[Diagnostic image (364). A boy with a painful inguinal mass]. / Diagnose in beeld (364). Een jongen met een pijnlijke zwelling in de lies.

A 9-year-old boy presented with right-sided abdominal pain and an inguinal mass due to torsion of an acquired ectopic testicle.

Quality of life after transanal endoscopic microsurgery and total mesorectal excision in early rectal cancer.

OBJECTIVE: Total mesorectal excision (TME) is the gold standard in rectal cancer, if curation is intended. Transanal endoscopic microsurgery (TEM) is a much safer technique and seems to have comparable survival in early rectal cancer. The impact of both procedures on quality of life has never been compared. In this study we compared quality of life after TEM and TME. METHOD: Fifty-four patients underwent TEM for a T1 carcinoma. Only patients without known locoregional or distant recurrences were included, resulting in 36 eligible patients in whom quality of life after TEM was studied. The questionnaires used included the EuroQol EQ-5D, EQ-VAS, EORTC QLQ-C30 and EORTC QLQ-CR38. The results were compared with a sex-and age-matched sample of T+N0 rectal cancer patients who had undergone sphincter saving surgery by TME and a sex- and age matched community-based sample of healthy persons. RESULTS: Thirty-one patients after TEM returned completed questionnaires (overall response rate 86%). Quality of life was compared with 31 TME patients and 31 healthy controls. From the patients' and social perspective quality of life did not differ between the three groups. Compared with TEM, significant defecation problems were seen after TME (P < 0.05). A trend towards better sexual functioning after TEM, compared with TME, was seen, especially in male patients, although it did not reach statistical significance. CONCLUSION: Transanal endoscopic microsurgery and TME do not seem to differ in quality of life postoperatively, but defecation disorders are more frequently encountered after TME. This difference could play a role in the choice of surgical therapy in (early) rectal cancer. Further prospective studies are needed to confirm our conclusions.

Introduction of preoperative radiotherapy in the treatment of operable rectal cancer in the Southwest region of the Netherlands.

INTRODUCTION: After publication of the results of the Dutch TME-trial preoperative radiotherapy followed by TME-surgery was introduced in July 2001 in the region of the comprehensive cancer centre Rotterdam as standard treatment for rectal cancer. The aim of this study is to identify the compliance to a new standardized treatment protocol i.e. the introduction of preoperative radiotherapy and to analyze the results of rectal cancer treatment in the Cancer Centre Rotterdam Region. PATIENTS AND METHODS: A total of 521 patients with adenocarcinoma of the rectum were included in the period from 2001 to 2003. All patients were treated with curative intent. RESULTS: There was a significant increase of preoperative radiotherapy for patients with a tumour in the lower two-third of the rectum (21% versus 69%, p<0.001). Peri-operative mortality rate was 2.7% and overall anastomotic leakage rate was 10.3%. There was a significant increase in the occurrence of anastomotic leakage in end-to-end anastomoses (p<0.0001). Most anastomotic leakages occurred when patients were operated in between 4 and 8 days after the end of radiotherapy. Several aspects such as continence for urine and faeces and sexual functions were poorly registered. The total number of lymph nodes registered in pathology reports was low. The rate of reported circumferential margins increased from 37% to 70% after feedback to the regional pathology working group. CONCLUSION: The regional quality of rectal cancer surgery is conform preset quality-demands. There was a significant increase in the percentage preoperative radiotherapy, but still about 25% of patients who qualified for radiotherapy did not receive radiation. Pathology reports improved during registration, which illustrates the importance of registration to assess and improve quality of rectal cancer treatment.

Quality of life after total mesorectal excision for rectal cancer.

BACKGROUND: After total mesorectal excision for rectal cancer, many surgeons try to avoid an abdominoperineal resection (APR) by performing a transanally double stapled low colo-rectal anastomosis (LRA), frequently without a pouch. This policy is mainly based on the assumption that the quality of life after such LRA is higher than after APR. It has been suggested that a better functional outcome and therefore a higher quality of life might be achieved by a colo-anal J-pouch anastomosis (CPA). The aim of this study was to assess quality of life among disease-free survivors after APR, LRA and CPA. METHODS: The charts of 301 consecutive patients who had undergone surgery for cancer in the middle or lower third of the rectum were analysed. Two hundred four patients were eligible for inclusion. The quality of life among these patients was assessed using one generic (EQ-5D) and two disease-specific questionnaires (EORTC QLQ-C30 and EORTC QLQ-CR38). RESULTS: The response rate was 82%. The median follow-up was 31 months. Overall, quality of life was good but CPA patients had better quality of life scores than APR and LRA patients. This difference was not only due to the better functional outcome but also to the lower incidence of disturbed micturition and sexual problems in the CPA group. CONCLUSION: The quality of life after colo-anal J-pouch anastomosis is better than after abdominoperineal resection (APR) and low colo-rectal anastomosis (LRA). The quality of life after APR is similar to that after LRA.

Hospital volume and post-operative mortality after resection for gastric cancer.

AIMS: In low-volume hospitals, expertise in gastric surgery is difficult to maintain because of the decreasing incidence of gastric cancer and the fall of surgery for ulcer disease. We evaluated the prognostic impact of hospital volume on post-operative mortality (POM) in a consecutive series of 1978 patients. METHODS: Information on patients undergoing resection for gastric cancer in the period 1987-97 was retrieved from the Rotterdam Cancer Registry. The relationship between hospital volume and POM was analysed by logistic regression, adjusting for other prognostic factors. RESULTS: POM was 7.9% on average but varied between the 22 hospitals from 3.1% to 15.1% (P=0.15). Hospital volume had no prognostic influence (P=0.74). Prognostic factors were age (70-79 years odds ratio (OR)=3.8, 80+ years OR=6.0), sex (male OR=1.7), stage (IV OR=1.8) and (partial) gastrectomy for cardia cancers (OR=2.0). CONCLUSION: Variation in POM between hospitals was large but not related to hospital volume. For cardia cancer, POM rates were lower after oesophagogastrectomy.

Effective reconstruction after pharyngolaryngo-oesophagectomy with an ileal autograft.

Total pharyngolaryngo-oesophagectomy is performed for carcinoma of the cervical oesophagus, the piriform sinuses and the postcricoid region. A safe effective way of reconstructing the cervical oesophagus is of the utmost importance in these patients. Use of a revascularized intestinal segment for this purpose is described. Twenty-one patients who underwent reconstruction of the cervical oesophagus with an ileal autograft were studied, with a follow-up period of one to .58 months. The low postoperative mortality and morbidity, quick resumption of oral intake, short hospitalization and good functional results obtained with this method yield benefits for these patients.

Carcinoma of the esophagus: results of treatment.

The treatment results of the Rotterdam working group on esophageal cancer during the period January 1970-January 1978 were assessed. A total number of 328 patients were treated: 230 males and 98 females. Of the 133 patients eligible for a combined treatment modality i.e. preoperative radiotherapy and surgery, 52 showed irresectable or metastatic disease during operation. The five year actuarial survival rate of the 81 patients, in whom curative surgical resection of the tumor was performed, amounted to 21%. Females fared better than males, the five year survivals being 42% and 12% respectively. This female preponderance in survival is partly explained by the considerable postoperative mortality of the male patients: 28% vs 7.4% in females. Patients who received only radiation therapy, whether curative or palliative, had a very bad prognosis. It is concluded that preoperative irradiation followed by surgical removal of the tumor should be performed in all operable-curable patients.

Rapid reversal of compensatory renal hypertrophy after withdrawal of the stimulus.

The permanence of the early phases of compensatory renal hypertrophy was tested by interrupting vascular parabiosis between an anephric rat and a normal rat after 48 hours. At the time of interruption, the weights and the ratio of ribonucleic acid (RNA) content to deoxyribonucleic acid (DNA) content of the kidneys were the same as those of the remaining kidney in a single rat subjected to unilateral nephrectomy, previously reported. Within 12 hours after parabiosis was stopped, renal mass and nucleic acid concentrations returned to normal. Compensatory hypertrophy could be produced again by unilateral nephrectomy. Regression of the early phase of compensatory hypertrophy appears to be faster than muscular atrophy produced by disuse or denervation. Compensatory hypertrophy can be activated at least twice.