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Aim: Anastomotic leakage (AL) is a common and serious complication following sphincter-preserving surgery for rectal cancer. Early detection and intervention can improve clinical outcomes. The aim of this prospective cohort study was to compare intraperitoneal microdialysis with a clinical scoring system for early detection of AL., Method: A microdialysis catheter was anchored near the anastomosis at low anterior resection (LAR) for rectal cancer. Peritoneal fluid samples were analysed (lactate, pyruvate, glucose and glycerol concentration) 4-hourly and compared with a daily clinical leak score (DULK = Dutch leakage). At day 7 a pelvic CT with rectal contrast enema was performed to establish if there had been a radiological leak., Results: In this two-centre study, 129 patients [median age 65 (26-82) years; 60.5% male] underwent LAR. The leak rate was 27% (grade A, n = 11; grade B, n = 12; grade C, n = 12). Receiver operator characteristic analysis demonstrated a lactate cut-off value of 9.8 mm and had 77% sensitivity, 82% specificity, 78% accuracy, a positive predictive value (PPV) of 58, a negative predictive value (NPV) of 88 (CI 79-94) and an area under the curve (AUC) of 0.9 for AL. This compared with a clinical score ≥ 4, which had 57% sensitivity, 79% specificity, 71% accuracy, a PPV of 46, a NPV of 82 and an AUC of 0.7 for AL. The mean day for a positive test when using delta lactate ≥ 6.3 mm was 1.6 days and for leak score ≥ 4 it was 3.3 days (NS)., Conclusion: When AL occurs, intraperitoneal lactate concentration increases over time, and at a certain cut-off has a higher sensitivity, specificity, accuracy, PPV and NPV than a clinical scoring system., (Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.)

Background: An accurate radiological staging of colon cancer is crucial to select patients who may benefit from neoadjuvant chemotherapy., Purpose: To evaluate the diagnostic accuracy of preoperative magnetic resonance imaging (MRI) in identifying locally advanced sigmoid colon cancer, poor prognostic factors, and the inter-observer variation of the tumor apparent diffusion coefficient (ADC) values of diffusion-weighted imaging (DWI)., Material and Methods: Using 1.5 T MRI with high resolution T2-weighted (T2W) imaging, DWI, and no contrast enhancement, 35 patients with sigmoid colon cancer were assessed. T-stage, N-stage, extramural vascular invasion (EMVI), and ADC values of the tumors were assessed and blindly compared by two observers using postoperative histopathological examination as the gold standard. Early tumors were defined as T1 to T3ab, and advanced tumors as T3cd or T4., Results: The accuracy of the two radiologists in staging early versus advanced tumors, N-stage, and identification of EMVI was 94%/89%, 60%/66%, and 77%/60% with an inter-observer agreement of к = 0.86 (95% confidence interval [CI] = 0.67-1.00), к = 0.64 (95% CI = 0.39-0.90), and к = 0.52 (95% CI = 0.23-0.80). All the measured mean ADC values were below 1.0 × 10 -3 mm 2 /s with an intra-class correlation coefficient in T3cd-T4 tumors of 0.85., Conclusion: Preoperative MRI can identify locally advanced sigmoid colon cancer and has potential as the imaging of choice to select patients for neoadjuvant chemotherapy. Initial experience with ADC measurement was achieved with an excellent inter-observer agreement in advanced tumors.

We report an unusual case of penile metastasis derived from a rectal adenocarcinoma, which was first interpreted as Peyronie's disease. The patient had a single palpable mass in the penile shaft within the corpus cavernosum, with no ulceration or pain in the area. Two years earlier he had been treated for rectal cancer with neoadjuvant radiation therapy and abdomino-perineal resection. The mass in the penis later turned out to be a manifestation of widespread metastatic disease. The patient lived three years after discovery of metachronous metastases in penis and lungs.

Objectives: To examine the frequency of re-resections and describe risk characteristics: invasive carcinoma or carcinoma in situ (CIS), palpability of the lesion, and neoadjuvant chemotherapy., Results: 1703 breast conserving surgeries were performed: 1575 primary breast conserving surgeries (BCS), and 128 diagnostic excisions (DE). 176 BCS (11.2% [9.6; 12.7]) and 100 DE had inadequate margins indicating re-resection. The overall re-resection rate was 16.2% [14.5; 18.0]. 10.3% of invasive carcinoma BCS patients, and 28.6% CIS patients underwent re-resection (relative risk (RR) 2.8 [1.9; 4.1]). Invasive lobular carcinoma (ilc) had an RR of re-resection of 2.5 [1.7; 3.8], compared with invasive ductal carcinoma (idc)., Conclusion: Overall 11.2% of the BCS patients needed a re-resection. For isolated CIS (28.6%), RR of re-resection was almost three times as high compared to invasive carcinoma (10.3%). Ilc had an RR of re-resection of 2.5 compared to idc. Palpability and neoadjuvant chemotherapy did not significantly influence the risk of re-resection., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

A case of disseminated rectal cancer in a 32-year-old pregnant woman is described. Pain was her main complaint, but this had been ascribed to haemorrhoids and treated with topical agents. She was diagnosed with rectal cancer late in the third trimester when her midwife referred her for surgical assessment. Following caesarian section, diagnostic workup showed multiple liver metastases. Rectal cancer in pregnancy is rare, while haemorrhoids are common. We recommend keeping the differential diagnoses in mind and performing a digital rectal examination if pregnant women have anal symptoms.

The aim of the present study was to determine plasma levels of protein C antigen (PC:Ag) and activity (PC:Act), tissue factor pathway inhibitor (TFPI), protein S (PS), antithrombin (AT), heparin cofactor II (HCII), and resistance to activated protein C (APCR) before, during and after elective gastric surgery in order to compare patients with and without gastric malignancy. Blood was collected from a forearm vein of two age-matched patient groups undergoing elective gastric surgery, 9 patients with and 9 patients without gastric malignancy. The plasma levels of the parameters were determined preoperatively, intraoperatively, and on days 1 and 7 postoperatively. On the 1st and 7th postoperative day, plasma levels of HCII were significantly lower in patients operated for gastric malignancy than in those operated for benign disorders, but levels of TFPI, PC:Act, PC:Ag, AT, PS and APCR did not differ in the postoperative period. The day-to-day variation was also rather similar in the two patient groups.

Background and Objectives: Previous studies have reported signs of haemostatic activation after haemorrhage. The aim of this study was to measure sensitive markers for haemostatic activation after blood donation or plasmapheresis in healthy donors., Materials and Methods: Blood samples were drawn before as well as 5 min and 1 h after donation in 40 male donors, of whom 29 gave 1 unit of blood and 11 underwent plasmapheresis. Standard assays were used., Results: Plasma concentrations of the activation markers prothrombin fragment 1 + 2, thrombin-antithrombin complexes, and von Willebrand factor did not increase after blood or plasma donation., Conclusions: In our opinion, these procedures are safe.

Pre- and postoperative plasma levels of tissue-type plasminogen activator (t-PA), single-chain urinary plasminogen activator, and plasminogen activator inhibitor 1 (PAI-1) were measured in 40 patients undergoing gastric surgery in order to compare patients operated for benign (n = 21) and malignant (n = 19) disease. On the 1st postoperative day, the PAI-1 activity was significantly increased and the t-PA activity significantly decreased in the malignant group, whereas only insignificant changes were seen in the benign group. In contrast, the t-PA activity was significantly increased 1 week after surgery in patients without malignancy. In both groups, the single-chain urinary plasminogen activator activity decreased on the 1st postoperative day, but was significantly increased 1 month after operation. Thus, the two groups reacted differently, but it remains to be determined whether this bears any relationship to the well-known high risk of postoperative venous thromboembolism in cancer patients.

The review encompasses all published clinical studies of prophylactic treatment with low molecular weight (LMW) heparins marketed in Denmark when used to prevent thrombosis in patients undergoing elective or emergency orthopaedic operations. In elective hip surgery, LMW-heparin was more effective than placebo in reducing the incidence of deep vein thrombosis. There was significantly better anti-thrombotic effect of LMW-heparin, given in recommended doses, than of Dextran 70. When compared to low-dose heparin, the incidence of deep vein thrombosis was lowest using LMW-heparin, but only one study found the difference significant. LMW-heparin compared to low-dose heparin in combination with dihydroergotamine showed no significant difference with respect to either effect of safety. The use of LMW-heparin as prophylactic treatment for patients with either trochanteric or femoral neck fractures is as yet not nearly so well-documented. The relatively few studies that have been carried out show large variation between the different LMW-heparins. There is need for a study comparing the effect of LMW-heparin with that of low-dose heparin in these patients, both with respect to thrombosis prevention and influence on total mortality.

A case of intrathoracic perforation of a chronic gastric ulcer in a hiatus hernia is presented. A 67-year-old woman had suffered from interscapular pain and epigastric discomfort following large meals for four years. During the week before admission, the epigastric and interscapular pain increased, reaching a crescendo in the 24 hours before the patient's arrival in the emergency room. Chest and abdominal x-ray showed free gas and a large hiatus hernia with an intrathoracic stomach. At laparotomy, the stomach was gently returned to the abdominal cavity, and a perforated chronic gastric ulcer was found on the greater curvature. The ulcer was excised, and the diaphragmatic crura were approximated. Apart from wound dehiscence, the postoperative course was uneventful.

In a prospective study including 30 traumatized patients, levels of fibrinogen, fibrinopeptide A (FpA), fibrin monomers (FM) and fibrin degradation products (FbDP) were measured on admission and on days 1, 2, 3 and 7 after the incident. High levels of FpA, FM and FbDP were observed immediately after the trauma. Fibrinogen levels increased during the first 7 posttraumatic days whereas FpA and FM decreased. FbDP was significantly higher on day 7 than on day 3. All variables were to some extent correlated to the injury severity score. FbDP were significantly lower on the day after admission in 4 patients who developed pulmonary dysfunction compared with patients without this complication.

The study was performed to detect activation of coagulation and fibrinolysis in terms of prothrombin fragment 1 and 2 (F1 + 2), thrombin-antithrombin III complex (TAT), fibrin degradation products (FbDP), fibrinogen degradation products (FgDP), and soluble fibrin monomers (FM) in plasma from 39 patients with fractures of the lower extremities. We found substantially elevated levels of the molecular markers at admission and on the day after admission (Day 1) compared with control levels. Admission levels of F1 + 2, TAT, FbDP and FgDP were significantly higher compared with levels on day 1, whereas levels of FM were not significantly different between the two days. Generally there were good correlations between all markers of coagulation and fibrinolysis at admission whereas correlations were weaker or absent on day 1. In conclusion we found substantial haemostatic activation as a immediate response to trauma. Increased levels of F1 + 2, TAT, FM, FbDP and FgDP appear to be a normal physiological reaction after fractures of the lower extremities.

In a randomized double-blind placebo-controlled study, plasma levels of prothrombin fragment 1 and 2 and total fibrin/fibrinogen degradation products were measured preoperatively and on days 1, 3, 5 and 7 postoperatively in 131 patients undergoing total hip replacement. Patients received a subcutaneous injection of either a low molecular weight heparin (Logiparin) or placebo once daily. Postoperative deep vein thrombosis was diagnosed by bilateral phlebography 7 to 10 days after operation. In the placebo group postoperative levels of prothrombin fragments 1 and 2 and total fibrin/fibrinogen degradation products were significantly higher in patients with postoperative thromboembolic complications, whereas in the low-molecular-weight heparin group no statistical differences were observed. Compared with placebo the administration of a low-molecular-weight heparin was associated with a significant reduction in the levels of prothrombin fragments 1 and 2 and total degradation products. Our observations suggest that the postoperative thrombin generation is moderated by thromboprophylaxis with Logiparin.

Heparin preparations have been used for prophylaxis and treatment of deep vein thrombosis for many years. Several biologic effects of heparin are known. Since 1978, there have been several reports about reversible elevation in serum values of AST and ALT in patients and healthy volunteers given heparin in small and high doses. Few studies report similar events in patients given LMW heparins. Results of two randomized studies (A and B) comprising 456 patients undergoing THR are presented. Two different compounds of LMW heparin (Logiparin or Enoxaparin) were used for thromboprophylaxis. Significant elevation during the postoperative period of AST and AP in study A, and AST, ALT, AP, LDH, and CK in study B were demonstrated in patients given LMW heparins in both studies. In study A the percentages of patients with normal preoperative values who reached pathologic values were 35% for AST and 15% for AP. In study B the percentages of patients with normal preoperative values who reached pathologic values were 36% for AST, 17% of ALT, 14% for AP, and 36% for LDH. The possible biologic mechanisms and the clinical perspectives are discussed. In all cases the changes in the liver enzymes returned to preoperative levels within 14 days.