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BACKGROUND: Personalized risk assessment provides opportunities for tailoring treatment, optimizing healthcare resources and improving outcome. The aim of this study was to develop a 90-day mortality-risk prediction model for identification of high- and low-risk patients undergoing surgery for colorectal cancer. METHODS: This was a nationwide cohort study using records from the Danish Colorectal Cancer Group database that included all patients undergoing surgery for colorectal cancer between 1 January 2004 and 31 December 2015. A least absolute shrinkage and selection operator logistic regression prediction model was developed using 121 pre- and intraoperative variables and internally validated in a hold-out test data set. The accuracy of the model was assessed in terms of discrimination and calibration. RESULTS: In total, 49 607 patients were registered in the database. After exclusion of 16 680 individuals, 32 927 patients were included in the analysis. Overall, 1754 (5.3 per cent) deaths were recorded. Targeting high-risk individuals, the model identified 5.5 per cent of all patients facing a risk of 90-day mortality exceeding 35 per cent, corresponding to a 6.7 times greater risk than the average population. Targeting low-risk individuals, the model identified 20.9 per cent of patients facing a risk less than 0.3 per cent, corresponding to a 17.7 times lower risk compared with the average population. The model exhibited discriminatory power with an area under the receiver operating characteristics curve of 85.3 per cent (95 per cent c.i. 83.6 to 87.0) and excellent calibration with a Brier score of 0.04 and 32 per cent average precision. CONCLUSION: Pre- and intraoperative data, as captured in national health registries, can be used to predict 90-day mortality accurately after colorectal cancer surgery.

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BACKGROUND: Mechanisms contributing to the perioperative stress response remain poorly understood. This study investigated changes in the amount of bacterial DNA in blood and the diversity of blood microbiota in the perioperative period in patients undergoing minimally invasive surgery for colonic cancer in an enhanced recovery after surgery setting. METHODS: DNA encoding the bacterial 16S ribosomal RNA gene (16S rDNA) in whole blood obtained the day before surgery, and on postoperative day (POD) 1 and POD 10-14 was amplified and quantified by PCR before sequencing for taxonomic assignment. Richness, evenness and similarity measures were calculated to compare microbiota between days. Differences in relative abundance were analysed using the linear discriminant analysis effect size (LEfSe) algorithm. RESULTS: Thirty patients were included between January and July 2016. The concentration of bacterial 16S rDNA in blood increased between the day before surgery and POD 1 (P = 0.025). Bacterial richness was lower on POD 10-14 than on the day before surgery and POD 1 (both P < 0·001). LEfSe analysis comparing the day before surgery and POD 10-14 identified changes in the abundance of several bacteria, including Fusobacterium nucleatum, which was relatively enriched on POD 10-14. CONCLUSION: These findings suggest that the blood of patients with colonic cancer harbours bacterial 16S rDNA, which increases in concentration after surgery.

ANTECEDENTES: Los mecanismos que contribuyen a la respuesta al estrés perioperatorio siguen siendo poco conocidos. Este estudio investigó los cambios en la cantidad de ADN bacteriano en la sangre y la diversidad de la microbiota sanguínea en el período perioperatorio en pacientes sometidos a cirugía mínimamente invasiva por cáncer de colon en el contexto de un programe de recuperación mejorada después de la cirugía. MÉTODOS: El ADN que codifica el gen de ARN ribosómico (rNDA) 16S bacteriano en sangre completa obtenido el día antes de la cirugía, el día 1 del postoperatorio y el día 10-14 del postoperatorio se amplificó y cuantificó mediante qPCR antes de la secuenciación para la asignación taxonómica. Se calcularon medidas de riqueza, uniformidad y similitud para comparar la microbiota entre los diferentes días. Las diferencias en la abundancia relativa se analizaron mediante un algoritmo de análisis discriminante lineal de tamaño de efecto (linear discriminant analysis effect size, LEfSe). RESULTADOS: De enero a julio de 2016 se incluyeron 30 pacientes. La concentración de 16S rNDA bacteriano en sangre aumentó desde el día antes de la operación al día 1 del postoperatorio. La riqueza bacteriana disminuyó en el día 10-14 del postoperatorio en comparación con el preoperatorio y el día 1 del postoperatorio. La comparación del preoperatorio y del día 10-14 postoperatorio por LEfSe identificó cambios en la abundancia de varias bacterias, incluida Fusobacterium nucleatum que mostró un enriquecimiento relativo el día 10-14 del postoperatorio. CONCLUSIÓN: Estos hallazgos sugieren que la sangre de los pacientes con cáncer de colon alberga 16S rNDA bacteriano cuya concentración aumenta tras la cirugía.

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BACKGROUND: Knowledge of risk factors for recurrence of colorectal adenomas may identify patients who could benefit from individual surveillance strategies. The aim of this study was to identify risk factors for recurrence of colorectal adenomas in a high-risk population. METHODS: Data were used from a randomized clinical trial that showed no effect of aspirin-calcitriol-calcium treatment on colorectal adenoma recurrence. Patients at high risk of colorectal cancer who had one or more sporadic colorectal adenomas removed during colonoscopy were followed up for 3 years. Independent risk factors associated with recurrence and characteristics of recurrent adenomas were investigated in a generalized linear model. RESULTS: After 3 years, the recurrence rate was 25·8 per cent in 427 patients. For younger subjects (aged 50 years or less), the recurrence rate was 19 per cent; 18 of 20 recurrent adenomas were located in the distal part of the colon. For older subjects (aged over 70 years), the recurrence rate was 35 per cent, and 16 of 25 recurrent adenomas were in the proximal colon. Age (odds ratio (OR) 1·04, 95 per cent c.i. 1·01 to 1·07) and number of adenomas (OR 1·27, 1·11 to 1·46) at the time of inclusion in the study were independent risk factors for recurrence. CONCLUSION: In contrast to current guidelines, advanced age is not a reason to discontinue adenoma surveillance in patients with an anticipated live expectancy in which recurrence can arise.

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Bladder cancer is a common urological malignancy with high recurrence rate, which may be reduced by chemoprevention. The aim was to evaluate chemoprevention in a mouse model of tobacco carcinogen-induced bladder tumors. A total of 60 A/J mice were randomized to normal diet, diet with low calcium, and diet with chemoprevention (acetyl salicylic acid, 1-alpha 25(OH)2-vitamin D3 and calcium). There were significantly fewer tumors (0 (0-0) vs. 0 (0-2), p = .045) and fewer animals with tumors (0/20 vs. 5/20, p = .045) in the chemoprevention group compared with controls. Thus, chemoprevention diet effectively reduced the tumor promoting effect of tobacco carcinogens in the mouse bladder.

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Nonmelanoma skin cancer is a common cancer type with increasing incidence. The purpose of this study was to evaluate topical application of diclofenac, calcipotriol, and difluoromethylornithine as chemoprevention in a mouse model of ultraviolet light-induced skin tumors, since these agents have been reported to have tumor inhibiting properties. One hundred twenty eight mice were treated with UVB radiation followed by chemoprevention or placebo. There were no significant effects of the treatments with respect to presence of skin tumors, number of tumors, tumor size, or survival. The investigated drugs were ineffective as chemoprevention in the dose regimens used in this study.

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BACKGROUND: Postoperative organ dysfunction contributes to morbidity, hospital stay and convalescence. Multimodal rehabilitation with epidural analgesia, early oral feeding, mobilization and laxative use after colonic resection has reduced ileus and hospital stay. METHODS: Fourteen patients receiving conventional care (group 1) and 14 patients who had multimodal rehabilitation (group 2) were studied before and 8 days after colonic resection. Outcome measures included postoperative mobilization, body composition by whole-body dual X-ray absorptiometry, cardiovascular response to treadmill exercise, pulmonary function and nocturnal oxygen saturation. RESULTS: Defaecation occurred earlier (median day 1 versus day 4) and hospital stay was shorter (median 2 versus 12 days) in patients who had multimodal treatment. Lean body and fat mass decreased in group 1 but not in group 2. Exercise performance decreased by 44 per cent in group 1 but was unchanged in group 2. A postoperative increase in heart rate (HR) response to exercise was avoided in group 2. Pulmonary function decreased in group 1 but not in group 2. There was less nocturnal postoperative hypoxaemia in group 2. Cardiac demand-supply (HR/oxygen saturation ratio) increased in group 1 but not in group 2. CONCLUSION: Multimodal rehabilitation prevents reduction in lean body mass, pulmonary function, oxygenation and cardiovascular response to exercise after colonic surgery.

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INTRODUCTION: The aim of the study was to evaluate the incidence of recurrence of local cancer, distant metastases and survival after conventional low anterior resection for cure in patients with rectal carcinoma, on the basis of the poor prognosis after colorectal cancer in Denmark. MATERIAL AND METHODS: Consecutive patients operated on in the nine Danish departments of surgical gastroenterology in 1992-1993. Retrospective collection of data on recurrence of local cancer, distant metastases, and over-all survival at the end of 1996. RESULTS: Of 268 patients, 77 (29%) developed recurrent local cancer and/or distant metastases. Forty-eight (18%) had local recurrence with a cumulative 5-year rate of 39%. Distant metastases were seen in 54 (20%). The local recurrence rate increased with increasing Dukes' tumour stage and was higher after operation by a non-specialist (30%) than by a consultant, another specialist, or a surgeon under training and supervised by a consultant (15-17%) (p = 0.04). Multiple regression showed that the recurrence rate was independent of tumour localisation, blood loss, transfusion, anastomotic leakage, and status of the surgeon. The cumulative crude 5-year survival was 50% and independent of the status of the surgeon. DISCUSSION: Our relatively high local recurrence rate and the results in the literature after total mesorectal excision (TME) indicate that the conventional technique should be replaced by TME, which has become the recommended method in recent years. Furthermore, we propose a changed strategy in the treatment of rectal cancer. The patients should be treated in fewer departments with established teams of rectal cancer specialists taking part in all operations for rectal cancer.

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Systemic palliative chemotherapy is usually regarded as ineffective in disseminated colorectal cancer, and the risk of toxic adverse effects is often considered a contraindication, as many patients are old and cannot be offered curative treatment. Randomized trials during the last decade have shown, however, that an effect on both survival and quality of life can be expected. Only casuistic reports of total remission have been published but a partial tumour response can be expected in 20-50% of patients. Toxicity is related to palliative chemotherapy and accelerated with old age (> 70 years). When disseminated colorectal cancer is diagnosed the possibility of palliative chemotherapy should be conferred with an oncologist.

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The prognosis for patients with cancer of the colon is dubious. An intendedly curative colon resection is performed in two-thirds of these patients, but half of them will subsequently die from metastatic disease. Randomized trials of adjuvant therapy with fluorouracil in combination with levamisole or leucovorin have shown significant benefit in terms of increased disease-free survival and overall survival. In 1990 adjuvant treatment was recommended as routine therapy in high risk patients in USA. A number of European countries are routinely treating high risk patients with Dukes' C coloncarcinoma. The recommendations are based on results from several cooperative trials reviewed in this article. Treatment related toxicity accelerates with increasing age but was acceptable in the reviewed trials. Adjuvant therapy is widely accepted as an important supplement to surgery in high risk patients. A Conference on the results and experiences now available should take place in the near future in order to establish a national consensus on adjuvant chemotherapy in Denmark. Patients with resected Dukes' C coloncarcinoma should receive adjuvant chemotherapy including 5-fluorouracil and leucovorin. Randomized trials are needed to establish the most effective regimens but "no-treatment" controls are no longer ethically acceptable.

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The prognosis following radical operation for rectal cancer is still dubious. There is urgent need for effective adjuvant treatment in order to control both local and distant recurrences. During the last years the use of combined adjuvant treatment (radiochemotherapy ) has increased both recurrence-free survival in several randomised trials. The trials are reviewed in this article. Adjuvant treatment has been recommended as standard therapy in the USA since 1990. Following the German national consensus conference in March 1994, adjuvant treatment is now being recommended in Germany as well. In several other countries in Europe adjuvant therapy is routinely being offered to high-risk colorectal cancer patients following the surgical procedure. The experiences and results that now are available ought to be discussed in the near future in order to establish a national consensus in Denmark.

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During the past decades the effect radiotherapy as adjuvant treatment of rectal cancer has been investigated in several prospective randomized trials. Only a marginal effect has been demonstrated on overall survival rate (3-4%) whereas the local recurrence rate can be significantly reduced by 33-50%. Using modern techniques the side-effects can be reduced to an insignificant level. Patients with rectal cancer who are not entering randomized prospective trials should be considered for pre-operative radiotherapy. Patients should be staged by preoperative CT-scanning and endoluminal ultrasound. Additionally, a down-staging effect and a reduction in tumor-size can be expected and accordingly an increase in resectability rate and a higher rate of sphincter-saving operations for large of fixed tumors is likely to be obtained.

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Heat-stable antigens from Helicobacter pylori were investigated for the detection of serum IgG, IgA and IgM antibodies against H. pylori by an ELISA technique. Antibody titers against H. pylori were measured in 167 dyspeptic patients, of whom 96 were H. pylori positive confirmed by culture or microscopy, and in 482 controls (0-98 years). Increased IgG antibody titers were found significantly more often in dyspeptic patients with active chronic gastritis than in patients with normal morphology, as well as in H. pylori-positive patients as compared to H. pylori-negative patients, independent of the endoscopic findings. The heat-stable antigens were compared with acid glycine-extracted antigens and a high degree of concordance was found in the results obtained with the two antigen preparations. The differences in the IgA antibody titers against H. pylori between H. pylori-positive and H. pylori-negative dyspeptic patients were significant and may be useful to confirm a borderline IgG result. No differences were found in IgM antibody titer between H. pylori-positive and -negative patients. The greatest age-dependent increase in IgG and IgA antibody titers was found in children, and if a lower cut-off level is used for children than for adults, as has been proposed, the proportion of people with increased antibody titers against H. pylori would be almost constant from the age of between five and 10 years until the time between 61 and 80 years. Comparison of H. pylori IgG antibodies with IgG antibodies against Campylobacter jejuni and total antibodies against cytomegalovirus (CMV) showed a greater similarity between H. pylori and C. jejuni (R = 0.51) than between H. pylori and CMV (R = 0.22). This may possibly be caused by cross-reactions between H. pylori and C. jejuni. The H. pylori heat-stabile antigen seems not to be very different from other crude H. pylori antigens like acid glycine-extracted antigens, but purification and characterization of the antigens are needed to improve antibody assays.

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A 19-year-old youth with known right cryptorchidism had repeated attacks of acute abdominal symptoms, previously transient but now intensifying. Surgical exploration revealed a gangrenous intra-abdominal testis, which was successfully removed. Histologic examination confirmed the diagnosis of torsion.

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Campylobacter pyloridis, a recently detected microorganism, was isolated from gastric antral mucosa in 58% of 119 consecutive patients with upper dyspepsia. There was a highly significant correlation between the presence of Campylobacter pyloridis and antral inflammation and a close relation to prepyloric and duodenal ulcer. There was no significant correlation with the severity or type of inflammation. This microorganism, which seems to be as common in Denmark as in other parts of the world, is considered a possible cause of gastroduodenal disease.

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Seven patients, four women and three men, with a median age of 64 years (range, 53-74 years) were randomized to treatment with either ketanserin, 40-160 mg daily, or placebo. The study included 13 treatment periods with ketanserin and 13 with placebo. All patients had typical symptoms, with flushing as their main complaint. The diagnosis had been verified histologically. All had elevated excretion of 5-hydroxy-3-indoleacetic acid in urine. During the trial ketanserin reduced the number of flushing attacks in five patients (p less than 0.05). Diarrhoea was reduced in two patients. No side effects were observed. Ketanserin seems valuable for the symptomatic relief in the carcinoid syndrome.

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Five cases of nonclostridial, gas-producing perianal infection are reported and the resemblance to clostridial gas gangrene is discussed. The importance of early diagnosis followed by aggressive surgical debridement and prompt administration of broad-spectrum antibiotics is emphasized.

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