Rudi M. H. Roumen

Complications and Management of Meckel's Diverticulum: A Review

OBJECTIVE To review the anatomy, symptomatology, diagnosis, complications and management of symptomatic and asymptomatic Meckels diverticula. DESIGN Retrospective study. SETTING Teaching hospital, The Netherlands. SUBJECTS 27 consecutive patients who underwent resection of a Meckels diverticulum during the 16 year period 1 January 1981-31 August 1997. MAIN OUTCOME MEASURES The symptomatology and histopathological findings. RESULTS 15 patients had symptoms and 12 did not. Haemorrhage and inflammation were the most common presenting symptoms. All histopathological signs of inflammation were found in those with symptomatic diverticula. Resected asymptomatic Meckels diverticula were abnormal in only two occasions: one contained an adenocarcinoma and one a faecolith. CONCLUSION All symptomatic Meckels diverticula should be resected. The surgical treatment of asymptomatic Meckels diverticula is still controversial.

Factors related to outcome after pneumonectomy : Retrospective study of 62 patients

OBJECTIVE To find out which risk factors affect outcome after pneumonectomy. DESIGN Retrospective study. SETTING Teaching hospital, The Netherlands. SUBJECTS 62 patients who were treated for bronchial cancer by pneumonectomy between 1984 and 1995. MAIN OUTCOME MEASURE Hospital mortality and postoperative complications. RESULTS Hospital mortality increased with age, being 5/51 (10%) in the 40-69 age group and 4/11 (36%) in patients aged 70 or more. In the American Society of Anesthesiologists (ASA) class I group hospital mortality was 8% (2/26), in class II 12% (3/26) and in class III 40% (4/10). Hospital mortality was highest when the FEV1:FVC-ratio was below 55%. Cardiac arrhythmias developed in 8 (13%), early bronchopleural fistulas in 7 (11%), and postpneumonectomy syndrome in 5 (8%). These major complications had a high mortality. CONCLUSION Respiratory function, ASA class, and age over 70 years are the main prognostic factors for hospital morbidity and mortality after pneumonectomy.

Dog ear formation after double-stapled low anterior resection as a risk factor for anastomotic disruption

PURPOSE: The aim of this study was to investigate the possible deleterious effect of the lateral intersecting margins (so-called dog ears) on anastomotic disruption after experimentally performed double-stapled anastomoses. METHODS: Two groups of double-stapled side-to-end anastomoses were performed using pig small intestines. Group A consisted of 35 circular anastomoses and Group B of 32 double-stapled anastomoses with a bilateral dog ear. In both groups bursting pressures were tested using a water-filled, pressure-controlled automatic pumping system (Hamou Endomat®), and special attention was paid to the location(s) in the anastomoses were the disruption(s) occurred. RESULTS: In Group A bursting pressures were significantly higher than in Group B (median pressure, 90vs. 60 mmHg;P<0.001, Mann-WhitneyU test). Remarkably, in Group B in 13 cases (42 percent) the first disruption occurred at the corner of a dog ear. CONCLUSIONS: We conclude that the lateral intersections of double-stapled anastomoses are a structural weak spot and that the currently most often applied double-stapled anastomosis is a less effective type of anastomosis than a complete circular one. Resolving this technical problem might help to reduce the number of anastomotic disruptions after low anterior resections.

Bleeding after excision of breast lumps.

Bleeding complications after excision of lumps in the breast are common and may be related to the prescription of heparin for prophylaxis of thrombo-embolism. Between I June 1997 and I January 2000, 206 lumps of the breast were removed in 186 patients. All patients received a low molecular weight heparin as a prophylaxis for deep venous thrombosis. The number of bleeding complications was 23 (11%). Patients operated on the day of admission had more bleeding complications than those who were operated on the day after admission (19/145 (13%) compared with 4/61 (7%)). The difference was not significant (p = 0.26). Smoking and use of antihypertensive medication were registered more often in patients without bleeding complications. Lumpectomy of the breast is an operation with a lot of bleeding complications. This might be related to the timing of deep venous thrombosis prophylaxis.

Neo-adjuvant chemotherapy followed by surgery versus surgery alone in high-risk patients with resectable colorectal liver metastases: The CHARISMA randomized multicenter clinical trial

BackgroundEfforts to improve the outcome of liver surgery by combining curative resection with chemotherapy have failed to demonstrate definite overall survival benefit. This may partly be due to the fact that these studies often involve strict inclusion criteria. Consequently, patients with a high risk profile as characterized by Fong’s Clinical Risk Score (CRS) are often underrepresented in these studies. Conceptually, this group of patients might benefit the most from chemotherapy. The present study evaluates the impact of neo-adjuvant chemotherapy in high-risk patients with primary resectable colorectal liver metastases, without extrahepatic disease. Our hypothesis is that adding neo-adjuvant chemotherapy to surgery will provide an improvement in overall survival (OS) in patients with a high-risk profile.Methods/DesignCHARISMA is a multicenter, randomized, phase III clinical trial. Patients will be randomized to either surgery alone (standard treatment, arm A) or to 6 cycles of neo-adjuvant oxaliplatin-based chemotherapy, followed by surgery (arm B). Patients must be ≥ 18 years of age with liver metastases of histologically confirmed primary colorectal carcinoma. Patients with extrahepatic metastases are excluded. Liver metastases must be deemed primarily resectable. Only patients with a CRS of 3–5 are eligible. The primary study endpoint is OS. Secondary endpoints are progression free survival (PFS), quality of life, morbidity of resection, treatment response on neo-adjuvant chemotherapy, and whether CEA levels can predict treatment response.DiscussionCHARISMA is a multicenter, randomized, phase III clinical trial that will provide an answer to the question if adding neo-adjuvant chemotherapy to surgery will improve OS in a well-defined high-risk patient group with colorectal liver metastases.Trial registrationThe CHARISMA is registered at European Union Clinical Trials Register (EudraCT), number: 2013-004952-39, and in the “Netherlands national Trial Register (NTR), number: 4893.

Epidermal growth factor receptor (EGFR) and prostaglandin-endoperoxide synthase 2 (PTGS2) are prognostic biomarkers for patients with resected colorectal cancer liver metastases.

Background:Resection of colorectal cancer liver metastasis (CRCLM) with curative intent has long-term benefit in ∼40% of cases. Prognostic biomarkers are needed to improve clinical management and reduce futile surgeries. Expression of epidermal growth factor receptor (EGFR) and prostaglandin-endoperoxide synthase 2 (PTGS2; also known as cyclooxygenase-2) has been associated with carcinogenesis and survival. We investigated the prognostic value of EGFR and PTGS2 expression in patients with resected CRCLM.Methods:Formalin-fixed paraffin-embedded CRCLM tissue and corresponding primary tumour specimens from a multi-institutional cohort of patients who underwent liver resection between 1990 and 2010 were incorporated into tissue microarrays (TMAs). TMAs were stained for EGFR and PTGS2 by immunohistochemistry. The hazard rate ratio (HRR) for the association between expression in CRCLM and overall survival was calculated using a 500-fold cross-validation procedure.Results:EGFR and PTGS2 expression could be evaluated in 323 and 351 patients, respectively. EGFR expression in CRCLM was associated with poor prognosis (HRR 1.54; P<0.01) with a cross-validated HRR of 1.47 (P=0.03). PTGS2 expression was also associated with poor prognosis (HRR 1.60; P<0.01) with a cross-validated HRR of 1.63 (P<0.01). Expression of EGFR and PTGS2 remained prognostic after multivariate analysis with standard clinicopathological variables (cross-validated HRR 1.51; P=0.02 and cross-validated HRR 1.59; P=0.01, respectively). Stratification for the commonly applied systemic therapy regimens demonstrated prognostic value for EGFR and PTGS2 only in the subgroup of patients who were not treated with systemic therapy (HRR 1.78; P<0.01 and HRR 1.64; P=0.04, respectively), with worst prognosis when both EGFR and PTGS2 were highly expressed (HRR 3.08; P<0.01). Expression of PTGS2 in CRCLM was correlated to expression in patient-matched primary tumours (P=0.02, 69.2% concordance).Conclusions:EGFR and PTGS2 expressions are prognostic molecular biomarkers with added value to standard clinicopathological variables for patients with resectable CRCLM.

Tumor growth pattern and thymidine phosphorylase expression are related with the risk of hematogenous metastasis in patients with Astler Coller B1/B2 colorectal carcinoma.

The benefit of adjuvant chemotherapy appears to be limited for patients with Astler Coller B1/B2 colorectal carcinoma but may be better in a subgroup of patients with a high recurrence risk. In the current case–control analysis, the authors evaluated whether patients with a high risk of hematogenous metastasis could be identified by means of a thorough histologic and immunohistochemical examination of the resection specimens.