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Aim: A total of 15–20% of patients with rectal cancer have liver metastases on presentation. The management of these patients is controversial. Heterogeneity in management strategies is considerable, with management often being dependent on local resources and available expertise. Method: Members of the PelvEx Collaborative were invited to participate in the generation of a consensus statement on the optimal management of patients with advanced rectal cancer with liver involvement. Fifteen statements were created for topical discussion on diagnostic and management issues. Panellists were asked to vote on statements and anonymous feedback was given. A collaborative meeting was used to discuss any nuances and clarify any obscurity. Consensus was considered when > 85% agreement on a statement was achieved. Results: A total of 135 participants were involved in the final round of the Delphi questionnaire. Nine of the 15 statements reached consensus regarding the management of patients with advanced rectal cancer and oligometastatic liver disease. Routine use of liver MRI was not recommended for patients with locally advanced rectal cancer, unless there was concern for metastatic disease on initial computed tomography staging scan. Induction chemotherapy was advocated as first-line treatment in those with synchronous liver metastases in locally advanced rectal cancer. In the presence of symptomatic primary disease, a diverting stoma may be required to facilitate induction chemotherapy. Overall, only one-quarter of the panellists would consider simultaneous pelvic exenteration and liver resection. Conclusion: This Delphi process highlights the diverse treatment of advanced rectal cancer with liver metastases and provides recommendations from an experienced international group regarding the multidisciplinary management approach.

Testosterone dose-dependently increases appendicular muscle mass. However, the effects of testosterone administration on the core muscles of the trunk and the pelvis have not been evaluated. The present study evaluated the effects of testosterone administration on truncal and pelvic muscles in a dose-response trial. Participants were young healthy men aged 18-50 years participating in the 5α-Reductase (5aR) Trial. All participants received monthly injections of 7.5 mg leuprolide acetate to suppress endogenous testosterone production and weekly injections of 50, 125, 300, or 600 mg of testosterone enanthate and were randomized to receive either 2.5 mg dutasteride (5aR inhibitor) or placebo daily for 20 weeks. Muscles of the trunk and the pelvis were measured at baseline and the end of treatment using 1.5-Tesla magnetic resonance imaging. The dose effect of testosterone on changes in the psoas major muscle area was the primary outcome; secondary outcomes included changes in paraspinal, abdominal, pelvic floor, ischiocavernosus, and obturator internus muscles. The association between changes in testosterone levels and muscle area was also assessed. Testosterone dose-dependently increased areas of all truncal and pelvic muscles. The estimated change (95% confidence interval) of muscle area increase per 100 mg of testosterone enanthate dosage increase was 0.622 cm2 (0.394, 0.850) for psoas; 1.789 cm2 (1.317, 2.261) for paraspinal muscles, 2.530 cm2 (1.627, 3.434) for total abdominal muscles, 0.455 cm2 (0.233, 0.678) for obturator internus, and 0.082 cm2 (0.003, 0.045) for ischiocavernosus; the increase in these volumes was significantly associated with the changes in on-treatment total and free serum testosterone concentrations. In conclusion, core muscles of the trunk and pelvis are responsive to testosterone administration. Future trials should evaluate the potential role of testosterone administration in frail men who are predisposed to falls and men with pelvic floor dysfunction.

The impact of quality of surgery, colorectal surgical specialization, training and expertise has been far greater on survival outcomes than adjuvant and neoadjuvant therapies. The review of the evidence by Professor Martling and expert discussion addresses the evidence base and the crucial importance of the surgeon as a prognostic factor, and how this has been relatively neglected in comparison to other resources invested in improving the treatment of colorectal cancer.

Aim Conventional, synchronous combined, abdominoperineal excision (APE) for low rectal cancer is associated with intra-operative tumour perforation and tumour involvement of the circumferential resection margin (CRM+). Several studies have demonstrated worse rates of local recurrence and survival after APE than after low anterior resection (LAR). Extralevator APE (ELAPE) in the prone position may reduce the risk of perforation and involvement of resection margins and may therefore improve outcome. The aim of this study was to report the outcome after the introduction of ELAPE in a prospective study of consecutive patients from a single colorectal unit. Method Between January 2000 and March 2013, 193 patients with low rectal cancer were treated with ELAPE at the Karolinska University Hospital, Stockholm, Sweden. All patients were recorded in the regional rectal cancer quality registry, where data on treatment and follow-up are prospectively reported. Results Preoperative staging with MRI assessed the tumour to be locally advanced (mrT4) in 126 (65%) of the 193 patients. The median tumour level above the anal verge was 3 cm. Intra-operative perforation occurred in 19 patients (10%) and histopathology revealed a positive CRM in 39 patients (20%). Until August 2013 [median follow-up 31 (0–156) months] local recurrence was detected in 12 patients. Five-year cancer specific survival was estimated to 68%. Conclusion Good local control and survival may be achieved with ELAPE in patients with low, advanced rectal cancer.

Aim The purpose of the study was to develop a tool for predicting the individual risk of metachronous peritoneal carcinomatosis after surgery for non-metastatic colorectal cancer. Method Independent predictors for metachronous colorectal carcinomatosis have previously been identified using a population-based database. Predictive models for colon and rectal cancer were developed from these data. The predictive models were based on multivariable Cox proportional hazard regression and were internally validated with bootstrapping. Performance was assessed by the concordance index and calibration plots. Results In all, 8044 patients who underwent abdominal resection of colorectal cancer Stage I–III were included. The colon and rectal cancer risk score models predicted metachronous peritoneal carcinomatosis with a concordance index of 80% and 78%, respectively. Factors in the models included age, pathological pT stage, pN stage, number of examined lymph nodes (0–11, 12+), type of surgery (emergency/elective), completeness of cancer resection (R0/R1/R2), adjuvant chemotherapy (yes/no), preoperative radiotherapy and tumour location. Conclusion The proposed predictive models showed high internal validity and enabled individualized prediction of peritoneal recurrence of colorectal cancer. The models may help in the planning of treatment and follow-up of patients. However, external validation is warranted to assess generalizability of the predicted absolute risks.

Aim Preoperative staging of colon cancer according to Swedish national guidelines implies imaging evaluation of the primary tumour, liver and lungs. Failure to adhere to these guidelines results in negative scorings in the national registration system. In the present study we report the extent of compliance with these guidelines. Method Since 2007 clinical data on all patients diagnosed with colon cancer in Sweden have been collected in a national database. This includes information on pretherapeutic diagnostic imaging performed, pretherapeutic TNM stage and data on treatment and follow-up. All patients diagnosed with colon cancer in Sweden between 2007 and 2010 were included. Results Nine thousand and eight-three patients (i.e. 60.5% of all patients) had a complete pretherapeutic radiological evaluation; 65.2% had a CT or MRI of the primary tumour, whereas over 80% had examinations of the liver and lungs. There were no difference related to sex, but more patients under 75 years had a complete evaluation. There were large differences between different regions; one region performed a complete evaluation of 78.3% of all patients. The proportion of patients examined increased from 53.9 to 65.0% during the study period. Elective cases were more frequently evaluated before treatment than those with an emergency presentation. Conclusion Most patients in Sweden had a complete pretreatment imaging evaluation of the colon cancer with geographical and time-dependent variations. Knowledge of the importance of these variations and correlation of pre- and postoperative TNM stage is warranted, and such studies are ongoing.

Background Rapid response teams (RRTs) are called to deteriorating ward patients in order to improve their outcome. The involvement of the team also in end-of-life care issues needs to be addressed. Our objective was to evaluate the RRT with focus on limitations of medical treatment (LOMT). Methods Observational cohort study of RRT calls from 2005 to 2010 at a university hospital. Results There were 2189 calls in 1818 admissions. Six hundred forty-two patients (35.3%) were assigned LOMT, and in 296 cases (46.1%) it was documented on the same day as the first RRT call. In total, 152 calls were for patients where a decision was already in place. Among patients with multiple calls, 44.6% received limitations. Hospital mortality was 25.6% in total, 60.6% for patients with limitations and 6.6% for patients without. Mortality at 180 days was 43.2% for the whole cohort, and 83.6% and 21.2% with and without limitations, respectively. Cardiac arrest rate has remained at the level of 0.82/1000 admissions since the introduction of the RRT. Conclusion Patients attended by the RRT have high short- and long-term mortality. Distinction of when deteriorations may be amenable to treatment or when focus should be laid on palliative care is not always made in the wards. Many decisions of limitations are taken in close conjunction to the call, although limitations do not preclude repeated visits from the team, indicating a need to support wards that care for patients at end of life.

BackgroundMany intensive care unit (ICU) patients describe noise as stressful and precluding sleep. No previous study in the adult setting has investigated whether room size impacts sound levels or ...

Introduction Trauma patients are susceptible to post-injury infections. We investigated the incidence, as well as risk factors for development of pneumonia in intensive care unit (ICU)-treated trauma patients. In addition, we report pathogens identified in patients that developed pneumonia. Methods The study cohort consisted of 322 trauma patients admitted to the ICU at a level-one trauma centre following initial resuscitation. Patients 15 years or older with an ICU stay of more than 24 h were included. We investigated pre-hospital and hospital parameters during the first 24 h after admission and their possible association with pneumonia within 10 days of ICU admission. Results Majority of the patients were male (78%) and the median age was 41 years. The overall degree of injury was high with a median Injury Severity Score (ISS) of 24. Overall 30-day mortality was 9%. Eighty-five (26%) patients developed pneumonia during their first 10 days in the ICU. Univariate logistic regression revealed that intubation in the field, shock, Glasgow Coma Scale (GCS) 3–8, major surgery within 24 h after admission, massive transfusion and ISS > 24 were all risk factors for subsequent development of pneumonia. In the multivariable model, only GCS 3–8 was identified as an independent risk factor. In 42 out of the 85 cases of pneumonia, the diagnosis was defined by significant growth of at least one pathogen where Enterobacteriaceae and Staphylococcus aureus were the most common. Conclusions Pneumonia is a common complication among ICU-treated trauma patients. Reduced consciousness is an independent risk factor for development of pneumonia after severe injury.

Aim Extra-levator abdominoperineal excision (APE) of the rectum has been introduced with the aim of improving the oncological outcome of low rectal cancer. The procedure includes resection of the levator muscles en bloc with the mesorectum, leaving a larger perineal defect than after conventional APE. This study reports short-term outcome of gluteus maximus myocutaneous flap reconstruction on perineal wound healing. Method Sixty-five patients were studied after extra-levator APE and a one-sided myocutaneous flap for a low or locally recurrent rectal cancer at the Karolinska University Hospital from January 2002 to December 2008. Fifty-nine had received neoadjuvant radio- or radiochemotherapy. All perineal complications occurring within 30 days after surgery were registered. In addition, the status of the perineal reconstruction at 6 months and 1 year after surgery was assessed based on medical records from outpatient visits. Results Twenty-seven (41.5%) patients had one or more perineal wound complications. A minor wound infection occurred in 15, while 12 had either a more severe infection with dehiscence or a pelvic abscess. The reconstruction was completely healed in 91% of the patients at 1 year. Conclusion Although the vast majority of the perineal reconstructions were healed at 1 year, the short-term perineal wound complication rate of gluteus maximus flap reconstruction was high.

Aim In recent decades, the focus has been on the treatment of rectal cancer with improved surgical techniques. This has resulted in improved results for patients with rectal cancer. Recently, the focus has shifted to colon cancer surgery with the introduction of preoperative staging, new surgical techniques, quality control and enhanced recovery programmes. The change in operative techniques has been most pronounced for patients with tumours on the right side of the colon, with more extensive resections and proximal ligations of the vessels. The aim of this study was to assess the number of analysed lymph nodes and the metastatic index (MI) in patients operated on for right-sided colon cancer in the Stockholm area between 1996 and 2009. Method All patients operated on for cancer of the right colon between January 1996 and December 2009 were divided into three groups based on the year in which they were operated (period 1, 1996–1999; period 2, 2000–2004; and period 3, 2005–2009). The number of lymph nodes and lymph node status were analysed. Results In total, 3536 patients were operated on for right-sided colon cancer during the study period. There was a significantly lower proportion of emergency operations in the third time period. The mean number of lymph nodes examined increased significantly during the overall study period (seven in period 1, 11 in period 2 and 18 in period 3; P

Aim Multidisciplinary team meetings have been introduced as a result of developments in preoperative radiological tumour staging and neoadjuvant treatment. Multidisciplinary team recommendations will influence treatment decisions but their effect on patient outcome is unknown. The aim of this study was to assess outcome in relation to preoperative local and distant staging, with or without multidisciplinary team assessment. Methods A population-based registry of all patients with rectal cancer, treated in the Stockholm region from 1995 to 2004, identified 303 patients with locally advanced primary rectal cancer. The patients were classified into three groups: group 1, preoperative local and distant radiological tumour staging with discussion at a multidisciplinary team meeting; group 2, preoperative staging but no multidisciplinary team assessment; and group 3, no proper preoperative radiological staging. Results Neoadjuvant treatment was more prevalent in groups 1 and 2 than in group 3. The incidence of R0 resection differed significantly between the groups (52% in group 1, 43% in group 2 and 21% in group 3; P

Background Acute kidney injury (AKI) necessitating renal replacement therapy (RRT) is associated with high short-term mortality, relatively little however is known of the long-term outcome in these patients. This narrative review describes renal recovery, long-term mortality, and quality of life in RRT patients with acute kidney injury. Methods A literature search using the PubMed search engine from the year 2000 to present with the MeSH terms 1) acute kidney injury, renal replacement therapy, prognosis, and 2) acute kidney injury, quality of life, prognosis, was performed, including studies addressing long-term outcome (over 60 days) in adults with AKI on RRT. Results According to inclusion criteria, twenty two studies were eligible. Outcome varied depending on AKI aetiology, setting, co-morbidity and pre-morbid renal function. Five-year-survival was between 15% and 35%, with dialysis dependence in less than 10% of survivors. Renal recovery, even if incomplete occurred during the first year. Quality of life assessment amongst survivors indicated moderate physical impairment and reduced mental health scores. A majority of patients returned to employment and self-sustainability and reported acceptable to good quality of life. Over 90% of patients indicated that they would undergo the same treatment again. Discussion and Conclusions Early initiation of treatment and fine-tuning of the RRT technique may improve outcome. Consensus regarding AKI definitions, renal function measurement and standardised follow-up regimens are required. Further long-term studies are needed.

Objective At diagnosis, 14–27% of patients with colorectal cancer (CRC) have distant metastases (stage IV) and a poor prognosis. Today, treatment decisions for CRC patients are often made at multidisciplinary team (MDT) conferences. The aim of this study was to evaluate the effects of development and implementation of MDT assessment and treatment in patients with stage IV colon cancer (CC) and rectal cancer (RC) in a large population. Method All 1449 patients who had stage IV CRC at the time of diagnosis and were registered in the regional quality registry of Stockholm from 1995 to 2004 were included. Patients with CC and RC were grouped according to treatment and their characteristics were analysed separately. Results In total, 1000 patients with CC and 449 patients with RC had stage IV disease. Of these, 689 (68.9%) CC patients and 352 (78.4%) RC patients were assessed by a MDT and the proportion increased over the study period (P

Prolonged sedation in the pediatric intensive care unit may be difficult because of tolerance, drug dependence and withdrawal, drug interactions and unwanted drug effects. We present three patients sedated with isoflurane via the Anesthetic Conserving Device, AnaConDa. AnaConDa is a modified heat and moisture exchanger that allows evaporation and delivery of inhalational anesthetics without an anesthesia machine, vaporizer or adapted ventilator. Two patients with abdominal complications and prolonged sedation for mechanical ventilation were converted to isoflurane sedation for several days. The third patient with refractory status epilepticus received isoflurane to treat epileptiform electroencephalogram activity. Patients weighing 40 and 30 kg were treated with AnaConDa placed at the Y-piece, while the patient weighing 20 kg was treated with AnaConDa in the inspiratory limb of the respiratory circuit. Adequate sedation was achieved with endtidal isoflurane concentration of 0.3-0.4%, while antiepileptic effect was achieved at a higher dose, 0.9%. Intravenous sedatives could be reduced or discontinued during isoflurane sedation. Inhaled sedation of isoflurane with AnaConDa was effective in these patients. It may provide an alternative in difficult cases needing prolonged sedation and should be evaluated further.

The effect of moisture content on the linear viscoelastic properties of gliadin hydrated to 30 and 40% moisture content [gliadin(30%) and gliadin(40%), respectively] was determined. These two moisture contents bracketed the equilibrium moisture content of gliadin, which was 37.6%. Time-temperature-superposition was used to develop master curves of the elastic modulus (G′), viscous modulus (G″), dynamic viscosity (η′), and tan δ (G″/G′) from isothermal frequency sweep data obtained at 25–80°C. Smooth master curves were obtained for all of the viscoelastic functions for both gliadins. G′ and G″ showed a power law dependency on frequency (with G″ > G′) for frequencies

BACKGROUND The Stockholm II trial is a population-based prospective randomized trial on preoperative radiotherapy in rectal carcinoma. METHODS Eligibility criteria were age younger than 80 years and biopsy-proven adenocarcinoma of the rectum judged resectable for cure with an abdominal procedure. Between 1987 and 1993, 557 patients were included. Patients were randomized to preoperative radiotherapy (RT+) followed by surgery within a week (n = 272) or surgery alone (RT−; n = 285). Radiotherapy was given with 25 grays in 1 week to the rectum and pararectal tissues. Curative resection was performed in 481 patients (86%). Median follow-up was 8.8 years. RESULTS Among patients who underwent curative surgery, the incidence of pelvic recurrence was 12% (RT+) and 25% (RT−), respectively (P < 0.001). The overall survival rate in irradiated patients who underwent curative surgery was improved (46%) versus (39%; P < 0.03). For all included patients, the difference was 39% (RT+) compared with 36% (RT−; P = 0.2). Within 6 months of surgery, 13 of 272 (5%) of the irradiated patients died of intercurrent disease versus 4 of 285 (1%) of the nonirradiated (P = 0.02). Cardiovascular death was the main cause of intercurrent death and occurred in 35 of 272 (13%) of the irradiated patients compared with 20 of 285 (7%) among the nonirradiated (P = 0.07). CONCLUSIONS Preoperative short-term radiotherapy reduces the risk of pelvic recurrence and can improve survival after curative surgery for rectal carcinoma. An increased risk of intercurrent death may reduce the benefit especially in elderly patients. Cancer 2001;92:896–902. © 2001 American Cancer Society.