The prognostic importance of MRI detected extramural vascular invasion (mrEMVI) in locally advanced rectal cancer.

BACKGROUND: MRI detected extramural vascular invasion (mrEMVI) is a poor prognostic factor in rectal cancer patients. The objectives of this study were to assess survival outcomes in patients with and without mrEMVI and to compare the prognostic value of mrEMVI with other rectal cancer features. METHODS: In a Dutch high volume rectal cancer center cohort of sixty-seven locally advanced rectal cancer patients, an independent radiologist reviewed all primary staging MRI scans. The presence of mrEMVI was correlated to tumor specific and survival outcomes. RESULTS: 20/67 patients had mrEMVI positive rectal cancer. 55% (11/20) developed metachronous metastases, compared with 23% (11/47) in the mrEMVI negative group (OR 4.0, p = 0.01). Overall survival was also decreased with a Hazard ratio of 3.3 (p = 0.01). A multivariable logistic regression with a backward selection procedure was conducted including cT-stage, c-N-stage, extramural tumor invasion depth, mesorectal fascia involvement, distance to anorectal junction, tumor length, mrEMVI, CEA level, and synchronous metastases. After stepwise removal based on p value, only positive mrEMVI remained as a single significant predictor for metachronous metastases (OR: 4.16 , p < 0.05). CONCLUSION: Positive mrEMVI is a poor prognostic factor in locally advanced rectal cancer with a 4-fold increased risk of developing metachronous metastases after surgery and a worsened overall survival. mrEMVI also appeared an independent risk factor, with a stronger prediction for metachronous metastases than other MRI-detectable tumor characteristics. mrEMVI should be incorporated in all risk stratification guidelines for rectal cancer.

Is current perioperative practice in hepatic surgery based on enhanced recovery after surgery (ERAS) principles?

BACKGROUND: The worldwide introduction of multimodal enhanced recovery programs has also changed perioperative care in patients who undergo liver resection. This study was performed to assess current perioperative practice in liver surgery in 11 European HPB centers and compare it to enhanced recovery after surgery (ERAS) principles. METHODS: In each unit, 15 consecutive patients (N = 165) who underwent hepatectomy between 2010 and 2012 were retrospectively analyzed. Compliance was classified as "full," "partial," or "poor" whenever ≥ 80, ≥ 50, or <50 % of the 22 ERAS protocol core items were met. The primary study end point was overall compliance with the ERAS core program per unit and per perioperative phase. RESULTS: Most patients were operated on for malignancy (91 %) and 56 % were minor hepatectomies. The median number of implemented ERAS core items was 9 (range = 7-12) across all centers. Compliance was partial in the preoperative (median 2 of 3 items, range = 1-3) and perioperative phases (median 5 of 10 items, range: 4-7). Median postoperative compliance was poor (median 2 of 9 items, range = 0-4). A statistically significant difference was observed between median length of stay and median time to recovery (7 vs. 5 days, P < 0.001). CONCLUSION: Perioperative care among centers that perform liver resections varied substantially. In current HPB surgical practice, some elements of the ERAS program, e.g., preoperative counselling and minimal fasting, have already been implemented. Elements in the perioperative phase (avoidance of drains and nasogastric tube) and postoperative phase (early resumption of oral intake, early mobilization, and use of recovery criteria) should be further optimized.