The prognostic value of a geriatric risk score for older patients undergoing emergency surgery of colorectal cancer: A retrospective cohort study

INTRODUCTION

Emergency surgery of colorectal cancer is associated with high mortality rates in older patients. We investigated whether information on four geriatric domains has prognostic value for 30-day mortality and postoperative morbidity including severe complications.

MATERIALS AND METHODS

All consecutive patients aged 70 years or older who underwent emergency colorectal cancer surgery in six Dutch hospitals (2014-2017) were studied. Presence of geriatric risk factors was scored prior to surgery as either 0 (risk absent) or 1 (risk present) in each of four geriatric domains and summed up to calculate a sumscore with a value between 0 and 4. In addition, we separately investigated the use of a mobility aid. Primary outcome was 30-day mortality. Secondary outcomes were any postoperative complications and severe complications. Multivariable logistic regression model was used to evaluate the sumscore and outcomes.

RESULTS

Two hundred seven patients were included. Median age was 79.4 years. One hundred seventy-five patients (76%) presented with obstruction, 22 (11%) with a perforation, and 17 (8%) with severe anemia. Mortality rates were 2.9%, 13.6%, and 29.6% for patients with a sumscore of 0, 1-2, and 3-4 respectively, with odds ratio (OR) 4.8 [95% confidence interval (CI) 1.03-22.95] and OR 10.6 [95% CI 1.99-56.34] for a sumscore of 1-2 and 3-4 respectively. Use of a mobility aid was associated with increased mortality OR 8.0 [95% CI 2.74-23.43] and severe complications OR 2.31 [95% CI 1.17-4.55].

DISCUSSION

This geriatric sumscore and the use of a mobility aid have strong association with 30-day mortality after emergency surgery of colorectal cancer. This could provide better insight into surgical risk and help select high-risk patients for alternative strategies.

Consensus on technical procedures for simulation-based training in thoracic surgery: an international needs assessment

OBJECTIVE

To identify and prioritize technical procedures for simulation-based training to be integrated into the thoracic surgical curriculum.

METHODS

A three-round Delphi survey was conducted from February 2022 to June 2022 among 34 key opinion leaders in thoracic surgery from 14 countries worldwide. The first round was a brainstorming phase to identify technical procedures that a newly qualified thoracic surgeon should be able to perform. All the suggested procedures were categorized, qualitatively analyzed, and sent to the second round. The second round investigated: the frequency of the identified procedure at each institution, the number of thoracic surgeons that should be able to perform these procedures, the degree of risk to the patient if the procedure is performed by a non-competent thoracic surgeon, and the feasibility of simulation-based education. In the third round, elimination, and re-ranking of the procedures from the second round were performed.

RESULTS

Response rates in the three iterative rounds were 80% (28 out of 34), 89% (25 out of 28) and 100% (25 out of 25) in the first, second, and third round, respectively. Seventeen technical procedures were included for simulation-based training in the final prioritized list. The top five procedures were VATS lobectomy, VATS segmentectomy, VATS mediastinal lymph node dissection, diagnostic flexible bronchoscopy, and RATS port placement, RATS docking and undocking.

CONCLUSION

The prioritized list of procedures represents a consensus of key thoracic surgeons worldwide. These procedures are suitable for simulation-based training and should be integrated in the thoracic surgical curriculum.

Laparoscopic peritoneal lavage versus sigmoidectomy for perforated diverticulitis with purulent peritonitis: three-year follow-up of the randomised LOLA trial

Background

This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.

Methods

Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.

Results

Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.

Conclusion

Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.

Graphical abstract

The Prognostic Value of a Geriatric Risk Score for Older Patients with Colorectal Cancer

INTRODUCTION

VMS is a Dutch risk assessment tool for hospitalized older adults that includes a short evaluation of four geriatric domains: risk for delirium, risk for undernutrition, risk for physical impairments, and fall risk. We investigated whether the information derived from this tool has prognostic value for outcomes of colorectal surgery.

METHODS

All consecutive patients over age 70 years who underwent elective colorectal cancer surgery in three Dutch hospitals (2014-2016) were studied. The presence of risk was scored prior to surgery and per geriatric domain as either 0 (risk absent) or 1 (risk present). The total number of geriatric risk factors was summed. The primary outcome was long-term survival. Secondary outcomes were postoperative complications, including delirium. Cox proportional hazards models were used to evaluate the sumscore and risk factors associated with overall survival.

RESULTS

Five hundred fifty patients were included. Median age was 76.5 years, and median follow-up was 870 days. Patients with intermediate (1-2) or high (3-4) sumscore were independently associated with lower overall survival, with hazard ratio (HR) of 1.9 [95% confidence interval (CI) 1.1-3.5; p = 0.03] and 8.7 (95% CI 4.0-19.2; p < 0.001), respectively. Sumscores were also associated with postoperative complications (intermediate sumscore OR 1.8; 95% CI 1.2-2.7; high sumscore OR 2.4; 95% CI 1.02-5.5).

CONCLUSIONS

This easy-to-use geriatric sumscore has strong associations with long-term outcome and morbidity after colorectal cancer surgery. This information may be included in risk models for morbidity and mortality and can be used in shared decision-making.

Multicentre randomized clinical trial of the effect of chewing gum after abdominal surgery

Background

Postoperative ileus is a common complication of abdominal surgery, leading to patient discomfort, morbidity and prolonged postoperative length of hospital stay (LOS). Previous studies suggested that chewing gum stimulates bowel function after abdominal surgery, but were underpowered to evaluate its effect on LOS and did not include enhanced recovery after surgery (ERAS)-based perioperative care. This study evaluated whether chewing gum after elective abdominal surgery reduces LOS and time to bowel recovery in the setting of ERAS-based perioperative care.

Methods

A multicentre RCT was performed of patients over 18 years of age undergoing abdominal surgery in 12 hospitals. Standard postoperative care (control group) was compared with chewing gum three times a day for 30 min in addition to standard postoperative care. Randomization was computer-generated; allocation was concealed. The primary outcome was postoperative LOS. Secondary outcomes were time to bowel recovery and 30-day complications.

Results

Between 2011 to 2015, 1000 patients were assigned to chewing gum and 1000 to the control arm. Median LOS did not differ: 7 days in both arms (P = 0·364). Neither was any difference found in time to flatus (24 h in control group versus 23 h with chewing gum; P = 0·873) or time to defaecation (60 versus 52 h respectively; P = 0·562). The rate of 30-day complications was not significantly different either.

Conclusion

The addition of chewing gum to an ERAS postoperative care pathway after elective abdominal surgery does not reduce the LOS, time to bowel recovery or the rate of postoperative complications. Registration number: NTR2594 (Netherlands Trial Register).

Adjuvant chemotherapy for rectal cancer patients treated with preoperative (chemo)radiotherapy and total mesorectal excision: a Dutch Colorectal Cancer Group (DCCG) randomized phase III trial

BACKGROUND

The discussion on the role of adjuvant chemotherapy for rectal cancer patients treated according to current guidelines is still ongoing. A multicentre, randomized phase III trial, PROCTOR-SCRIPT, was conducted to compare adjuvant chemotherapy with observation for rectal cancer patients treated with preoperative (chemo)radiotherapy and total mesorectal excision (TME).

PATIENTS AND METHODS

The PROCTOR-SCRIPT trial recruited patients from 52 hospitals. Patients with histologically proven stage II or III rectal adenocarcinoma were randomly assigned (1:1) to observation or adjuvant chemotherapy after preoperative (chemo)radiotherapy and TME. Radiotherapy consisted of 5 × 5 Gy. Chemoradiotherapy consisted of 25 × 1.8-2 Gy combined with 5-FU-based chemotherapy. Adjuvant chemotherapy consisted of 5-FU/LV (PROCTOR) or eight courses capecitabine (SCRIPT). Randomization was based on permuted blocks of six, stratified according to centre, residual tumour, time between last irradiation and surgery, and preoperative treatment. The primary end point was overall survival.

RESULTS

Of 470 enrolled patients, 437 were eligible. The trial closed prematurely because of slow patient accrual. Patients were randomly assigned to observation (n = 221) or adjuvant chemotherapy (n = 216). After a median follow-up of 5.0 years, 5-year overall survival was 79.2% in the observation group and 80.4% in the chemotherapy group [hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.62-1.39; P = 0.73]. The HR for disease-free survival was 0.80 (95% CI 0.60-1.07; P = 0.13). Five-year cumulative incidence for locoregional recurrences was 7.8% in both groups. Five-year cumulative incidence for distant recurrences was 38.5% and 34.7%, respectively (P = 0.39).

CONCLUSION

The PROCTOR-SCRIPT trial could not demonstrate a significant benefit of adjuvant chemotherapy with fluoropyrimidine monotherapy after preoperative (chemo)radiotherapy and TME on overall survival, disease-free survival, and recurrence rate. However, this trial did not complete planned accrual.

REGISTRATION NUMBER

Dutch Colorectal Cancer group, CKTO 2003-16, ISRCTN36266738.

The DULK (Dutch leakage) and modified DULK score compared: actively seek the leak

AIM

A standardized postoperative score, the DULK (Dutch leakage) score, has been demonstrated to be a useful clinical tool in the diagnosis of anastomotic leakage. It is complicated, however, and a simplification (the modified DULK score) based on fewer parameters derived from multiple logistic regression analyses has been developed. These include clinical condition, abdominal pain not localized at the wound, C-reactive protein level and respiratory rate. The accuracy of each was compared.

METHOD

Data of all patients from five Dutch centres operated on between 16 October 2007 and 1 November 2009 with an anastomosis in the colon or rectum were entered into a prospectively maintained database.

RESULTS

In total, 782 patients were included of whom 81 (10.4%) had a clinically relevant anastomotic leakage. The DULK score gave an overall sensitivity of 97% for anastomotic leakage, overall specificity of 53%, a positive predictive value (PPV) of 16% and a negative predictive value (NPV) of 99%. The modified DULK score used clinical condition, abdominal pain not localized at the wound, C-reactive protein level and respiratory rate. With at least one parameter present, overall sensitivity was 97%, overall specificity 57%, PPV 17% and NPV 99.5%. With at least two points PPV was 41% and with three points 57%.

CONCLUSION

Both the original and modified DULK scores are useful for the early diagnosis of clinically relevant anastomotic leakage. The modified DULK score offers the benefit of fewer parameters and so can easily be used in a clinical environment to estimate the likelihood of anastomotic leakage. However, the early diagnosis of anastomotic leakage remains difficult.

Centralization of esophageal cancer surgery: does it improve clinical outcome?

Background

The volume–outcome relationship for complex surgical procedures has been extensively studied. Most studies are based on administrative data and use in-hospital mortality as the sole outcome measure. It is still unknown if concentration of these procedures leads to improvement of clinical outcome. The aim of our study was to audit the process and effect of centralizing oesophageal resections for cancer by using detailed clinical data.

Methods

From January 1990 until December 2004, 555 esophagectomies for cancer were performed in 11 hospitals in the region of the Comprehensive Cancer Center West (CCCW); 342 patients were operated on before and 213 patients after the introduction of a centralization project. In this project patients were referred to the hospitals which showed superior outcomes in a regional audit. In this audit patient, tumor, and operative details as well as clinical outcome were compared between hospitals. The outcome of both cohorts, patients operated on before and after the start of the project, were evaluated.

Results

Despite the more severe comorbidity of the patient group, outcome improved after centralizing esophageal resections. Along with a reduction in postoperative morbidity and length of stay, mortality fell from 12% to 4% and survival improved significantly (P = 0.001). The hospitals with the highest procedural volume showed the biggest improvement in outcome.

Conclusion

Volume is an important determinant of quality of care in esophageal cancer surgery. Referral of patients with esophageal cancer to surgical units with adequate experience and superior outcomes (outcome-based referral) improves quality of care.

High-volume versus low-volume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data

Background

Most studies addressing the volume–outcome relationship in complex surgical procedures use hospital mortality as the sole outcome measure and are rarely based on detailed clinical data. The lack of reliable information about comorbidities and tumor stages makes the conclusions of these studies debatable.

The purpose of this study was to compare outcomes for esophageal resections for cancer in low- versus high-volume hospitals, using an extensive set of variables concerning case-mix and outcome measures, including long-term survival.

Methods

Clinical data, from 903 esophageal resections performed between January 1990 and December 1999, were retrieved from the original patients’ files. Three hundred and forty-two patients were operated on in 11 low-volume hospitals (<7 resections/year) and 561 in a single high-volume center.

Results

Mortality and morbidity rates were significantly lower in the high-volume center, which had an in-hospital mortality of 5 vs 13% (P < .001). On multivariate analysis, hospital volume, but also the presence of comorbidity proved to be strong prognostic factors predicting in-hospital mortality (ORs 3.05 and 2.34). For stage I and II disease, there was a significantly better 5-year survival in the high-volume center. (P = .04).

Conclusions

Hospital volume and comorbidity patterns are important determinants of outcome in esophageal cancer surgery. Strong clinical endpoints such as in-hospital mortality and survival can be used as performance indicators, only if they are joined by reliable case-mix information.

[Diversity of complaints in manifesting carcinoma of the gallbladder]

A man of 47 years with hypercholesterolaemia had no complaints but the family doctor suspected cholecystolithiasis because of abnormal results of the haematological study. Ultrasonography of the abdomen revealed a polyp in the gallbladder. The patient underwent laparoscopic cholecystectomy. Pathological examination revealed that the polyp was a carcinoma. No evidence for a recurrence was found during a return visit after 2 years. A woman of 74 years was admitted to the hospital due to persistent rectal bleeding. She had fever, loss of appetite, nausea and weight loss. A bleeding duodenal ulcer was identified during gastroduodenoscopy. Laparotomy was performed due to haemodynamic instability. During the operation an abnormal gallbladder was found with infiltration in and perforation of the duodenum. The gallbladder was resected and the perforation of the duodenum was sutured. Pathological examination revealed carcinoma of the gallbladder. A palliative policy was adhered to; the patient died 1 month later. Carcinoma ofthe gallbladder is an uncommon but highly fatal malignancy. Several risk factors have been identified and treatment is primarily surgical.

Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients--a Dutch colorectal cancer group study

PURPOSE

Preoperative short-term radiotherapy improves local control in patients treated with total mesorectal excision (TME). This study was performed to assess the presence and magnitude of long-term side effects of preoperative 5 x 5 Gy radiotherapy and TME. Also, hospital treatment was recorded for diseases possibly related to late side effects of rectal cancer treatment.

PATIENTS AND METHODS

Long-term morbidity was assessed in patients from the prospective randomized TME trial, which investigated the efficacy of 5 x 5 Gy before TME surgery for mobile rectal cancer. Dutch patients without recurrent disease were sent a questionnaire.

RESULTS

Results were obtained from 597 patients, with a median follow-up of 5.1 years. Stoma function, urinary function, and hospital treatment rates did not differ significantly between the treatment arms. However, irradiated patients, compared with nonirradiated patients, reported increased rates of fecal incontinence (62% v 38%, respectively; P < .001), pad wearing as a result of incontinence (56% v 33%, respectively; P < .001), anal blood loss (11% v 3%, respectively; P = .004), and mucus loss (27% v 15%, respectively; P = .005). Satisfaction with bowel function was significantly lower and the impact of bowel dysfunction on daily activities was greater in irradiated patients compared with patients who underwent TME alone.

CONCLUSION

Although preoperative short-term radiotherapy for rectal cancer results in increased local control, there is more long-term bowel dysfunction in irradiated patients than in patients who undergo TME alone. Rectal cancer patients should be informed on late morbidity of both radiotherapy and TME. Future strategies should be aimed at selecting patients for radiotherapy who are at high risk for local failure.

Risk factors for anastomotic failure after total mesorectal excision of rectal cancer

BACKGROUND

Anastomotic leakage is a major complication of rectal cancer surgery. The aim of this study was to investigate risk factors associated with symptomatic anastomotic leakage after total mesorectal excision (TME).

METHODS

Between 1996 and 1999, patients with operable rectal cancer were randomized to receive short-term radiotherapy followed by TME or to undergo TME alone. Eligible Dutch patients who underwent an anterior resection (924 patients) were studied retrospectively.

RESULTS

Symptomatic anastomotic leakage occurred in 107 patients (11.6 per cent). Pelvic drainage and the use of a defunctioning stoma were significantly associated with a lower anastomotic failure rate. A significant correlation between the absence of a stoma and anastomotic dehiscence was observed in both men and women, for both distal and proximal rectal tumours. In patients with anastomotic failure, the presence of pelvic drains and a covering stoma were both related to a lower requirement for surgical reintervention.

CONCLUSION

Placement of one or more pelvic drains after TME may limit the consequences of anastomotic failure. The clinical decision to construct a defunctioning stoma is supported by this study.

[Diagnostic image (221). A female multitrauma patient]

A 39-year-old woman who was involved in a high-energy trauma suffered a haematopneumothorax, subcutaneous emphysema, multiple fractures including a fracture of corpus Tx, and air in the epidural space.

Patterns of lymphatic spread in rectal cancer. A topographical analysis on lymph node metastases

The presence of lymph node (LN) metastases is the most important prognostic factor in rectal cancer. The exact LN status can only be known when an extended lymph node dissection (LND) has been performed, a process not routinely performed. If the likelihood of LN metastases can be more accurately assessed preoperatively, then an optimal multimodality treatment plan can be established. 605 patients with primary rectal cancer operated upon with wide LND (D3 level) were analysed for LN metastases combining topographical localisation and morphological features of the tumour. More distal rectal tumours tend to more LN metastases and more lateral lymphatic spread. Tumours >or=3 cm show more LN metastases compared with those smaller than 3 cm. Depth of bowel wall invasion is strongly related to the presence of LN metastases. The peritoneal reflection has no discriminating role in the mode of spread. Intra-operative assessment by the surgeon for presence of LN metastases is not reliable. When localisation, depth of bowel wall invasion and diameter of a rectal tumour are known, a likelihood of LN metastases can be assessed pre-operatively, not intra-operatively.

Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial

PURPOSE

Total mesorectal excision (TME) surgery in the treatment of rectal cancer has been shown to result in a reduction in the number of local recurrences in retrospective studies. Reports on improved local control after preoperative, hypofractionated radiotherapy (RT) have led to the introduction of a prospective randomized multicenter trial, in which the effect of TME surgery with or without preoperative RT were evaluated. Any benefit in regard to a reduced local recurrence rate and possible improved survival must be weighed against potential adverse effects in both the short-term and the long-term. The present study was undertaken to assess the acute side effects of short-term, preoperative RT in rectal cancer patients and to study the influence of five doses of 5 Gy on surgical parameters, postoperative morbidity and mortality in patients randomized in the Dutch TME trial.

PATIENTS AND METHODS

We analyzed 1,530 Dutch patients entered onto a prospective randomized trial, comparing preoperative RT with five doses of 5 Gy followed by TME surgery with TME surgery alone, of which 1,414 patients were assessable. Toxicity from RT, surgery characteristics, and postoperative complications and mortality were compared.

RESULTS

Toxicity during RT hardly occurred. Irradiated patients had 100 mL more blood loss during the operation (P <.001) and showed more perineal complications (P =.008) in cases of abdominoperineal resection. The total number of complications was slightly increased in the irradiated group (P =.008). No difference was observed in postoperative mortality (4.0% v 3.3%) or in the number of reinterventions.

CONCLUSION

Preoperative hypofractionated RT is a safe procedure in patients treated with TME surgery, despite a slight increase in complications when compared with TME surgery only.

Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial

PURPOSE

Total mesorectal excision (TME) surgery in the treatment of rectal cancer has been shown to result in a reduction in the number of local recurrences in retrospective studies. Reports on improved local control after preoperative, hypofractionated radiotherapy (RT) have led to the introduction of a prospective randomized multicenter trial, in which the effect of TME surgery with or without preoperative RT were evaluated. Any benefit in regard to a reduced local recurrence rate and possible improved survival must be weighed against potential adverse effects in both the short-term and the long-term. The present study was undertaken to assess the acute side effects of short-term, preoperative RT in rectal cancer patients and to study the influence of five doses of 5 Gy on surgical parameters, postoperative morbidity and mortality in patients randomized in the Dutch TME trial.

PATIENTS AND METHODS

We analyzed 1,530 Dutch patients entered onto a prospective randomized trial, comparing preoperative RT with five doses of 5 Gy followed by TME surgery with TME surgery alone, of which 1,414 patients were assessable. Toxicity from RT, surgery characteristics, and postoperative complications and mortality were compared.

RESULTS

Toxicity during RT hardly occurred. Irradiated patients had 100 mL more blood loss during the operation (P <.001) and showed more perineal complications (P =.008) in cases of abdominoperineal resection. The total number of complications was slightly increased in the irradiated group (P =.008). No difference was observed in postoperative mortality (4.0% v 3.3%) or in the number of reinterventions.

CONCLUSION

Preoperative hypofractionated RT is a safe procedure in patients treated with TME surgery, despite a slight increase in complications when compared with TME surgery only.

Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer

BACKGROUND

Short-term preoperative radiotherapy and total mesorectal excision have each been shown to improve local control of disease in patients with resectable rectal cancer. We conducted a multicenter, randomized trial to determine whether the addition of preoperative radiotherapy increases the benefit of total mesorectal excision.

METHODS

We randomly assigned 1861 patients with resectable rectal cancer either to preoperative radiotherapy (5 Gy on each of five days) followed by total mesorectal excision (924 patients) or to total mesorectal excision alone (937 patients). The trial was conducted with the use of standardization and quality-control measures to ensure the consistency of the radiotherapy, surgery, and pathological techniques.

RESULTS

Of the 1861 patients randomly assigned to one of the two treatment groups, 1805 were eligible to participate. The overall rate of survival at two years among the eligible patients was 82.0 percent in the group assigned to both radiotherapy and surgery and 81.8 percent in the group assigned to surgery alone (P=0.84). Among the 1748 patients who underwent a macroscopically complete local resection, the rate of local recurrence at two years was 5.3 percent. The rate of local recurrence at two years was 2.4 percent in the radiotherapy-plus-surgery group and 8.2 percent in the surgery-only group (P<0.001).

CONCLUSIONS

Short-term preoperative radiotherapy reduces the risk of local recurrence in patients with rectal cancer who undergo a standardized total mesorectal excision.

A prospective study on radical and nerve-preserving surgery for rectal cancer in the Netherlands

INTRODUCTION

Preservation of the pelvic autonomic nerves is thought to lower bladder and sexual dysfunction after rectal cancer surgery. A prospective study was undertaken in a Dutch population to evaluate functional outcome, local recurrence and survival of a Japanese operative technique combining nerve preservation with radical tumour resection.

METHODS

Forty-seven patients were operated upon by a Japanese surgeon. Voiding and sexual function were prospectively analysed using questionnaires. Two-year follow-up on urinary function was complete in 73%, and 2-year follow-up of male sexual function was complete in 77%. Median follow-up for survival and recurrence was 42 months and was complete in all patients.

RESULTS

Five patients (19%) developed minor urinary incontinence in the period between 1 and 2 years of follow-up. Six patients (22%) had a persistently elevated frequency of voiding. There was no statistically significant correlation between the extent of nerve preservation and the reported minor voiding dysfunctions. None of the patients reported major incontinence of urine. Impotence was related to sacrifice of the inferior hypogastric plexus and ejaculatory dysfunction was related to sacrifice of the superior hypogastric plexus. Sexual function did not change during follow-up. Of 42 curatively-operated patients, three (7.1%) developed local recurrence. Sixty-seven per cent were overall free of recurrence. Disease-free survival was 57%.

CONCLUSIONS

Preservation of the pelvic autonomic nerves minimizes bladder dysfunction after rectal cancer surgery. The preservation of the total autonomic nerve system is essential for normal sexual function in male patients. Nerve preservation does not compromise radicality in mesorectal excision. Mesorectal excision should involve identification and preservation of the pelvic autonomic nerves.

Influence of abdominal-wound closure technique on complications after surgery: a randomised study

BACKGROUND

Wound complications that occur after closure of midline laparotomy remain challenging. A new continuous double-loop closure (CDLC) technique was developed to avoid wound rupture through resistance to high intra-abdominal pressure and continued approximation of wound edges. We investigated the efficacy of this technique.

METHODS

We randomly assigned 390 patients undergoing midline laparotomy-wound closure with the commonly used continuous running suture (CRS) technique (n=204) or with the CDLC technique (n=186). We assessed the influence of closure technique on the rate of wound and other complications, with emphasis on wound dehiscence, pulmonary complications, and death.

FINDINGS

The rate of wound complications did not differ significantly between groups. Pulmonary complications were seen in 11 patients (5.4%) in the CRS group, and in 32 patients (17.2%) in the CDLC group (p=0.0002). In the CRS group, 17 (8.3%) patients died, compared with 39 (21.0%) patients in the CDLC group (p=0.0004).

INTERPRETATION

The CDLC technique should not be used. The lessened compliance of the abdominal wall, which raises intra-abdominal pressure for long periods, may increase the risk of postoperative pulmonary complications and death. The ideal closure technique should combine strength to prevent wound rupture with elasticity to adapt to increased intra-abdominal pressure.

Total mesorectal excision (TME) with or without preoperative radiotherapy in the treatment of primary rectal cancer. Prospective randomised trial with standard operative and histopathological techniques. Dutch ColoRectal Cancer Group

OBJECTIVE

To document local recurrence in primary rectal cancer when standardised techniques of surgery, radiotherapy, and pathology are used, and to investigate whether the local recurrence rate after total mesorectal excision permits the omission of adjuvant short term preoperative radiotherapy.

DESIGN

Prospective randomised study.

SETTING

Dutch (n = 80), English (n = 1), German (n = 1), Swedish (n = 9), and Swiss (n = 1) hospitals.

SUBJECTS

The first 500 randomised Dutch patients with primary rectal cancer.

MAIN OUTCOME MEASURES

Local recurrence, survival, operation-related factors, specific pathological tumour characteristics, short and long term morbidity, and quality of life.

RESULTS

Between January 1996 and April 1998, 871 Dutch and 94 other patients were randomised. Our feasibility analysis shows that cooperation between and within the participating disciplines goes well. With regard to the surgical part, this can be confirmed by the large number of operations attended by consultant surgeons (58%). The number of abdominoperineal resections appeared to be low (30%), as did the percentage of lateral margins involved (13%). The rate of adverse effects of radiotherapy was acceptable. Apart from a larger operative blood loss and a higher infective complication rate in the irradiated group, no significant differences were found with regard to morbidity and mortality between the randomised groups.

CONCLUSIONS

The accrual of our trial is going well and it is feasible; short term preoperative radiotherapy is safe even in combination with TME.

Local recurrence in patients with rectal cancer diagnosed between 1988 and 1992: a population-based study in the west Netherlands

AIMS

We carried out a population-based study of local recurrence rates in curatively resected patients with rectal cancer, diagnosed between 1988 and 1992. The first objective was to make an inventory of the overall local recurrence rate after non-standardized conventional surgery, inter-institutional recurrence rate variability, and correlations between patient- and tumour-related factors and recurrence rate. A second objective was to investigate the compliance to guidelines for post-operative radiotherapy.

METHODS

Data were obtained from the Comprehensive Cancer Centre West. The study comprised 1105 patients from 12 hospitals. Of these patients, 437 were ineligible because of missing medical records, no carcinoma, incorrect registration, no laparotomy, non-curative resection, or loss to follow-up.

RESULTS

The overall local recurrence rate was 22.5% with a range of 9-36% between the hospitals. These differences were not significant. Dukes' Astler-Coller stage, tumour location, and residual tumour were significant independent prognostic factors for the risk of local recurrence. Indications for post-operative radiotherapy were Dukes' Astler-Coller B2 and C tumours, positive surgical margins, and tumour spill. Compliance to the guidelines for radiotherapy was only 50%. However, no significant difference in recurrence rate was found between patients treated according to the guidelines and those not treated according to the guidelines.

CONCLUSION

This study shows a large variability in local recurrence rate between the participating hospitals and confirms that the risk of recurrence in primary rectal cancer is dependent on Dukes' Astler-Coller stage, tumour location and residual tumour. Furthermore, this study contributes to the discussion about the feasibility of guidelines for post-operative radiotherapy.

Radical and nerve-preserving surgery for rectal cancer in The Netherlands: a prospective study on morbidity and functional outcome

BACKGROUND

Operative procedures for primary rectal cancer from Japan combine pelvic nerve-preserving techniques with radical tumour resection to ensure optimal local tumour control with minimal bladder and sexual dysfunction. A prospective study was undertaken to evaluate morbidity and functional outcome of such a technique in Dutch patients.

METHODS

Forty-seven patients were operated on by a Japanese surgeon. Postoperative course was monitored. Voiding and sexual function were analysed using questionnaires completed by patients.

RESULTS

After operation, only prolonged paralytic ileus (five of 47 patients) and perineal wound dehiscence (five of 18) occurred more frequently than reported in literature. There were no deaths. No patient developed urinary incontinence. Three of 11 women and 19 of 30 men were sexually active. Two men were impotent after operation. Impotence was related to sacrifice of the inferior hypogastric plexus (P = 0.037). Preservation of the superior hypogastric plexus was crucial for ejaculation (P = 0.003).

CONCLUSION

A relationship between sacrifice of specific nerve structures and accompanying dysfunction was established. The nerve-preserving technique yields good results in terms of morbidity and functional outcome, and should be considered for adoption as a standard surgical procedure for primary rectal cancer.

Tumors of the esophagogastric junction. Long-term survival in relation to the pattern of lymph node metastasis and a critical analysis of the accuracy or inaccuracy of pTNM classification

From 1983 to 1989, 95 patients with carcinoma of the esophagogastric junction underwent resection. Overall hospital mortality rate was 6.2% (6/95). Actuarial survival analysis showed 5- and 10-year survivals of 33% and 31%, respectively. Five- and 10-year survivals of patients according to TNM stages were as follows: stage I (n = 13), 90% at both 5 and 10 years; stage II (n = 13), 70% at both intervals; stage III (n = 28), 28% at both intervals; and stage IV (n = 40), 11% and 8%, respectively. For patients with undiseased nodes (n = 26), 5- and 10-year survivals were 72% and 72%, compared with 18% and 16% for patients with diseased nodes (n = 68; p < 0.005). In patients who had involvement of both the abdominal and thoracic lymph nodes (n = 28), 5- and 10-year survivals were 13% and 13%, compared with 26% and 26% if metastases were confined to the abdomen (n = 37; p > 0.05). Grouping patients with diseased intrathoracic nodes together with patients with N2 abdominal nodes showed survivals of 14% at both 5 and 10 years. When tumors were staged as an esophageal carcinoma, classification of individual patients changed, as did the 5- and 10-year survivals. Five- and 10-year survivals were as follows: stage I (n = 8), 100% for both 5 and 10 years; stage II (n = 18), 68% for both 5 and 10 years; stage III (n = 27), 37% for both 5 and 10 years; and stage IV (n = 41), 10% for 5 years and 6% for 10 years. These data indicate that tumors of the esophagogastric junction tend to spread to both abdominal and thoracic nodes. However, reasonably good 5- and 10-year survivals can be obtained even in patients with nodal metastases in both areas. We suggest that N2 labeling be included for thoracic node metastases instead of the actual M+Ly label, because the N2 label better reflects the potential for curative surgery. Finally, staging tumors as gastric or esophageal carcinoma makes no significant difference in survival analysis, which raises the question whether these tumors behave more like esophageal carcinoma than gastric carcinoma.

An analysis on the effect of blood transfusion on recurrence and survival in patients undergoing extended lymphadenectomy for colorectal cancer

In a retrospective study data were collected from 644 patients with cancer of the colon or rectum undergoing curative surgery with extended lymphadenectomy to evaluate a possible effect of blood transfusion, given perioperatively, on tumor recurrence and patient survival. Univariate analysis showed depth of bowel wall invasion, number and level of lymph node metastases to be of highly significant prognostic factors. After 5 years the overall recurrence rate was 16.6% for the non-transfused (n = 223) and 26.1% for the transfused (n = 421; p < .01) patients, and survival rates showed borderline significance favoring the non-transfused patients (90.5% vs. 80.0% after 5 years; p < 0.05). However, after stratification for the prognostically important factors, in a multivariate analysis a possible detrimental effect of perioperative blood transfusions could not be demonstrated.

Protective effect of blood transfusions on postoperative recurrence of Crohn's disease in parous women

BACKGROUND

Perioperative blood transfusion (BT) appeared to have adverse effects on survival after surgery for malignant tumors while pretransplantation BT suppressed allograft rejection. Interest grew in the effect of BT on postoperative recurrence of Crohn's disease.

STUDY DESIGN AND METHODS

To determine the effect of perioperative BT on the recurrence of Crohn's disease after primary surgery, the medical histories of 148 patients with Crohn's disease, 62 males and 86 females (49 nonparous and 37 parous), were reviewed. Eighty-seven patients received perioperative BT.

RESULTS

Overall, perioperative BT showed no effect on recurrence. Patients with Crohn's disease limited to the ileum had a better prognosis with regard to recurrence than did patients with Crohn's disease located in the colon or located in both ileum and colon, but the difference was not significant. Perioperative transfusion seemed to protect against recurrent disease after colon resection, which might be explained by the fact that colon resections, which often necessitate perioperative BT, generally result in a shorter bowel segment at risk for recurrent disease. Overall, parous women showed a worse prognosis than nonparous females and men (p = 0.022). Transfusions had a beneficial effect in parous women (p = 0.068) and, after correction for type of operation, this beneficial effect was significant (p = 0.026). After perioperative BT, parous women had a similar prognosis with respect to recurrent Crohn's disease as nonparous females and men.

CONCLUSION

Perioperative BT has a beneficial effect on the postoperative recurrence of Crohn's disease in parous women.

Surgery for cancer of the colon and rectum

Surgery is the cornerstone of treatment of primary colorectal cancer, independent of the patients age and extent of disease. In the case of locoregionally confined tumors, an en-bloc resection of the primary tumor and adequate lymph node dissection should be performed. However, this is still not generally done. A subtle surgical technique is the most important prophylaxis against local recurrences. Standardized operative techniques, extended resections and perioperative measures led to a reduction of the rate of palliative resections and to a reduction of perioperative mortality (approximately 3%). However, despite modern surgical approaches, the long term prognosis of patients with stage II/III was not essentially improved. Therefore, especially in these stages, a further improvement of the current situation can at best expected by perioperative chemotherapy +/-irradiation.

[Measurement of the quality of care for surgical patients in an intensive care unit in a peripheral hospital]

OBJECTIVE

To determine the quality of care in an intensive care unit.

DESIGN

Prospective investigation for one year. Comparison with results from the literature.

SETTING

Surgical intensive care unit of a community hospital.

PATIENTS

Measurement of the APACHE-II-score was performed on days 1, 3 and 7 in all surgical intensive care unit patients admitted during a one-year period. The predicted mortality from the literature was compared with the actual mortality in our hospital.

RESULTS

A total of 301 patients were admitted to the intensive care unit. Overall mortality was 9%. All the patients with an APACHE II score above 25 on admission died. The actual mortality was comparable with the predicted mortality from the literature.

CONCLUSION

The APACHE II score can be used to determine the quality of care in an intensive care unit. Early prediction of a bad prognosis makes transportation to a more specialized hospital possible, before irreversible organ damage develops.

The effect of perioperative blood transfusion on recurrence after primary operation for Crohn's disease

The effect of perioperative blood transfusion on recurrence after primary operation was retrospectively studied in a group of 104 patients with Crohn's disease. Patients who had minor procedures like strictureplasty, segmental small-bowel resection, and operation for perianal fistula were excluded. Patients who had more extensive surgery were selected, to have an approximately equal distribution of blood transfusion in the different subgroups. Sixty-six female and 45 male patients were included; 65 patients had perioperative blood transfusion and 39 did not. Irrespective of blood transfusion it was confirmed that patients with small-bowel localization have a better prognosis than patients with combined or colonic localization. Patients who had resection of a specimen of less than 30 cm or more than 70 cm had a worse prognosis than the others. The reason for this observation is unclear. Except for patients with colonic localization only, blood transfusion was about equally distributed among patients with ileocaecal localization (19 of 36) and patients with ileal disease (17 of 34). Perioperative blood transfusion had no effect on disease recurrence, either for the whole group of transfused patients or for any of the subgroups, apart from those with colonic localization only. They had a significantly lower recurrence, as diagnosed before 60 months of follow-up. This is ascribed to the fact that these patients had large colonic resection with a lower chance of having active recurrent disease. In conclusion, we could not confirm the protective effects of blood transfusion on recurrence of Crohn's disease, as observed by others.