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OBJECTIVE: To evaluate the role of interstitial pulsed dose rate brachytherapy (PDR-BT) in multimodality treatment of locally advanced primary or recurrent rectal and sigmoid cancer with high risk of microscopic incomplete resection (R1). METHODS AND MATERIAL: A total of 73 consecutive patients (recurrent/primary: 40/33) were treated with PDR-BT between 2001 and 2010. Patients received preoperative external beam radiotherapy (EBRT) and concomitant chemotherapy. Following resection of the tumor and the involved pelvic organs, a median of four (3-8) catheters were sutured to the tumor bed with a distance of approximately 1 cm between the catheters. A target respecting the catheters with a margin of 5 mm was contoured on computed tomography (CT) and three-dimensional (3D) dose planning with a planning aim for BT of D90 > 30 Gy, (0.6 Gy/pulse, 1 pulse/h) was performed. Previously irradiated patients (27%) underwent surgery that was directly followed by PDR-BT. Postoperative EBRT was then applied to the tumor bed 3-5 weeks after PDR-BT. RESULTS: A total of 23 patients (31%) received a radical resection (R0) and 45 patients (62%) received an R1 resection. Five patients (7%) received a macroscopic incomplete resection (R2). The five-year overall survival was 33%. Local control at five years was 67% for patients who received a R0 resection and 32% for patients who received an R1 resection. The five-year actuarial risk of a grade 3-4 BT-related complication was 5%. CONCLUSIONS: Meaningful disease control and survival can be obtained at an acceptable rate of late morbidity in selected patients with locally advanced primary and recurrent rectal or sigmoid cancer using (chemo) RT, extensive surgery and PDR-BT when a high risk of an R1 resection is expected

The Andaman and Nicobar archipelago consists of 572 islands, islets and rocky outcrops extending over 800 km. Biodiversity is very rich in this archipelago and endemism is also high due to isolation. The studies on the avifauna of this region were carried out by the authors from 2008 through 2017 covering extensive field survey in various islands. This paper was prepared based on the field surveys and available literature. A total of 349 species/subspecies of birds were recorded from Andaman and Nicobar Islands in this paper.

Aim The study was conducted in a dedicated centre treating the majority of Danish patients with intended curative total pelvic exenteration for primary advanced (PARC) or locally recurrent (LRRC) rectal cancer. We compared PARC and LRRC and analysed postoperative morbidity and mortality, and long-term outcome. Method There were 90 consecutive patients (PARC/LRRC 50/40) treated between January 2001 and October 2010, recorded on a prospectively maintained database. Results The median age was 63 (32–75) years with a gender ratio of 7 women to 83 men. All patients were American Society of Anesthesiologists level I or II. Sacral resection was performed in five patients with PARC and 15 with LRRC (P = 0.002). R0 resection was achieved in 33 (66%) patients with PARC and in 15 (38%) with LRRC, R1 resection in 17 (34%) with PARC and 20 (50%) with LRRC and R2 resection in five (13%) with LRRC. R0 resection was more frequent in PARC (P = 0.007). Forty-four (49%) patients had no postoperative complications. Fifty-five major complications were registered. Two (2.2%) patients died within 30 days, and the total in-hospital mortality was 5.6%. The median follow-up was 12 (0.4–91) months. The 5-year survival was 46% for PARC and 17% for LRRC (P = 0.16). Conclusion Pelvic exenteration is associated with considerable morbidity but low mortality in an experienced centre. Pelvic exenteration can improve long-term survival, especially for patients with PARC. However, pelvic exenteration is also justified for patients with LRRC.

Aim Eight highly selected patients are reported, undergoing external hemipelvectomy (EHP) for malignant infiltration of the lumbosacral neural plexus. Method All patients were evaluated by positron emission tomography-computed tomography (PET-CT), CT and magnetic resonance imaging. No evidence of disseminated disease was found. With agreement by the multidisciplinary team, surgery was performed by a colorectal surgeon and an orthopaedic sarcoma surgeon and, if needed, by an urologist and vascular surgeon. Patients were reconstructed with either a femoral or a gluteal musculocutaneous flap. Results Of the eight women [median age 54.5 (40–68) years], two had primary carcinoma and six local recurrence of a previously treated carcinoma. R0 was possible in six patients and R1 resection in two. The median duration of hospital stay was 29.5 (17–102) days. The median follow up was 8.3 (4.7–52.8) months. Three patients have died, one from postoperative complications at 5 months and two from recurrence at 5 and 52.8 months. Phantom-limb was experienced in six patients. Four patients received a prosthesis, one is considering this and one does not want a prosthesis. Conclusion Hemipelvectomy may be considered for a highly selected group of patients with locally advanced carcinoma or recurrence involving the lumbosacral neural plexus.

Aim Advances in the treatment of rectal cancer have made it possible to perform complex rectal cancer surgery (COMP-RCS) in patients with primary advanced rectal cancer penetrating beyond the total mesorectal excision planes and in patients with locally recurrent rectal cancer. The aim of this study was to examine health-related quality of life (HRQoL) before and during the first 2 years after COMP-RCS. Method Between 2001 and 2008, 180 patients were treated with COMP-RCS at Aarhus University Hospital. HRQoL was assessed preoperatively and 3, 6, 12, 18 and 24 months after surgery using three questionnaires. The results were compared with those for patients treated with standard rectal cancer surgery (STAN-RCS) and with data from the general Danish population (NORM-data). Results One hundred and twenty-two (68%) patients responded to the questionnaires. Of these 80 (66%) with disease-free survival for 2 years after surgery were included in the main analysis. The lowest level of functioning and the highest degree of symptoms were reported preoperatively. The majority of the HRQoL scales improved or remained stable during the first postoperative year; a decrease was observed for body image only. One year after surgery, HRQoL in patients treated with COMP-RSC was comparable to that for patients treated with STAN-RCS. Lower levels were found for physical and emotional role functioning, compared with NORM-data. Conclusion Patients treated with COMP-RCS experienced improvement in HRQoL in the first year after surgery. One year after surgery, HRQoL was similar to that of patients treated with STAN-RCS. Compared with NORM-data, lower levels were found for physical and emotional role functioning.

Consensus abstract Background The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. Methods Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus. Results The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management. Conclusion The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.

Aim Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment option with curative intent for selected patients with peritoneal carcinomatosis (PC). CRS and HIPEC have been implemented in Denmark at a single centre since 2006. Six years of data on these patients were analysed. Method Patients with PC from colorectal or appendiceal cancer, pseudomyxoma peritonei or malignant peritoneal mesothelioma referred to the single national HIPEC centre were prospectively registered from June 2006 to July 2012. Morbidity, 30-day mortality and long-term survival of patients who underwent CRS and HIPEC were analysed. Results In total, 80 patients underwent CRS and HIPEC. PC originated from colorectal cancer in 34 patients, pseudomyxoma peritonei in 29, appendiceal cancer in 13 and malignant peritoneal mesothelioma in four patients. Thirty-two patients had one or more complications during the hospital stay. The 30-day mortality rate was 1.3%. The predicted 2-, 3- and 5-year survival was 60%, 47% and 38% in patients with PC from colorectal cancer, and 100%, 93% and 73% in pseudomyxoma peritonei patients. Conclusion CRS and HIPEC is a safe procedure when centralized as in Denmark. Favourable long-term outcome was achieved in selected patients with PC from colorectal cancer and pseudomyxoma peritonei. Short-term and long-term outcomes were comparable to results from international centres.

Background The outcome of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) depends on the extent of peritoneal carcinomatosis. The role of laparoscopy in the preoperative assessment of extent of peritoneal carcinomatosis in potential candidates for cytoreductive surgery and HIPEC was evaluated in a consecutive series. Methods Patients with peritoneal carcinomatosis from colorectal cancer or appendiceal cancer, pseudomyxoma peritonei or peritoneal mesothelioma referred to a single, national HIPEC centre were included prospectively between June 2006 and January 2012. From September 2010, preoperative evaluation also included a laparoscopy in patients deemed amenable to cytoreductive surgery and HIPEC after radiological evaluation, apart from those with pseudomyxoma peritonei with massive amounts of mucin. Results In the period before laparoscopic evaluation, 70 patients underwent laparotomy of whom 39 (56 per cent) completed cytoreductive surgery and HIPEC. After the introduction of laparoscopic assessment, diagnostic laparoscopy was planned in 45 patients and successful in 43. The laparoscopic evaluation excluded 18 patients from surgery because of extensive disease, among other reasons. Laparoscopy was uneventful and associated with no deaths. Twenty-seven patients were considered amenable to cytoreductive surgery and HIPEC based on laparoscopic findings, of whom 17 completed this treatment; the disease was unresectable in the remaining ten patients. Of 13 patients who were not eligible for laparoscopic evaluation and were subjected to cytoreductive surgery plus HIPEC, 11 completed the procedure. The overall completion rate of cytoreductive surgery and HIPEC increased to 70 per cent (28 of 40) after the introduction of laparoscopic evaluation. Conclusion Diagnostic laparoscopy was valuable in preoperative evaluation of the extent of peritoneal carcinomatosis, and improved patient selection for cytoreductive surgery and HIPEC.

The study was conducted in a dedicated centre treating the majority of Danish patients with intended curative total pelvic exenteration for primary advanced (PARC) or locally recurrent (LRRC) rectal cancer. We compared PARC and LRRC and analysed postoperative morbidity and mortality, and long-term outcome.There were 90 consecutive patients (PARC/LRRC 50/40) treated between January 2001 and October 2010, recorded on a prospectively maintained database.The median age was 63 (32-75) years with a gender ratio of 7 women to 83 men. All patients were American Society of Anesthesiologists level I or II. Sacral resection was performed in five patients with PARC and 15 with LRRC (P=0.002). R0 resection was achieved in 33 (66%) patients with PARC and in 15 (38%) with LRRC, R1 resection in 17 (34%) with PARC and 20 (50%) with LRRC and R2 resection in five (13%) with LRRC. R0 resection was more frequent in PARC (P=0.007). Forty-four (49%) patients had no postoperative complications. Fifty-five major complications were registered. Two (2.2%) patients died within 30 days, and the total in-hospital mortality was 5.6%. The median follow-up was 12 (0.4-91) months. The 5-year survival was 46% for PARC and 17% for LRRC (P=0.16).Pelvic exenteration is associated with considerable morbidity but low mortality in an experienced centre. Pelvic exenteration can improve long-term survival, especially for patients with PARC. However, pelvic exenteration is also justified for patients with LRRC.

Udgivelsesdato: 2008-Jun PURPOSE: The modern treatment of pseudomyxoma peritonei is cytoreductive surgery plus intraperitoneal chemotherapy resulting in a survival of up to 70 percent after 20 years. The goal of this study was to investigate the impact on quality of life of this very aggressive treatment, which has not been done before. METHODS: Twenty-three prospective patients underwent cytoreductive surgery and early postoperative intraperitoneal chemotherapy for pseudomyxoma peritonei. Patients were followed in clinic 3, 6, 12, 18, and 24 months after surgery and had CT scan of the abdomen every 6 months. Quality of life was prospectively assessed with the generic quality of life instrument Short Form-36 Questionnaire, together with the two symptom-specific instruments--European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, and Colorectal Cancer Module 38--before surgery and at every postoperative visit. RESULTS: Complete cytoreduction was achieved in 21 patients. No patients died within 30 days. Seventy percent of patients had one or more complications during or after surgery, but all had recovered. Fourteen percent had an asymptomatic recurrence detected within two years. The impact on quality of life of the disease and of its treatment was very modest despite the high morbidity after the treatment. There was a significant decrease in the scores on the Short Form-36 Questionnaire scales of physical dimension and role physical three months after surgery, only returning to normal after another three months. The other scores corresponded to the scores in a normal population. CONCLUSIONS: Cytoreductive surgery plus early postoperative intraperitoneal chemotherapy is an extensive treatment with a high morbidity but with relatively little impact on quality of life in patients with pseudomyxoma peritonei.

Placing of ileal conduit at the time of pelvic exenteration in combination with a same-side vertical rectus abdominis myocutaneous flap is controversial. We report our experience with the placement of the ileal conduit at the same side as the donor site of the vertical rectus abdominis myocutaneous flap in 12 patients and describe our technical approach.

Changes in gastric mucosal-pH (pHi) are correlated with the oxygenation of the gastric mucosa. We have measured the gastric mucosal-pH (pHi) in 11 healthy patients undergoing laparoscopic cholecystectomy and calculated the "pH-gap" as the difference between arterial-pH and pHi. The measurements were obtained at 30 minute intervals from the induction of anaesthesia to the end of surgery. The pHi decreased during surgery, but the pH-gap showed only insignificant changes. The results of this study did therefore not indicate gastric mucosal hypoxia during laparoscopic cholecystectomy.

Two cases of synergist postoperative infection are described. The importance of radical wound toilet and broad-spectrum antibiotic treatment is emphasized. Synergist infection should be borne in mind in cases where postoperative wound infection continues to spread despite thorough wound toilet.

In a randomized prospective controlled trial involving 311 patients undergoing acute or elective colorectal surgery, the efficacy and safety of two different single dose and one triple dose regimen of antibiotic prophylaxis, as well as the influence of blood transfusion on postoperative infectious complications, were studied. Postoperative infectious complications occurred in a total of 59 patients (19-0 per cent). There were no major differences between the three treatment groups. Thirty-four patients (10·9 per cent) developed abdominal wound infection, 17 patients (5·5 per cent) intra-abdominal abscess and 16 patients (5·1 per cent) anastomotic leakage. Of 202 patients (65·0 per cent) requiring blood transfusion during hospitalization 57 (28·2 per cent; 95 per cent confidence limits of 23·36 per cent) developed infectious complications, whereas two non-transfused patients (1·8per cent; 95per cent confidence limits of 0·2 to 6per cent; P