Y. Van Nieuwenhove

Prognostic Value of the Lymph Node Ratio in Stage III Colorectal Cancer: A Systematic Review

BackgroundAlthough nodal invasion represents one of the most powerful prognostic indicators in colorectal cancer, marked heterogeneity exists within stage III patients. Recently, the lymph node ratio (LNR), defined as the ratio of the number of positive nodes over the total number of examined nodes, was proposed to stratify outcome in stage III patients.MethodsA systematic search was performed for studies examining the prognostic significance of the LNR in colon or rectal cancer. Individual studies were assessed for methodological quality and summary data extracted. Hazard ratios from multivariate analyses were entered in a fixed-effects meta-analysis model.ResultsIn total, 16 studies were identified including 33,984 patients with stage III colon or rectal cancer. In all identified studies, the LNR was identified as an independent prognostic factor in patients with stage III cancer of the colon or rectum. The prognostic separation obtained by the LNR was superior to that of the number of positive nodes (N stage). The pooled hazard ratios for overall and disease-free survival were 2.36 (95% confidence interval, 2.14–2.61) and 3.71 (95% confidence interval, 2.56–5.38), respectively.ConclusionsThe LNR allows superior prognostic stratification in stage III colorectal cancer and should be validated in prospective studies.Although nodal invasion represents one of the most powerful prognostic indicators in colorectal cancer, marked heterogeneity exists within stage III patients. Recently, the lymph node ratio (LNR), defined as the ratio of the number of positive nodes over the total number of examined nodes, was proposed to stratify outcome in stage III patients. A systematic search was performed for studies examining the prognostic significance of the LNR in colon or rectal cancer. Individual studies were assessed for methodological quality and summary data extracted. Hazard ratios from multivariate analyses were entered in a fixed-effects meta-analysis model. In total, 16 studies were identified including 33,984 patients with stage III colon or rectal cancer. In all identified studies, the LNR was identified as an independent prognostic factor in patients with stage III cancer of the colon or rectum. The prognostic separation obtained by the LNR was superior to that of the number of positive nodes (N stage). The pooled hazard ratios for overall and disease-free survival were 2.36 (95% confidence interval, 2.14–2.61) and 3.71 (95% confidence interval, 2.56–5.38), respectively. The LNR allows superior prognostic stratification in stage III colorectal cancer and should be validated in prospective studies.

Laparoscopic repair of parastomal hernias: a multi-centre retrospective review and shift in technique.

Abstract Purpose: To describe the reasons for a shift in our technique of laparoscopic repair of parastomal hernias towards repair with a non-slit mesh. Our initial results with repair using meshes with a keyhole had high recurrence rates. Methods: We performed a multi-centre retrospective study focusing on complications and recurrences. Data were gathered retrospectively from the medical records. The last follow-up date was the latest clinical examination by the surgeon. Recurrences were diagnosed clinically or by CT scan performed for oncological follow-up in cancer patients. Results: From September 2001 till May 2007, twenty-four patients with a symptomatic parastomal hernia were treated laparoscopically. No major intra-or postoperative complications were encountered. We had no conversions, no enterotomies and the overall postoperative morbidity was 8.4% (2/24). During a mean follow-up of 21.2 months, ten recurrences or 41.7% (10/24) have been diagnosed. In patients treated with a “keyhole technique” recurrence rate was 72.7% (8/11) with a mean follow-up of 30.7 months. In patients treated with a “modified Sugarbaker technique” recurrence rate was 15.4% (2/13) with a mean follow-up of 14.0 months. Conclusions: We found laparoscopic parastomal hernia repair could be performed with few complications. We abandoned the “keyhole techniques” because of a high recurrence rate. We currently use a “modified Sugarbaker technique” with promising early results.

Effect of perfusion temperature on glucose and electrolyte transport during hyperthermic intraperitoneal chemoperfusion (HIPEC) with oxaliplatin

INTRODUCTION Hyperthermic intraperitoneal chemoperfusion (HIPEC) with oxaliplatin is increasingly used in patients with carcinomatosis from colorectal cancer. For reasons of chemical stability, oxaliplatin can only be administered in a dextrose (D5%) solution, and this causes peroperative glucose and electrolyte shifts. Here, we examined the influence of perfusion temperature on glucose and electrolyte transport, metabolic shifts, and surgical morbidity. METHODS Patients with carcinomatosis underwent cytoreduction and HIPEC using oxaliplatin (460 mg/m(2) in D5%, open abdomen) during 30 min at 39°-41 °C. Intraperitoneal (IP) temperature was measured at three locations using thermocouple probes. The area under the temperature versus time curve (AUCt) was calculated using the trapezoid rule. The influence of perfusion temperature on surgical outcome was assessed using linear regression models and the Mann Whitney U test where appropriate. RESULTS From July 2005 until March 2011, 145 procedures were performed in 139 patients with a diagnosis of CRC (70%), pseudomyxoma peritonei (11%), ovarian cancer (10%), or miscellaneous peritoneal malignancies (9%). Postoperative mortality and major morbidity were 1.4% and 26%, respectively. Higher perfusion temperature was related to more pronounced changes in serum glucose (P = 0.058), sodium (P = 0.017), and lactate (P < 0.001). The median duration of nasogastric drainage was 5 days, and this was unrelated to perfusion temperature (P = 0.76). The GI fistula rate and reoperation rate were 12.4% and 16.5% respectively; neither was related to perfusion temperature. CONCLUSIONS In patients undergoing HIPEC with oxaliplatin, perfusion temperature exacerbates peroperative metabolic shifts but does not affect surgical outcome.

Defining the Optimal Therapy Sequence in Synchronous Resectable Liver Metastases from Colorectal Cancer: A Decision Analysis Approach

Abstract Introduction: Approximately 5%-20% of colorectal cancer (CRC) patients present with synchronous potentially resectable liver metastatic disease. Preclinical and clinical studies suggest a benefit of the ‘liver first’ approach, i.e. resection of the liver metastasis followed by resection of the primary tumour. A formal decision analysis may support a rational choice between several therapy options. Methods: Survival and morbidity data were retrieved from relevant clinical studies identified by a Web of Science® search. Data were entered into decision analysis software (TreeAge® Pro 2009, Williamstown, MA, USA). Transition probabilities including the risk of death from complications or disease progression associated with individual therapy options were entered into the model. Sensitivity analysis was performed to evaluate the model’s validity under a variety of assumptions. Results: The result of the decision analysis confirms the superiority of the ‘liver first’ approach. Sensitivity analysis demonstrated that this assumption is valid on condition that the mortality associated with the hepatectomy first is < 4.5%, and that the mortality of colectomy performed after hepatectomy is < 3.2%. Conclusion: The results of this decision analysis suggest that, in patients with synchronous resectable colorectal liver metastases, the ‘liver first’ approach is to be preferred. Randomized trials will be needed to confirm the results of this simulation based outcome.

Effect of Neoadjuvant Radiation Dose on Surgical and Oncological Outcome in Locally Advanced Esophageal Cancer

Abstract Introduction : Neoadjuvant chemoradiation (CRT) confers a survival benefit in locally advanced esophageal cancer. The optimal dose of radiotherapy remains undefined. Methods : From a prospective database, we identified patients who received CRT followed by Ivor Lewis esophagectomy. Surgical complications, pathological response, and oncological outcome were compared between patients who received a radiotherapy (RT) dose of 36 Gy (group1) versus a dose of > 40 Gy (group 1). Results : 147 patients were evaluated: 109 received 36 Gy, while 38 received 41–50Gy. Mean age was 61 ± 9 years (84% male). Median hospital stay was 16 days. Anastomotic leakage occurred in 4.0%. Pulmonary complications occurred in 41.8%, neither being influenced by RT dose. Complete resection (R0) was achieved in 95% (group 1) and 100% (group 2), P = 0.3. Pathological complete response (pCR) was observed in 19% (group 1) and 37% (group 1), P = 0.04. Local recurrence developed in 9% in group 1, and 3% in group 2 (P = 0.3), but regional recurrence developed significantly higher in the low dose group (18% vs 3%, P < 0.001). Metastatic recurrence occurred in 48% in group 1 and 13% in group 1 (P < 0.001). Conclusions : In patients with locally advanced esophageal cancer a higher RT dose does not affect surgical outcome, enhances pCR rate, and reduces the locoregional and metastatic recurrence risk.INTRODUCTION Neoadjuvant chemoradiation (CRT) confers a survival benefit in locally advanced esophageal cancer. The optimal dose of radiotherapy remains undefined. METHODS From a prospective database, we identified patients who received CRT followed by Ivor Lewis esophagectomy. Surgical complications, pathological response, and oncological outcome were compared between patients who received a radiotherapy (RT) dose of 36 Gy (group1) versus a dose of > 40 Gy (group 1). RESULTS 147 patients were evaluated: 109 received 36 Gy, while 38 received 41-50Gy. Mean age was 61 ± 9 years (84% male). Median hospital stay was 16 days. Anastomotic leakage occurred in 4.0%. Pulmonary complications occurred in 41.8%, neither being influenced by RT dose. Complete resection (R0) was achieved in 95% (group 1) and 100% (group 2), P = 0.3. Pathological complete response (pCR) was observed in 19% (group 1) and 37% (group 1), P = 0.04. Local recurrence developed in 9% in group 1, and 3% in group 2 (P = 0.3), but regional recurrence developed significantly higher in the low dose group (18% vs 3%, P < 0.001). Metastatic recurrence occurred in 48% in group 1 and 13% in group 1 (P < 0.001). CONCLUSIONS In patients with locally advanced esophageal cancer a higher RT dose does not affect surgical outcome, enhances pCR rate, and reduces the locoregional and metastatic recurrence risk.

Early Belgian experience with the Kugel patch inguinal hernia repair.

Abstract The Kugel hernia repair is an open but minimally invasive, tension free repair, offering the advantages of a preperitoneal repair without the need for general anaesthesia. We report our initial experience with this technique in 25 inguinal hernia repairs. Operating time averaged 40 ± 16 min, and one complication, a bladder tear, occurred intra-operatively. Patients were discharged after a median of 2 days and were then seen after 3 weeks and after at least one year. Three weeks postoperatively, there were two superficial skin inflammations and one haematoma. One year postoperatively no recurrences occurred but two patients complained of persistent inguinodynia. The Kugel hernia repair is a relatively new technique with a short operating time and minimal postoperative pain, but a learning curve, comparable to that of TEP has to be overcome in order to reproduce the results of its inventor.

Metabolic surgery in patients over 60 years old: short- and long-term results.

Abstract Purpose: Laparoscopic Roux-en-Y gastric bypass can treat obesity related comorbidities and can prolong life expectancy. It remains unclear whether this type of surgery is also indicated in obese patients with advanced age. Materials and methods: In this retrospective monocentric study, we investigated the morbidity and outcomes of weight and metabolic control of bariatric surgery in patients older than 60 years and compared these findings with those of younger patients. Results: At 18 months after RY gastric bypass, weight losses of respectively 30 ± 11% and 34 ± 9% of total initial body weight were measured in the older and younger patients (p < 0.05). After 12 months, HbA1c dropped below 6.5% in 89% of patients younger and in 81% of patients older than 60 (p = 0.11). There was no mortality in either group, but there were significantly more complications and there was a longer hospital stay in the older patients. Conclusion: RY gastric bypass comes with a significantly higher morbidity and hospital stay in older patients, but weight loss and improvement of DM are similar as in the younger patients.

Quality assessment in surgery: where do we stand now and where should we be heading?

While surgery is gaining in efficiency it is equally getting more and more complex. Meanwhile patients are getting more and more demanding. In the past decades, safety and quality have become prominent criteria by which surgical care is evaluated. Several important factors can be identified which are influencing the quality of surgical care, in our view these factors can be classified into four major groups: the team of caretakers, the patient, the material, and the procedure. For all of these factors, a high level of knowledge and optimal communication is crucial to guarantee a high standard of care and minimize the chance of complications. Different quality assessment tools are currently used in surgery. Databases of surgical procedures have the potential to offer an enormous amount of information on the quality of care. However, the implementation of comprehensive databases is difficult and expensive, while its value is overshadowed by possible underreporting. Introducing surgical checklists is a cheap yet efficient way to increase both the safety and the quality of surgical care. Nevertheless, its implementation is sometimes opposed since they slow down the patient flow. The risk of complications tends to increase when a new technique is introduced. Therefore, quality assurance (QA) programs have to be implemented. Surgical simulation training is rapidly becoming a necessary adjunct to traditional patient-based training models. Finally, key performance indicators (KPI) can be used for measuring the success of medical interventions such as surgery. For the near future, the introduction of one comprehensive medical file per patient could be a major step in increasing the safety and efficiency of our medical deeds. In parallel, a nationwide prospective registry for surgical interventions should be introduced. Postgraduate surgical training should be organized by the national professional groups and should be adapted to the local needs. A system of accreditation for specific interventions should be introduced guaranteeing their state-of-the-art application.