Clinical implantation of 92 VACStents in the upper gastrointestinal tract of 50 patients-applicability and safety analysis of an innovative endoscopic concept

Introduction

Endoscopic vacuum therapy (EVT) has emerged as a promising treatment option for upper gastrointestinal wall defects, offering benefits such as evacuation of secretions and removal of wound debris by suction, and reduction and healing of wound cavities to improve clinical outcomes. In contrast, covered stents have a high rate of migration and lack functional drainage, while endoluminal EVT devices obstruct the GI tract. The VACStent is a novel device that combines the benefits of EVT and stent placement. Its design features a fully covered Nitinol-stent within a polyurethane sponge cylinder, enabling EVT while maintaining stent patency.

Methods

This study analyzes the pooled data from three different prospective study cohorts to assess the safe practicality of VACStent placement, complete leak coverage, and effective suction-treatment of esophageal leaks. By pooling the data, the study aims to provide a broader base for analysis.

Results

In total, trans-nasal derivation of the catheter, suction and drainage of secretion via vacuum pump were performed without any adversity. In the pooled study cohort of 92 VACStent applications, the mean stent indwelling time was 5.2 days (range 2-8 days) without any dislocation of the device. Removal of the VACStent was done without complication, in one case the sponge was lost but subsequently fully preserved. Minor local erosions and bleeding and one subsequent hemostasis were recorded unfrequently during withdrawal of the device (5.4%, 5/92) but no perforation or pressure ulcer. Despite a high heterogeneity regarding primary disease and pretreatments a cure rate of 76% (38/50 patients) could be achieved.

Discussion

In summary, insertion and release procedure was regarded as easy and simple with a low potential of dislocation. The VACStent was well tolerated by the patient while keeping the drainage function of the sponge achieving directly a wound closure by continuous suction and improving the healing process. The implantation of the VACStent provides a promising new procedure for improved clinical treatment in various indications of the upper gastrointestinal wall, which should be validated in larger clinical studies.Clinical Trial Registration: Identifier [DRKS00016048 and NCT04884334].

BIOLAP: biological versus synthetic mesh in laparo-endoscopic inguinal hernia repair: study protocol for a randomized, multicenter, self-controlled clinical trial

Background

Inguinal hernia repair is one of the most common surgical operations globally; more than 20 million groin herniae are repaired annually worldwide. Recurrence after an inguinal hernia operation is a considerable clinical problem. Another remaining problem after hernia surgery is the occurrence of chronic pain. Up to now, the use of synthetic meshes is the standard procedure, but there is increasing evidence that biological meshes could be advantageous concerning the occurrence of chronic pain due to different postoperative remodeling, without the disadvantages of a life-long implant.

We hypothesize that the use of a biological mesh reduces postoperative pain without being inferior in terms of recurrence rate compared with a synthetic mesh.

Methods/design

The trial compares possible the advantages of biological matrices to synthetic meshes in laparo-endoscopic inguinal hernia repair. Four hundred and ninety-six patients with primary bilateral inguinal herniae in 20 German hernia centers will be enrolled. Biological mesh is used for one of the bilateral herniae, the other side will be operated on with a synthetic mesh. Randomization will preset which side is repaired with which material and trial participants will not be informed about the location of each mesh type. The primary endpoints will be intensity of postoperative local pain and the incidence of recurrent hernia after 2 years.

Discussion

There is no reasonably sized trial that assesses the use of biological meshes in laparo-endoscopic inguinal hernia repair.

Our self-controlled trial design allows a direct comparison of the two meshes with very few confounding factors as well as minimizing the exclusion criteria. As we compare CE-certified medical devices in their designated indication the medical risk is not different compared to routine clinical care. Due to the common nature of bilateral inguinal hernia, a high recruitment rate is achievable. Because guidelines for hernia repair have stressed the need for reliable data on the already frequent use of biological meshes, we can expect our trial to have a direct implication on hernia-repair standards.

Trial registration

German Clinical Trials Register, ID: DRKS00010178. Registered on 16.June.2016. BIOLAP underwent full external peer review as part of the funding process with the German Research Foundation.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3122-5) contains supplementary material, which is available to authorized users.

What is the evidence for the use of biologic or biosynthetic meshes in abdominal wall reconstruction?

INTRODUCTION

Although many surgeons have adopted the use of biologic and biosynthetic meshes in complex abdominal wall hernia repair, others have questioned the use of these products. Criticism is addressed in several review articles on the poor standard of studies reporting on the use of biologic meshes for different abdominal wall repairs. The aim of this consensus review is to conduct an evidence-based analysis of the efficacy of biologic and biosynthetic meshes in predefined clinical situations.

METHODS

A European working group, "BioMesh Study Group", composed of invited surgeons with a special interest in surgical meshes, formulated key questions, and forwarded them for processing in subgroups. In January 2016, a workshop was held in Berlin where the findings were presented, discussed, and voted on for consensus. Findings were set out in writing by the subgroups followed by consensus being reached. For the review, 114 studies and background analyses were used.

RESULTS

The cumulative data regarding biologic mesh under contaminated conditions do not support the claim that it is better than synthetic mesh. Biologic mesh use should be avoided when bridging is needed. In inguinal hernia repair biologic and biosynthetic meshes do not have a clear advantage over the synthetic meshes. For prevention of incisional or parastomal hernias, there is no evidence to support the use of biologic/biosynthetic meshes. In complex abdominal wall hernia repairs (incarcerated hernia, parastomal hernia, infected mesh, open abdomen, enterocutaneous fistula, and component separation technique), biologic and biosynthetic meshes do not provide a superior alternative to synthetic meshes.

CONCLUSION

The routine use of biologic and biosynthetic meshes cannot be recommended.

Training or non-surgical factors-what determines a good surgical performance? A randomised controlled trial

BACKGROUND

Acquiring laparoscopic skills is a necessity for every young surgeon. Whether it is a talent or a non-surgical skill that determines the surgical performance of an endoscopic operation has been discussed for years. In other disciplines aptitude testing has become the norm. Airlines, for example, have implemented assessments to test the natural aptitude of future pilots to predict their performance later on. In the medical field, especially surgery, there are no similar comparable tests implemented or even available. This study investigates the influence of potential factors that may predict the successful performance of a complex laparoscopic operation, such as the surgeon's age, gender or learning method.

METHODS

This study focussed 70 surgical trainees. It was designed as a secondary analysis of data derived from a 2 × 2 factorial randomised controlled trial of practical training and/or multimedia training (four groups) in an experimental exercise. Both before and then after the training sessions, the participating trainees performed a laparoscopic cholecystectomy in a pelvitrainer. Surgical performance was then evaluated using a modified objective structured assessment of technical skills (OSATS). Participants were classified as 'Skilled' (high score in the pre-test), 'Good Learner' (increase from pre- to post-test) or 'Others' based on the OSATS results. Based on the results of the recorded performance, the training methods as well as non-surgical skills were eventually evaluated in a univariate and in a multivariate analysis.

RESULTS

In the pre-training performance 11 candidates were categorised as 'Skilled' (15.7%), 35 participants as 'Good Learners' (50.0%) and 24 participants were classified as 'Others'. The univariate analysis showed that the age, a residency in visceral surgery, and participation in a multimedia training were significantly associated with this grouping. Multivariate analyses revealed that residency in visceral surgery was the most predictive factor for the 'Skilled' participants (p = 0.059), and multimedia training was most predictive for the 'Good Learner' (p = 0.006). Participants in the group of 'Others' who were neither 'Skilled' nor improved in the training phase were younger (p = 0.011) and did not receive multimedia (p < 0.001) or practical (p = 0.025) training.

CONCLUSION

The type of learning method has been shown to be the most effective factor to improve laparoscopic skills, with multimedia training proving to be more effective than practical training.

[Transvaginal/transumbilical hybrid NOTES appendicectomy : Comparison of techniques in uncomplicated and complicated appendicitis]

BACKGROUND

Appendicectomy (AE), the most frequent emergency surgical procedure, can be performed as a transvaginal hybrid natural orifice translumenal endoscopic surgery (NOTES) technique (TVAE). The question of feasibility also arises in cases of advanced inflammation with perforation.

MATERIAL AND METHODS

Since May 2012 all female patients with suspected acute appendicitis were offered a TVAE as an alternative to the standard procedure. Preoperative, intraoperative and postoperative parameters were registered prospectively.

RESULTS

Until October 2013 a total of 13 TVAEs had been performed. The median age of the patients was 41 years (range 20-76 years), median BMI was 23.1 (range 18.1-28.3 kg/m(2)) and the American Society of Anesthesiologists score (ASA) distribution (I/II/≥ III) was 8/5/0. Histology revealed three cases of perforated, one hemorrhagic necrotizing and seven phlegmonous appendicitis. Furthermore, there were two findings without inflammation, namely one neurogenic appendicopathy and one neuroendocrine tumor. For the three patients with perforated appendicitis, there was a trend for higher age (67.0 years versus 33.5 years, p=0.063) and a higher C-reactive protein (CRP) level on admission (134.4 mg/l versus 26.4 mg/l, p=0.043). Also, procedural time and hospital stay were longer (64 min versus 47 min, p=0.033 and 14 days versus 3 days, p=0.004, respectively). The former was mostly due to more extensive intraoperative flushing (volume 3000 ml versus 500 ml, p=0.013 and duration 13 min versus 2 min, p=0.011). None of the cases required conversion but two of the three postoperative complications occurred in patients with perforation, which also resulted in the longer hospital stay.

CONCLUSION

Technically, TVAE seems feasible also in cases of perforated appendicitis. However, in these cases procedural time is prolonged due to more extensive flushing. Whether or not the longer hospital stay can be attributed to the perforation or if TVAE results in a higher rate of complications in cases of perforated appendicitis needs further evaluation.

Is the transnasal access for esophagogastroduodenoscopy in routine use equal to the transoral route? A prospective, randomized trial

BACKGROUND AND STUDY AIMS

Routine esophagogastroduodenoscopy (EGD) is increasingly performed without sedation. Transoral (TO) and transnasal (TN) EGD offer different patient comfort and complications.

PATIENTS AND METHODS

For a controlled, randomized, clinical trial comparing TN-EGD with TO-EGD without sedation, patients were assigned to TN-EGD using a thin endoscope (group 1, 93 patients), or TO-EGD using a standard endoscope (group 2, 90 patients). Physician-rated procedural time and complications as well as patient-rated side effects and preferences were compared. In group 3, patients (118) who had previously undergone TO-EGD, now underwent TN-EGD.

RESULTS

Between group 1 and 2 there was no significant difference for procedural time. Nausea (p = 0.047) and epistaxis (p < 0.001) were significantly more frequent for TN-EGD. Conversion rate from TN- to TO-EGD was low with 4.3 %. For TN-EGD, patients' tolerance was better (p < 0.001), gagging was less (p < 0.001). In case of a future EGD, patients who know both procedures (group 3), strongly vote for TN-EGD (80 %). All groups vote against sedation for future procedures (90 %/90 %/89 %).

CONCLUSIONS

Epistaxis can be relevant after TN-EGD, but can mostly be managed conservatively. TN-EGD is superior to TO-EGD regarding subjective and objective gagging as well as procedural tolerance. Patients who experienced both access routes, prefer TN-EGD. TN-EGD without sedation should be aspired for patient comfort and is recommended for routine use.

Deterioration in quality of life (QoL) in patients with malignant ascites: results from a phase II/III study comparing paracentesis plus catumaxomab with paracentesis alone

BACKGROUND

Malignant ascites (MA) is associated with poor prognosis and limited palliative therapeutic options. Therefore, quality of life (QoL) assessment is of particular importance to demonstrate new treatment value. Following the demonstration of the superiority of catumaxomab and paracentesis over paracentesis on puncture-free survival, this analysis aimed at comparing deterioration in QoL between both the treatment options.

PATIENTS AND METHODS

In a randomised, multicentre, phase II/III study of patients with MA due to epithelial cell adhesion molecule (EpCAM) positive cancer, the QoL was evaluated using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 items (EORTC QLQ-C30) questionnaire at screening, 1, 3 and 7 months after treatment and in the case of re-puncture on the day of paracentesis. Time to first deterioration in QoL was defined as a decrease in the QoL score of at least five points and compared between the catumaxomab (n=160) and control (n=85) groups using the log-rank test and Cox proportional hazards models adjusted for baseline score, country and primary tumour type.

RESULTS

Deterioration in QoL scores appeared more rapidly in the control than in the catumaxomab group (median 19-26 days versus 47-49 days). The difference in time to deterioration in QoL between the groups was statistically significant for all scores (P<0.01). The hazard ratios ranged from 0.08 to 0.24 (P<0.01).

CONCLUSIONS

Treatment with catumaxomab delayed deterioration in QoL in patients with MA. Compared with paracentesis alone, catumaxomab enabled patients to benefit from better QoL for a prolonged survival period.

Catumaxomab therapy in peritoneal carcinomatosis from colon cancer: Clinical benefit in comparison to systemic chemotherapy alone and cytoreductive surgery/hyperthermic chemoperfusion

488

Background: There is still no effective treatment for the majority of patients suffering from peritoneal carcinomatosis (PC) of colon cancer. Palliative chemotherapy (CHEM) had limited efficacy. Cytoreductive surgery and hyperthermic chemoperfusion (HIPEC) showed promising results, but was manageable in early stage PC patients only. Catumaxomab therapy (CATU) offers a new option for intraperitoneal treatment in all stages of PC. Aim of the study was to evaluate CATU therapy in comparison to HIPEC and systemic therapy.

Methods: Between 2005 and 2008, 76 patients suffering from PC of colon cancer were included and treated with systemic chemotherapy alone (35), HIPEC +/- systemic chemotherapy (21) and CATU +/- chemotherapy (22). All patients were assessed for therapy-related severe side effects, incidence of intestinal obstruction-ileus and ascites and for overall survival.

Results: Grade IV side effects were observed in 9.1% of CATU patients, 14.3% after HIPEC and 5.7% after CHEM. Ascites was found in not a single patient after CATU vs. one patient after HIPEC (4.5%) and 7 patients after chemotherapy (20%, p<0.03). Intestinal obstruction was found in 22.7% of patients after CATU vs. 14.3% after HIPEC and in 42.9% of patients after chemotherapy (p<0.04). In comparison to systemic chemotherapy, overall survival was significantly increased after CATU (15.2 months, p=0.03) and HIPEC (20.1 months, p=0.02; median follow-up 17 months).

Conclusions: Catumaxomab therapy of patients with PC from colon cancer was associated with a preventive effect for accumulation of malignant ascites and intestinal obstruction. Patients receiving CATU or HIPEC therapy concepts showed a survival benefit compared to systemic chemotherapy alone. Therapy strategies containing intraperitoneal catumaxomab treatment may be beneficial in patients with PC from colon cancer, even in advanced PC disease, when HIPEC was not feasible.

[Table: see text]

Effect of catumaxomab treatment in patients with peritoneal carcinomatosis and malignant ascites due to gastrointestinal cancers on survival

490

Background: In 2009 the trifunctional antibody catumaxomab was approved for the intraperitoneal (i.p.) treatment of malignant ascites (MA) in EpCAM-positive carcinomas in Europe. Overall survival (OS) results for gastric cancer patients from the pivotal trial showed a significant treatment benefit of catumaxomab in this patient group. We present the results for the gastrointestinal (GI) cancer subgroup from the pivotal trial including long-term survivors.

Methods: A total of 86 patients with MA due to GI cancer (gastric, pancreatic, colon, esophagus, rectum carcinoma) were treated with paracentesis plus catumaxomab (59 patients) vs. paracentesis alone (control, 27 patients). The primary endpoint was puncture-free survival; main secondary endpoints were time to next puncture, overall survival and safety parameters. The endpoints were compared between the catumaxomab and the control group using the Kaplan-Meier method and log-rank test. Analyses were performed for the Full Analysis Set (FAS) and the Safety Set (patients who received at least 1 catumaxomab infusion; 95%).

Results: For puncture-free survival, a median of 35 days for catumaxomab vs. 14 days for control was observed (p<0.0001, HR: 0.340 with 95 % CI from 0.194 to 0.597, FAS). Time to next puncture resulted in a median of 118 days vs. 15 days (p<0.0001, HR: 0.161 with 95 % CI from 0.069 to 0.378, FAS). Although the study was not powered nor designed for OS, the difference between treatment and control arm was significant for the Safety Set (median: 61 vs. 44 days, p<0.05, HR: 0.553). ADRs were generally mild to moderate, limited to the treatment period and reversible.

Conclusions: I.p. catumaxomab is an EMA-approved treatment for patients suffering from malignant ascites. The positive efficacy results were demonstrated in an advanced stage patient population together with a predictable and manageable safety profile. Patients suffering from peritoneal carcinomatosis with malignant ascites due to GI cancers experience a significant survival benefit from i.p. treatment with catumaxomab.

[Table: see text]

[Modern didactics in surgical education--between demand and reality]

Surgical residency contains an inadequate amount of hands-on training in the operating room and time constraints further make this type of education on the floor unlikely. Due to these deficits in residency training, private surgical courses outside of the established residency programmes are in high demand. Therefore, surgical residents must spend their own resources and time in addition to their residency training in order to receive adequate clinical exposure. Didactic approaches like problem-based learning have begun to influence our modern education. These novel education approaches along with visualisation training, video-based presentations, and multimedia-based training can be useful adjuncts to traditional surgical training.

Liver transplantation for hilar cholangiocarcinoma: a German survey

BACKGROUND

The present study reports a German survey addressing outcomes in nonselected historical series of liver transplantation (OLT) for hilar cholangiocarcinoma (HL).

PATIENTS AND METHODS

We sent to all 25 German transplant centers performing OLT a survey that addressed (1) the number of OLTs for HL and the period during which they were performed; (2) the incidence of HL diagnosed prior to OLT/rate of incidental HL (for example, in primary sclerosing cholangitis); (3) tumor stages according to Union Internationale Centre le Cancer; (4) patient survival; and (5) tumor recurrence rate.

RESULTS

Eighty percent of centers responded, reporting 47 patients who were transplanted for HL. Tumors were classified as pT2 (25%), pT3 (73%), or pT4 (2%). HL was diagnosed incidentally in 10% of cases. A primary diagnosis of PSC was observed in 16% of patients. Overall median survival was 35.5 months. When in-hospital mortality (n = 12) was excluded, the median survival was 45.4 months, corresponding to 3- and 5-year survival rates of 42% and 31%, versus 31% and 22% when in-hospital mortality was included. HL recurred in 34% of cases. Three- and 5-year survivals for the 15 patients transplanted since 1998 was 57% and 48%, respectively. Median survival ranged from 20 to 42 months based on the time period (P = .014).

CONCLUSIONS

The acceptable overall survival, the improved results after careful patient selection since 1998, and the encouraging outcomes from recent studies all suggest that OLT may be a potential treatment for selected cases of HL. Prospective multicenter randomized studies with strict selection criteria and multimodal treatments seem necessary.

Liver transplantation for hilar cholangiocarcinoma: a German survey

BACKGROUND

The present study reports a German survey addressing outcomes in nonselected historical series of liver transplantation (OLT) for hilar cholangiocarcinoma (HL).

PATIENTS AND METHODS

We sent to all 25 German transplant centers performing OLT a survey that addressed (1) the number of OLTs for HL and the period during which they were performed; (2) the incidence of HL diagnosed prior to OLT/rate of incidental HL (for example, in primary sclerosing cholangitis); (3) tumor stages according to Union Internationale Centre le Cancer; (4) patient survival; and (5) tumor recurrence rate.

RESULTS

Eighty percent of centers responded, reporting 47 patients who were transplanted for HL. Tumors were classified as pT2 (25%), pT3 (73%), or pT4 (2%). HL was diagnosed incidentally in 10% of cases. A primary diagnosis of PSC was observed in 16% of patients. Overall median survival was 35.5 months. When in-hospital mortality (n = 12) was excluded, the median survival was 45.4 months, corresponding to 3- and 5-year survival rates of 42% and 31%, versus 31% and 22% when in-hospital mortality was included. HL recurred in 34% of cases. Three- and 5-year survivals for the 15 patients transplanted since 1998 was 57% and 48%, respectively. Median survival ranged from 20 to 42 months based on the time period (P = .014).

CONCLUSIONS

The acceptable overall survival, the improved results after careful patient selection since 1998, and the encouraging outcomes from recent studies all suggest that OLT may be a potential treatment for selected cases of HL. Prospective multicenter randomized studies with strict selection criteria and multimodal treatments seem necessary.

Immunotherapy of peritoneal carcinomatosis

Intraperitoneal immunotherapy actually is a promising concept for treatment of peritoneal carcinomatosis for several reasons: The use of specifically engineered therapy in terms of antibodies or stimulated T lymphocytes against epithelial tumour antigens offers an elegant way to attack tumours on the peritoneal surface, as peritoneal cells have a mesenchymal origin. This is especially true for modern multimodal treatment concepts, were local compartment treatment together with systemic chemotherapy and (if possible) surgical tumour removal will be individually combined.

Immunomonitoring results of a pivotal phase II/III study with the trifunctional antibody catumaxomab (anti-EpCAM x anti-CD3) in ovarian cancer patients with malignant ascites

3020

Background: Malignant ascites is a symptom of late-stage tumor disease and associated with a poor prognosis. The trifunctional antibody catumaxomab specifically binds to EpCAM+ tumor cells and redirects CD3+ T lymphocytes and FcγR I/III+ accessory cells simultaneously to the tumor site. Methods: 129 (85 catumaxomab; 44 control paracentesis) EpCAM-positive ovarian cancer patients with symptomatic malignant ascites were compared in an open-label, multicenter, randomized study for efficacy and tolerability of intraperitoneally given catumaxomab. Various in vivo and in vitro immunological and pharmacodynamic parameters were measured directly from ascites cell preparations. Results: During the course of catumaxomab treatment in the ascites fluid tumor cells dramatically decreased and leukocytes increased. Accordingly, the in vivo effector/target ratio (CD45+/EpCAM+) showed an drastic increase from a baseline of 6:1 to 10,000:1 already after the first infusion (all median). Leukocyte expansion was accompanied by in vivo upregulation of T cell activation marker CD69 on CD4+ and CD8+ T cells in the ascites fluid and an increase of IL-6 in serum at 24 hours after each infusion indicating systemic effects of catumaxomab. In vitro pharmacodynamic studies were carried out with screening samples to further validate the in vivo results. Similarly, the in vitro experiments showed efficient EpCAM+ tumor cell elimination, leukocyte expansion, drastical improvement of the effector/target ratio and activation of T cells. Additionally, a strong upregulation of activating cytokines IL-2 and IFN-γ (TH1 cytokine profile) and proliferation of CD4+, CD8+ T cells and CD11c+ accessory cells were demonstrated in the samples with catumaxomab compared to controls. Conclusions: Intraperitoneal catumaxomab treatment triggers activation and proliferation of different immune cells and leads to elimination of tumor cells within malignant ascites. These data confirm the postulated mode of action of trifunctional catumaxomab in vivo and correlate with clinical efficacy in patients with malignant ascites.

[Table: see text]

Treatment of ovarian cancer patients with malignant ascites using the trifunctional antibody catumaxomab: Results of a phase II/III study

5520

Background: Malignant ascites in ovarian carcinoma patients (pts.) is associated with a poor prognosis and reduced quality of life. Catumaxomab (anti-EpCAM × anti-CD3) is known to effectively eliminate tumor cells within ascites by simultaneously activating T cells and Fc gamma-receptor positive cells and redirecting them against the tumor. Methods: A total of 129 ovarian cancer pts. with recurrent symptomatic malignant ascites containing EpCAM+ tumor cells were enrolled in the study; 85 were randomized to treatment with catumaxomab (paracentesis plus intraperitoneal infusions of 10, 20, 50 and 150 μg for 11 days), and 44 to the control arm (paracentesis alone). The primary endpoint was puncture free survival (time to first need for paracentesis after treatment or time to death, which ever occurred first). Results: Pts. characteristics were well balanced in both arms. Median puncture free survival was 52 days for catumaxomab vs. 11 days for control (p<0.0001) whereas the median time to first need for paracentesis was 71 days vs. 11 days l (p<0.0001). There was a pronounced decrease of tumor cell load accompanied by a distinct increase of leukocyte count during catumaxomab treatment within the ascites fluid. Overall and progression free survival data suggest longer survival for catumaxomab-treated pts. compared to control. Follow-up data will be presented. The most frequent AEs were symptoms related to cytokine release (pyrexia, nausea, vomiting). These were generally mild to moderate in intensity, and fully reversible. Transient increases in liver enzymes and bilirubin, and transient WBC abnormalities such as leukocytosis, neutrophilia and a decrease in peripheral lymphocyte were regularly observed as abnormal laboratory values but rarely considered clinically significant. Conclusions: Intraperitoneal therapy with catumaxomab resulted in a significant and clinically relevant improvement of puncture-free survival time, tumor cell load, and time to first need for puncture compared to the control group of best available treatment. The safety profile reflects catumaxomabs mode of action and reveals a low and acceptable toxicity.

No significant financial relationships to disclose.

Efficacy of intraperitoneal treatment with the trifunctional antibody catumaxomab in patients with GI-tract cancer and peritoneal carcinomatosis: A matched-pair analysis

2544

Background: Peritoneal carcinomatosis (PC) due to GI-tract cancer is an advanced tumor stage with poor survival. At present, no standard therapy has been recommended, as chemotherapy and surgery showed only limited efficacy in affected patients. When applied intraperitoneally (i.p.), the trifunctional antibody catumaxomab could be shown to destroy intraperitoneal tumor cells in patients with malignant ascites due to ovarian cancer. While binding simultaneously to EpCAM (on tumor cells), CD3 (T cells) and, via the Fc region, to Fc gamma receptor 1 and 3 on accessory cells, it induces a complex immunoreaction against epithelial tumor cells. The aim of this study was to investigate clinical efficacy of i.p. catumaxomab therapy in patients with PC compared to a matched control group. Methods: Between 2003 and 2005, 22 patients with PC due to cancer of colon (n=10), stomach (8), pancreas (3) and CUP (1) received treatment with catumaxomab within a phase I study. Treatment consisted of 3 to 4 i.p. applications (10–200 μg) of escalating catumaxomab doses. The survival was compared with patients receiving conventional therapies in a matched-pair analysis regarding sex, age, tumor surgery, chemotherapy, and extent of PC. Patients with existing ileus and clinically significant ascites were not included. Results: Follow up of patients receiving catumaxomab showed a median survival of 12.2 months (range 2–34) after first diagnosis of peritoneal carcinomatosis vs. 9.7 months (range 1–40) in patients with conventional treatment (p=0.005; log-rank). These data will be updated at presentation. Conclusion: Intraperitoneal treatment with the trifunctional antibody catumaxomab may be an attractive option for treatment of patients with peritoneal carcinomatosis due to GI-tract cancer. The convincing results have to be further investigated in clinical phase II/III trials.

[Table: see text]

[Laparoscopic incisional hernia repair -- an alternative to the conventional procedure?]

INTRODUCTION

Tension-free incisional hernia repair using alloplastic material increasingly replaces conventional repair techniques. The aim of the present study was to evaluate the early and long-term complications as well as patients' satisfaction.

METHODS

Laparoscopic hernia repair with intraperitoneal mesh implantation (PTFE) was performed on 28 patients at the Klinikum Grosshadern between 2000 and 2003 (16 males, 12 females, average age 61.2). Intra- and postoperative complications were registered retrospectively. In addition, 25 patients were evaluated for recurrence, postoperative pain and patient contentment (median follow-up 383 days).

RESULTS

A low complication rate was observed in our patient collective. One trocar bleeding occurred. 2 patients presented with wound hematoma. The recurrence rate was 8 % (2/25). 60 % of the patients were free of pain postoperatively. 88 % would once again choose the laparoscopic approach for incisional hernia repair.

DISCUSSION

The laparoscopic technique was associated with a low recurrence rate, a small rate of wound infections and high patient comfort. Thus, the laparoscopic approach for mesh implantation appears to be a safe and effective method for the treatment of incisional hernias. The efficiency of laparoscopic intraperitoneal mesh implantation, however, should be evaluated within a prospectively randomized multicenter trial.

Rifampin and Triclosan but not silver is effective in preventing bacterial infection of vascular dacron graft material

OBJECTIVES

To evaluate the efficacy of silver- or Triclosan-coated prosthetic material compared to Rifampin bonded Dacron concerning their resistance to infection following subcutaneous implantation and contamination with Staphylococcus aureus.

DESIGN

Animal experimental study in mice.

MATERIAL AND METHODS

Thirty-six C3H/HcN mice (Charles River Lab., Sulzfeld, Germany) with a weight between 24 and 27 g were randomised into six groups counting six animals each. Group I: control, gel-sealed dacron graft, group II: gel-sealed dacron graft and local contamination, group III: Intergard-Silver-prosthesis and contamination, group IV: silver/gel-sealed dacron prosthesis (test graft) and contamination, group V: Rifampin-bonded gel-sealed graft and contamination, group VI: Triclosan/collagen-coated dacron graft and contamination. Dacron graft material 0.8x1 cm was subcutaneously implanted in mice. Local contamination with 2x10(7)/0.2 ml S. aureus ATCC 25923 was carried out in groups II to VI. On day 14 the animals were killed and the grafts were explanted. The microscopic, histologic and microbiological evaluation of the graft material and the perigraft tissue was performed.

RESULTS

In control group I no case of infection was detected. In group II, 6 of 6 animals showed infection. In group III (Intergard-Silver) and group IV (silver/gel-test graft) were 6 of 6, in group V (Rifampin) only 1 of 6 grafts and in group VI (Triclosan) 4 of 6 grafts were infected. The difference between the low rate of infection in group V (Rifampin) in comparison to the completely infected groups III and IV (Silver) as well as the control group II was significant. Treatment of grafts with Triclosan could prevent infection only in 1/3 of the cases in group IV.

CONCLUSION

Silver coating failed to prevent graft infection material. A potential antimicrobial property was evident for Triclosan whereas Rifampin-bonded grafts exhibit a significantly reduced infection rate. Thus, silver-coated vascular grafts cannot ensure protection from vascular graft infection.

[Experimental examination concerning the efficacy of silver-coated Dacron prostheses in vascular graft infections following subcutaneous implantation in a standardized infection model]

It was the aim of the study to examine the efficacy of silver coated prostheses in comparison to Rifampin in impregnated prostheses in the prevention of vascular graft infections.

MATERIAL AND METHODS

24 C3H/HcN mice with a bodyweight between 24 and 27 grams were assigned to four different groups. GROUP I: control gel-sealed Dacron graft (Uni-Graft DV) (6), GROUP II: gel-sealed Dacron graft (Uni-Graft DV) contaminated locally with 2 x 10(7) CFU/1.2 ml Staphylococcus aureus ATCC 25923 (6), GROUP III: silver prosthesis (Intergard Silver) contaminated locally with 2 x 10(7) CFU/0.2 ml Staphylococcus aureus ATCC 25923 (6), GROUP IV: Rifampin impregnated prosthesis contaminated locally with 2 x 10(7) CFU/0.2 ml Staphylococcus aureus ATCC 25923 (6). 14 days after primary operation all animals were euthanized and the grafts harvested. Specimens were examined for signs of infections by histology and microbiology.

RESULTS

At termination of the trial on day 14 none of the grafts of group I were contaminated. 6 out of 6 grafts in group II, 6 out of 6 grafts in group III and 1 out of 6 grafts in group IV presented with infected grafts. The use of antimicrobial Rifampin could significantly prevent infection after bacterial challenge in group IV.

CONCLUSION

The silver protected prosthesis (Intergard Silver) seems to be not effective in protecting vascular infection in vivo. However, the Rifampin group showed excellent results. In conclusion Rifampin bonded gelatin-sealed Dacron grafts are significantly more resistant to bacteremic infection than are silver/collagen-coated Dacron grafts.

[Minimal residual disease in solid cancer. Prognostic value and therapeutic consequences]

Minimal residual disease (MRD) is one of the issues in solid carcinomas which is still discussed controversially as to its prognostic value and therapeutic implications. In the past, the evidence for MRD was especially given by immunocytochemistry for epithelial cytokeratin markers which were able to detect single disseminated tumor cells within the mesenchymal background of the bone marrow at sufficient sensitivity and specificity. However, for the perioperative detection of disseminated tumor cells, numerous studies have given controversial results regarding the prognostic relevance of these cells. Some other studies investigating the postoperative development of disseminated tumor cells in the bone marrow after curative tumor resection observed substantial changes in status over time, suggesting that microenvironment interactions and phenotypic characteristics of these cells rather than the mere evidence of MRD will be able to indicate the stage of systemic disease which is of metastatic and prognostic relevance. Currently, new molecular biology techniques are applied to achieve the objective of MRD phenotyping which has good chances of providing new models for a new molecular tumor staging. Based on this development, targeting biologically relevant disseminated tumor cells will most likely become an important issue in carcinoma therapy, and first therapeutic studies are under way. However, at the present time, the mere screening for disseminated tumor cells must still be seen as a very helpful diagnostic tool for monitoring MRD especially in the setting of follow-up, rather than being able to be a key essential in therapeutic applications.

[Experimental study of antiseptic (tauroline, taurolidine) and antibiotic (sulmycin implant) drugs in vascular prosthesis infections in a standardized infection model]

It was the aim to examine whether local application of antiseptic and antibiotic substances is an effective treatment of vascular graft infection.

MATERIAL AND METHODS

19 pigs with a bodyweight between 20 and 30 kg were assigned to three different groups. Group I: control (6), group II: local treatment with Sulmycin implant, group (6) III: local treatment with Taurolin (Taurolidine) (7). An unprotected vascular graft was inserted in the right femoral artery of all pigs. After finishing the proximal and distal anastomosis and prior to closure of the incision, the vascular grafts were contaminated locally with 2 x 10(7) CFU/ml Staphylococcus aureus ATCC 29213. Seven days later all animals received another unprotected vascular prosthesis with or without additional treatment according to groups I, II, III. 28 days after primary operation the animals were euthanized and the grafts harvested. The specimens were examined for signs of infection by histology and microbiology.

RESULTS

After the primary operation all animals presented with infected vascular prosthesis. At termination of the trial on day 28 all grafts of group I were contaminated, 5 out of 6 grafts in group II, and 5 out of 7 in group III presented with infected grafts. There was no significant statistical difference between the groups. Infection could not be prevented by the antimicrobial agents used. The primary infecting organism Staphylococcus aureus, however, was eliminated in all cases.

CONCLUSIONS

Both antimicrobial substances examined were not effective in the treatment of vascular graft infection, but might be used as adjuvant therapy of vascular graft infection, whereby Sulmycin implant seems to be more effective regarding the incorporation of the prosthesis.

[The value of blood transfusion in tumor surgery. Experiences from randomized trials]

Since the first publication by Tartter in 1982 [3] multiple studies were performed concerning the association between blood transfusion and outcome in surgical oncology. The hypothesis was that blood transfusion-associated immunosuppression influences postoperative infection rates and long-term prognosis. Due to the fact that most of these studies were uncontrolled observational the decisive question about the causal relationship could not be answered so long. In randomized studies different methodological approaches were performed. Jeekel from Rotterdam and our group tried to control the allogeneic transfusion-associated immunosuppression by use of autologous transfusions. We found in our monocentric study with a very homogenous study population a significantly reduced infection rate in the autologous blood group which was not observed in the multicentric Dutch trial. The second approach was chosen by Jensen from Denmark and van de Velde from the Netherlands. They used leucocyte-depletion to create a less immunosuppressive blood product, which was then randomized and compared with conventional allogeneic transfusions. Whereas the monocentric Dutch study showed a significant effect in the pilot study and also in the later larger confirmational study, again this was not found in the multicentric Dutch trial. Concerning the association between prognosis and transfusion the results of two randomized studies are available. The multicentric study from Jeekel from Rotterdam and our monocentric study found also in this endpoint different results. Whereas in our study allogeneic transfusions were an independent risk factor demonstrated in the intention-to-treat comparison by a clear trend (p = 0.067), this could not be detected in the multicentric Dutch study. In conclusion, the results from actually available randomized studies are not compulsive. Whereas the homogeneous monocentric studies showed a significant transfusion effect for the postoperative infection rate and also for long-term prognosis, this could not be verified in two multicentric trials. Also the cumulative meta-analyses are not able to answer the decisive question concerning the causal relationship between transfusion and long-term prognosis. Therefore new and innovative study designs are mandatory.

The prevention and treatment of vascular graft infection with a Triclosan (Irgasan)-bonded Dacron graft: an experimental study in the pig

OBJECTIVES

to evaluate the role of Triclosan (Irgasan(R)) in the prevention of prosthetic graft infection.

MATERIAL AND METHODS

fifty-one pigs were assigned randomly to six groups. Group I (graft) and II (graft and Triclosan) were control groups. Groups III (graft) and IV (grafts and Triclosan) were contaminated with 2 x 10(7)CFU/ml S. aureus. Groups V (graft) and VI (graft and Triclosan) were intraoperatively contaminated with 2 x 10(7)CFU/ml S. aureus and reoperated on after 7 days. Remaining animals were sacrificed on day 28. The end point of the investigation was vascular graft infection, defined as the bacteriological and/or histological proof of infection. Results in both control groups no vascular graft infections were detected in Groups I and II. All of the group III animals presented but none of the group IV developed a graft infection (p <0.02). All of the group V animals presented and 10 of 12 animals developed a graft infection.

CONCLUSION

in this animal model Triclosan bonding appears effective in preventing prosthetic graft infection. However, the in situ replacement of Triclosan-protected grafts was not successful in the treatment of graft infection.

c-erbB-2 is of independent prognostic relevance in gastric cancer and is associated with the expression of tumor-associated protease systems

PURPOSE

The c-erbB-2 gene (encoding the protein p185) is overexpressed in diverse human cancers and has been implicated to be of prognostic value in gastric cancer. Recent studies suggest a role of p185 in tumor progression by specifically promoting the invasive capacity of tumor cells. Therefore, the present study was conducted with the following three objectives: (1) to support the prognostic value of c-erbB-2 in gastric cancer in a large prospective series using a monoclonal antibody and a highly sensitive immunohistochemical method; (2) to determine the association of c-erbB-2 expression with the expression of invasion-related genes; and (3) to perform the first overall multivariate analysis including c-erbB-2 and the invasion-related tumor-associated protease systems.

PATIENTS AND METHODS

In a consecutive prospective series of 203 gastric cancer patients (median follow-up, 42 months), expression of c-erbB-2 and a panel of tumor-associated proteases and inhibitors by tumor cells were evaluated semiquantitatively (score 0 to 3) and analyzed for correlation (chi(2) test, Bonferroni-corrected). Kaplan-Meier survival analysis and multivariate Cox analysis were performed to determine the relative prognostic impact of c-erbB-2 and the invasion-related parameters.

RESULTS

Kaplan-Meier analysis (log-rank statistics) revealed a significant association of increasing expression of c-erbB-2 with shorter disease-free (P =. 0023) and overall survival (P =.0160). High amounts of p185 were significantly associated with a high expression of urokinase-type plasminogen activator (uPA) (P <.010), uPA-receptor (P =.030), type-1 plasminogen activator inhibitor (PAI) (P <.010), type-2 PAI (P =.021), cathepsin D (P =.036), matrix metalloproteinase-2 (P =. 024), alpha-1-antichymotrypsin (P =.025), and alpha-2-macroglobulin (P =.017). Multivariate analysis considering these proteases/protease inhibitors, in addition to alpha-1-antitrypsin, tissue plasminogen activator, plasminogen, alpha-2-antiplasmin, and antithrombin III, and established prognostic parameters revealed that, in addition to surgical curability, pT stage, pN stage, and PAI-1, c-erbB-2 is an independent prognostic factor for overall survival of curatively resected patients (n = 139; P =.049; relative risk, 1.54; 95% confidence interval, 1.08 to 1.67) and all patients (P =.028; relative risk 1.33; 95% CI, 1.28 to 1.38).

CONCLUSION

c-erbB-2 is confirmed as a new independent, functional prognostic parameter for overall survival in gastric cancer, even when a panel of invasion-related factors, including the strong prognostic parameter PAI-1, are considered. The significant correlation of p185 with several tumor-associated proteases supports the hypothesis that c-erbB-2 is a promoter of invasion and metastasis. This strongly suggests that c-erbB-2 may be a promising target for anti-invasive therapy in gastric cancer.