D.J. Lips

FDG-PET has no definite role in preoperative imaging in gastric cancer.

BACKGROUND Gastric cancer is fourth on the incidence list of cancers worldwide with a high disease-related mortality rate. Curation can only be achieved by a radical resection including an adequate lymphadenectomy. However, prognosis remains poor and cancer recurrence rates are high, also due to lymph node metastases. To improve outcome, (neo)adjuvant treatment strategies with chemo- and/or radiotherapy regimes are employed. AIMS Accurate staging of gastric cancer at primary diagnosis is essential for adequate treatment. In this non-systematic review the role 18-F-Fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) in preoperative staging is investigated. Furthermore, the results of neoadjuvant chemotherapy-induced tumour response monitoring by FDG-PET are discussed. RESULTS AND CONCLUSION It is concluded that currently FDG-PET has no role in the primary detection of gastric cancer due to its low sensitivity. FDG-PET shows, however, slightly better results in the evaluation of lymph node metastases in gastric cancer compared to CT and could have therefore a role in the preoperative staging. Improvement in accuracy could be achieved by using PET/CT or other PET tracers than FDG, but these modalities need further investigation. FDG-PET, however, adequately detects therapy responders at an early stage following neoadjuvant chemotherapy.

The influence of micrometastases on prognosis and survival in stage I-II colon cancer patients: the Enroute⊕ Study.

BackgroundThe presence of lymph node metastases remains the most reliable prognostic predictor and the gold indicator for adjuvant treatment in colon cancer (CC). In spite of a potentially curative resection, 20 to 30% of CC patients testing negative for lymph node metastases (i.e. pN0) will subsequently develop locoregional and/or systemic metastases within 5 years. The presence of occult nodal isolated tumor cells (ITCs) and/or micrometastases (MMs) at the time of resection predisposes CC patients to high risk for disease recurrence. These pN0micro+ patients harbouring occult micrometastases may benefit from adjuvant treatment. The purpose of the present study is to delineate the subset of pN0 patients with micrometastases (pN0micro+) and evaluate the benefits from adjuvant chemotherapy in pN0micro+ CC patients.Methods/designEnRoute+ is an open label, multicenter, randomized controlled clinical trial. All CC patients (age above 18 years) without synchronous locoregional lymph node and/or systemic metastases (clinical stage I-II disease) and operated upon with curative intent are eligible for inclusion. All resected specimens of patients are subject to an ex vivo sentinel lymph node mapping procedure (SLNM) following curative resection. The investigation for micrometastases in pN0 patients is done by extended serial sectioning and immunohistochemistry for pan-cytokeratin in sentinel lymph nodes which are tumour negative upon standard pathological examination. Patients with ITC/MM-positive sentinel lymph nodes (pN0micro+) are randomized for adjuvant chemotherapy following the CAPOX treatment scheme or observation. The primary endpoint is 3-year disease free survival (DFS).DiscussionThe EnRoute+ study is designed to improve prognosis in high-risk stage I/II pN0 micro+ CC patients by reducing disease recurrence by adjuvant chemotherapy.Trial RegistrationClinicalTrials.gov: NCT01097265

Surgical re-interventions following colorectal surgery: open versus laparoscopic management of anastomotic leakage.

BACKGROUND Increasing numbers of colorectal resections are performed laparoscopically each year. In 2010, 42% of all colorectal procedures in The Netherlands were performed laparoscopically. Although the anastomotic leakage rate is 3%-19% of all patients, little is known about laparoscopic options for re-intervention. Our study aims to evaluate the safety and feasibility of laparoscopic re-intervention compared with open surgery following colorectal surgery. PATIENTS AND METHODS All patients who required a surgical re-intervention for an anastomotic leak, bowel perforation, or abscess after laparoscopic colorectal surgery between January 2008 and June 2012 were analyzed retrospectively. Demographic data, operative management, morbidity, hospital stay, and mortality were collected and analyzed for each patient. RESULTS Fifty-six patients were included. Eighteen patients had a laparotomy following laparoscopy, and 38 patients had a laparoscopic re-intervention following laparoscopy. The median age was 65 years, with a median body mass index of 26 kg/m(2). Four patients had a previous laparotomy, and 73% had surgery for malignant colorectal disease. The length of hospital stay was 20 days in the laparoscopic group versus 31 days in the open group (P=.044). Six out of 38 versus 7 out of 18 patients required an additional re-intervention (P=.056). Fewer patients developed fascial dehiscence in the laparoscopic group (P=.033). In-hospital mortality was 4 out of 18 in the open group compared with 2 out of 38 in the laparoscopic group (P=.077). CONCLUSIONS Laparoscopic re-intervention could be a safe and feasible treatment for anastomotic leakage after laparoscopic colorectal surgery. These promising results need to be further investigated in a prospective study to reduce uncertainty in the patients condition and perioperative findings.

Sentinel lymph node biopsy to direct treatment in gastric cancer. A systematic review of the literature

Gastric cancer is one of the main causes of cancer-related deaths around the world. The prevalence of early gastric cancer (EGC) among all gastric cancers of 45-51% in Japan, but only 7-28% in Western countries. The prevalence of EGC is growing partly because of better diagnostics and screening programmes. Possible treatment options for EGC treatment are expanded by the introduction of endoscopic mucosal resection and endoscopic submucosal dissection Therefore, detailed knowledge about nodal metastatic risk is warranted. We performed a systematic review of the literature concerning studies investigating the role of sentinel lymph node biopsy in EGCr and whether there is enough proof to introduce SLN as a part of treatment for EGC in the Netherlands. Several detection substances (dye or radiocolloid) and injection methods (submucosal or subserosal) are investigated. An overall sensitivity percentage of 85.4% was found. In comparison, high and clinically sufficient percentages were observed for specificity (98.2%), negative predictive value (90.7%) and accuracy (94%). Subgroup analyses showed that the combination of dye and radiocolloid detection substances is the best method for sentinel lymph node detection in early gastric cancer. However, the precise method of sentinel lymph node biopsy in EGC has to be determined further. Large, randomized series should be initiated in Europe to address this issue.

The number of high-risk factors is related to outcome in stage II colonic cancer patients.

BACKGROUND A subgroup of stage II colonic cancer patients are considered to be at high-risk for recurrent/metastatic disease based on 1) tumour obstruction/perforation 2) <10 lymph nodes 3) T4 lesions and 4) lymphangio-invasion. Their prognosis is regarded as comparable to stage III (T1-4N+M0) colonic cancer and it is therefore strongly advised to treat them with adjuvant chemotherapy. The purpose of this study was i) to determine the magnitude of prognostic significance of the conventional high-risk factors and ii) to determine whether the number of high-risk factors influences outcome. METHODS We retrospectively analyzed 212 stage II colonic cancer patients undergoing surgery between January 2002 and December 2008. No adjuvant chemotherapy was given. Survival analyses were performed. RESULTS 154/212 (73%) patients were considered to be high-risk patients based on conventional high-risk factors. 58 patients did not meet any high-risk factor, 125 patients met 1 high-risk factor and 29 patients met ≥2 high-risk factors. Median follow up was 40 months. Multivariate analysis identified four independent risk factors for recurrent/metastatic disease: age, obstruction, perforation and lymphangio-invasion. The three-year-DFS-rates for the low-risk group, the high-risk group with 1 high-risk factor and the high-risk group with ≥2 high-risk criteria are 90.4%, 87.6% and 75.9% respectively. Patients meeting ≥2 conventional high-risk criteria had a significantly worse three-year disease free survival (p < 0.002). CONCLUSIONS Four independent high-risk factors were identified. The number of high-risk factors does influence outcome. More attention should be given to the definition and treatment of high-risk stage II colonic cancer patients.

Single-port laparoscopic cholecystectomy vs standard laparoscopic cholecystectomy: A non-randomized, age-matched single center trial

AIM To compare the safety of single-port laparoscopic cholecystectomies with standard four-port cholecystectomies. METHODS Between January 2011 and December 2012 datas were gathered from 100 consecutive patients who received a single-port cholecystectomy. Patient baseline characteristics of all 100 single-port cholecystectomies were collected (body mass index, age, etc.) in a database. This group was compared with 100 age-matched patients who underwent a conventional laparoscopic cholecystectomy in the same period. Retrospectively, per- and postoperative data were added. The two groups were compared to each other using independent t-tests and χ(2)-tests, P values below 0.05 were considered significantly different. RESULTS No differences were found between both groups regarding baseline characteristics. Operating time was significantly shorter in the total single-port group (42 min vs 62 min, P < 0.05); in procedures performed by surgeons the same trend was seen (45 min vs 59 min, P < 0.05). Peroperative complications between both groups were equal (3 in the single-port group vs 5 in the multiport group; P = 0.42). Although not significant less postoperative complications were seen in the single-port group compared with the multiport group (3 vs 9; P = 0.07). No statistically significant differences were found between both groups with regard to length of hospital stay, readmissions and mortality. CONCLUSION Single-port laparoscopic cholecystectomy has the potential to be a safe technique with a low complication rate, short in-hospital stay and comparable operating time. Single-port cholecystectomy provides the patient an almost non-visible scar while preserving optimal quality of surgery. Further prospective studies are needed to prove the safety of the single-port technique.

“Benign” superior vena cava syndrome

A 41-year-old man, known to have congenital antithrombin (AT)-III deficiency, presented to the emergency department with progressive dyspnea, facial swelling, generalized edema, and hypotension. A viral gastroenteritis, several weeks before the admission, resulted in subtherapeutic international normalized ratio (INR) levels. Echocardiography showed inflow obstruction of the right ventricle with preserved left ventricular function. Computed tomography (CT) confirmed ‘‘benign’’ superior vena cava thrombosis with several collateral veins (Fig. 1). Endovascular stenting was carried out as a minimally invasive and simple procedure, restoring venous return with immediate relief of symptoms in our patient (Figs. 2, 3). Long-term anticoagulation was intensified, and he is currently doing well, 5 years after this complication of his AT-III deficiency.

Single-port laparoscopic appendectomy in children: single center experience in 50 patients.

Abstract Background : Recent years evolution of minimal invasive laparoscopic procedures led to new techniques, like single-port laparoscopy (SPL), resulting in nearly-scarless procedures. The purpose of this study is to evaluate that SPL appendectomy is a safe and feasible procedure using a commercially available trocar (LESS: Laparo Endoscopic Single Site trocar; Olympus TriPort+) in pediatric patients. Methods : From July 2011 to March 2014 all patients undergoing SPL appendectomy under 18 years were included in this retrospective study. Per-en postoperative data were collected in a prospective database. Results : A total of 50 children (mean age 12 years) diagnosed as acute appendicitis underwent SPL appendectomy. SPL appendectomy was feasible and safe in all cases, both in non-perforated and perforated appendicitis. In one procedure (2%) an extra trocar was placed. Seven patients (14%) were readmitted to the hospital after initial uncomplicated postoperative course. One patient (2%) needed reoperation due to a wound abscess. Three patients (6%) were readmitted due to intra-abdominal abscesses for which antibiotics were given. Conclusion : SPL appendectomy is a safe and feasible procedure in children with acute appendicitis.

Use of a multi-instrument access device in abdominoperineal resections.

Background: Laparoscopic colorectal surgery results in less post-operative pain, faster recovery, shorter length of stay and reduced morbidity compared with open procedures. Less or minimally invasive techniques have been developed to further minimise surgical trauma and to decrease the size and number of incisions. This study describes the safety and feasibility of using an umbilical multi-instrument access (MIA) port (Olympus TriPort+) device with the placement of just one 12-mm suprapubic trocar in laparoscopic (double-port) abdominoperineal resections (APRs) in rectal cancer patients. Patients and Methods: The study included 20 patients undergoing double-port APRs for rectal cancer between June 2011 and August 2013. Preoperative data were gathered in a prospective database, and post-operative data were collected retrospectively. Results: The 20 patients (30% female) had a median age of 67 years (range 46-80 years), and their median body mass index (BMI) was 26 kg/m2 (range 20-31 kg/m2). An additional third trocar was placed in 2 patients. No laparoscopic procedures were converted to an open procedure. Median operating time was 195 min (range 115-306 min). A radical resection (R0 resection) was achieved in all patients, with a median of 14 lymph nodes harvested. Median length of stay was 8 days (range 5-43 days). Conclusion: Laparoscopic APR using a MIA trocar is a feasible and safe procedure. A MIA port might be of benefit as an extra option in the toolbox of the laparoscopic surgeon to further minimise surgical trauma.