P.W. de Graaf

Extended Lymph-Node Dissection for Gastric Cancer

BACKGROUND Curative resection is the treatment of choice for gastric cancer, but it is unclear whether this operation should include an extended (D2) lymph-node dissection, as recommended by the Japanese medical community, or a limited (D1) dissection. We conducted a randomized trial in 80 Dutch hospitals in which we compared D1 with D2 lymph-node dissection for gastric cancer in terms of morbidity, postoperative mortality, long-term survival, and cumulative risk of relapse after surgery. METHODS Between August 1989 and July 1993, a total of 996 patients entered the study. Of these patients, 711 (380 in the D1 group and 331 in the D2 group) underwent the randomly assigned treatment with curative intent, and 285 received palliative treatment. The procedures for quality control included instruction and supervision in the operating room and monitoring of the pathological results. RESULTS Patients in the D2 group had a significantly higher rate of complications than did those in the D1 group (43 percent vs. 25 percent, P<0.001), more postoperative deaths (10 percent vs. 4 percent, P= 0.004), and longer hospital stays (median, 16 vs. 14 days; P<0.001). Five-year survival rates were similar in the two groups: 45 percent for the D1 group and 47 percent for the D2 group (95 percent confidence interval for the difference, -9.6 percent to +5.6 percent). The patients who had R0 resections (i.e., who had no microscopical evidence of remaining disease), excluding those who died postoperatively, had cumulative risks of relapse at five years of 43 percent with D1 dissection and 37 percent with D2 dissection (95 percent confidence interval for the difference, -2.4 percent to +14.4 percent). CONCLUSIONS Our results in Dutch patients do not support the routine use of D2 lymph-node dissection in patients with gastric cancer.

Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients

For patients with gastric cancer deemed curable the only treatment option is surgery, but there is disagreement about whether accompanying lymph-node dissection should be limited to the perigastric nodes (D1) or should extend to regional lymph nodes outside the perigastric area (D2). We carried out a multicentre randomised comparison of D1 and D2 dissection. 1078 patients were randomised (539 to each group). 26 allocated D1 and 56 allocated D2 were found not to satisfy eligibility criteria (histologically confirmed adenocarcinoma of the stomach without clinical evidence of distant metastasis). Each of the remainder was attended by one of eleven supervising surgeons who decided whether curative resection was possible and, if so, assisted with the allocated procedure. Among the 711 patients (380 D1, 331 D2) judged to have curable lesions, D2 patients had a higher operative mortality rate than D1 patients (10 vs 4%, p = 0.004) and experienced more complications (43 vs 25%, p < 0.001). They also needed longer postoperative hospital stays (median 25 [range 7-277] vs 18 [7-143] days, p < 0.001). Morbidity and mortality differences persisted in almost all subgroup analyses. While we await survival results, D2 dissection should not be used as standard treatment for western patients.

Preparation and properties of arylgold compounds. Scope and limitations of the auration reaction

Several ligand-free monoarylgold dichlorides (RC6H4AuCl2)2 (R = H, Me, Et, i-Pr, t-Bu, Ph) have been prepared from arenes and AuCl3; contrary to earlier reports, addition of ligands is not necessary in order to obtain thermally stable products. The auration is inhibited if the arenes contain potentially coordinating substituents. The properties and reactions of the arylgold dichlorides are discussed.

Application of a mixed imaging sequence for MR imaging characterization of human breast disease.

Single slice MR images were obtained from 9 normal breasts, 17 breasts with benign tumors, and 11 breasts with malignant tumors using an interleaved (mixed) spin echo (SE) inversion-recovery (IR) imaging sequence. SE and IR MR images were synthesized with variable repetition, echo and inversion times from the mixed sequence data. These images were used to qualitatively evaluate the contrast possibilities available when imaging the breast with MR imaging. Proton T1 and T2 relaxation times were determined for normal breast tissues and malignant and benign breast tumors from pure T1 and T2 images calculated using the mixed sequence data. The mean T1 value in benign tumors of 1049.02 ± 40.31 was found to be significantly longer (p < 0.0001) than the mean value of malignant tumors (876.09 ± 27.83) and normal tissues (795.64 ± 21.12). The value of T2 in benign tumors (89.15 ± 8.33) was significantly longer (p < 0.01) than the value of T2 in normal tissues (62.82 ± 4.06). The mixed sequence can be applied to improve image contrast between malignant tumors, benign tumors, and normal tissues of the breast and can potentially differentiate between these tissues in vivo.

Synthesis and characterization of triarylgoldzinc compounds

Abstract The reactions of diphenylzinc and di-p-tolylzinc with gold(I) and gold(III) salts yield dimeric species of the type (Ar3AuZn)2. On the basis of spectroscopic data and physical measurements a cyclic structure is proposed which contains both aryl groups exclusively bound to zinc and aryl groups bridging between gold and zinc. Upon reaction with bidentate nitrogen-containing ligand molecules, complexes of the type Ar3AuZnL are obtained which probably have an “ate”-like structure, ArZn+LAu-Ar2. In reactions with phosphorus-containing ligand molecules, the Ar3AuZn compounds are cleaved to give ArAuL complexes. This difference in behaviour is discussed in terms of the differing affinities of gold and zinc for N- and P-donor molecules.

CT prediction of irresectability in esophageal carcinoma: value of additional patient positions and relation to patient outcome

Abstract.Background: To improve computed tomographic (CT) prediction of local irresectability and to correlate preoperative CT findings with patient outcome. Methods: Eighty-five patients with esophageal carcinoma underwent CT in supine, left lateral decubitus, and prone positions. CT signs that were indicative of local irresectability included (1) an angle of contact >45° with the aorta; (2) obliteration of triangular fat pad between the tumor, aorta, and spine; (3) tumor contiguous with the aorta in all three positions; and (4) indentation of the airway in all three positions. Results: All CT signs indicative for local irresectability concerning the aorta had comparable percentages of false-positive scans (75%) when correlated with surgical findings. When correlated with pathologic findings, >45° angle of contact with the aorta yielded the fewest false-positive cases (9%). Concerning the airway, additional positions changed the staging correctly in 1 of 18 cases. Median survival was 21 and 8 months, respectively, for tumors considered CT resectable or irresectable. Conclusion: Additional patient positions do not improve the CT prediction of aortic invasion. Predicted resectability correlates with a significant longer life expectancy.

The synthesis and properties of diarylgoldzinc chlorides, diphenylgoldcadmium chloride, and diphenylgoldmercury chloride

Abstract The arylation of carbonylgold chloride with diarylzinc compounds yields either triarylgoldzinc or diarylgoldzinc chlorides, depending on the reactant ratio and the nature of the aryl group. The same reactions with diphenylcadmium and diphenylmercury yield exclusively diphenylgoldcadmium chloride and diphenylgoldmercury chloride, respectively. The reactions of the products with N , N , N ′, N ′-tetramethylethylenediamine and triphenylphosphine were studied. Phenylgold has been obtained as a very unstable solid from diphenylgoldzinc chloride and diphenylgoldmercury chloride.

Improved healing of extraperitoneal intestinal anastomoses in the early phase when surrounded by omentum.

Background: The extra-anatomical position of a cervical oesophagogastrostomy is a reason for impaired anastomotic healing, but transposition of the omentum that is covered with mesothelial cells may be a way to improve that. Method: This hypothesis was tested in a rat model. An end-to-end jejuno-jejunostomy was placed subcutaneously in group I (n = 29), subcutaneously surrounded by omentum in group II (n = 29) and intra-abdominally surrounded by omentum in group III (n = 20). After 3, 7 or 14 days, the rats were sacrificed and bursting pressure (BP) of the anastomosis or jejunum was measured and the hydroxyproline (HP) level was determined. Results: In group I 5/29, in group II 2/29 and in group III 0/20 rats died following anastomotic leakage (nonsignificant) and were excluded from other measurements. BP was decreased after 3 days in group I (60 ± 9 mm Hg) compared with group II (101 ± 8 mm Hg) and group III (107 ± 11 mm Hg) (p = 0.002). After 7 days, BP in groups I (122 ± 10 mm Hg) and II (132 ± 10 mm Hg) were lower as compared with group III (230 ± 8 mm Hg) (p < 0.001). Differences in HP levels were not statistically significant between the groups after 3, 7 and 14 days. Conclusion: The healing of intestinal anastomoses in an extraperitoneal position is improved in the early phase only when surrounded by omentum.

Results of Surgery for Perforated Gastroduodenal Ulcers in a Dutch Population

Objective: Despite improvements in anesthesiology and intensive care medicine, mortality for perforated gastroduodenal ulcer disease remains high. This study was designed to evaluate the results of surgery for perforated ulcer disease and to identify prognostic factors for mortality in order to optimize treatment. Patients and Methods: The medical records of 272 patients undergoing emergency surgery for perforated ulcer disease from 2000 to 2005 in two large teaching hospitals and one university hospital in the Netherlands were retrospectively analyzed. Information on 89 pre-, peri- and postoperative data were recorded. Statistical analysis was performed using multiple logistic regression analysis. The primary endpoint was 30-day mortality. Results: The 30-day mortality rate was 16%. Variables associated with 30-day mortality were age, shock, tachycardia, anemia and ASA class. Conclusions: A relatively low 30-day mortality rate was achieved. Age, shock, tachycardia and anemia were significantly associated with 30-day mortality. Finding that shock, tachycardia and anemia are independently associated with 30-day mortality could indicate that patients are septic upon admission. Improvements in survival might be achieved by early sepsis treatment.

Temporary end ileostomy with subcutaneously buried efferent limb: results and potential advantages

Purpose: To evaluate the results of a modified technique of creating a defunctioning end ileostomy. Methods: Medical records of all consecutive patients with a defunctioning end ileostomy with buried efferent limb operated at our hospital between January 2000 and December 2007 were reviewed. The defunctioning end ileostomy with buried efferent limb is created by closing the distal limb and positioning it in the subcutis. Parameters studied were: stomal and reversal related complications. Results: 66 patients were included. Between construction and closure of the stoma, a total of 21 patients (31.8%) developed stoma-related complications. In 1 patient (1.5%) high output occurred, in 6 (9%) stomal retraction and in 4 (6.1%) a parastomal hernia occurred. Peristomal skin problems were observed in 14 patients (21.2%) in the early postoperative period, decreasing to 6 patients (9.1%) after 3 weeks. In 1 patient, stoma closure could not be performed through a local approach and formal laparotomy was necessary. Complications of loop ileostomy as reported in the literature show relatively high rates of peristomal skin and leakage problems. Conclusions: Our results suggest that end ileostomy with subcutaneous buried efferent limb offers advantages over loop ileostomy with regard to the risk of developing peristomal skin and leakage problems.