No description available.

Bakgrund: Inför ett kirurgiskt ingrepp erhålls information kring pre/intra/post – operativa rutiner. Det är inte helt klarlagt hur patienter uppfattar och kan ta till sig denna information. Syfte: Att beskriva patienters erfarenheter av preoperativ information inför kolo-rektal cancer kirurgi. Design: Kvalitativ deskriptiv studie med semi-strukturerade intervjuer. Kontext: Intervjuerna genomfördes på en vårdavdelning tillhörande ett universitetssjukhus i Sverige. Deltagare: 14 deltagare tillfrågades att delta i studien varav sju accepterade att delta. Metod: Intervjuerna spelades in på band och transkriberades ordagrant, insamlad data analyserades efter latent innehåll utefter Graneheim och Lundmans modell för innehållsanalys. Resultat: Huvudtema: Personcentrerad omvårdnad, och fyra teman: 1. Betydelsen av individuellt anpassad information. 2. Tydliga besked och bra bemötande främjar trygghet. 3. Stöd av närstående är betydelsefullt. 4. Väntan på svar främjar ovisshet. Deltagarna var sammantaget nöjda med erhållen preoperativ information. Några av deltagarna hade dock svårigheter att minnas all information som givits. Att leva i ovisshet kring fortsatt prognos samt framtiden gav känslor av otrygghet och oro. Betydelsen av närstående och anhöriga var stor, dels för att uppfatta informationen korrekt, för att minnas den samt för emotionellt stöd. Behov av ytterligare information gällde biverkningar av läkemedel, kostråd efter kirurgi, provsvar, peroperativa förlopp samt information kring livet efter sjukhusvistelsen. Slutsats: : Att utgå från en personcentrerad vård, där patientens egna berättelse är i fokus, kan bidra till att ge en mer individbaserad preoperativ information, och på så sätt stärka patientens egna resurser under vårdtiden. / Background: Information regarding the pre/intra/post – operative routines is given prior to surgical interventions. It is not entirely clarified how patients perceive this information. Objective: To explore patients´ experiences regarding preoperative information before undergoing colo-rectal cancer surgery. Design: Qualitative descriptive study with semi-structured interviews. Setting: Interviews were conducted in a hospital ward on a university hospital in Sweden. Participants: 14 participants were asked to participate and seven accepted to participate in the study. Method: Interviews were tape recordered and collected data were transcribed verbatim and analyzed for latent content using Graneheim and Lundman´s outline for content analysis. Results: Main theme: Person-centered nursing care. Four themes were identified: 1. The meaning of individual-based information. 2. Explicit notifications and warm receptions promote feelings of safety. 3. Support from next of kin are meaningfull. 4. Waiting for answers promotes feelings of uncertainty. All of the participants were satisfied with acquired preoperative information. However, a few of the participants had difficulties remembering all of the information given. Feelings of uncertainty about the prognosis and the future were present and were experienced as to somewhat burdensome. The importance of relatives and next of kin were very important in regard of understanding and memorizing given information, but also for emotional support. The need for further desired information included pharmacological side effects, dietary advice following surgery, test results, perioperative complications and information regarding life after discharge. Conclusions: Providing person-centered care based on the narrative from the patient can help healthcare professionals to provide more accurate and individual based preoperative information.

No Brasil, os cânceres de cólon e de reto são considerados as neoplasias gastrintestinais mais comumente observadas na população. Nos últimos anos vêm se relatando na literatura nacional e internacional a possível relação da presença de microrganismos com o desenvolvimento de câncer; entretanto, ainda não se observam evidências científicas convincentes dessa interação. Este estudo teve como objetivo determinar a presença e participação dos diferentes patótipos de Escherichia coli em pacientes com e sem câncer de reto. Foram coletadas amostras fecais de pacientes com neoplasia de reto, e de indivíduos sadios sem sinais de câncer (pólipos e/ou tumor), usadas como controle. Uma porção fecal foi semeada em ágar MacConkey isolando-se aletaoriamente quatro colônias de cada amostra. A identificação em nível de espécie, e dos patótipos, assim como dos fatores de virulência das cepas extra-intestinais de E. coli foi realizada por PCR convencional. Para a caracterização molecular das E. coli foi usada a técnica de ERIC-PCR. Os pacientes com neoplasia de reto apresentaram idade média de 63 anos de idade (P < 0,001). A ocorrência de E. coli extra-intestinal (ExPEC; 44,17%) foi menor que as cepas de E. coli diarreiogênicas (DEC; 49,2%). A presença de E. coli enteroagregativa típica (tEAEC) foi observada em 44,1% das amostras fecais de pacientes com câncer de reto e em indivíduos sadios (12,9%) (P = 0,003); entretanto, as E. coli enteropatogênicas atípicas (aEPEC) foram isoladas em ambos os grupos de pacientes (câncer: 37,3%; sadios: 48,4%). O gene afa/dra da adesina Afa/Dr foi observado em maior prevalência nas ExPEC isoladas de pacientes com câncer (P < 0,001). As cepas de E. coli mostraram combinações gênicas que variaram de 2 a 8 genes, observando-se 39 e 24 combinações gênicas nas cepas de pacientes com câncer e sadios, respectivamente. Pelo ERIC-PCR observou-se elevada diversidade genética em todas as cepas. Foi observada a presença dos oito filogrupos de E. coli, sendo o filogrupo B2 (55,2%) o mais predominante. Os filogrupos D e E não agruparam cepas de indivíduos sadios. Os resultados sugerem maiores estudos para determinar o papel das DEC, particularmente das aEPEC, tEAEC e ExPEC de forma individual ou em associação, avaliando-se o provável sinergismo e/ou a co-infecção de diferentes patótipos nesses processos, assim como sua presença no trato intestinal em pacientes assintomáticos com câncer de reto. / In Brazil, colon and rectal cancer are increasing and they are considered the gastrointestinal neoplasia most commonly observed in the population. In recent years, national and international literatures have shown a possible correlationship among the presence of microorganisms with the development of cancer; however, no convincing scientific evidence of this interaction has been observed. This study aimed to determine the presence and participation of different pathotypes of Escherichia coli isolated from patients with or without rectal cancer. Fecal samples were collected from patients with rectal cancer and healthy individuals with no signs of cancer (polyps and/or tumor) used as a control. Feces were plated onto agar MacConkey and four strains were randomly selected from each sample. Conventional PCR was used for identification of E. coli and pathotypes, as well as to detect virulence genes in extra-intestinal strains. The molecular characterization of E. coli was performed by ERIC-PCR. Patients with rectal cancer were mean age of 63 years old (P < 0.001). Diarrheogenic E. coli (DEC, 49.17%) were more prevalent than extra-intestinal E. coli (ExPEC, 44.17%). The presence of tEAEC was observed in 44.1% of the patients with cancer compared to healthy (12.9%) (P = 0.003). Atypical enteropathogenic E. coli (aEPEC) strains were isolated in both patient groups (cancer: 37.3%; healthy: 48.4%). The gene afa/dra for adhesion Afa/Dr was observed in higher prevalence than in ExPEC strains in patients with cancer and healthy subjects (P < 0.001). E. coli strains showed genetic combinations from 2 to 8 genes, showed 39 and 24 genetic combinations in strains from cancer and healthy patients, respectively. All strains showed high genetic diversity by ERIC-PCR. It was observed presence of eight filogroups and B2 filogroup (55.2%) was the most prevalent. Filogroups D and E were absent in strains from healthy. The results suggest further studies to determine the role of DEC, particularly aEPEC, tEAEC, and ExPEC, individually or in combination, and the synergism and co-infection of different pathotypes in these processes, as well as its presence in the intestinal microbiota in asymptomatic patients with rectal cancer.

INTRODUÇÃO: A excisão total do mesorreto é o procedimento cirúrgico padrão para o tratamento do adenocarcinoma do reto. Resultados satisfatórios, em termos de prognóstico, alcançados com a associação da linfonodectomia retroperitoneal e pélvica lateral questionam se somente a excisão total do mesorreto seria suficiente para um estadiamento adequado, podendo afetar decisões relacionadas ao tratamento adjuvante. Este estudo avaliou o impacto das metástases em linfonodos retroperitoneais e/ou pélvicos laterais na mudança do estadiamento de pacientes com adenocarcinoma do reto e a acurácia da identificação de metástases em linfonodos das cadeias retroperitoneais e/ou pélvicas laterais com o uso de tecnécio-99m-fitato e/ou azul patente. MÉTODOS: Foi realizado estudo prospectivo de janeiro de 2004 a agosto de 2008, composto por 97 pacientes com adenocarcinoma do reto extraperitoneal submetidos a tratamento cirúrgico curativo com excisão total do mesorreto e linfonodectomia retroperitoneal e pélvica lateral, com pesquisa de linfonodos das cadeias retroperitoneais e pélvicas laterais identificados com tecnécio-99m-fitato e/ou corados em azul patente. Os linfonodos radioativos e/ou azuis, quando negativos ao exame histopatológico com hematoxilina-eosina, foram submetidos à multisecções histológicas com uso de técnicas imunohistoquímicas com anticorpos anticitoqueratinas (AE1/AE3). RESULTADOS: A média de linfonodos nas peças de excisão total do mesorreto foi de 11,5 (1119/97) e nas cadeias retroperitoneais e pélvicas laterais foi de 11,7 (1136/97). A linfonodectomia retroperitoneal e pélvica lateral identificou metástases em 17,5% dos pacientes do estudo e promoveu aumento do estádio TNM II para III em 8,2% dos pacientes. As variáveis relacionadas à presença de linfonodos retroperitoneais e/ou pélvicos laterais metastáticos foram o estádio III estabelecido na peça cirúrgica da excisão total do mesorreto (P < 0,04); a classificação pT3/pT4 do tumor primário (P = 0,047); níveis elevados de antígeno carcinoembrionário, com média de 30,6 ng/ml e mediana de 9,9 ng/ml (P = 0,014); e grandes tumores, com tamanho médio de 5,5 ± 3,2 cm (P = 0,03). A migração do tecnécio e/ou azul patente para linfonodos retroperitoneais e/ou pélvicos laterais ocorreu em 37,1% (36/97), modificando o estadiamento em 11,1% dos pacientes estudados. A acurácia do uso do tecnécio e/ou azul patente na detecção de metástases nos linfonodos retroperitoneais e pélvicos laterais foi de 100%, com sensibilidade de 100%, valor preditivo negativo de 100% e zero de falso-negativos. CONCLUSÕES: Deve-se aprimorar o uso de marcadores na identificação de metástases para indicação seletiva da linfonodectomia retroperitoneal e pélvica lateral em adenocarcinoma retal. / BACKGROUND: Total mesorectal excision is the standard surgical procedure for rectal adenocarcinoma treatment. Good prognostic results achieved with retroperitoneal and lateral pelvic lymphadenectomy have questioned that total mesorectal excision might not be satisfactory for adequate patient staging, affecting adjuvant therapeutic definitions. The aims of this study were to define the upstaging impact of metastasis to retroperitoneal and/or lateral pelvic nodes in patients with rectal adenocarcinoma and the accuracy of dye and/or probe search in the detection of metastatic retroperitoneal and/or lateral pelvic nodes. METHODS: A prospective study was carried on from January of 2004 to August of 2008, composed of 97 extraperitoneal rectal adenocarcinoma patients submitted to curative intent surgeries with total mesorectal excision and retroperitoneal and lateral pelvic lymphadenectomy, with retroperitoneal and lateral pelvic nodes mapping using technetium-99m-phytate and/or patent blue. The radioactive and/or blue nodes, when negative to histopathological hematoxylin-eosin staining, were submitted to step-sectioning and immunohistochemical examination with antibody against cytokeratin (AE1/AE3). RESULTS: Mean node count of the mesorectal excision specimen was 11.5 (1119/97) and of the retroperitoneal and lateral pelvic lymphadenectomy was 11.7 (1136/97). Retroperitoneal and lateral pelvic lymphadenectomy identified metastasis in 17.5% of the studied patients and modified TNM stage II to III in 8.2% of the patients. Factors related to metastatic retroperitoneal and lateral pelvic nodes were stage III defined by examination of the surgical specimen of the total mesorectal excision (P < 0,004); tumor pT3/pT4 classification (P = 0,047); high levels of carcinoembryonic antigen, with average of 30.6 ng/ml and median of 9.9 ng/ml (P = 0,014); and large tumors, with mean size of 5.5 cm ± 3,2 cm (P = 0,03). Technetium and/or patent blue migration to retroperitoneal and/or lateral pelvic nodes occurred in 37.1% (36/97), upstaging 11.1% of the studied patients. Technetium and/or patent blue accuracy in the detection of metastasis to retroperitoneal and/or lateral pelvic nodes was of 100%, with sensibility of 100%, negative predictive value of 100% and zero false negatives. CONCLUSIONS: The use of markers should be improved in the identification of metastasis for selective indication of retroperitoneal and lateral pelvic lymphadenectomy.

No description available.

In dieser Arbeit wurden 48 Patienten nach multimodaler Tumortherapie bei lokal fortgeschrittenem Rektumkarzinom im Rahmen der CAO/ARO/AIO-04-Studie untersucht. Die Patienten wurden neoadjuvant radiochemotherapiert und entweder in Arm A mit 5-FU (1. und 5. RTx-Woche, 1000 mg/m2/Tag) oder in Arm B mit 5-FU und Oxaliplatin (5-FU Tag 1-14 und Tag 22-35, 250 mg/m2/Tag; Oxaliplatin Tag 1,8,22,29, 50 mg/m2/Tag) zusätzlich zur Bestrahlung mit 50,4 Gy (1,8 Gy/Tag; 3DCRT oder IMRT oder VMAT oder VMAT und 3DCRT) behandelt. Bei Nachsorgeuntersuchungen (NS) 1 und 2 Jahre nach Therapieende wurde die Spättoxizität nach LENT/SOMA-Kriterien erfasst. Blutproben wurden akquiriert zur Durchführung des Mikronukleustests (MNT), eines zuverlässigen und einfach durchführbaren Tests zur Darstellung genomischer Schäden in peripheren Blutlymphozyten (PBL). Innerhalb des Kollektivs trat eine interindividuelle Variabilität der Mikrokern(MK)-Ausbeuten auf, die nur zum Teil (Effekt des Geschlechts bei BE 1y) durch Patientenalter und geschlecht, Bestrahlungsart und –volumina und Zeitpunkte der NS erklärt werden konnte. Bezogen auf einzelne Patienten traten im Verlauf der NS konstant hohe bzw. niedrige MK-Ausbeuten auf. Im Vorfeld konnte eine Zunahme der MK-Ausbeuten im Verlauf der RCT gezeigt werden (Helms 2010; Hennies 2010; Wolff et al. 2011b). Die MK-Ausbeuten waren jeweils 1 Jahr und 2 Jahre nach Ende der RCT signifikant (p<0,0001) über dem Level von vor Beginn der RCT. Die MK-Ausbeuten lagen bei beiden NS signifikant (p<0,0001) unter dem Level des Endes der RCT. Für die Gesamt-, Rektum- und Hautspättoxizität bestand keine Korrelation mit dem Ausmaß der MK-Ausbeuten. Die Befunde im Bereich der Blase sollten weiter beobachtet werden, da ein Zusammenhang zwischen dem Grad der Blasenspättoxizität und den MK-Ausbeuten bei der 1. NS bestand. Auf der einen Seite kann vermutet werden, dass genetische Faktoren (Radiosensitivität) interindividuelle Schwankungen der MK-Ausbeuten erklären könnten. Auf der anderen Seite könnten dezidiertere Kenntnisse der Einflussvariablen (z. B. integrale Dosis des Knochenmarks) zur Klärung beitragen. Die Ergebnisse der vorliegenden Arbeit könnten die Kenntnis der Relation experimentell darstellbarer zytogenetischer Schäden und klinischer Folgen einer multimodalen Tumortherapie bei einzelnen Patienten verbessern.

The management of rectal cancer has changed in many countries over the last two decades and resulted in improved survival for the majority of rectal cancer patients. In this thesis some surgical strategies and histopathological aspects to improve and clarify the management of rectal cancer patients are investigated. Even in the era of TME surgery and radiotherapy, a higher local recurrence rate and shorter survival for rectal cancer patients operated with abdominoperineal resection is reported. In the first paper we describe a new strategy with partial anterior en bloc resection of either the prostate or the vagina, resulting in very low local recurrence rates and excellent long-term survival. Histopathological examination of the specimen lays the foundation for decision making on oncological therapy. A positive circumferential resection margin (CRM) has, in previous papers, been related to a high risk of local recurrence. In the second paper we show that a CRM ≤ 1 mm was not correlated with an increased risk of local recurrence when patients were managed in a multidisciplinary setting with preoperative radiotherapy and optimal TME surgery. As the complexity of rectal cancer management is increasing, demands on organizational structure are growing. In paper three we could show that long-term survival was increased for all rectal cancer patients after the centralization to a single unit. Whether or not to resect the primary rectal tumour in patients with metastatic disease is an ongoing debate in the literature. In paper four, we studied the national management of rectal cancer patients with primary metastatic disease. Nineteen per cent of rectal cancer patients present with Stage IV disease and, at a national level, there is a clear shift to a more selective and restrictive approach. The 30-day mortality was low for patients that underwent a resectional surgery, for patients having an exploratory laparotomy, however, it was high. Overall survival was improved over time even though up to one fourth of patients received no surgical treatment.

No description available.

INTRODUÇÃO: A excisão total do mesorreto é o procedimento cirúrgico padrão para o tratamento do adenocarcinoma do reto. Resultados satisfatórios, em termos de prognóstico, alcançados com a associação da linfonodectomia retroperitoneal e pélvica lateral questionam se somente a excisão total do mesorreto seria suficiente para um estadiamento adequado, podendo afetar decisões relacionadas ao tratamento adjuvante. Este estudo avaliou o impacto das metástases em linfonodos retroperitoneais e/ou pélvicos laterais na mudança do estadiamento de pacientes com adenocarcinoma do reto e a acurácia da identificação de metástases em linfonodos das cadeias retroperitoneais e/ou pélvicas laterais com o uso de tecnécio-99m-fitato e/ou azul patente. MÉTODOS: Foi realizado estudo prospectivo de janeiro de 2004 a agosto de 2008, composto por 97 pacientes com adenocarcinoma do reto extraperitoneal submetidos a tratamento cirúrgico curativo com excisão total do mesorreto e linfonodectomia retroperitoneal e pélvica lateral, com pesquisa de linfonodos das cadeias retroperitoneais e pélvicas laterais identificados com tecnécio-99m-fitato e/ou corados em azul patente. Os linfonodos radioativos e/ou azuis, quando negativos ao exame histopatológico com hematoxilina-eosina, foram submetidos à multisecções histológicas com uso de técnicas imunohistoquímicas com anticorpos anticitoqueratinas (AE1/AE3). RESULTADOS: A média de linfonodos nas peças de excisão total do mesorreto foi de 11,5 (1119/97) e nas cadeias retroperitoneais e pélvicas laterais foi de 11,7 (1136/97). A linfonodectomia retroperitoneal e pélvica lateral identificou metástases em 17,5% dos pacientes do estudo e promoveu aumento do estádio TNM II para III em 8,2% dos pacientes. As variáveis relacionadas à presença de linfonodos retroperitoneais e/ou pélvicos laterais metastáticos foram o estádio III estabelecido na peça cirúrgica da excisão total do mesorreto (P < 0,04); a classificação pT3/pT4 do tumor primário (P = 0,047); níveis elevados de antígeno carcinoembrionário, com média de 30,6 ng/ml e mediana de 9,9 ng/ml (P = 0,014); e grandes tumores, com tamanho médio de 5,5 ± 3,2 cm (P = 0,03). A migração do tecnécio e/ou azul patente para linfonodos retroperitoneais e/ou pélvicos laterais ocorreu em 37,1% (36/97), modificando o estadiamento em 11,1% dos pacientes estudados. A acurácia do uso do tecnécio e/ou azul patente na detecção de metástases nos linfonodos retroperitoneais e pélvicos laterais foi de 100%, com sensibilidade de 100%, valor preditivo negativo de 100% e zero de falso-negativos. CONCLUSÕES: Deve-se aprimorar o uso de marcadores na identificação de metástases para indicação seletiva da linfonodectomia retroperitoneal e pélvica lateral em adenocarcinoma retal. / BACKGROUND: Total mesorectal excision is the standard surgical procedure for rectal adenocarcinoma treatment. Good prognostic results achieved with retroperitoneal and lateral pelvic lymphadenectomy have questioned that total mesorectal excision might not be satisfactory for adequate patient staging, affecting adjuvant therapeutic definitions. The aims of this study were to define the upstaging impact of metastasis to retroperitoneal and/or lateral pelvic nodes in patients with rectal adenocarcinoma and the accuracy of dye and/or probe search in the detection of metastatic retroperitoneal and/or lateral pelvic nodes. METHODS: A prospective study was carried on from January of 2004 to August of 2008, composed of 97 extraperitoneal rectal adenocarcinoma patients submitted to curative intent surgeries with total mesorectal excision and retroperitoneal and lateral pelvic lymphadenectomy, with retroperitoneal and lateral pelvic nodes mapping using technetium-99m-phytate and/or patent blue. The radioactive and/or blue nodes, when negative to histopathological hematoxylin-eosin staining, were submitted to step-sectioning and immunohistochemical examination with antibody against cytokeratin (AE1/AE3). RESULTS: Mean node count of the mesorectal excision specimen was 11.5 (1119/97) and of the retroperitoneal and lateral pelvic lymphadenectomy was 11.7 (1136/97). Retroperitoneal and lateral pelvic lymphadenectomy identified metastasis in 17.5% of the studied patients and modified TNM stage II to III in 8.2% of the patients. Factors related to metastatic retroperitoneal and lateral pelvic nodes were stage III defined by examination of the surgical specimen of the total mesorectal excision (P < 0,004); tumor pT3/pT4 classification (P = 0,047); high levels of carcinoembryonic antigen, with average of 30.6 ng/ml and median of 9.9 ng/ml (P = 0,014); and large tumors, with mean size of 5.5 cm ± 3,2 cm (P = 0,03). Technetium and/or patent blue migration to retroperitoneal and/or lateral pelvic nodes occurred in 37.1% (36/97), upstaging 11.1% of the studied patients. Technetium and/or patent blue accuracy in the detection of metastasis to retroperitoneal and/or lateral pelvic nodes was of 100%, with sensibility of 100%, negative predictive value of 100% and zero false negatives. CONCLUSIONS: The use of markers should be improved in the identification of metastasis for selective indication of retroperitoneal and lateral pelvic lymphadenectomy.

Rectal cancer is a common malignancy treated with surgical resection and curative intent in the majority of cases. One treatment option is low anterior resection (LAR) with preserved bowel continuity, often involving the formation of a temporary defunctioning stoma (DS). The general aim of this thesis was to improve understanding of the role of DS in rectal cancer surgery with regard to timing of stoma reversal and development of anastomotic leakage (AL), impact on long-term anorectal function (AF), as well as aspects of cost-effectiveness. Study I addressed the timing of stoma reversal following LAR. We found that 19% of reversed patients were reversed within 4 months of LAR, while 81% of reversals were delayed. In 58% of delayed reversals the delay was due to low priority on surgical waiting lists. Studies II-IV were based on 234 patients randomized to receive a DS or no DS following LAR. Study II compared patients with AL following LAR diagnosed during the initial hospital stay (early leakage, EL) with patients diagnosed after hospital discharge (late leakage, LL). LL was more common in females, and originated more frequently from the transverse stapler line. EL was more common in males, and originated more frequently from the circular stapler line. Study III assessed AF 5 years after LAR with regard to whether patients initially had a DS or no DS. We found no difference in AF between the two randomized groups. When comparing with a 1-year follow-up in the same patient cohort, there were no further changes in AF over time. Study III assessed necessary healthcare resources and cost within 5 years of LAR, depending on whether patients initially had a DS or no DS. The overall cost analysis revealed a higher cost for patients randomized to DS, regardless of the cost-savings associated with a reduced frequency of anastomotic leakage.