J. E. van Hooft

Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer

BACKGROUND AND STUDY AIMS The introduction of self-expandable metal stents has offered a promising alternative for palliation of malignant left-sided colonic obstruction. This randomized clinical trial aimed to assess whether a nonsurgical policy, with endoluminal stenting, is superior to surgical treatment in patients with stage IV left-sided colorectal cancer and imminent obstruction. PATIENTS AND METHODS Patients with incurable left-sided colorectal cancer who fulfilled the study criteria were randomly assigned to nonsurgical or surgical treatment. The primary outcome measure was survival in good health out of hospital (World Health Organization performance scores 0 or 1). RESULTS A high number of serious adverse events in the nonsurgical arm led to premature closure of the trial. Ten patients were allocated to surgical treatment and 11 patients to nonsurgical palliation. The median survival in good health out of hospital during the first year was 56 days (interquartile range 7.5 - 338.5 days) in the surgical arm vs. 38 days (interquartile range 5.25 - 288.75 days) in the nonsurgical arm (P = 0.68). Eleven adverse events (six perforations) occurred in the nonsurgical arm vs. one adverse event in the surgical arm (P < 0.001). Of the six perforations, two were stent-related because they occurred at the proximal edge of the stent by erosion through a normal colon wall; one was probably stent-related (it was located in the region of the proximal half of the stent); one was a colon blowout; and two were late tumor perforations in patients on chemotherapy. CONCLUSIONS The unexpected high rate of perforation in the nonsurgical arm might be specifically WallFlex-related or enteral stent-related in patients on chemotherapy and warrants attention.

Endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions provides inadequate material for cytology and laboratory analysis: initial results from a prospective study

BACKGROUND AND STUDY AIMS Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is considered a valuable and safe technique for further investigation of pancreatic cystic lesions. In the framework of a prospective study on the accuracy of EUS-FNA we report our initial technical results regarding puncture access, sample adequacy, and complications PATIENTS AND METHODS Consecutive patients with indeterminate pancreatic cystic lesions underwent EUS and EUS-FNA. Pancreatic cyst fluid was collected for cytopathological analysis and measurement of amylase, carcinoembryonic antigen (CEA), and carbohydrate antigen 19.9 (CA 19.9) levels. Main outcome parameter for this analysis was the percentage of samples adequate for cytologic and laboratory analysis. RESULTS Of 143 patients (median age 63 years; median cyst size 2.8 cm) who underwent EUS, FNA was performed in 128 (90 %). The various reasons for not doing FNA included large distance between transducer and cystic lesion (n = 9), cyst not seen or too small (n = 2), and evident diagnosis not requiring FNA (n = 3). FNA was not possible in four patients (technical failures). Cyst fluid sent for cytology provided adequate cellular material in 44 cases only, accounting for an intention-to-diagnose yield of 31 % (44/143). Sufficient fluid for biochemical analysis was obtained in 68 cases (49 %). Complications occurred in three patients (2.4 %). CONCLUSIONS Although EUS-guided FNA was technically feasible in the majority of patients with pancreatic cystic lesions (87 %), it was possible to obtain a classifying cytopathologic diagnosis and a chemical analysis in only a third and a half of cases, respectively.

Oncological outcome of malignant colonic obstruction in the Dutch Stent-In 2 trial

The Stent‐In 2 trial randomized patients with malignant colonic obstruction to emergency surgery or stent placement as a bridge to elective surgery. The aim of this study was to compare the oncological outcomes.

Safety and efficacy of a new non-foreshortening nitinol stent in malignant gastric outlet obstruction (DUONITI study): a prospective, multicenter study.

BACKGROUND AND STUDY AIMS Gastric outlet obstruction (GOO) is a late complication of advanced gastric, periampullary, and duodenal malignancies. Palliation of obstruction is the primary aim of treatment in these patients. Self-expandable metal stents have emerged as a promising treatment option. Our aim was to investigate the safety and efficacy of a new non-foreshortening nitinol duodenal stent. PATIENTS AND METHODS A total of 52 patients with symptomatic malignant GOO were studied in this prospective multicenter cohort study. All patients received a D-Weave Niti-S duodenal stent (Taewoong Medical, Seoul, South Korea). Patients were followed up until withdrawal of informed consent or death. RESULTS The cause of GOO was pancreatic cancer in the majority of patients (62%). The technical and clinical success rates were 96% and 77%, respectively. The GOO Scoring System score improved significantly (P < 0.0001) when the scores before stenting were compared with the mean scores until death. Median survival was 82 days and stent patency was observed in 75% for up to 190 days, accounting for death as a competing risk. In 13 patients (25%) stent dysfunction occurred (tumor ingrowth in 11, stent migration in two). Over time, the body mass index, the World Health Organization performance score, and the EuroQol visual analog scale revealed a not significant change (P = 0.52, P = 0.43, and P = 0.15, respectively), whereas the global health status improved significantly (P = 0.001). CONCLUSION Placement of a new non-foreshortening nitinol enteral stent is safe and without major complications. This stent design produces significant relief of obstructive symptoms and improves quality of life in patients with incurable malignant GOO.

Bridge-to-surgery stent placement versus emergency surgery for acute malignant colonic obstruction

Endoscopic self‐expanding metal stent (SEMS) placement as a bridge to surgery is an option for acute malignant colonic obstruction. There is ongoing debate regarding the superiority and oncological safety of SEMS placement compared with emergency surgery. This retrospective study aimed to compare outcomes of these treatment approaches.

Definitive chemoradiation for patients with inoperable and/or unresectable esophageal cancer: locoregional recurrence pattern

A locoregional recurrence after definitive chemoradiation (dCRT) for patients with inoperable or unresectable esophageal cancer occurs in about 50% of the patients and is a major cause of failure with a poor prognosis. The aim of this study was to determine the pattern of locoregional recurrence and its prognostic factors after dCRT in order to search for improvements in radiation treatment. We retrospectively reviewed 184 patients treated with external beam radiotherapy (50.4 Gray/28 fractions), combined with weekly concurrent paclitaxel and carboplatin. Locoregional recurrences were defined by clinical signs of recurrent or progressive disease, combined with progression on computed tomography/positron emission tomography-computed tomography scan, or suspicious endoscopic findings and/or histological proof of recurrence. The site of locoregional recurrence was analyzed with respect to the borders of the radiation fields. After a mean follow up of 22.8 months, 76 patients (41%) had evidence of locoregional recurrence. The 3-years locoregional recurrence-free rate was 45%. The majority of locoregional recurrences occurred within 12 months, nearly all within 24 months. The majority of these patients failed at the site of the primary tumor (86%). Infield locoregional recurrences at the site of the lymph nodes only occurred in 1% compared with 57% at the site of the primary tumor only. Outfield locoregional lymph node recurrences occurred in 22%, without infield recurrence occurred in only 4% of all patients. The 1-, 3-, and 5-year overall survival was 65%, 28%, and 21%, respectively. The current analysis demonstrates that a locoregional recurrence after dCRT occurs in 41% of the patients, the majority at the site of the primary tumor. These data suggest a benefit of dose intensification of the primary tumor, but not at the site of the lymph nodes. Higher radiation doses should be assessed with prospective trials.

First data on the Evolution duodenal stent for palliation of malignant gastric outlet obstruction (DUOLUTION study): a prospective multicenter study.

BACKGROUND AND STUDY AIMS Enteral stent placement has emerged as a safe and effective palliative treatment option for patients with malignant gastric outlet obstruction (GOO). In an attempt to further optimize this treatment new enteral stents have been designed. This study is the first to describe the results regarding technical success, clinical success, complication rate, and stent dysfunction of the Evolution duodenal stent (Cook Medical, Limerick, Ireland). PATIENTS AND METHODS A total of 46 patients with symptomatic malignant GOO were included in this prospective multicenter cohort study. All patients who successfully received an Evolution duodenal stent were followed until death. RESULTS The technical and clinical success rates were 89 % (95 % confidence interval [CI] 77 % - 95 %) and 72 % (95 %CI 58 % - 83 %), respectively. The GOO Scoring System score, the Global Health Score, and the EuroQol visual analog scale improved significantly (GOOSS and Global Health Score P < 0.0001; EuroQol P = 0.005) when scores before stenting were compared with scores after stent placement. Median survival was 87 days, and stent patency was observed in 67 % for up to 395 days, accounting for death unrelated to the stent as a competing risk. Stent dysfunction occurred in 14 patients (30 %) (stent ingrowth n = 9; stent migration n = 2; extrinsic compression on the stent n = 2; food impaction n = 1). CONCLUSION These first data on the new Evolution duodenal stent show that it is safe and effective for the palliative treatment of symptomatic malignant GOO.

Modern work-up and extended resection in perihilar cholangiocarcinoma: the AMC experience

AimPerihilar cholangiocarcinoma (PHC) is a challenging disease and requires aggressive surgical treatment in order to achieve curation. The assessment and work-up of patients with presumed PHC is multidisciplinary, complex and requires extensive experience. The aim of this paper is to review current aspects of diagnosis, preoperative work-up and extended resection in patients with PHC from the perspective of our own institutional experience with this complex tumor.MethodsWe provided a review of applied modalities in the diagnosis and work-up of PHC according to current literature. All patients with presumed PHC in our center between 2000 and 2016 were identified and described. The types of resection, surgical techniques and outcomes were analyzed.Results and conclusionUpcoming diagnostic modalities such as Spyglass and combinations of serum biomarkers and molecular markers have potential to decrease the rate of misdiagnosis of benign, inflammatory disease. Assessment of liver function with hepatobiliary scintigraphy provides better information on the future remnant liver (FRL) than volume alone. The selective use of staging laparoscopy is advisable to avoid futile laparotomies. In patients requiring extended resection, selective preoperative biliary drainage is mandatory in cholangitis and when FRL is small (< 50%). Preoperative portal vein embolization (PVE) is used when FRL volume is less than 40% and optionally includes the left portal vein branches to segment 4. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as alternative to PVE is not recommended in PHC. N2 positive lymph nodes preclude long-term survival. The benefit of unconditional en bloc resection of the portal vein bifurcation is uncertain. Along these lines, an aggressive surgical approach encompassing extended liver resection including segment 1, regional lymphadenectomy and conditional portal venous resection translates into favorable long-term survival.

TU-H-206-08: Quantitative Impact of Biliary Stent Artefacts On MR Images

PURPOSE Biliary stents may cause artifacts in MR-images. These artifacts are caused by differences in susceptibility (artifact-1), eddy currents during read-out (artifact-2) and eddy currents due to the excitation pulse (artifact-3), which all are MRI sequence-dependent. In this study, we investigated and quantified the magnitude of these artifacts as a function of the distance from biliary stents, using a sequence-independent approach where possible. METHODS Eight phantoms were made containing different commercial biliary stents made of nitinol, platinol, stainless steel or polyethylene. To quantify artifact-1 sequence-independently, we acquired ΔB0-maps and T2*-maps. To maximize artifact-2, the phantom was placed 130mm off center. We then compared signal ratios from acquisitions with gradients in directions that induced eddy currents and acquisitions with gradients in directions that did not induce eddy currents, to assess the contribution of artifact-2. We acquired B1-maps to quantify the effect of artifact-3.These experiments were performed at 3T. The ΔB0-maps and T2*-maps were also acquiered at 1.5T.Finally, we acquired ΔB0-maps, T2*-maps and clinical MR-images in vivo in two pancreatic cancer patients with platinol stents. RESULTS Artifact-1 was dominant over the other artifacts. The stainless steel stent showed the largest artifact-1: decreased T2* and ΔB0>75Hz up to 20mm from the stents edge which results in signal shifts>3voxels for typical diffusion weighted images with bandwidth BW=25Hz/voxel. The other stents showed a decreased T2* up to 8.5mm/5.1mm (3T/1.5T) from the edge of the stent and had a BW<95Hz/55Hz, resulting in signal shifts <0.2voxels for sequences with BW>500Hz/275Hz at 3T/1.5T. The plastic stent showed no artifacts. In vivo, the changes in B0 and T2* induced by the stent were larger than typical variations in B0 and T2* induced by anatomy. CONCLUSION We presented a sequence-independent measure to quantify susceptibility artifacts. Other artifacts are negligible compared to susceptibility artifacts for biliary stents.