Medico-legal autopsy in postoperative hemodynamic collapse following coronary artery bypass surgery

Sudden unexpected postoperative hemodynamic collapse with a high mortality develops in 1–3% of patients undergoing coronary artery bypass surgery (CABG). The contribution of surgical graft complications to this serious condition is poorly known and their demonstration at autopsy is a challenging task. Isolated CABG was performed in 8,807 patients during 1988–1999. Of the patients, 76 (0.9%) developed sudden postoperative hemodynamic collapse resulting in subsequent emergency reopening of the median sternotomy and open cardiac massage. Further emergency reoperation could be performed in 62 (82%) whereas 14 patients died prior to reoperation and a further 21 did not survive the reoperation or died a few days later. All 35 (46%) patients who did not survive were subjected to medico-legal autopsy combined with postmortem cast angiography. By combining clinical data with autopsy and angiography data, various types of graft complications were observed in 27 (36%, 1.3 per patient) of the 76 patients with hemodynamic collapse. There were no significant differences in the frequency (33 vs. 40%) or number of complicated grafts per patient (1.2 vs. 1.4) between those who survived reoperation and who did not. Autopsy detected 25 major and minor findings not diagnosed clinically. Postmortem cast angiography visualized 2 graft twists not possible to detect by autopsy dissection only. Surgical graft complications were the most frequent single cause for sudden postoperative hemodynamic collapse in CABG patients leading to a fatal outcome in almost half of the cases. Postmortem angiography improved the accuracy of autopsy diagnostics of graft complications

Time trends in socioeconomic differences in incidence rates of cancers of gastro-intestinal tract in Finland

BACKGROUND: The magnitude of socioeconomic differences in health varies between societies, and over time within a given society. We studied the association between social class and incidence of cancers of the gastro-intestinal tract over time in a large cohort in Finland. METHODS: We studied social class variation among 45–69 year-old Finns during 1971–95 in incidence of cancers of the gastro-intestinal tract by means of a computerized record linkage of the Finnish Cancer Registry and the 1970 Population Census, which included social class data. RESULTS: There were 2.3 million individuals in the cohort under follow-up, with 1622 cases of cancer of the esophagus, 8069 stomach (non-cardia), 1116 cardia, 408 small intestine, 6361 colon, 5274 rectum, 1616 liver, 1756 gallbladder, and 5084 pancreas during 1971–1995. Cancers of the esophagus, stomach, cardia, gallbladder and pancreas were most common among persons belonging to a low social class. Cancers of the small intestine in males only, colon in both genders, and rectum in females were most common in the higher social classes. Incidence of stomach cancer decreased and incidence of colon cancer increased over time in both genders in all social classes, and the large differences between social classes remained unchanged over time. Incidence rates of cardia cancer did not change substantially over time. CONCLUSION: There is a large variation in incidence of cancer of the gastrointestinal tract by social class in Finland. Although much of the observed social class differences probably could be explained by known etiological factors such as diet, physical exercise, alcohol consumption, smoking and exogenous hormone use, part of the variation is apparently attributable to largely unknown factors

Fyysisen suorituskyvyn merkitys ruokatorvi- ja keuhkosyövän leikkaushoidossa

Tiivistelmä JOHDANTO: Tutkimuksessamme arvioitiin porrastestin hyötyjä vakavien komplikaatioiden ja kuolleisuuden ennustajana vaativassa syöpäkirurgiassa. POTILAAT JA MENETELMÄT: Aineiston muodostivat Keski-Suomen keskussairaalassa vuosina 2012–2021 leikatut 495 ruokatorvi- ja keuhkosyöpäpotilasta. Porrastestistä muodostettiin kolme ryhmää: yli 14 metriä (neljä kerrosta), 10–14 metriä (3–4 kerrosta) ja alle kymmenen metriä (alle kolme kerrosta) nousevat. Potilaat vastasivat myös suorituskykykyselyyn. Päätemuuttujat olivat vakavat komplikaatiot, kuolleisuus 90 vuorokauden kuluessa, viiden vuoden kokonaiskuolleisuus sekä kuolemat muuhun kuin syöpään. TULOKSET: Vakavia komplikaatioita ilmaantui eniten huonon (alle 10 m) suorituskyvyn ryhmässä (23 %) verrattuna 10–14 metrin (12 %) ja yli 14 metrin (11 %) ryhmiin (p = 0,037). Yhdeksänkymmenen vuorokauden kuolleisuus oli vastaavasti 10 %, 4,1 % ja 0,7 % (p < 0,001), ja viiden vuoden elossaolo-osuudet olivat 45 %, 36 % ja 69 % (p < 0,001). Kun tarkasteltiin muita kuin syövästä johtuvia kuolemia, elossaolo-osuudet olivat 47 %, 66 % ja 88 % (p < 0,001). Monimuuttujamallissa porrastestitulos oli kuolleisuuden lisääntymisen itsenäinen riskitekijä. PÄÄTELMÄT: Suorituskyky vaikuttaa ruokatorvi- ja keuhkosyöpäkirurgiassa potilaan hoitolinjaukseen, leikkauskomplikaatioihin ja pitkän ajan tuloksiin

Elämänlaadun palautumista ruokatorvi- ja mahasyöpäleikkauksen jälkeen voidaan tukea

Ruokatorvi- ja mahasyöpäkirurgia on raskasta kirurgiaa, johon liittyy runsaasti komplikaatioita. Tiivistelmä Leikkausten yhdistävä tekijä on mahalaukun säiliötoiminnan häviäminen kokonaan tai osittain. Tämä aiheuttaa ruoansulatuskanavan oireita. Elämänlaatu huononee kuukausien ajaksi leikkauksesta, mutta palautuu vuoden jälkeen lähes normaaliväestön tasolle. Keskeistä on tunnistaa selvittelyä vaativat ja hoidettavissa olevat oireet, kuten nielemisvaikeudet, refluksi ja dumping-oireet. Ongelmia lievitetään ravitsemuksen, lääkityksen, tähystystoimenpiteiden ja psykologisen tuen keinoin

Short-term outcomes following minimally invasive and open esophagectomy:a population-based study from Finland and Sweden

Abstract Background: Population-based studies comparing minimally invasive esophagectomy (MIE) and open esophagectomy (OE) relative to 90-day postoperative mortality are needed. Objective: The aim of this study was to compare short-term outcomes following these two techniques for esophageal cancer. Methods: Patients undergoing MIE (n = 217) or OE (n = 1397) for esophageal cancer between 2007 and 2014 were identified from nationwide complete registries in Finland and Sweden. The primary outcome was 90-day mortality, and secondary outcomes were 30-day mortality, length of hospital stay, and 30- and 90-day readmission rate. Results were adjusted for age, sex, comorbidity, tumor histology, surgery year, and country. Results: Ninety-day mortality rates were 4.1% (n = 9 of 217) for MIE and 6.8% (n = 95 of 1397) for OE; 90-day mortality was halved after MIE [adjusted hazard ratio (HR) 0.49, 95% confidence interval (CI) 0.24–0.99]. There was no difference in 30-day mortality (adjusted HR 0.87, 95% CI 0.29–2.66). Median hospital stay was 15 days for MIE and 16 days for OE (adjusted β −0.17, standard error 0.08, p = 0.030). The 30-day readmission rates were 8.9% after MIE and 12.0% after OE (adjusted HR 0.57, 95% CI 0.34–0.94), while the 90-day readmission rates were 28.8% and 33.6%, respectively, without a statistically significant difference (adjusted HR 0.82, 95% CI 0.61–1.10). <em<Conclusions: This population-based study from Finland and Sweden revealed lower 90-day mortality, shorter hospital stay, and lower 30-day readmission rates after MIE compared with OE for esophageal cancer. These findings support the use of minimally invasive approaches

Implementation of multimodality therapy and minimally invasive surgery:short- and long-term outcomes of gastric cancer surgery in medium-volume center

Abstract Background: Multimodal treatment of gastric cancer includes careful preoperative staging, perioperative oncological treatment, and selective minimally invasive approach. The aim was to evaluate whether this approach improves short- and long-term outcomes in operable gastric cancer. Methods: This study included 181 gastric cancer patients who underwent curative intent surgery in Central Finland Central Hospital between years 2005 and 2021 for gastric or esophagogastric junction adenocarcinoma. Those 65 patients in group 1 operated between years 2005–2010 had open surgery with possible adjuvant therapy. During the second period including 58 patients (2011–2015), perioperative chemotherapy and minimally invasive surgery were implemented. The period, when these treatments were standard practise, was years 2016–2021 including 58 patients (group 3). Outcomes were lymph node yield, major complications and 1- and 3-year survival rates. Results: Median lymph node yield increased from 17 in group 1 and 20 in group 2 to 23 in group 3 (p &lt; 0.001). Major complication rates in groups 1–3 were 12.3%, 32.8%, and 15.5% (group 1 vs. group 2, p = 0.007; group 2 vs. group 3, p = 0.018), respectively. Overall 1-year survival rates between study groups 1–3 were 78.5% vs. 69.0% vs. 90.2% (p = 0.018) and 3-year rates 44.6% vs. 44.8% vs. 68.1% (p = 0.016), respectively. For overall 3-year mortality, adjusted hazard ratio (HR) was 1.02 (95%CI 0.63–1.66) in group 2 and HR 0.37 (95%CI 0.20–0.68) in group 3 compared to group 1. Conclusions: In medium-volume center, modern multimodal therapy in operable gastric cancer combined with minimally invasive surgery increased lymph node yield and improved long-term survival without increasing postoperative morbidity

Predictive value of p53, Ki67 and TLR5 in neoplastic progression of Barrett’s esophagus:a matched case–control study

Abstract Barrett’s esophagus progresses to high-grade dysplasia or cancer along the well-established metaplasia-dysplasia-adenocarcinoma sequence. The aim of this study was to evaluate the value of p53, Ki67, and toll-like receptor 5 (TLR5) in prediction of malignant progression of Barrett’s metaplasia and low-grade dysplasia. This was a retrospective matched case–control study based on Northern and Central Finland population. Patients diagnosed with esophageal high-grade dysplasia or adenocarcinoma were included. From these patients, all previous endoscopy samples were obtained along with original diagnostic HE-slides and clinical data. Age- and sex-matched patients with non-progressing Barrett’s metaplasia and low-grade dysplasia confirmed with follow-up endoscopies were used as controls. Two gastrointestinal pathologist re-reviewed all original HE-slides, and newly made sections to confirm representative tissue material blinded from clinical data. p53, Ki67, and TLR5 were immunohistochemically stained. Final cohort included 45 patients with progressive Barrett’s metaplasia (n = 21) or low-grade dysplasia (n  = 24), and 92 patients with non-progressive Barrett’s metaplasia (n  = 52) or low-grade dysplasia (n  = 40). In Barrett’s metaplasia, aberrant p53 expression was observed in 6% of samples in progressors and 0% in non-progressors. In low-grade dysplasia, aberrant p53 was seen in 56% of samples in progressors and 17% in non-progressors (Odd’s ratio 6.7, 95% CI 1.8–24.6). Ki67 or TLR5 showed no association with disease progression. In this matched case–control study, p53 expression associated with a high risk of malignant progression in Barrett’s low-grade dysplasia. Routine staining of p53 is indicated in expert confirmed low-grade dysplasia

Minimally invasive esophagectomy learning curves with different types of background experience

Abstract Background: Minimally invasive esophagectomy (MIE) is a complex procedure with learning associated morbidity. The aim was to evaluate the learning curve for MIE focusing on short-term outcomes in two settings: (I) experienced MIE surgeon in new hospital (Hospital 1); (II) surgeons experienced with open esophagectomy and minimally invasive surrogate surgery (Hospital 2). Methods: In Hospital 1 and Hospital 2, on intent-to-treat basis number of MIEs were 132 and 57, respectively. The primary outcomes were major complications and anastomosis leaks. Secondary outcomes were operative time, blood loss, lymph node yield, hospital stay and 1-year mortality. Length of learning curves were analyzed with risk-adjusted cumulative sum (RA-CUSUM) method. Results: In Hospital 1, major complication and anastomosis leak rates were 9.8% and 4.5%, 22.8% and 12.3% in Hospital 2, respectively. In Hospital 1, complication and leak rates remained stable. In Hospital 2, improvement occurred after 34 cases in major complications and 29 cases in leaks. Of secondary outcomes, improvements were seen in Hospital 1 in operative time after 61, blood loss after 86, lymph node yield after 52, hospital stay after 19 and 1-year mortality after 24 cases. In Hospital 2, improvement occurred in operative time after 30, blood loss after 15, lymph node yield after 45, hospital stay after 50 and 1-year mortality after 15 cases. Conclusions: According to this study, learning phase of the individual surgeon determines the outcomes of MIE, not the institutional learning phase

Tertiary lymphoid structures in pulmonary metastases of microsatellite stable colorectal cancer

Abstract Tertiary lymphoid structures (TLSs) are ectopic lymphoid aggregates located at sites of chronic inflammation and recognized as prognosticators in several cancers. We aimed to analyse the prognostic effect of TLSs in colorectal cancer (CRC) pulmonary metastases and primary tumours, with a comparison to the CD3+ and CD8+ cell density-based immune cell score (ICS). For TLS density and TLS maximum diameter analysis, 67 pulmonary metastases and 63 primary tumours were stained with haematoxylin and eosin. For ICS scoring and analysis, CD3 and CD8 immunohistochemistry was performed. Excellent interobserver agreement was achieved in all TLS measurements. Of all patients, 36 patients had low TLS density (&lt; 0.222 follicles/mm) and 31 patients had high TLS density (≥ 0.222 follicles/mm) in the first resected pulmonary metastases. TLS density (adjusted HR 0.91, 0.48–1.73) or maximum diameter (adjusted HR 0.78, 0.40–1.51) did not have prognostic value in pulmonary metastases. In primary tumours, higher TLS density (adjusted HR 0.39, 0.18–0.87) and maximum diameter (adjusted HR 0.28, 0.11–0.73) were associated with lower mortality. In the pulmonary metastases, ICS had superior prognostic value to TLSs; however, TLSs and ICS were significantly associated. In conclusion, TLSs in CRC pulmonary metastases had no prognostic value but correlated with the ICS. TLSs in primary tumours associated with favourable prognosis

Finnish National Esophago-Gastric Cancer Cohort (FINEGO) for studying outcomes after oesophageal and gastric cancer surgery:a protocol for a retrospective, population-based, nationwide cohort study in Finland

Abstract Introduction: Surgery for oesophageal and gastric cancers is associated with high morbidity, mortality and poor quality of life postoperatively. The Finnish National Esophago-Gastric Cancer Cohort has been established with the aim of identifying factors that could contribute to improved outcomes in oesophago-gastric cancer. Methods and analysis: All patients with oesophageal and gastric cancer diagnosed in Finland between 1987 and 2015 will be identified from the Finnish national registries. The Finnish Cancer Registry and Finnish Patient Registry will be used to identify patients that fulfil the inclusion criteria for the study: (1) diagnosis of oesophageal, gastro-oesophageal junction, or gastric cancer, (2) any surgical treatment for the diagnosed cancer and (3) age of 18 or over at the time of diagnosis. Clinical variables and complication information will be retrieved in extensive data collection from the medical records of the relevant Finnish hospitals and complete follow-up for vital status from Statistics Finland. Primary endpoint is overall all-cause mortality and secondary endpoints include complications, reoperations, medication use and sick leaves. Sub-studies will be implemented within the cohort to investigate specific populations undergoing oesophageal and gastric cancer surgery. The initial estimated sample size is 1800 patients with surgically treated oesophageal cancer and 7500 patients with surgically treated gastric cancer. Ethics and dissemination: The study has been approved by the Ethical Committee in Northern Ostrobothnia, Finland and The National Institute for Health and Welfare, Finland. Study findings will be disseminated via presentations at conferences and publications in peer-reviewed journals. Introduction Surgery for oesophageal and gastric cancers is associated with high morbidity, mortality and poor quality of life postoperatively. The Finnish National Esophago-Gastric Cancer Cohort has been established with the aim of identifying factors that could contribute to improved outcomes in oesophago-gastric cancer