Evolutions in rectal cancer MRI staging and risk stratification in The Netherlands

Purpose

To analyze how the MRI reporting of rectal cancer has evolved (following guideline updates) in The Netherlands.

Methods

Retrospective analysis of 712 patients (2011–2018) from 8 teaching hospitals in The Netherlands with available original radiological staging reports that were re-evaluated by a dedicated MR expert using updated guideline criteria. Original reports were classified as “free-text,” “semi-structured,” or “template” and completeness of reporting was documented. Patients were categorized as low versus high risk, first based on the original reports (high risk = cT3-4, cN+, and/or cMRF+) and then based on the expert re-evaluations (high risk = cT3cd-4, cN+, MRF+, and/or EMVI+). Evolutions over time were studied by splitting the inclusion period in 3 equal time periods.

Results

A significant increase in template reporting was observed (from 1.6 to 17.6–29.6%; p < 0.001), along with a significant increase in the reporting of cT-substage, number of N+ and extramesorectal nodes, MRF invasion and tumor-MRF distance, EMVI, anal sphincter involvement, and tumor morphology and circumference. Expert re-evaluation changed the risk classification from high to low risk in 18.0% of cases and from low to high risk in 1.7% (total 19.7%). In the majority (17.9%) of these cases, the changed risk classification was likely (at least in part) related to use of updated guideline criteria, which mainly led to a reduction in high-risk cT-stage and nodal downstaging.

Conclusion

Updated concepts of risk stratification have increasingly been adopted, accompanied by an increase in template reporting and improved completeness of reporting. Use of updated guideline criteria resulted in considerable downstaging (of mainly high-risk cT-stage and nodal stage).

Graphic abstract

Abstract P5-14-01: Chemotherapy randomization of the EORTC 10041/ BIG 3-04 MINDACT (microarray in node-negative and 1 to 3 positive lymph node disease may avoid chemotherapy) trial

This abstract was withdrawn by the authors.

Stomal mucocutaneous dehiscence as a complication of topical negative pressure used to treat an open abdomen: a case series

Although mucocutaneous dehiscence in cases of laparostomies is rare, this complication occurred in three patients in The Netherlands (all men, 53 to 65 years old) who received topical negative pressure (TNP) therapy in the management of open abdomens. Two patients experienced anastomotic failure following colonic resection and one had iatrogenic suturing of the small bowel to the fascia. TNP therapy was initiated and stomal dehiscence occurred after 2 to 3 days, contaminating the area. All patients developed sepsis and one died. Two required numerous additional surgeries and antibiotic treatments for 6 and 8 months, respectively. The complication was believed to have occurred as a result of tension on the proximal bowel of the stoma (the bowel inside the abdomen) not due to tension on the sutures or the small part of the bowel outside the abdomen. A modified TNP procedure, consisting of careful placement of the primary dressing around the stoma using separate primary dressing flaps, has since been used without complications in one patient. With implementation of TNP increasing and because of concerns regarding its use, additional research and innovative, simple solutions to manage complex wounds such as the one presented here are needed.

The effect of laparoscopic partial fundoplication on dysphagia, esophageal and lower esophageal sphincter motility

It has been suggested that dysphagia is less common after partial versus complete fundoplication. The mechanisms contributing to postoperative dysphagia remain unclear. The objective of the present prospective study was to investigate esophageal motility and the prevalence of dysphagia in patients who have undergone laparoscopic partial fundoplication. Symptoms, lower esophageal sphincter (LES) characteristics and esophageal body motility were evaluated prospectively in 62 patients before and after laparoscopic partial fundoplication: 33 women and 29 men with a mean age of 44 +/- 1.5 years (range, 21-71). The patients filled in symptom questionnaires and underwent stationary and ambulatory manometry and 24-h pH-metry before and after operation. A small but significant increase in LES pressure from 14.8 +/- 0.9 to 17.8 +/- 0.8 mmHg was seen after laparoscopic partial fundoplication. Further, LES characteristics and esophageal body motility were not different post- versus preoperation. Three months after surgery, dysphagia was present in eight patients. No differences in LES characteristics or body motility were present between patients with and without dysphagia. Six months after the operation dysphagia was present in only three patients (3.2% mild and 1.6% severe dysphagia). Adequate reflux control was obtained in 85% of the patients. Laparoscopic partial fundoplication offers adequate reflux control without affecting esophageal body motility and with a very low incidence of postoperative dysphagia.

Negative pressure wound therapy to treat peri-prosthetic methicillin-resistant Staphylococcus aureus infection after incisional herniorrhaphy. A case study and literature review

The preferred treatment for incisional hernias occurring post laparotomy involves use of prosthetic mesh. If this mesh becomes infected, it may have to be removed to achieve wound healing. A patient with a methicillin-resistant Staphylococcus aureus-infected prosthetic mesh received negative pressure wound therapy to help facilitate healing without removing the prosthetic mesh applied to manage his hernia. After almost 4 weeks of treatment, the wound was closed secondarily. The literature contains many case studies about the use of NPWT for a variety of wounds but information about its safety and effectiveness for managing methicillin-resistant Staphylococcus aureus-infected prosthetic mesh is limited. The results of this case study add to the evidence that controlled clinical studies are warranted.

Gastric emptying and vagus nerve function after laparoscopic partial fundoplication

OBJECTIVE

To establish the relation between vagus nerve dysfunction, gastric emptying, and antireflux surgery.

SUMMARY BACKGROUND DATA

Delayed gastric emptying occurs in up to 40% of reflux patients. After antireflux surgery, gastric emptying becomes normal or is even accelerated. Occasionally, severe gastric stasis is found and is associated with a negative outcome of the antireflux procedure. It has been suggested that injury to the vagus nerve could be the cause of this delayed emptying.

METHODS

We evaluated in a prospective study gastric emptying of solids and vagus nerve function (pancreatic polypeptide response to hypoglycemia) before and after surgery in 41 patients (22 women; age 43 +/- 1.6 years) who underwent laparoscopic hemifundoplication.

RESULTS

All patients had relief of reflux symptoms varying from adequate (n = 8) to complete relief (n = 33). Gastric emptying of solids increased significantly (P < 0.001) after operation: lag phase from 19 +/- 2 to 10 +/- 1 minute, emptying rate (%/h) from 37 +/- 2 to 48 +/- 5 and half emptying time from 110 +/- 8 to 81 +/- 4 minutes. Gastric emptying improved to a similar extent in patients with delayed and normal preoperative gastric emptying. Postoperative signs of vagus nerve damage (PP peak < 47pmol/L) were present in 4 patients (10%). In these 4 patients gastric emptying both before and after operation did not differ from patients with normal vagus nerve function. In fact, none of the 41 patients had severely delayed emptying after laparoscopic hemifundoplication.

CONCLUSIONS

Laparoscopic hemifundoplication affects vagus nerve integrity in 10% of patients, but this does not lead to a delay in gastric emptying. In fact, gastric emptying improved significantly after fundoplication.

Function of the proximal stomach after partial versus complete laparoscopic fundoplication

OBJECTIVES

After antireflux surgery, more than 30% of patients develop dyspeptic symptoms such as fullness and early satiety. We have previously shown that these symptoms are related to fundoplication-induced changes in proximal gastric motor and sensory function, especially impaired postprandial relaxation. We hypothesize that impaired fundus relaxation may be more pronounced after complete versus partial fundoplication.

METHODS

Fasting and postprandial proximal gastric motor and sensory function were measured with an electronic barostat in patients after laparoscopic partial (n = 14) and complete (n = 14) fundoplication, in gastroesophageal reflux disease (GERD) patients (n = 12), and in healthy control subjects (n = 15). Gastric emptying and vagus nerve function tests were performed in all patients.

RESULTS

Minimal distending pressure (MDP) and proximal gastric compliance were not significantly different among patients after antireflux surgery, GERD patients, and healthy controls. Maximal postprandial fundus relaxation was significantly (p < 0.01) reduced in patients after partial (267 +/- 32 ml) and complete (294 +/- 34 ml) fundoplication compared with GERD patients (448 +/- 30 ml) and healthy controls (409 +/- 25 ml). Sensations of fullness were not significantly different between patients with partial and complete fundoplication. There was a significant positive correlation between the postoperative duration and the degree of postprandial fundus relaxation (r = 0.67; p < 0.001).

CONCLUSIONS

Both after complete and after partial fundoplication, proximal gastric motor function is affected, with impaired postprandial relaxation and increased sensation of fullness. These alterations are not related to the type of fundoplication but correlate significantly with the duration of the postoperative period.

Effect of laparoscopic partial fundoplication on reflux mechanisms

OBJECTIVES

Transient lower esophageal sphincter relaxations (TLESRs) are the main mechanism causing gastroesophageal reflux. Since 1994 we have performed laparoscopic partial instead of complete fundoplication as standard surgical treatment for therapy resistant reflux disease to minimize postoperative dysphagia. To better understand the management of gastroesophageal reflux, we conducted a prospective study of the effects of laparoscopic partial fundoplication on TLESRs and other reflux mechanisms.

METHODS

From 1994 to 1999, 65 patients underwent laparoscopic partial fundoplication (180-200 degrees) and 28 of these patients (16 female, 12 male, mean age 43 +/- 2 yr [range, 26-66 yr]) agreed to participate in this prospective study on reflux mechanisms. Before and 6 months after surgery, all patients were evaluated by simultaneous recording of pH and lower esophageal sphincter characteristics, using sleeve manometry.

RESULTS

After partial fundoplication basal LES pressure increased significantly (p < 0.05), from 14.3 +/- 1.2 mm Hg to 17.8 +/- 1 mm Hg. Partial fundoplication significantly (p < 0.05) decreased the number of TLESRs, from 3.4 +/- 0.8 to 1.6 +/- 0.3 per hour in the fasting period, and from 4.7 +/- 0.5 to 1.9 +/- 0.3 per hour postprandially. The percentage of TLESRs associated with reflux also decreased significantly (p < 0.05), from 45 +/- 7% to 27 +/- 6% after operation. The number of reflux episodes decreased significantly (p < 0.05), from 4.1 +/- 0.7 to 1.3 +/- 0.3 per hour postoperatively. The majority of these episodes were associated with TLESRs: 57% and 46%, pre- and postoperatively, respectively.

CONCLUSIONS

Laparoscopic partial fundoplication significantly increased fasting and postprandial LES pressure and significantly decreased TLESR frequency. This resulted in a significant reduction in esophageal acid exposure, with preservation of postprandial LES characteristics.