Colorectal cancer surgery in octogenarians: real-world long-term results.

AIMS: Colon cancer is the most common intra-abdominal cancer in older people. In the elderly with cancer, clinical decision making is often complicated by the effects of aging. However, as life expectancy continues to rise, more people aged 80 and older will present with colorectal cancer and may need major surgery. METHODS: Between 2000 and 2020 we operated on 352 patients aged 80 and older for colorectal cancer. We reviewed the case-notes of these patients and made a survival analysis for those patients who had a surgical resection of the tumor. RESULTS: In 20 patients a palliative procedure was performed. Three hundred and thirty-two (332) patients had a colorectal cancer resected. Of these, 57 patients died within 90 days postoperatively. Survival analysis was done for 275 patients who were alive longer than 90 days postoperatively. The overall 5-year survival in this group is 41.5%. There was no significant difference in postoperative survival between patients over the age of 85 and patients aged 80-84 at the time of operation. The survival of patients with stage IV colorectal adenocarcinoma is significantly worse than survival in stage I-III patients (Cox-Mantel log-rank test p < 0.001). CONCLUSIONS: After exclusion of the patients in the 90-day mortality group the overall 5-year survival in octogenarians who had a resection of a colorectal cancer was 41.5%. The most difficult problem is to choose the right treatment for the right patient. Optimal surgical and adjuvant treatment should not be denied to these older patients.

Rectal Biopsy for Hirschsprung's Disease: A Multicentre Study Involving Biopsy Technique, Pathology and Complications.

BACKGROUND: The heterogeneity of rectal biopsy techniques has encouraged us to search for a surgical and pathological standardisation of this diagnostic technique to exclude Hirschsprung's disease. The different amounts of information on the anatomopathology report prompted us to compile a template for the anatomopathology report for diagnostic rectal biopsies for surgical colleagues and pathologists working on Hirschsprung's disease. METHODS: We gathered the anonymous biopsy information and its pathology information from five hospitals for all patients in which rectal biopsies were taken to diagnose Hirschsprung's disease over two years (2020-2021). RESULTS: Of the 82 biopsies, 20 suction (24.4%), 31 punch (37.8%) and 31 open biopsies (37.8%) were taken. Of all biopsies, 69 were conclusive (84.2%), 13 were not (15.8%). In the suction biopsy group, 60% were conclusive and 40% were not; for punch biopsy, the values were 87% and 13%, respectively and for open biopsy, 97% and 3%. Inconclusive results were due to insufficient submucosa in 6/8 suction biopsies, 4/4 punch biopsies and 0/1 open biopsies. An insufficient amount of submucosa was the reason for an inconclusive result in 6/20 cases (30%) after suction biopsy, 4/31 (12.9%) cases after punch biopsy and 0 cases (0%) after open biopsy. We had one case with major postoperative bleeding post suction biopsy; there were no further adverse effects after biopsy. CONCLUSIONS: Diagnostic rectal biopsies in children are safe. Non-surgical biopsies are more likely to give inconclusive results due to smaller amounts of submucosa present in the specimen. Open biopsies are especially useful when previous non-surgical biopsies are inconclusive. An experienced pathologist is a key factor for the result. The anatomopathology report should specify the different layers present in the specimen, the presence of ganglion cells and hypertrophic nerve fibres, their description and a conclusion.

Early-Onset Pectus Excavatum Is More Likely to Be Part of a Genetic Variation.

BACKGROUND: Potential underlying genetic variations of pectus excavatum (PE) are quite rare. Only one-fifth of PE cases are identified in the first decade of life and thus are of congenital origin. The objective of this study is to test if early-onset PE is more likely to be part of genetic variations than PE that becomes apparent during puberty or adolescence. MATERIALS AND METHODS: Children younger than 11 years who presented with PE to the outpatient clinic of the Department of Pediatric Surgery at our center between 2014 and 2020 were screened by two clinical geneticists separately. Molecular analysis was performed based on the differential diagnosis. Data of all young PE patients who already had been referred for genetic counseling were analyzed retrospectively. RESULTS: Pathogenic genetic variations were found in 8 of the 18 participants (44%): 3 syndromic disorders (Catel-Manzke syndrome and two Noonan syndromes), 3 chromosomal disorders (16p13.11 microduplication syndrome, 22q11.21 microduplication syndrome, and genetic gain at 1q44), 1 connective tissue disease (Loeys-Dietz syndrome), and 1 neuromuscular disorder (pathogenic variation in BICD2 gene). CONCLUSION: Early-onset PE is more likely to be part of genetic variations than PE that becomes apparent during puberty or adolescence. Referral for genetic counseling should therefore be considered. TRIAL REGISTRATION: NCT05443113.

Effect of Suture Used for Closure of Mesenteric Defects After Laparoscopic Roux-en-Y Gastric Bypass: Single-Center Study.

INTRODUCTION: Small bowel obstruction (SBO) due to internal herniation (IH) is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). The objective of this study is to evaluate different types of non-absorbable sutures used for closure of the defects regarding the incidence of SBO due to IH/adhesions, adhesion formation in general, or reopening of the defects. METHODS: A single-center retrospective study was performed. Patients who underwent LRYGBP were divided in 3 groups: group A closure of the defects with monofilament Polypropylene suture (Prolene®), group B with braided polyester suture (Ethibond®), group C with barbed knotless Polybutester suture (V-Loc®). Descriptive statistics were performed regarding SBO due to IH/adhesions, adhesion formation, and reopening of closed defects. RESULTS: From 5145 patients, 224 patients underwent exploratory laparoscopy for suspicion of SBO. Mean time interval was 28.4 months. IH or intermittent IH was found in 1.94% in group A, 1.78% in group B, and 1.40% in group C. Obstruction due to adhesions was found in 0.70%, 0.36%, and 0.42% per group, respectively. Adhesions in general were observed in 1.47% in group A, 1.43% in group B, and 1.06% in group C. The incidence of reopening was higher in group A (2.24%) in comparison with group B (1.13%, P = 0.041) and group C (1.05%, P = 0.001). CONCLUSIONS: After descriptive analysis, these results can withhold no difference among the 3 non-absorbable sutures regarding incidence of SBO due to IH or SBO due to adhesions, yet tendency for higher reopening rates after closure with monofilament Polypropylene suture is observed.

The Management of Asymptomatic Congenital Pulmonary Airway Malformation: Results of a European Delphi Survey.

Consensus on the optimal management of asymptomatic congenital pulmonary airway malformation (CPAM) is lacking, and comparison between studies remains difficult due to a large variety in outcome measures. We aimed to define a core outcome set (COS) for pediatric patients with an asymptomatic CPAM. An online, three-round Delphi survey was conducted in two stakeholder groups of specialized caregivers (surgeons and non-surgeons) in various European centers. Proposed outcome parameters were scored according to level of importance, and the final COS was established through consensus. A total of 55 participants (33 surgeons, 22 non-surgeons) from 28 centers in 13 European countries completed the three rounds and rated 43 outcome parameters. The final COS comprises seven outcome parameters: respiratory insufficiency, surgical complications, mass effect/mediastinal shift (at three time-points) and multifocal disease (at two time-points). The seven outcome parameters included in the final COS reflect the diversity in priorities among this large group of European participants. However, we recommend the incorporation of these outcome parameters in the design of future studies, as they describe measurable and validated outcomes as well as the accepted age at measurement.

Development of a core outcome set for congenital pulmonary airway malformations: study protocol of an international Delphi survey.

INTRODUCTION: A worldwide lack of consensus exists on the optimal management of asymptomatic congenital pulmonary airway malformation (CPAM) even though the incidence is increasing. Either a surgical resection is performed or a wait-and-see policy is employed, depending on the treating physician. Management is largely based on expert opinion and scientific evidence is scarce. Wide variations in outcome measures are seen between studies making comparison difficult thus highlighting the lack of universal consensus in outcome measures as well. We aim to define a core outcome set which will include the most important core outcome parameters for paediatric patients with an asymptomatic CPAM. METHODS AND ANALYSIS: This study will include a critical appraisal of the current literature followed by a three-stage Delphi process with two stakeholder groups. One surgical group including paediatric as well as thoracic surgeons, and a non-surgeon group including paediatric pulmonologists, intensive care and neonatal specialists. All participants will score outcome parameters according to their level of importance and the most important parameters will be determined by consensus. ETHICS AND DISSEMINATION: Electronic informed consent will be obtained from all participants. Ethical approval is not required. After the core outcome set has been defined, we intend to design an international randomised controlled trial: the COllaborative Neonatal NEtwork for the first CPAM Trial, which will be aimed at determining the optimal management of patients with asymptomatic CPAM.

Internal Hernia After Laparoscopic Gastric Bypass: Effect of Closure of the Petersen Defect - Single-Center Study.

BACKGROUND AND AIMS: Bowel obstruction due to internal hernia (IH) is a well-known late complication of a laparoscopic roux-en-y gastric bypass (LRYGBP). The objective of this study is to evaluate if closure of the mesenteric defect and Petersen's space will decrease the rate of internal hernias compared to only closure of the mesenteric defect. METHODS: A single-center retrospective descriptive study was performed. All patients with LRYGBP from 2011 till April 2017 were included. An antecolic technique was used with closure of the mesenteric defect with a non-absorbable running suture between 2011 and October 2013 (group A), and from November 2013, we added closure of the Petersen defect (group B). RESULTS: From a total of 3124 patients, 116 patients (3.71%) had an exploratory laparoscopy due to suspicion of bowel obstruction, but in only 67 (2.14%) patients, an IH was found. Preoperative CT predicted the diagnosis in only 73%. In group A, including 1586 patients, 53 (3.34%) were diagnosed with an internal hernia: 39 at Petersen's space and 14 at the mesenteric defect. The mean time interval was 24.2 months and the mean BMI 25.7 kg/m2. After routine closure of the Petersen defect in 1538 patients in group B, an internal hernia during laparoscopy was found in 14 (0.91%) patients after a mean period of 13.5 months: 11 at Petersen's space and 3 at the mesenteric defect. In two subgroups (C and D) with an equal follow-up time (24-42 m), the incidence of 1.15% (8/699) was halved in the closure group of both defects compared to the incidence of 2.58% (23/893) in the group with only closure of the mesenteric defect. CONCLUSIONS: After descriptive analysis, these results can provide strong recommendation of closure of the mesenteric defect and Petersen's space, as we notice a tendency to lower incidence of internal hernias.

Myasthenia gravis appearing after thymectomy heralding recurrent thymoma.

INTRODUCTION: Thirty to fifty percent of thymoma patients develop myasthenia gravis (MG). In 1.5-28% of cases, MG appears many years after removal of a thymoma. PATIENTS AND METHODS: We present a case report of a 72-year-old female who presented with MG four months after total thymectomy. RESULTS: A 72-year-old female patient presents with MG four months after total thymectomy. Imaging revealed a PET-positive nodule anterior to the superior vena cava. By median sternotomy, the nodule was removed at our hospital. Pathology confirmed a recurrent B2/B3 thymoma with R0 resection. No adjuvant therapy was given. Large population studies show the appearance of new-onset MG associated with recurrent thymoma in 3% of cases. CONCLUSIONS: New-onset MG postthymectomy heralds recurrent disease in 3% of cases. Thorough screening is needed in such patients.

Prognostic factors and genetic markers in thymoma.

In this literature review prognostic factors and genetic markers that play a role in the staging of thymomas are discussed. The effect on prognosis of different factors, such as paraneoplastic syndromes, age, gender, classification, capsular invasion and surgical treatment, is evaluated. There is no generally accepted pathological classification of thymomas. More recently developed surgical techniques such as video-assisted or robotic thoracic surgery require longer follow-up times to determine whether they have equal long-term results compared to the classical surgical techniques. Many genetic markers have been described but at the present time no definite guidelines can be provided regarding screening and staging of thymomas.

Atypical presentation of an atypical carcinoid.

Carcinoids are malignant neuroendocrine tumors consisting of a spectrum of neoplasms from low-grade typical carcinoid to high-grade small cell carcinoma. Primary neuroendocrine lesions in the mediastinum, especially the thymic region, are rare. Therefore, presently no uniform criteria are available for diagnosis, staging, risk assessment, and treatment. Generally, carcinoid tumors are indolent. However, when they occur in the thymic region, these tumors should be considered as aggressive neoplasms with an elevated risk of local recurrence and distant metastases.

Recurrent myasthenia gravis due to a pleural implant 3 years after radical thymectomy.

Although recurrence of a thymoma is rare, pleural dissemination or local relapses have been described. We present a patient who underwent complete thymectomy for a thymoma, type AB according to the World Health Organization classification and stage II according to Masaoka, followed by adjuvant radiotherapy. Three years later, a relapse of the myasthenic symptoms occurred. An isolated pleural implant above the left diaphragm was removed by video-assisted thoracoscopy. Pathology confirmed the recurrence of the thymoma. As this is a rare occurrence, no precise therapeutic guidelines exist. In our case, surgical resection of the recurrence with adjuvant immunomodulating therapy for myasthenia provided good results.