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Background Local excisions are important in a tailored approach to treatment of rectal neoplasms. In cases of low risk T1 local excision facilitates rectal-preserving treatment. Transanal minimally invasive surgery (TAMIS) is the most recent alternative developed for local excision. In this study we evaluate the results after implementing TAMIS as the routine procedure for local excision of rectal neoplasms. Methods All patients who underwent TAMIS from January 2016 to January 2020 at St. Olav’s University Hospital were included, and clinical, pathological and oncological data were prospectively registered. The primary endpoint was local recurrence, and the secondary endpoint was complications. Results There were 76 patients (42 men, mean age was 69 years [range 26–88 years]), The mean tumour level was 82 mm (range 20–140 mm) from the anal verge measured on rigid proctoscopy, and mean tumour size was 32 mm (range 8–73 mm). Three patients experienced complications needing intervention (Clavien–Dindo > 3A). Seventeen patients had rectal adenocarcinoma, 9 of whom underwent R0 completion total mesorectal excision (cTME). Fifty-five patients had an adenoma, 3 of whom developed recurrence (5.4%) within 12 months. All recurrences were treated successfully with a new TAMIS procedure. In addition, TAMIS was used in treatment of 2 patients with a neuroendocrine tumour, 1 patient with a haemangioma and 1 patient with a solitary rectal ulcer. Conclusions TAMIS surgery is associated with a low risk of complications and a low recurrence rate in rectal neoplasms. In cases of adenocarcinoma, R0 cTME surgery is feasible in the sub-group with high risk T1 and T2 tumours.

Background Iron absorption is disturbed after Roux-en-Y gastric bypass (RYGB) and iron deficiency with or without anaemia affects almost half of all patients. Intravenous iron is an option when per oral iron is insufficient or not tolerated. This study explores whether routinely offering intravenous iron treatment when iron stores are empty can prevent anaemia and iron deficiency after RYGB. Methods This is a study of prospectively registered data on clinical information, haematological tests and intravenous iron treatment from 644 RYGB patients who underwent surgery between 2004 and 2013, postoperatively followed more than 5 years. Intravenous iron treatment was offered to patients with ferritin ≤ 15 μg/L. Results Clinical information was available for all patients at baseline and for 553/644 patients at 5 years; laboratory results were available for 540/644 patients at baseline and 411/644 patients after 5 years. The mean age was 39.8 (± 9.7) years. Overall, 187/483 (38.7%) women and 9/161 (5.6%) men were given intravenous iron treatment in the observation period. From baseline to 5 years, mean haemoglobin decreased by 0.3 g/dL in both men and women. Anaemia occurred in 18/311 (5.8%) women and 9/100 (9%) men at 5 years. Depleted iron stores (ferritin ≤ 15 μg/L) were seen among 44/323(13.6%) women and 3/102 (2.9%) men, and low iron stores (ferritin 16–50 μg/L) occurred in 144/326 (44.6%) women and 38/102 (37.3%) men 5 years after RYGB. Conclusion By routinely offering intravenous iron treatment to patients with depleted iron stores after RYGB, haemoglobin levels were preserved. Half of the patients experienced low or depleted iron stores at 5 years. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Roux-en-Y gastric bypass (RYGB), implies a considerable weight loss during the first two years after surgery. Excess skin due to rapid weight loss might affect self-esteem, decrease quality of life and be a hindrance to physical activity. Removing excess skin might reduce secondary weight regain. Among plastic surgeons, a BMI 30 kg/m2 within two years after RYGB who underwent AP regained 12.9 (±19.3) % compared to 31.4 (±24.7) % in 188 patients without AP (p < 0.001). This procedure was more common among women than men, as 224 (46.4%) women, and 36 (22.2%) men underwent AP. Abdominoplasty was associated with reduced secondary weight regain after RYGB in this study. Whether this is caused by increased bodily satisfaction and better physical function, or a biological response to reduction of adipose tissue remains unclear. If removing abdominal subcutaneous adipose tissue prevent secondary weight regain and increase the robustness of bariatric surgery, this should be offered as part of the standard treatment after bariatric surgery.

Background Many countries lack sufficient medical doctors to provide safe and affordable surgical and emergency obstetric care. Task-sharing with associate clinicians (ACs) has been suggested to fill this gap. The aim of this study was to assess maternal and neonatal outcomes of caesarean sections performed by ACs and doctors. Methods All nine hospitals in Sierra Leone where both ACs and doctors performed caesarean sections were included in this prospective observational multicentre non-inferiority study. Patients undergoing caesarean section were followed for 30 days. The primary outcome was maternal mortality, and secondary outcomes were perinatal events and maternal morbidity. Results Between October 2016 and May 2017, 1282 patients were enrolled in the study. In total, 1161 patients (90·6 per cent) were followed up with a home visit at 30 days. Data for 1274 caesarean sections were analysed, 443 performed by ACs and 831 by doctors. Twin pregnancies were more frequently treated by ACs, whereas doctors performed a higher proportion of operations outside office hours. There was one maternal death in the AC group and 15 in the doctor group (crude odds ratio (OR) 0·12, 90 per cent confidence interval 0·01 to 0·67). There were fewer stillbirths in the AC group (OR 0·74, 0·56 to 0·98), but patients were readmitted twice as often (OR 2·17, 1·08 to 4·42). Conclusion Caesarean sections performed by ACs are not inferior to those undertaken by doctors. Task-sharing can be a safe strategy to improve access to emergency surgical care in areas where there is a shortage of doctors.

Background Anastomotic leak after rectal cancer surgery is a severe complication associated with poorer oncologic outcome and quality of life. Preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity to create a defunctioning stoma. Objective The purpose of this study was to identify and quantify the risk factors for anastomotic leak to minimize risk by either not restoring bowel continuity or protecting the anastomosis with a temporary diverting stoma. Methods Potentially relevant studies were identified from the following databases: PubMed, Embase and Cochrane Library. This meta-analysis included studies on transabdominal resection for rectal cancer that reported data about anastomotic leak. The risk for anastomotic leak after rectal cancer surgery was investigated. Preoperative, intraoperative, and postoperative factors were extracted and used to compare anastomotic leak rates. All variables demonstrating a p value < 0.1 in the univariate analysis were entered into a multivariate logistic regression model to determine the risk factors for anastomotic leak. Results Twenty-six centers provided individual data on 9735 patients. Selected preoperative covariates (time before surgery, age, gender, smoking, previous abdominal surgery, BMI, diabetes, ASA, hemoglobin level, TNM classification stage, anastomotic distance) were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. With a threshold value of the receiver operating characteristics (ROC) curve corresponding to 0.0791 in the training set, the area under the ROC curve (AUC) was 0.585 (p < 0.0001). Sensitivity and specificity of the model's probability > 0.0791 to identify anastomotic leak were 79.1% and 32.9%, respectively. Accuracy of the threshold value was confirmed in the validation set with 77.8% sensitivity and 35.2% specificity. Conclusions We trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. The score is now available online ().

Open abdomen treatment (OAT) is a significant burden for patients and is associated with considerable mortality. The primary aim of this study was to report survival and cause of mortality after OAT. Secondary aims were to evaluate length of stay (LOS) in intensive care unit (ICU) and in hospital, time to abdominal closure and major complications. Retrospective review of prospectively registered patients undergoing OAT between October 2006 and June 2014 at Trondheim University Hospital, Norway. The 118 patients with OAT had a median age of 63 (20–88) years. OAT indications were abdominal compartment syndrome (ACS) (n = 53), prophylactic (n = 29), abdominal contamination/second look laparotomy (n = 22), necrotizing fasciitis (n = 7), hemorrhage packing (n = 4) and full-thickness wound dehiscence (n = 3). Eight percent were trauma patients. Vacuum-assisted wound closure (VAWC) with mesh-mediated traction (VAWCM) was used in 92 (78 %) patients, the remaining 26 (22 %) had VAWC only. Per-protocol primary fascial closure rate was 84 %. Median time to abdominal closure was 12 days (1–143). LOS in the ICU was 15 (1–89), and in hospital 29 (1–246) days. Eighty-one (68 %) patients survived the hospital stay. Renal failure requiring renal replacement therapy (RRT) (OR 3.9, 95 % CI 1.37–11.11), ACS (OR 3.1, 95 % CI 1.19–8.29) and advanced age (OR 1.045, 95 % CI 1.004–1.088) were independent predictors of mortality in multivariate analysis. The nine patients with an entero-atmospheric fistula (EAF) survived. Two-thirds of the patients treated with OAT survived. Renal failure with RRT, ACS and advanced age were predictors of mortality, whereas EAF was not associated with increased mortality.

Treatment of early stage rectal cancer has excellent oncological results. To reduce treatment-related mortality and morbidity and improve functional results, a focus on local resections is increasingly important.The purpose of this study was to compare outcomes after transanal endoscopic microsurgery and total mesorectal excision for early stage rectal cancer (T1 + T2) in Norway.This was an observational study based on prospective data from the Norwegian Colorectal Cancer Registry.The study was conducted as a national, population-based study.All 543 patients with T1 and 1593 patients with T2 rectal cancer without distant metastases that was treated by transanal endoscopic microsurgery or total mesorectal excision without radiochemotherapy during 2000-2009 were included.The primary outcomes were 5-year relative survival and 5-year local recurrence rate.Among 543 patients with T1 cancer, the 5-year overall survival rate was 65.3% after transanal endoscopic microsurgery versus 81.5% after total mesorectal excision (p = 0.012). Adjusted for age and sex there was no excess mortality for transanal endoscopic microsurgery (HR = 1.28 (95% CI, 0.8-1.9); p = 0.22). The 5-year relative survival rate was 96.8% after transanal endoscopic microsurgery versus 98.2% after total mesorectal excision (p = 0.603), and the 5-year local recurrence rate was 14.5% versus 1.4% (p0.001). Among 1593 patients with T2 cancer, 5-year overall survival was 42.1% versus 76.1% (p0.001), 5-year relative survival was 65.4% versus 93.9% (p0.001), and 5 year local recurrence rate was 11.4% versus 4.4% in the 2 groups.The study is limited by its observational design and that the 2 groups were different according to patient and tumor characteristics. Another limitation was the low number of transanal endoscopic microsurgery procedures.Transanal endoscopic microsurgery had comparable 5-year relative survival to total mesorectal excision in T1 rectal cancer but inferior 5-year relative survival in T2 rectal cancer. Transanal endoscopic microsurgery was associated with higher local recurrence rates for both T1 and T2 tumors.

Background Limited data exist on surgical providers and their scope of practice in low-income countries (LICs). The aim of this study was to assess the distribution and productivity of all surgical providers in an LIC, and to evaluate correlations between the surgical workforce availability, productivity, rates, and volume of surgery at the district and hospital levels. Methods Data on surgeries and surgical providers from 56 (93.3 %) out of 60 healthcare facilities providing surgery in Sierra Leone in 2012 were retrieved between January and May 2013 from operation theater logbooks and through interviews with key informants. Results The Sierra Leonean surgical workforce consisted of 164 full-time positions, equal to 2.7 surgical providers/100,000 inhabitants. Non-specialists performed 52.8 % of all surgeries. In rural areas, the densities of specialists and physicians were 26.8 and 6.3 times lower, respectively, compared with urban areas. The average individual productivity was 2.8 surgeries per week, and varied considerably between the cadres of surgical providers and locations. When excluding four centers that only performed ophthalmic surgery, there was a positive correlation between a facility’s volume of surgery and the productivity of its surgical providers (rs = 0.642, p

Background In an attempt to assess the effects of the Ebola viral disease (EVD) on hospital functions in Sierra Leone, the aim of this study was to evaluate changes in provisions of surgery and non-Ebola admissions during the first year of the EVD outbreak. Methods All hospitals in Sierra Leone known to perform inpatient surgery were assessed for non-Ebola admissions, volume of surgery, caesarean deliveries and inguinal hernia repairs between January 2014 and May 2015, which was a total of 72 weeks. Accumulated weekly data were gathered from readily available hospital records at bi-weekly visits during the peak of the outbreak from September 2014 to May 2015. The Mann-Whitney U test was used to compare weekly median admissions during the first year of the EVD outbreak, with the 20 weeks before the outbreak, and weekly median volume of surgeries performed during the first year of the EVD outbreak with identical weeks of 2012. The manuscript is prepared according to the STROBE checklist for cross-sectional studies. Results Of the 42 hospitals identified, 40 had available data for 94% (2719/2880) of the weeks. There was a 51% decrease in weekly median non-Ebola admissions and 41% fewer weekly median surgeries performed compared with the 20 weeks before the outbreak (admission) and 2012 (volume of surgery). Governmental hospitals experienced a smaller reduction in non-Ebola admissions (45% versus 60%) and surgeries (31% versus 53%) compared to private non-profit hospitals. Governmental hospitals realized an increased volume of cesarean deliveries by 45% during the EVD outbreak, thereby absorbing the 43% reduction observed in the private non-profit hospitals. Conclusions Both non-Ebola admissions and surgeries were severely reduced during the EVD outbreak. In addition to responding to the EVD outbreak, governmental hospitals were able to maintain certain core health systems functions. Volume of surgery is a promising indicator of hospital functions that should be further explored. © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/)

Background Colon cancer in older patients represents a major public health issue. As older patients are hardly included in clinical trials, the optimal treatment of these patients remains unclear. The present international EURECCA comparison explores possible associations between treatment and survival outcomes in elderly colon cancer patients. Subjects, Materials, and Methods National data from Belgium, Denmark, The Netherlands, Norway, and Sweden were obtained, as well as a multicenter surgery cohort from Germany. Patients aged 80 years and older, diagnosed with colon cancer between 2001 and 2010, were included. The study interval was divided into two periods: 2001–2006 and 2007–2010. The proportion of surgical treatment and chemotherapy within a country and its relation to relative survival were calculated for each time frame. Results Overall, 50,761 patients were included. At least 94% of patients with stage II and III colon cancer underwent surgical removal of the tumor. For stage II–IV, the proportion of chemotherapy after surgery was highest in Belgium and lowest in The Netherlands and Norway. For stage III, it varied from 24.8% in Belgium and 3.9% in Norway. For stage III, a better adjusted relative survival between 2007 and 2010 was observed in Sweden (adjusted relative excess risk [RER] 0.64, 95% confidence interval [CI]: 0.54–0.76) and Norway (adjusted RER 0.81, 95% CI: 0.69–0.96) compared with Belgium. Conclusion There is substantial variation in the rate of treatment and survival between countries for patients with colon cancer aged 80 years or older. Despite higher prescription of adjuvant chemotherapy, poorer survival outcomes were observed in Belgium. No clear linear pattern between the proportion of chemotherapy and better adjusted relative survival was observed. Implications for Practice With the increasing growth of the older population, clinicians will be treating an increasing number of older patients diagnosed with colon cancer. No clear linear pattern between adjuvant chemotherapy and better adjusted relative survival was observed. Future studies should also include data on surgical quality.

Introduction Acute, intermittent, and chronic abdominal pain is a common complaint after Roux-en-Y gastric bypass (RYGB). Objectives The aimof the study was to evaluate the use of medical imaging and the need for surgery treating abdominal pain after RYGB in a cohort with long-term follow-up. Methods Data from 569 patients who underwent RYGB as the primary bariatric procedure at a public hospital in Norway between April 2004 and June 2011 were prospectively registered in a local quality registry for bariatric surgery. All abdominal imaging and abdominal surgical procedures were registered until August 2017. Results Mean follow-up was 100 months (61–159). During the observation period, 22% had one CT, 9% had two CTs, 4% had three CTs, and 5% had four or more CTs for abdominal pain. Twenty-two percent underwent abdominal surgery, as 16% had one and 6% had two or more operations and gynecological procedures excluded. The purpose of operation was postoperative complications (1.4%), suspected internal herniation (9.3%), cholecystectomy (9.3%), appendectomy (2.3%), hernias (3.2%), and perforated ulcer in the gastrojejunal anastomosis (0.7%). Mean time interval was 42 ± 27 months from RYGB to cholecystectomy and 51 ± 26 months for suspected IH. Conclusion With a mean follow-up period of more than 8 years after RYGB, 40% of the patients suffered from abdominal pain, needing one or more CT scans. The need for surgery treating suspected internal hernia and cholecystectomy was equal, at 9.3% for both procedures, but the mean time from RYGB to operation was shorter for cholecystectomies. Keywords Roux-en-Y gastric bypass . RYGB . Abdominal pain . CT . Internal herniation . Cholecystectomy . Gallbladder disease . Postbariatric This is a post-peer-review, pre-copyedit version of an article published in [Obesity Surgery] Locked until 4.4.2019 due to copyright restrictions. The final authenticated version is available online at: https://doi.org/10.1007/s11695-018-3223-y

Sympathetic vasoconstriction is blunted in exercising muscle (functional sympatholysis) but becomes attenuated with age. We tested the hypothesis that functional sympatholysis is further impaired in chronic obstructive pulmonary disease (COPD) patients. We determined leg blood flow and calculated leg vascular conductance (LVC) during 1) femoral-arterial Tyramine infusion (evokes endogenous norepinephrine release, 1 µmol·min−1·kg leg mass−1), 2) one-legged knee extensor exercise with and without Tyramine infusion [10 W and 20% of maximal workload (WLmax)], 3) ATP (0.05 µmol·min−1·kg leg mass−1) and Tyramine infusion, and 4) incremental ATP infusions (0.05, 0.3, and 3.0 µmol·min−1·kg leg mass−1). We included 10 patients with moderate to severe COPD and 8 age-matched healthy control subjects. Overall, leg blood flow and LVC were lower in COPD patients during exercise ( P < 0.05). Tyramine reduced LVC in both groups at 10-W exercise (COPD: −3 ± 1 ml·min−1·mmHg−1and controls: −3 ± 1 ml·min−1·mmHg−1, P < 0.05) and 20% WLmax(COPD: −4 ± 1 ml·min−1·mmHg−1and controls: −3 ± 1 ml·min−1·mmHg−1, P < 0.05) with no difference between groups. Incremental ATP infusions induced dose-dependent vasodilation with no difference between groups, and, in addition, the vasoconstrictor response to Tyramine infused together with ATP was not different between groups (COPD: −0.03 ± 0.01 l·min−1·kg leg mass−1vs. controls: −0.04 ± 0.01 l·min−1·kg leg mass−1, P > 0.05). Compared with age-matched healthy control subjects, the vasodilatory response to ATP is intact in COPD patients and their ability to blunt sympathetic vasoconstriction (functional sympatholysis) as evaluated by intra-arterial Tyramine during exercise or ATP infusion is maintained.NEW & NOTEWORTHY The ability to blunt sympathetic vasoconstriction in exercising muscle and ATP-induced dilation in chronic obstructive pulmonary disease patients remains unexplored. Chronic obstructive pulmonary disease patients demonstrated similar sympathetic vasoconstriction in response to intra-arterial Tyramine during exercise and ATP-induced vasodilation compared with age-matched healthy control subjects.

The primary aim of this study was to characterise complications, identify predictors of postoperative morbidity and mortality and to evaluate existing risk prediction models in elderly rectal cancer patients. An observational single-centre study of 330 consecutive patients >75 years treated in 1994–2006. Analyses were performed by age group: 75–79 years, 80–85 years and >85 years. Total observed in-hospital morbidity was 48.7 %. In multivariate analysis, age (OR 1.04, 95 % CI 1.01–1.08, p = 0.04), ASA grade ≥ 3 (p = 0.01), acute presentation (OR 1.67, 95 % CI 1.2–13.2, p = 0.02) and major surgery (APR OR 3.72, 95 % CI 1.37–10.15, p = 0.01, LAR OR 2.98, 95 % CI 1.14–7.79, p = 0.03, Hartmann OR 5.46, 95 % CI 1.60–19.28, p = 0.02) were independent risk factors for postoperative morbidity. The 30-day mortality was 6.3, 6.4 and 14.3 % (p = 0.146) in the three age groups, and the 100-day mortality was 8.7, 10.1 and 22.2 % (p = 0.03), respectively. ASA group 3 (OR 6.21, 95 % CI 4.39–27.69, p = 0.017), ASA group 4 (OR 32.6, 95 % CI 5.12–207.75, p

Background. Understanding a country’s baseline operative actors and capacity is critical to improving the quality of services and outcomes. The aim of this study was to describe all operative providers and national operative production, to evaluate district and nationwide population rates for operations, and to estimate unmet operative need in Sierra Leone. Methods. A nationwide, exhaustive, retrospective, facility-based study of operative actors and surgical procedures was performed in Sierra Leone. Between January and May 2013, 4 teams of 12 medical students collected data on the characteristics of the institutions and of the operations performed in 2012. Data were retrieved from the log books of operations, anesthesia, and delivery. Results. A total of 24,152 operative procedures were identified, equal to a national rate of 400 operative procedures per 100,000 inhabitants (district range 32–909/100,000, interquartile range 95–502/ 100,000). Hernia repair was the most common operative procedure at 86.1 per 100,000 inhabitants (22.4% of the total national volume) followed by cesarean delivery at 80.6 per 100,000 (21.0% of the total). Private, nonprofit facilities performed 54.0% of the operations, compared with 39.6% by governmental and 6.4% by private for-profit facilities. More than 90% of the estimated operative need in Sierra Leone was unmet in 2012. Conclusion. The unmet operative need in Sierra Leone is very high. The 30-fold difference in operative output between districts also is very high. As the main training institution, operative services within the governmental sector need to be strengthened. An understanding of the existing operative platform is a good start for expanding operative services. (Surgery 2015;157:992-1001.) © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC-BY-NC-ND 4.0 license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

The traditional tools to assess surgical capacity in low-income countries require significant amounts of time and resources, and have thus not been utilized systematically in this context. Proxy indicators have been suggested as a simpler tool to estimate surgical volume. The aim of this study was to assess caesarean section and inguinal hernia repair as proxy indicators of the total number of surgeries performed per capita in a given region of sub-Saharan Africa.Surgical data was compiled from 58 health institutions (96.7%) that performed major surgery in Sierra Leone in 2012. In total, 24,152 operative procedures were included in the study. Validity of proxy indicators was tested by logistic regression analyses with the rate of caesarean sections compared with total operations (%CS), hernia repairs (%HR) or both (%CSHR) as dependent variables and the operations per 100,000 capita as the covariate.There was significant correlation for each of the proxy indicators, with the estimated odds ratio for %CS being 0.675 (95% CI, 0.520-0.876; P.01), the estimated odds ratio for %HR being 0.822 (95% CI, 0.688-0.983; P.05), and the estimated odds ratio for %CSHR being 0.838 (95% CI, 0.731-0.962; P.05).The unmet need for surgical services in a region of sub-Saharan Africa can be estimated by using any of the 3 proxy indicators. However, it seems that %CS is more sensitive for small changes in operations per 100,000 capita, compared with the %HR. There is no obvious added benefit for using the combined proxy indicator.

Several studies have shown remarkable differences in colorectal cancer survival across Europe. Most of these studies lacked information about stage and treatment. In this study we compared short-term survival as well as differences in tumour stage and treatment strategies between five European countries: Norway, Sweden, Denmark, Belgium, and the Netherlands. For this retrospective cohort study all patients aged 18 years or older and operated on adenocarcinoma of the rectum without distant metastases and diagnosed in 2008 and 2009 were selected in national audit registries from Norway, Sweden, Denmark, Belgium, and the Netherlands. Differences in pre-operative treatment between the countries were compared using univariable and multivariable logistic regression. One year relative survival and one year relative excess risk of death (RER) were compared between the five countries. Large variation in the use of preoperative radiotherapy and chemoradiation was found between the countries. Even though, there was little variation in relative survival between the countries, except Sweden, which had a significant better one year RER of death among the elderly patients after adjustment. The differences in survival are expected to be caused by differences in peri-operative care, selection of patients, and especially management of elderly patients. The effects of preoperative treatment are expected to be seen on long term follow-up.

To evaluate how age influences the selection to different treatment modalities for rectal cancer and how these differences in approach affect the short- and long-term outcomes.A single-center cohort of all 837 rectal cancer patients diagnosed between 1994 and 2006 was analyzed. Patients75, 75-79, 80-84, and85 years were compared.Treatment for cure was judged possible for 80.8, 77.9, 74.6, and 65.3 % of the four age groups (p = 0.02), and radiochemotherapy was given to 22.9, 19.3, 10.2, and 2 % of the same groups (p = 0.001). Local resection was performed for 3.7, 14.7, 13.6, and 24.5 % (p0.001) and anterior resection for 66.6, 54.1, 56.8, and 49 % (p0.001). The 5-year rates of local recurrence were 5.3, 8.3, 12.8, and 22.3 % (p0.001), and overall survival was 70, 54, 45.9, and 29.8 % in the four groups treated with curative intent (p0.001). Relative survival was 76.4, 72.6, 72.9, and 72.3 % (ns).Age caused treatment to be modified; there was less surgery for patients over 85 years, less radiochemotherapy over 80 years, and less major radical surgery over 75 years. This strategy resulted in more local recurrences among the elderly, although no certain effect on relative survival was observed.

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?

Background There is no standard for reporting rectal cancer distances from the distal resection margin in the literature. The objective was to demonstrate the importance of rectal cancer measurement from a standardized point. Methods Review of databases at two international institutions identified 50 patients with rectal adenocarcinoma within 15 cm of the anal verge (AV), who had preoperative magnetic resonance imaging (MRI) and underwent surgery with curative intent. Expert radiologists reviewed the magnetic resonance images for anatomical distances from the anorectal ring (ARR) to the AV, from the ARR to the dentate line (DL), and from the DL to the AV. Anatomical measurements were compared with preoperative measurements to assess reporting inconsistencies. Results Fifty patients with rectal adenocarcinoma were included in the study. The mean(s.d.) anatomical distance was 1·66(0·61) cm from the ARR to the DL, 3·78(0·61) cm from the ARR to the AV (maximum 5·5 cm) and 2·11(0·10) cm from the DL to the AV. The mean radiological distance from the distal tumour was 2·90(1·60) (median 3·2, range 0–7·5) cm to the ARR, 4·36(3·20) (median 4·2, range −0·5 to 12·8) cm to the DL and 6·13(3·39) (median 6·0, range 0–14·1) cm to the AV. There was a significant difference in the distal tumour margin between measurements made by the expert radiologists and reported preoperative measurements (P < 0·001). Significant differences were also found between the expert radiologists' MRI and rigid proctoscopic measurements (P = 0·025). Conclusion There was up to 5·5 cm variation, depending on which landmark was chosen for reporting the distal margin of rectal cancer. This has potential implications for surgical planning, interpreting radiological images and comparative studies.

Aim The Spanish Rectal Cancer Project was established in 2006, inspired by the Norwegian Rectal Cancer Project. It consisted of an educational project aiming to introduce mesorectal excision surgery to surgeons, pathologists and radiologists. Its effect on local recurrence (LR) was compared with the Norwegian Project. Method An observational cohort study was carried out including all patients (4700) with rectal cancer from a population of 19 329 992 inhabitants operated on in 51 Spanish hospitals between March 2006 and June 2010. Curative resection was defined as a resection with an uninvolved circumferential margin in patients without distant metastases and without intra-operative rectal perforation. The effectiveness of the programme was measured by a central registry with feedback to participating institutions of their own results compared with the national average. The main outcome measures were LR and adverse effects in curative resections. Results Of the 4700 patients, 3213 had a resection considered to be curative. LR rates were 4.7% (95% CI 0.03–0.59), metastasis rate was 16% (95% CI 0.14–0.17) and overall survival was 87.8% (95% CI 0.86–0.89). Multivariate analysis showed that advanced TNM stage and decreasing distance of the tumour from the anal verge had a negative influence on LR. Conclusion This study shows that the results obtained in Norway have been reproduced in a larger population in Spain applying a similar methodology.

Law, WL is one of the members of the International Rectal Cancer Study Group, BACKGROUND: Little is known regarding variations in preoperative treatment and practice for rectal cancer (RC) on an international level, yet practice variation may result in differences in recurrence and survival rates. METHODS: One hundred seventy-three international colorectal centers were invited to participate in a survey of preoperative management of rectal cancer. RESULTS: One hundred twenty-three (71%) responded, with a majority of respondents from North America, Europe, and Asia. Ninety-three percent have more than 5 years' experience with rectal cancer surgery. Fifty-five percent use CT scan, 35% MRI, 29% ERUS, 12% digital rectal examination and 1% PET scan in all RC cases. Seventy-four percent consider threatened circumferential margin (CRM) an indication for neoadjuvant treatment. Ninety-two percent prefer 5-FU-based long-course neoadjuvant chemoradiation therapy (CRT). A significant difference in practice exists between the US and non-US surgeons: poor histological differentiation as an indication for CRT (25% vs. 7.0%, p = 0.008), CRT for stage II and III rectal cancer (92% vs. 43%, p = 0.0001), MRI for all RC patients (20% vs. 42%, p = 0.03), and ERUS for all RC patients (43% vs. 21%, p = 0.01). Multidisciplinary team meetings significantly influence decisions for MRI (RR = 3.62), neoadjuvant treatment (threatened CRM, RR = 5.67, stage II + III RR = 2.98), quality of pathology report (RR = 4.85), and sphincter-saving surgery (RR = 3.81). CONCLUSIONS: There was little consensus on staging, neoadjuvant treatment, and preoperative management of rectal cancer. Regular multidisciplinary team meetings influence decisions about neoadjuvant treatment and staging methods., published_or_final_version

Aim The purpose of the present national study was to determine whether improved local control has been accompanied by a change in the incidence of metastases. Method The data were from a national population-based rectal cancer registry and included all 6501 rectal cancer patients treated for cure. The study periods were 1993–1997, 1998–2000, 2001–2003 and 2004–2006. Results Major changes in the handling of rectal cancer from the first to the last study period included an increased use of MRI from zero to 81% and the use of preoperative radiotherapy from 5% to 20%. The proportion of patients with circumferential resection margin (CRM) ≤ 2 mm decreased from 23% to 13%. The 4-year rate of local recurrence decreased from 13% to 8% (P

Aims The EURECCA (European Registration of Cancer Care) consortium is currently formed by nine independently founded national colorectal audit registrations, of which most already run for many years. The cumulative experience of EURECCA’s participants could be used to identify a ‘core dataset’ that covers all important aspects needed for high quality auditing and at the same time lacking needless data items that only consumes administrative effort. The aim of this study is to compare the data items used by the nine registries participating in EURECCA to identify a core dataset and explore options for future research. Methods All colorectal outcome registrations participating in the EURECCA project were asked to supply a list with all the data items they score. Items were scored ‘present’ if they appeared literally in a registration or in case they could be calculated using other items in the same registration. The definition of a ‘shared data item’ was that at least eight of the nine participating registries scored the item. Results The number of registered data items varied between 254 (Belgium) and 83 (Norway). Among the 45 variables were patient data, data about preoperative staging, surgical treatment, pre- or postoperative radio- and/or chemotherapy, and follow-up. Items about tumour recurrence or quality of life were scored too little to become shared data items. Conclusions A total of 45 items were collected by 8 or more of the participating registries and subsequently met the criteria for a shared data item.

Aim The aim of this study was to examine what constitutes an acceptable distal resection margin (DRM) when performing sphincter-saving surgery for rectal cancer without preoperative radiotherapy. Method This national study consisted of 3571 patients for whom information on DRM was available and who were radically treated by anterior resection between 1993 and 2004. Of these, 3342 (93.5%) patients had not received preoperative radiotherapy. The DRM was measured on fixed specimens. Results The 5-year local recurrence rate was 14.5% for patients with a DRM of 0–10 mm compared to 9.6% for patients with a DRM of 11–20 mm, 8.9% for a DRM of 21–30 mm, 7.0% for a DRM of 31–40 mm, 7.7% for a DRM of 41–50 mm and 8.7% for a DRM of > 50 mm. After adjustment for other independent prognostic factors, a DRM of 0–10 mm was found to have significant impact on local recurrence. The DRM had no impact on distant metastases or overall survival. Conclusion For rectal cancer patients treated without radiotherapy, a DRM of > 10 mm is recommended.

AIM: There are conflicting reports regarding long term function after ileal pouch-anal anastomosis (IPAA). The aim of the present prospective study was to investigate the influence of duration as a ...

The aim of this study was to present detailed population-based survival estimates for patients with a rectal adenocarcinoma, using cancer register data supplemented with clinical data. Based on cancer register data, differences in rectal cancer survival have been reported between countries in Europe. Variation in the distribution of stage at diagnosis, initial therapy including surgical technique, and comorbidity are possible explanatory factors. Adenocarcinomas in the rectum, diagnosed in 1997 and identified in the national cancer registries in the Nordic countries and Scotland were included. Age standardized 5-year relative survival and multiplicative regression models for the relative excess mortality were calculated. 3888 patients were included in the survival study. Men in Denmark, Finland and Iceland had lower 5-year relative survival and poorer stage distribution compared to Norway, Sweden and Scotland. Danish men had the highest rate of excess deaths in the first six months after diagnosis. Stage adjusted, the elevated relative excess mortality decreased and after six months the excess mortality rates were the same in all countries. The poor 5-year relative survival in Danish men was mainly due to a high excess rate of death during the first six months after diagnosis. The low survival in Finland and Iceland was not in accordance with other periods. For both countries this may be explained by random variation due to small numbers. The study emphasizes the need for high quality and detailed data in order to understand international survival differences, and cautions comparisons between large national samples and those of smaller areas.

The use of preoperative radiotherapy in patients with T3 tumors shows considerable variation among countries and institutions. The Norwegian guidelines have been very restrictive, limiting the indication to T4. This study was designed to identify subgroups of patients with T3 tumors with presumed high risks on adverse outcome and to use these results to reevaluate the national guidelines for preoperative radiotherapy. This was a national cohort study of 2,460 patients with pT3 rectal adenocarcinoma, undergoing major surgery without preoperative radiotherapy from November 1993 to December 2002. Circumferential resection margin in millimeters was given for 1,676 patients. Multivariate analyses identified circumferential resection margin and nodal status as independent prognostic factors for local recurrence, metastases, and overall mortality. Analyses based on 12 combinations of N stage and circumferential resection margin showed that the estimated five-year rate of local recurrence increased from 11.1 percent (circumferential resection margin >3 mm; N0) to 36.5 percent (circumferential resection margin ≤1 mm; N2). The rate of distant metastases increased from 18.5 to 77.7 percent and the five-year survival decreased from 68.6 to 25.7 percent, respectively. There is great variation in outcome for patients with T3 cancers, and the outcome is not acceptable for the groups of patients with circumferential resection margin

The treatment of anal carcinoma changed from surgery to chemoradiotherapy 2025 years ago. The aim of this observational study was to compare surgery with chemoradiotherapy with regard to side effects, local recurrence and survival during and after the implementation of a new treatment policy for anal carcinoma. The study includes all 111 patients with anal carcinoma diagnosed between 1970 and 2000 in mid-Norway. One hundred patients were treated with the intention to cure, and 11 patients received palliative treatment. Thirty-four patients were treated with surgery alone, and 57 patients with chemoradiotherapy. Among patients treated for cure, 17 patients (17%) developed local recurrence; ten patients (33%) in the surgically treated group and 4 (7%) in the chemoradiotherapy group (p /0.15). Five year overall survival was 48% after surgery, compared to 78% after chemoradiotherapy (p /0.004). Stage, age and treatment were all significant indicators of survival in uni- and multivariable analysis. Late side effects were moderate after combined therapy; only one patient preferred getting a stoma due to radiation damage of the anal sphincter. The change of strategy for anal cancer treatment from surgery to combined therapy has probably reduced local recurrence and improved survival. Side effects in this series of patients were minor after chemoradiotherapy compared to a permanent stoma after surgery. Squamous cell carcinoma of the anal canal is an uncommon disease. The incidence rates are approximately 3550 new cases each year in Norway

Purpose To investigate long-term changes in the rectal mucosa after curative external beam radiation therapy in the treatment of prostate cancer. Methods and Materials In the Scandinavian Prostate Cancer Group 7 trial, 880 men with locally advanced prostate cancer were randomized to hormonal therapy alone versus hormonal therapy plus radiation therapy to 70 Gy. A subcohort from this trial being randomized at our center (n=178) was invited to a study on late anorectal side effects during 2003-2005, approximately 5 years after treatment, including measuring health-reported quality of life and physician-assessed toxicity score by the Late Effects Normal Tissue Task Force/Subjective, Objective, Management, Analytic (LENT/SOMA) and European Organization for Research and Treatment of Cancer/Radiation Therapy Oncology Group score. Sixty-seven patients had a rectal mucosa biopsy. Sixty-four biopsies were included in the final analysis, of which 33 patients were randomized to hormonal treatment and 31 to hormonal treatment plus radiation therapy. The presence of fibrosis, number of capillaries, and lymphocyte infiltration was then evaluated by light microscopy. Results The group receiving radiation therapy had significantly higher LENT/SOMA and function/bother scale scores than the group that only received hormonal treatment, but there was no significant difference in the presence of fibrosis, ectasia, number of capillaries in the lamina propria, or lymphocyte infiltration between the groups. Conclusion Radiation therapy to 70 Gy to the prostate does not induce long-term microscopic mucosal changes in the rectum 5 years after treatment. This is in contrast to the general assumption that structural changes, including fibrosis, seen after radiation therapy include the mucosa. We speculate that the main late effects of radiation therapy on the structure of the rectum are located in the deeper layers of the rectal wall than the mucosa.

Surgical services are essential components of health-care systems. Monitoring of surgical activity is important, but resource demanding. Simpler tools to estimate surgical volume, particularly in low-income countries, are needed. Previous work hypothesises that the relative frequency of caesarean sections, expressed as a proportion of total operative procedures, could serve as a proxy measure of surgical capacity. We aimed to establish nationwide and district-wide rates of surgery and caesarean sections, and to explore correlations between districts rates for caesarean sections and corresponding rates for total volume of surgery in Sierra Leone in 2012.A nationwide, exhaustive, retrospective, facility-based study of all surgical providers and surgical procedures was performed in Sierra Leone. Between Jan 14, and May 20, 2013, four teams of 12 medical students collected data on the characteristics of the institutions and of the surgeries performed in 2012. Data were retrieved from operation, anaesthesia, and delivery logbooks.Of 60 facilities performing surgery, complete annual data for 2012 was collected from 58 (97%) institutions. 24 152 surgical procedures identified, gave a national rate of 400 surgeries per 100 000 inhabitants (district range 32-909 per 100 000 [IQR 95-502 per 100 000]). National caesarean section rate was 2·1% (district range 0·3-4·0% [IQR 0·8-2·1]). District caesarean sections rate significantly correlated with the rate of total surgical procedures per 100 000 population (p0·01). With known caesarean section rate, total volume of surgeries per 100 000 can be calculated with the equation: -9·8 + 4·68 × caesarean sections per 100 000.The close correlation between rate of caesarean section and population rates of total volume of surgery at district level in Sierra Leone indicates that rate of caesarean section should be further explored as a proxy indicator for overall surgical volume in low performing settings. By collecting data from three sources, missing procedures was considered less likely.Norwegian University of Science and Technology.

The Norwegian Rectal Cancer Project was initated in 1993 with the aims of improving surgery, decreasing local recurrence rates, improving survival, and establishing a national rectal cancer registry. Here we present results from the Norwegian Colorectal Cancer Registry (NCCR) from 1993 to 2010.A total of 15 193 patients were diagnosed with rectal cancer in Norway 1993-2010, and were registered with clinical data regarding diagnosis, treatment, locoregional recurrences and distant metastases. Of these, 10 796 with non-metastatic disease underwent tumour resection. The results were stratified into five time periods, and the treatment outcomes were compared. Recurrence rates are presented for the 9785 patients who underwent curative major resection (R0/R1).Among all 15 193 patients, relative five-year survival increased from 54.1% in 1993-1997 to 63.4% in 2007-2010 (p0.001). Among the 10 796 patients with stage I-III disease who underwent tumour resection, from 1993-1997 to 2007-2010, relative five-year survival improved from 71.2% to 80.6% (p0.001). An increasing proportion of these patients underwent surgery at large-volume hospitals; and 30- and 100-day mortality rates, respectively, decreased from 3.0% to 1.4% (p0.001) and from 5.1% to 3.0% (p0.011). Use of preoperative chemoradiotherapy increased from 6.5% in 1993 to 39.0% in 2010 (p0.001). Estimated local recurrence rate after major resection (R0/R1) decreased from 14.5% in 1993-1997 to 5.0% in 2007-2009 (p0.001), and distant recurrence rate decreased from 26.0% to 20.2% (p0.001).Long-term outcomes from a national population-based rectal cancer registry are presented. Improvements in rectal cancer treatment have led to decreased recurrence rates of 5% and increased survival on a national level.

Background The purpose of this study was to analyse the impact of radiotherapy on local recurrence of rectal cancer in Norway after the national implementation of total mesorectal excision (TME). Methods This was a prospective national cohort study of 4113 patients undergoing major resection of rectal carcinoma between November 1993 and December 2001. Results The proportion of patients who had radiotherapy before or after operation increased from 4·6 per cent in 1994 to 23·0 per cent in 2001. The cumulative 5-year local recurrence rate decreased from 16·2 to 10·7 per cent. Multivariable analysis showed that preoperative radiotherapy significantly reduced local recurrence (hazard ratio 0·59 (95 per cent confidence interval 0·39 to 0·87)). The use of preoperative radiotherapy in patients from a local hospital offering radiotherapy was 50 per cent higher than that for patients from a hospital without such services (P = 0·003); cumulative 5-year local recurrence rates for these patients were 10·6 and 15·8 per cent respectively (P < 0·001). Conclusion Following national implementation of TME for rectal cancer, increased use of preoperative radiotherapy appeared to reduce recurrence rates further.

Aims Most reports on locally advanced rectal cancer come from specialized centres, with a selected patient material. The purpose of this study was to examine the results after surgical treatment of patients with locally advanced rectal cancer at a population level. Methods National cohort study of 896 patients undergoing surgery for a locally advanced primary adenocarcinoma of the rectum from November 1993 to December 2001. Results Surgery with resection was undertaken in 724 patients and 172 patients underwent palliative procedures. Of 557 patients treated for cure, a R0 resection was achieved in 342 (61%). In a multivariate analysis, pre-operative radiotherapy was the only factor with a positive association with R0 status (odds ratio 3.7, 95% confidence interval (CI) 2.1–6.4). Five-year local recurrence rates were 18% (CI 14–23) for R0 resections and 40% (CI 26–52) for R1 resections. Overall 5-year survival rate was 23%; for the group of patients with a R0 resection the survival rate was 49%. Conclusion The radical resection rate and survival rates in this national study were similar to those reported from specialized centres.

Aims The aims of the study were (1) to evaluate quality of life (QoL) and functional outcome in patients following anterior resection (AR) or abdominoperineal resection (APR) for rectal cancer, and (2) whether these outcomes were dependent on the level of anastomosis. Methods Patients who were without recurrent or metastatic disease were identified from the Norwegian Rectal Cancer Registry. QoL was assessed by the EORTC questionnaires QLQ-C30 and QLQ-CR38, and rectal function by a short questionnaire. Of 319 patients studied, 229 had undergone AR and 90 APR. The median age was 73 years, and the median time since surgery was 64 months. Results Mean QoL scores for body image and male sexual problems were better following AR than APR (P

Objective Mesorectal excision is successfully implemented as the standard surgical technique for rectal cancer resections in Norway. This technique has been associated with higher rates of anastomotic leakage (AL) and the purpose of this study was to examine AL in a large national cohort of patients. Methods This was a prospective national cohort study of 1958 patients undergoing rectal cancer surgery with anterior resection in Norway from November 1993 to December 1999. Results The overall rate of AL was 11.6% (228 of 1958 patients). In a multivariate analysis, the risk of AL was significantly higher in males (odds ratio (OR) 1.6, 95% confidence interval (CI) 1.1‐2.2), in patients receiving pre-operative radiotherapy (OR 2.2, CI 1.0‐4.7) and in low level (4‐6 cm) (OR 3.5, CI 1.6‐7.7) and ultra-low level (£ 3 cm) anastomoses (OR 5.4, CI 2.3‐12.9). The presence of a diverting stoma was associated with a 60% reduction in the risk of AL (OR 0.4, CI 0.3‐0.7) for anastomoses 6 cm and below. 30-day mortality was significantly higher for the patients with AL (7.0%, CI 3.7‐10.3) compared with no AL (2.4%, CI 1.7‐3.2) AL had no significant effect on local recurrence rate (log rank P ¼ 0.608). Conclusion Low anastomoses should be defunctioned to avoid AL and the associated high perioperative mortality. No effect of AL on local recurrence was found in this large cohort.

Background The purpose of this prospective study was to examine the influence of hospital caseload on long-term outcome following standardization of rectal cancer surgery at a national level. Methods Data relating to all 3388 Norwegian patients with rectal cancer treated for cure between November 1993 and December 1999 were recorded in a national database. Treating hospitals were divided into four groups according to their annual caseload: hospitals in group 1 (n = 4) carried out 30 or more procedures, those in group 2 (n = 6) performed 20–29 procedures, group 3 (n = 16) 10–19 procedures and group 4 (n = 28) fewer than ten procedures. Results The 5-year local recurrence rates were 9·2, 14·7, 12·5 and 17·5 per cent (P = 0·003) and 5-year overall survival rates were 64·4, 64·0, 60·8 and 57·8 per cent (P = 0·105) respectively in the four hospital caseload groups. An annual hospital caseload of less than ten procedures increased the risk of local recurrence compared with that in hospitals where 30 or more procedures were performed each year (hazard ratio 1·9 (95 per cent confidence interval (c.i.) 1·3 to 2·7); P < 0·001). Overall survival was lower for patients treated at hospitals with an annual caseload of less than ten versus hospitals with 30 or more (hazard ratio 1·2 (95 per cent c.i. 1·0 to 1·5); P = 0·023). Conclusion The rate of local recurrence was higher for hospitals with a low annual caseload of less than ten procedures than for hospitals with a high treatment volume of 30 or more. Patients treated in small hospitals also had a shorter long-term survival than those treated in large hospitals.

The treatment of anal carcinoma has a vigorous follow-up regimen, and several authors have stated that endoanal ultrasound is a useful and necessary part of this regimen. This study was designed to evaluate the value of endoanal ultrasound in follow-up of anal carcinoma. In this retrospective study, 82 patients were treated between 1983 and 1999. Main outcome measures were five-year survival and local recurrence rates, and in particular, it was focused on how local recurrences have been detected. Overall five-year survival was 68 percent. Fourteen patients (17 percent) developed local recurrence. Despite an estimated number of 780 scheduled endoanal ultrasound examinations, all the local recurrences were detected by digital and visual examination before the ultrasound procedures. In this study, all the local recurrences of anal carcinoma were detected by digital and visual examination. Thus, the addition of endoanal ultrasound was costly and unnecessary.

PURPOSE; This study was designed to examine the outcome of cancer of the lower rectum, particularly the rates of local recurrence and survival for tumors located in this area that have been treated by anterior or abdominoperineal resections. METHODS: A prospective, observational, national, cohort study which is part of the Norwegian Rectal Cancer Project. The present cohort includes all patients undergoing total mesorectal excision in 47 hospitals during the period November 1993 to December 1999. A total of 2,136 patients with rectal cancer within 12 cm of the anal verge were analyzed; there were 1,315 (62 percent) anterior resections and 821 (38 percent) abdominoperineal resections. The lower edge of the tumor was located 0 to 5 cm from the anal verge in 791 patients, 6 to 8 cm in 558 patients, and 9 to 12 cm in 787 patients. According to the TNM classification, there were 33 percent Stage 1, 35 percent Stage II, and 32 percent Stage III. RESULTS: Universiate analyses : The five-year local recurrence rate was 15 percent in the lower level, 13 percent in the intermediate level, and 9 percent in the upper level (P = 0.014). It was 10 percent local recurrence after anterior resection and 15 percent after abdominoperineal resection (P = 0.008). The five-year survival rate was 59 percent in the lower level, 62 percent in the intermediate level, and 69 percent in the upper level (P < 0.001), respectively, and it was 68 percent in the anterior-resection group and 55 percent in the abdominoperineal-resection group (P < 0.001). Multivariate analyses: The level of the tumor influenced the risk of local recurrence (hazard ratio 1.8; 95 Percent confidence interval, 1.1-2.3), but the operative procedure, anterior resection vs. abdominoperineal resection, did not (hazard ratio, 1.2; 95 percent confidence interval, 0.7-1.8). On the contrasry, operative procedure influenced survival (hazard ratio, 1.3; 95 percent confidence interval, 1-1.6), but tumor level did not (hazard ratio, 1.1; 95 percent confidence interval, 0.9-1.5). In addition to patient and tumor characteristics (T4 tumors), intraoperative bowel perforation and tumor involvement of the circumferential margin were identified as significant prognostic factors, which were more common in the lower rectum, explaining the inferior prognosis for tumors in this region. CONCLUSIONS: T4 tumors, R1 resections, and/or intraoperative perforation of the tumor or bowel wall are main features of low rectal cancers, causing inferior oncologic outcomes for tumors in this area. If surgery is optimized. preventing intraoperative perforation and involvement of the circumferential resection margin, the prognosis for cancers of the lower rectum seems not to he inherently different from that for tumors at higher levels. In that case, the level of the tumor or the type of resection will not be indicators for selecting patients for radiotherapy.

Objective The results of rectal cancer surgery in Norway have been poor. In a national audit for the period 1986–88, 28% of the patients developed local recurrence (LR) following treatment with a curative intent. Five-year overall survival was 55% for patients younger than 75 years. The aim of this study is to report how an initiative focusing on better surgery can improve the prognosis for rectal cancer patients on a national level. Methods In 1994, the Norwegian Rectal Cancer Group was founded. The aim of this initiative was to improve the surgical standard by implementing total mesorectal excision (TME) on a national level and to evaluate the results. A number of courses were arranged to teach the surgeons the TME technique, and pathologists were trained to increase the standard of both macroscopic and microscopic assessment of specimens. A rectal cancer registry was established, and all surgical departments treating rectal cancer were invited to transfer their clinical data to this registry. Each department regularly receives its own results together with the national average for comparison and quality control. Results The Rectal Cancer Registry includes all patients with rectal cancer diagnosed since November 1993. From then until December 1999, 5382 patients had a tumour located within 16 cm from the anal verge, and 3432 patients underwent rectal resection with a curative intent. Of these, 9% had adjuvant radiotherapy, and 2% were given chemotherapy. There was a rapid implementation of the new technique, as 78% underwent TME in 1994, increasing to 96% in 1998. After 39 months mean follow-up the rate of local recurrence was 8%, and 5-year overall survival was 71% for patients younger than 75 years. Conclusions An optimized surgical technique (TME) for rectal cancer can reduce the rate of local recurrence and increase overall survival. This improved surgical treatment can be implemented on a national level within a few years. Specialization of surgeons, feedback of results and a separate rectal cancer registry are thought to be major contributors to the improved treatment.

INTRODUCTION: Rectal cancer surgery has been characterized by a high incidence of local recurrence, an occurrence which influences survival negatively. In Norway there was a growing recognition that local recurrence rates were related to surgeon performance and that surgeons applying a standardized surgical technique in the form of total mesorectal excision could achieve better results. This contrasts with the prevailing argument voiced by many opinion leaders that local recurrence rates and possibly survival rates can only be improved by adjuvant or neoadjuvant treatment strategies. The Norwegian Rectal Cancer Project—initiated in 1993—aimed at improving the outcome of patients with rectal cancer by implementing total mesorectal excision as the standard rectal resection technique. METHODS: This observational national cohort study covers all new patients (3,319) with rectal cancer from a population of 4.5 million treated between November 1993 and August 1997. The main outcome measures were local recurrence, survival, and postoperative mortality and morbidity rates. The technique of total mesorectal excision was compared with conventional surgery. RESULTS: The proportion of patients undergoing total mesorectal excision was 78 percent in 1994, increasing to 92 percent in 1997. The observed local recurrence rate for patients undergoing a curative resection was 6 percent in the group treated by total mesorectal excision and 12 percent in the conventional surgery group. Four-year survival rate was 73 percent after total mesorectal excision and 60 percent after conventional surgery. Postoperative mortality rate was 3 percent and the anastomotic dehiscence rate was 10 percent. Radiotherapy was given to 5 percent and chemotherapy to 3 percent of the patients in the curative resection group. CONCLUSION: A refinement of the surgical resection technique for rectal cancer can be achieved on a national level, the technique of total mesorectal excision can be widely distributed, and surgery alone can give good results.

Contains fulltext : 125368.pdf (Publisher’s version ) (Closed access) BACKGROUND: Care for patients with colon and rectal cancer has improved in the last twenty years however still considerable variation exists in cancer management and outcome between European countries. Therefore, EURECCA, which is the acronym of European Registration of cancer care, is aiming at defining core treatment strategies and developing a European audit structure in order to improve the quality of care for all patients with colon and rectal cancer. In December 2012 the first multidisciplinary consensus conference about colon and rectum was held looking for multidisciplinary consensus. The expert panel consisted of representatives of European scientific organisations involved in cancer care of patients with colon and rectal cancer and representatives of national colorectal registries. METHODS: The expert panel had delegates of the European Society of Surgical Oncology (ESSO), European Society for Radiotherapy & Oncology (ESTRO), European Society of Pathology (ESP), European Society for Medical Oncology (ESMO), European Society of Radiology (ESR), European Society of Coloproctology (ESCP), European CanCer Organisation (ECCO), European Oncology Nursing Society (EONS) and the European Colorectal Cancer Patient Organisation (EuropaColon), as well as delegates from national registries or audits. Experts commented and voted on the two web-based online voting rounds before the meeting (between 4th and 25th October and between the 20th November and 3rd December 2012) as well as one online round after the meeting (4th-20th March 2013) and were invited to lecture on the subjects during the meeting (13th-15th December 2012). The sentences in the consensus document were available during the meeting and a televoting round during the conference by all participants was performed. All sentences that were voted on are available on the EURECCA website www.canceraudit.eu. The consensus document was divided in sections describing evidence based algorithms of diagnostics, pathology, surgery, medical oncology, radiotherapy, and follow-up where applicable for treatment of colon cancer, rectal cancer and stage IV separately. Consensus was achieved using the Delphi method. RESULTS: The total number of the voted sentences was 465. All chapters were voted on by at least 75% of the experts. Of the 465 sentences, 84% achieved large consensus, 6% achieved moderate consensus, and 7% resulted in minimum consensus. Only 3% was disagreed by more than 50% of the members. CONCLUSIONS: It is feasible to achieve European Consensus on key diagnostic and treatment issues using the Delphi method. This consensus embodies the expertise of professionals from all disciplines involved in the care for patients with colon and rectal cancer. Diagnostic and treatment algorithms were developed to implement the current evidence and to define core treatment guidance for multidisciplinary team management of colon and rectal cancer throughout Europe.

Contains fulltext : 137861.pdf (Publisher’s version ) (Closed access) BACKGROUND: Care for patients with colon and rectal cancer has improved in the last 20years; however considerable variation still exists in cancer management and outcome between European countries. Large variation is also apparent between national guidelines and patterns of cancer care in Europe. Therefore, EURECCA, which is the acronym of European Registration of Cancer Care, is aiming at defining core treatment strategies and developing a European audit structure in order to improve the quality of care for all patients with colon and rectal cancer. In December 2012, the first multidisciplinary consensus conference about cancer of the colon and rectum was held. The expert panel consisted of representatives of European scientific organisations involved in cancer care of patients with colon and rectal cancer and representatives of national colorectal registries. METHODS: The expert panel had delegates of the European Society of Surgical Oncology (ESSO), European Society for Radiotherapy & Oncology (ESTRO), European Society of Pathology (ESP), European Society for Medical Oncology (ESMO), European Society of Radiology (ESR), European Society of Coloproctology (ESCP), European CanCer Organisation (ECCO), European Oncology Nursing Society (EONS) and the European Colorectal Cancer Patient Organisation (EuropaColon), as well as delegates from national registries or audits. Consensus was achieved using the Delphi method. For the Delphi process, multidisciplinary experts were invited to comment and vote three web-based online voting rounds and to lecture on the subjects during the meeting (13th-15th December 2012). The sentences in the consensus document were available during the meeting and a televoting round during the conference by all participants was performed. This manuscript covers all sentences of the consensus document with the result of the voting. The consensus document represents sections on diagnostics, pathology, surgery, medical oncology, radiotherapy, and follow-up where applicable for treatment of colon cancer, rectal cancer and metastatic colorectal disease separately. Moreover, evidence based algorithms for diagnostics and treatment were composed which were also submitted to the Delphi process. RESULTS: The total number of the voted sentences was 465. All chapters were voted on by at least 75% of the experts. Of the 465 sentences, 84% achieved large consensus, 6% achieved moderate consensus, and 7% resulted in minimum consensus. Only 3% was disagreed by more than 50% of the members. CONCLUSIONS: Multidisciplinary consensus on key diagnostic and treatment issues for colon and rectal cancer management using the Delphi method was successful. This consensus document embodies the expertise of professionals from all disciplines involved in the care for patients with colon and rectal cancer. Diagnostic and treatment algorithms were developed to implement the current evidence and to define core treatment guidance for multidisciplinary team management of colon and rectal cancer throughout Europe.

Aim To report data supporting the development of tailored treatment strategies for rectal cancer. Method A comprehensive review of the literature on the impact of prognostic factors cur-rently not included in international guidelines in rectal cancer management. Results There is considerable variation in treatment guidelines for rectal cancer worldwide, especially for Stage II and Stage III disease. Long-term side effects of chemoradiotherapy are not considered in any guideline. Detailed knowledge, and the prognostic impact, of the circumferential resection margin, tumour grade and venous invasion should be factored into the development of a treatment strategy. Conclusion Factors additional to the TNM system should improve decision making for contemporary rectal cancer treatment. Optimized radiological and pathological evaluations, and a focus on detailed clinical factors, should be the basis for treatment decisions. International guidelines should consider all known prognostic factors for long-term oncological and functional outcomes.