 0.0001). Median LNY, according to preoperative CRT or no preoperative CRT, was 10 (IQR: 6-16) and 14 (IQR: 8-18), respectively (P < 0.0001). The percentages of patients with an LNY of < 12, according to preoperative CRT or no preoperative CRT, were 58.7% and 37.1%, respectively (P < 0.0001).

CONCLUSION

An increase in the LNY over the period of the study was observed, probably reflecting improved quality of surgery and histopathology. A minor significant reduction of LNY was found with increasing age of the patient. LNY was significantly related to pT-stage and to the use of preoperative chemoradiotherapy. For these reasons the minimum harvest of 12 LNs as a surrogate marker for the oncological quality of surgery should be questioned.

Health-related quality of life after laparoscopic and open surgery for rectal cancer in a randomized trial

Background

Previous studies comparing laparoscopic and open surgical techniques have reported improved health-related quality of life (HRQL). This analysis compared HRQL 12 months after laparoscopic versus open surgery for rectal cancer in a subset of a randomized trial.

Methods

The setting was a multicentre randomized trial (COLOR II) comparing laparoscopic and open surgery for rectal cancer. Involvement in the HRQL study of COLOR II was optional. Patients completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR38, and EuroQol – 5D (EQ-5D™) before surgery, and 4 weeks, 6, 12 and 24 months after operation. Analysis was done according to the manual for each instrument.

Results

Of 617 patients in hospitals participating in the HRQL study of COLOR II, 385 were included. The HRQL deteriorated to moderate/severe degrees after surgery, gradually returning to preoperative values over time. Changes in EORTC QLQ-C30 and QLQ-CR38, and EQ-5D™ were not significantly different between the groups regarding global health score or any of the dimensions or symptoms at 4 weeks, 6 or 12 months after surgery.

Conclusion

In contrast to previous studies in patients with colonic cancer, HRQL after rectal cancer surgery was not affected by surgical approach. Registration number: NCT0029779 (http://www.clinicaltrials.gov).

The relation between lymph node status and survival in Stage I-III colon cancer: results from a prospective nationwide cohort study

AIM

This study involved a large nationwide Danish cohort to evaluate the hypothesis that a high lymph node harvest has a positive effect on survival in curative resected Stage I-III colon cancer and a low lymph node ratio has a positive effect on survival in Stage III colon cancer.

METHOD

Analysis of overall survival was conducted using a nationwide Danish cohort of patients treated with curative resection of Stage I-III colon cancer. All 8901 patients in Denmark diagnosed with adenocarcinoma of the colon and treated with curative resection in the period 2003-2008 were identified from the Danish Colorectal Cancer Group (DCCG). The impact of lymph node count and lymph node ratio was analysed.

RESULTS

Overall 5-year survival was 56.8 and 66.6%, (P < 0.0001) for lymph node counts of fewer than 12 and 12 or more, respectively. The percentages of lymph node positive patients in the two groups were 29.8 and 40.3% (P < 0.0001), respectively. When putting the Stage III patients into four subgroups according to the lymph node ratio (cut-off points 1/12, 1/4 and 1/2) we found an overall 5-year survival rate of 68.1, 57.2, 49.3 and 32.4% (P < 0.0001). Lymph node count and lymph node ratio were independent prognostic factors in multivariate analysis.

CONCLUSION

High lymph node count was associated with improved overall survival in colon cancer. Lymph node ratio was superior to N-stage in differentiating overall survival in Stage III colon cancer. Stage migration was observed.

Validation of the Danish version of the disease specific instrument EORTC QLQ-CR38 to assess health-related quality of life in patients with colorectal cancer

Background

The European Organisation for Research and Treatment of Cancer (EORTC) quality of life colorectal questionnaire module (QLQ-CR38) was developed in 1999, and an update, the QLQ CR29 was published recently. To date the Danish version of the questionnaire has not been validated. The aim of this study was to examine the psychometric properties of the Danish version of EORTC QLQ-CR38.

Methods

EORTC QLQ-CR38 was administered to 190 patients with colorectal cancer in two Danish hospitals, one month after their operation. A psychometric evaluation of the questionnaire’s structure, reliability, convergent, divergent and known-groups validity was performed.

Results

Data from 164 (86.3%) patients were available for analysis. The Danish version of EORTC QLQ-CR38 showed satisfactory psychometric properties for the scales: body image, sexual functioning, male sexual problems and defecations problems. Suboptimal psychometric performances were found for the scales: micturition problems, symptoms of the gastrointestinal tract and weight loss. Evaluation of the psychometric properties of the scale chemotherapy side effects was limited by the low number of patients receiving chemotherapy. It was not possible to assess the psychometric properties of the scale female sexual problems and the single item sexual enjoyment due to a high number of missing values. The homogeneity of the study population made the evaluation of known-group validity difficult.

Conclusions

The results of this study suggest that the validity of the Danish version of EORTC QLQ-CR38 is acceptable. Furthermore, the results support the appropriateness of the updated version, the EORTC QLQ-CR29.

Use of a balloon catheter in management of the pelvic space following laparoscopic abdominoperineal excision

AIM

Management of the pelvic space following laparoscopic abdominoperineal excision remains controversial. We describe a simple technique for obliteration of the pelvic space after laparoscopic abdominoperineal excision.

METHOD

Pneumoperitoneum was re-established after completion of the operative procedure and a Foley catheter Ch. 24 was inserted through the right lower port under direct vision. The balloon of the catheter, placed in the presacral space, was filled with 50 ml of sterile saline and connected to passive drainage. The catheter was removed 10 days postoperatively.

RESULTS

This technique was used in 15 patients with the median age of 74 years (range 63-86). Eleven patients were treated with preoperative chemoradiotherapy. The median length of hospital stay was 9 days (range 5-11). Two patients (13.3%) treated with chemoradiotherapy developed a superficial perineal wound infection and four patients (26.6%) had a deep pelvic abscess, which required surgical drainage. The median time of perineal wound healing was 3 months (range 2-8). The median follow-up time was 36 months (range 18-60). None of the patients developed perineal hernia or intestinal obstruction in the follow-up period. One patient underwent small bowel resection due to stenosis caused by radiation enteritis. There was no local recurrence, but two patients developed distant metastases after 12 months.

CONCLUSION

Our results suggest that filling the pelvic cavity with a balloon catheter for 10 days results in the creation of a thin, fibrotic peritoneal layer which keeps the small intestine out of the pelvis and prevents loops of intestine adhering in the pelvic cavity.

Health-related quality of life after surgery for primary advanced rectal cancer and recurrent rectal cancer: a review

AIM

Health-related quality of life is an important outcome measure in treatment of cancer. A review of the literature was undertaken to provide an overview of health-related quality of life (HRQoL) after surgery for primary advanced or recurrent rectal cancer and to outline proposals for future HRQoL studies in this area.

METHOD

A systematic literature search was undertaken. Only studies concerning surgery for primary advanced or recurrent rectal cancer and describing methods used for measuring HRQoL were considered.

RESULTS

Seven studies were identified, including two prospective longitudinal studies, three cross-sectional studies and two based on qualitative data. Global quality of life, and physical, social, role and sexual function seemed to be impaired for a varying time after surgery. All the studies had methodical problems due to small sample size (12-44 patients) and different points of time for the assessment of HRQoL (12.3-47 months), which made it difficult to determine the period of time of impaired HRQoL and also if this is different after surgery for locally advanced or recurrent disease compared with after total mesorectal excision used for earlier tumours.

CONCLUSION

Several aspects of HRQoL are impaired for a variable time after treatment for locally advanced or recurrence of rectal cancer. Larger prospective longitudinal studies are needed to provide further information regarding the effects of this extensive surgery on quality of life.

COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer

INTRODUCTION

Laparoscopic resection of rectal cancer has been proven efficacious but morbidity and oncological outcome need to be investigated in a randomized clinical trial.

TRIAL DESIGN

Non-inferiority randomized clinical trial.

METHODS

The COLOR II trial is an ongoing international randomized clinical trial. Currently 27 hospitals from Europe, South Korea and Canada are including patients. The primary endpoint is loco-regional recurrence rate three years post-operatively. Secondary endpoints cover quality of life, overall and disease free survival, post-operative morbidity and health economy analysis.

RESULTS

By July 2008, 27 hospitals from the Netherlands, Belgium, Germany, Sweden, Spain, Denmark, South Korea and Canada had included 739 patients. The intra-operative conversion rate in the laparoscopic group was 17%. Distribution of age, location of the tumor and radiotherapy were equal in both treatment groups. Most tumors are located in the mid-rectum (41%).

CONCLUSION

Laparoscopic surgery in the treatment of rectal cancer is feasible. The results and safety of laparoscopic surgery in the treatment of rectal cancer remain unknown, but are subject of interim analysis within the COLOR II trial. Completion of inclusion is expected by the end of 2009.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT00297791 (www.clinicaltrials.gov).

Quality of life after anterior resection versus abdominoperineal extirpation for rectal cancer

BACKGROUND

Abdominoperineal extirpation has been assumed to put patients at higher risk of disruption to quality of life than sphincter-preserving surgery in rectal cancer surgery. The aim of this study was to investigate quality of life in patients after anterior resection versus abdominoperineal extirpation for rectal cancer and to evaluate the psychometrics of the Danish version of a symptom-specific Fecal Incontinence Quality of Life Scale.

METHODS

Fourteen patients undergoing abdominoperineal extirpation and 26 undergoing anterior resection. The generic quality of life instrument SF-36 together with a new symptom-specific Fecal Incontinence Quality of Life Scale were used. Psychometric analysis of the symptom-specific scale was carried out.

RESULTS

The only significant difference between the two groups was found in the total score of the symptom-specific scale in favour of anterior resection (P = 0.02). Psychometric evaluation of the symptom-specific fecal incontinence questionnaire proved it reliable and valid.

CONCLUSIONS

The present study shows that a stoma influences quality of life only slightly, while a relatively high anterior resection does not. However, a few appropriate newer studies indicate that the cost of spinchter-preserving techniques in the form of incontinence disturbances may influence the quality of life seriously, which should be borne in mind when low anterior resection is intended. Further studies in this field are necessary and could benefit from use of the Fecal Incontinence Quality of Life Scale, including its total score.

Acute terminal ileitis, yersiniosis, and Crohn's disease: a long-term follow-up study of the relationships

Background: During the past decade, very little has been published on the relationships between Yersinia enterocolitica, acute terminal ileitis (ATI), and Crohn's disease, possibly due to a decrease in Yersinia infections and, consequently, in ATI. Methods: Fifty-three patients admitted to Herlev University Hospital during the period 1976-1998 were diagnosed as having ATI while undergoing surgery for suspected acute appendicitis. The patients were followed up, and both Yersinia titers and the development of Crohn's disease were registered. Results: Forty-four patients (83%) were tested for Yersinia, 17 of whom (39%; 95% confidence limits, 24-55%) were positive. The incidence of yersiniosis in ATI decreased significantly during the observation period (P<0.05), whereas the incidence of ATI itself was unchanged. Thirteen of the 53 patients (25%; 95% confidence limits, 14-38%) had, in addition to ATI, an inflamed appendix. Three patients developed Crohn's disease during a median observation period of 13 years (cumulative risk 6.1%). None of them had yersiniosis. Conclusions: The incidence of ATI remained stable during the observation period, even though the number of Yersinia infections decreased. This may have been due to an increase in gastrointestinal infections caused by other enteric pathogens. In accordance with previous findings, ATI patients who developed Crohn's disease did not have yersiniosis. Thus, it is still of prognostic value to test patients with ATI for Yersinia and perhaps for other enteric pathogens as well.

Systemic inflammatory responses during laparoscopic and open inguinal hernia repair: a randomised prospective study

OBJECTIVE

To see if the inflammatory responses during and after laparoscopic and open inguinal hernia repairs differed.

DESIGN

Randomised prospective study.

SETTING

County hospital, Denmark.

PATIENTS

18 men aged 25-77 years with unilateral inguinal hernias.

INTERVENTIONS

Ten patients had a laparoscopic repair and 8 an open tension-free repair.

MAIN OUTCOME MEASURES

Serum concentrations of interleukin (IL)-2 receptors (R) of the alpha group (IL-2Ralpha), IL-6, anti-IL-6, IL-10, tumour necrosis factor (TNF)-alpha, sTNF-RI and sTNF-RII before and 2, 6, 12, and 24 hours after the repairs. Duration of operation and time for return to normal activities or work were also recorded.

RESULTS

Serum IL-6 concentrations increased significantly after operation in both groups (p < 0.0001), but the increase was significantly higher after open than after laparoscopic surgery at all sampling times (p = 0.00) at 6 hours postoperatively). Anti-IL-6 and IL-10 remained undetectable at all time points. There were no significant differences or increases in the concentrations of TNF-alpha or sTNF-RII. However, sTNF-RI concentrations increased significantly in both groups (p < 0.001) though there was no difference in between the two groups. IL-2Ralpha decreased significantly in both groups (p < 0.01) with no differences between the groups. The median operation time was 85 min (range 55-100 min) in the laparoscopic group and 52 min (range 45-79 min) in the "open" group (p < 0.01). Median time to return to normal activities/work were 2 and 13 days after laparoscopic and open operations, respectively (p < 0.01).

CONCLUSION

The surgical trauma of laparoscopic inguinal hernia repair is less than that of open tension-free hernia operations as assessed by circulating mediators of the postoperative inflammatory response. The clinical relevance of this finding must be evaluated in larger randomised studies.

Gastroscopic treatment of gastric band penetrating the gastric wall

Gastric wall penetration of a gastric band after operation for morbid obesity is a well known late complication. The treatment is usually reoperation. In this case report we show that a band penetrating the gastric wall can be successfully treated by gastroscopic operation. This technique is more simple than reoperation, especially in case of morbid obesity at the time of the complication.

[Gastroscopic removal of penetrating gastric band]

Gastric wall penetration of a gastric band after operation for morbid obesity is a well known late complication. The treatment is usually reoperation. In this case report we show that a band penetrating the gastric wall can be successfully treated by gastroscopic operation. This technique is more simple than reoperation, especially in case of morbid obesity at the time of the complication.

Long-term results of repair of the internal ring for primary inguinal hernia

OBJECTIVE

To evaluate the long-term results of repair of the internal ring for primary inguinal hernia.

DESIGN

Retrospective study.

SETTING

University hospital, Denmark.

SUBJECTS

1159 patients with primary unilateral inguinal hernia.

INTERVENTIONS

Repair of the internal ring--annulorrhaphy.

MAIN OUTCOME MEASURES

Recurrence during the median observation period of 10 years (range 1-17).

RESULTS

Eighty-four (7%) were women, and the overall median age was 49 years (range 18-90). The overall recurrence rate calculated by life table analysis was 18%. Twenty-one of the recurrences were indirect hernias (49%), 11 were direct (26%), 8 were combined direct and indirect (19%) and 3 (7%) were femoral hernias.

CONCLUSION

Repair of the internal ring alone carries an unacceptably high recurrence rate.

[Laparoscopic ileocecal resection in Crohn disease]

Laparoscopic intestinal surgery has theoretical advantages compared with conventional intestinal surgery by minimizing the surgical trauma. The aim of the study was to examine the operative and postoperative course as well as the time for recovery after laparoscopic-assisted ileocoecal resection for Crohn's disease. Seventeen patients were operated on. The operations were assessed with regard to duration of operation, rate of conversion to open procedure, complications, time for discharge from hospital, and ability to take up work. Median operation time was 145 min. Two operations (12%) were converted to open procedure. Complications occurred in three patients (18%). Median postoperative time to discharge was five days. Median time to return to work was 26 days. In conclusion laparoscopic-assisted ileocoecal resection seems suited to Crohn's disease, but the benefit of the method needs confirmation in controlled, randomized studies.

Neuroticism in relation to recovery and persisting pain after laparoscopic cholecystectomy

BACKGROUND

Persisting pain is seen in 20%-30% of patients after cholecystectomy for symptomatic gallbladder stones. The only preoperative factor that seems predictive is psychic vulnerability or neuroticism. Findings with regard to the influence of psychologic factors on recovery are contradictory, too. The aim of the present study was to examine a possible relationship between neuroticism and recovery and the outcome of operation.

METHODS

Ninety-four patients who had had a laparoscopic cholecystectomy performed were tested psychologically with a Danish psychic vulnerability scale and with the Eysenck Neuroticism Scale before and 1 year after operation. The course of recovery was registered 1 month after operation, and outcome with regard to persisting pain 1 year postoperatively.

RESULTS

No correlations were found between neuroticism scores and postoperative hospital stay or time to regain work/normal activities (P > 0.05). Persisting pain was found in 18% of the patients 1 year after operation. Although the patients with persisting pain had higher neuroticism scores preoperatively, the difference from the patients with successful outcome of the operation first became statistically significant 1 year postoperatively (P < 0.01-0.05).

CONCLUSIONS

The results do not indicate that neuroticism influences the short recovery process after laparoscopic cholecystectomy. With regard to persisting pain, the higher neuroticism scores in these patients 1 year after the operation could be the consequence of the pain rather than aetiologic factors.

CT in the diagnosis of abdominal wall hernias: a preliminary study

The aim of the study was to estimate the value of CT in the diagnosis of abdominal wall hernias and at the same time to create a standard for this CT investigation. Twenty-four patients with suspected hernia of the abdominal wall were examined. All were operated on. The CT scans were assessed by two radiologists to estimate the interobserver variation. The CT diagnoses made by the two radiologists were correct in 83 % and 79 % of cases, respectively. The sensitivity was 0.83 in both CT evaluations and the specificity was 0.83 and 0.67, respectively. The predictive value of a positive CT finding was 0.94 and 0.88, while the predictive value of a negative CT finding was 0.63 and 0.57, respectively. The interobserver variation (kappa) was 0.87. The study therefore indicates that a positive CT finding of abdominal wall hernia is reliable, while a negative finding does not exclude the diagnosis. The interobserver variation of the CT diagnoses is acceptable. To achieve the highest diagnostic accuracy, it is recommended to always use the Valsalva manoeuvre, oral intake of contrast and 10/10 mm CT slices.

Laparoscopic-assisted ileocecal resection for Crohn's disease: a preliminary study

BACKGROUND

The aim of the study was to present our preliminary results with laparoscopic-assisted ileocecal resection in Crohn's disease of the terminal ileum.

METHODS

Eight patients were operated on. The operations were assessed with regard to duration of operation, rate of conversion to open procedure, complications, time for discharge from hospital, and ability to take up work.

RESULTS

Median operation time was 145 min. One operation (12.5%) was converted to open procedure. Minor complications occurred in one patient (12.5%). Median postoperative time for discharge was 5 days. Median time to return to work was 21 days.

CONCLUSIONS

Laparoscopic-assisted ileocecal resection seems suited to Crohn's disease, but the benefit of the method needs confirmation in controlled, randomized studies.

Rate and treatment of pelvic recurrence after abdominoperineal resection and low anterior resection for rectal cancer

PURPOSE

This study was designed to analyze factors of importance for local recurrence after radical surgery for rectal cancer and to analyze course and outcome of treatment of pelvic recurrence.

METHODS

One hundred seventy-five patients treated for rectal cancer with low anterior resection (LAR) or abdominoperineal resection (APR) were studied, retrospectively. Seventy-four patients had LAR and 101 had APR.

RESULTS

The two groups were comparable with respect to Dukes classification, histologic differentiation, and male to female ratio. The rate of pelvic recurrence was 18 percent for LAR and 24 percent for APR (not significant). Recurrence rates were 27 percent after stapled anastomoses and 10 percent after handsewn anastomoses respectively (P = 0.09). Twenty five had pelvic recurrence diagnosed without signs of distant metastatic disease. They were treated with radiotherapy, palliative operations, or analgesics. The group receiving radiotherapy had a significantly longer survival (15.9 months) compared with other groups (2.4 months; P < 0.001).

CONCLUSIONS

There is no difference in local recurrence rate after LAR and APR. Radiotherapy seems to increase survival in patients with an unresectable recurrence and should be offered irrespective of pain.

[Personality characteristics in ulcer disease. A cohort study]

The purpose of the study was to investigate the direction of a possible relationship between peptic ulcer disease and personality disorders. A cohort study was carried out in Glostrup County, Denmark (population 100,000). A representative sample of 50-years old persons born in 1914 (n = 673) were followed for 20 years. All 673 filled in the Minnesota Multiphasic Personality Inventory (MMPI) in 1964 and 513 were retested with MMPI in 1974. The prevalence of peptic ulcer disease in 1964 was 7% and the average annual incidence in the period 1964-1984 was 2.1 per 1000 persons. The persons with incidental peptic ulcer in 1964-84 had normal MMPI scores in 1964, while persons with peptic ulcer in 1964 had a slight but statistically significant increase in one neuroticism scale (HS) only. The group with prevalent ulcer disease in 1974 exhibited statistically significant increases in the three neuroticism scales (HS, D, HY) and in scale Pd and scale Pt at MMPI retesting. In addition they had statistically significantly higher scores in the three neuroticism scales compared with the other persons who still had normal scores in all scales. It is concluded that personality disorders in persons with peptic ulcer are consequences of the disease and not causal factors.

[Laparoscopic ultrasonography of liver, biliary tract and pancreas with flexible tip transducers]

The scanning procedure and the ultrasound-anatomy of the liver, gall-bladder, bile ducts and pancreas are presented. Ten consecutive patients referred for laparoscopic cholecystectomy were scanned through a 10/11 mm trocar inserted periumbilically. In two cases concrements in the bile ducts were found peroperatively. The flexible-tip enables operator steering of the transducer which ensures an optimal acoustic contact. Colour and spectral Doppler were frequently used to identify vascular structures. We conclude that a flexible-tip laparoscopic ultrasound-scanner provides valuable assistance in abdominal laparoscopic procedures, and may substitute the palpation of the abdominal organs in laparoscopic abdominal surgery.

Personality pattern in peptic ulcer disease: a cohort study

OBJECTIVES

To investigate the direction of a possible relationship between peptic ulcer disease and personality disorders.

DESIGN

A cohort study of 50-year old patients, observed for 2 decades.

SETTING

Glostrup County, Denmark (population 100000).

SUBJECTS

A representative sample of 50-year old people born in 1914 (n = 673) were followed for 20 years. All 673 filled in the Minnesota Multiphasic Personality Inventory (MMPI) in 1964 and 513 were retested with MMPI in 1974.

MAIN OUTCOME MEASURES

Prevalence of peptic ulcer disease 1964, incidence of peptic ulcer disease 1964-84, MMPI scores.

RESULTS

The prevalence of peptic ulcer disease in 1964 was 7% and the average annual incidence in the period 1964-84 was 2.1 per 1000 persons. Those with incidental peptic ulcer in 1964-84 had normal MMPI scores in 1964, whilst those with peptic ulcer in 1964 had a slight but statistically significant increase in one neuroticism scale (HS) only. The group with prevalent ulcer disease in 1974 exhibited statistically significant increases in the three neuroticism scales (HS, D, HY) and in scale Pd and scale Pt at MMPI retesting. In addition they had statistically significantly higher scores in the three neuroticism scales compared with the other persons who still had normal scores in all scales.

CONCLUSIONS

Personality disorders in patients with peptic ulcer are consequences of the disease and not causal factors.

Laparoscopic loop ileostomy for fecal diversion

PURPOSE

The aim of this study was to describe the procedure for laparoscopic loop ileostomy.

METHODS

Technique description is given.

CONCLUSION

The method is suitable for temporary fecal diversion in patients with anal disorders, where no other intraperitoneal operation is required.

The personality patterns in patients with duodenal ulcer and ulcer-like dyspepsia and their relationship to the course of the diseases. Hvidovre Ulcer Project Group

OBJECTIVES

To compare personality characteristics in duodenal ulcer patients and patients with ulcer-like dyspepsia from the primary health sector with duodenal ulcer patients from a hospital and to evaluate the relationship of the personality characteristics to the course of the diseases.

DESIGN

A prospective study using the Minnesota Multiphasic Personality Inventory (MMPI) with retesting of a subgroup of patients after a median observation period of 14 months.

SETTING

Departments of Medical and Surgical Gastroenterology, Hvidovre University Hospital, and the primary health sector in Roskilde County, Denmark.

SUBJECTS

Sixty hospital patients with duodenal ulceration and 17 patients with duodenal ulceration plus 25 patients with ulcer-like dyspepsia from the primary health sector.

MAIN OUTCOME MEASURES

MMPI scores.

RESULTS

The hospital patients differed from the two other groups of patients by having higher scores of depression and anxiety (P < 0.05). Twenty-eight of the patients were retested with MMPI. Contrary to the patients with persisting complaints, abnormal personality characteristics disappeared in patients without complaints (P < 0.05-0.001).

CONCLUSIONS

The results indicate that abnormal personality characteristics in patients with functional and organic upper dyspepsia are consequential rather than causal factors.

Gastric acid secretion in relation to personality, affect and coping ability in duodenal ulcer patients. A multivariate analysis. Hvidovre Ulcer Project Group

The role of personality, mood state (affect) and coping ability (ego strength) on basal and stimulated gastric acid secretion were assessed in 56 duodenal ulcer patients using the Minnesota, Multiphasic Personality Inventory. The patients had high scores on most MMPI scales, but basal acid output was related significantly only to the hypochondriasis scale and the validity scale L. Peak acid output was related significantly only to the validity scale L. Both basal and peak acid output were related significantly, but positively to coping ability. No relations were found to mood state. The personality disorders found in peptic ulcer patients may evidently be consequences of the disease rather than causal factors.

The validity of Eysenck's neuroticism dimension within the Minnesota Multiphasic Personality Inventory in patients with duodenal ulcer. The Hvidovre Ulcer Project Group

A psychometric analysis on patients with duodenal ulcer using latent structure coefficients (Loevinger and Mokken) showed that the MMPI subscales of depression, psychasthenia, hypochondriasis, hysteria, schizophrenia and social introversion all could be considered as indicators of Eysenck's dimension of neuroticism. Both a MMPI neuroticism scale of 15 items (MMPI/N-15) and of 21 items (MMPI/N-21) were psychometrically valid, i.e. the total score was a sufficient statistic. Patients with duodenal ulcer who improved during treatment also had a significant decrease in their neuroticism scores, whereas patients who did not improve had unchanged neuroticism scores. In other words, neuroticism is secondary to the clinical symptoms of duodenal ulcer (a psychological adjustment to illness) and not an etiological factor.

[Surgical interventions in ulcer diseases in Denmark. A questionnaire study]

Surgical practice in the treatment of peptic ulceration in Denmark is illustrated by means of a questionnaire. The percentage of replies was 96. The investigation reveals that the predominant method of elective surgery for duodenal ulceration is still proximal gastric vagotomy rather than vagotomy+antrectomy. In elective surgery for prepyloric ulcer, vagotomy+antrectomy is employed most frequently and for elective operation for gastric ulcer partial gastric resection. In operative interventions for complications of ulceration such as haemorrhage and perforation, the operative strategy appears to be determined by the difficult current possibilities for training in ulcer surgery to a not inconsiderable extent, rather than to be based on a rational scientific basis as the definitive intervention here is replaced to a great extent by minor interventions such as simple undersewing of a bleeding gastric ulcer followed by H2-blocker treatment and simple closure of a perforated duodenal ulcer.

Phaeochromocytoma--an unusual cause of haematuria

A patient was admitted to hospital because of haematuria. A papillomatous bladder tumor was removed. Histological examination revealed a phaeochromocytoma. Fourteen days postoperatively the urinary excretion rates of catecholamines were elevated but normalized afterwards. Abdominal computed tomography and metaiodobenzylguanidine scintigraphy were normal. No hypertension or characteristic micturitional attacks preceded removal of the tumor.