Associations between the Geriatric-8 and 4-meter gait speed test and subsequent delivery of adjuvant chemotherapy in older patients with colon cancer.

OBJECTIVES: Feasible screening methods are important to identify older patients who might benefit from adjuvant chemotherapy. The aim of this study was to investigate the associations between the outcomes of screening for frailty with the Geriatric-8 questionnaire (G8) and the 4-meter gait speed test (4MGST) and subsequent delivery of adjuvant chemotherapy and treatment tolerance in older patients with colon cancer. MATERIAL AND METHODS: This retrospective multicentre study included all patients aged ≥70 with primary colon carcinoma who underwent elective surgery between May 2016 and December 2018 and for whom adjuvant chemotherapy was indicated. Data were analysed using multivariate regression models. RESULTS: 97 (73.5%) of 132 eligible patients were screened by the G8 and 85 (64.4%) by the 4MGST. In univariate analyses, patients who scored indicative for frailty on both the G8 (≤14) and the 4MGST (>4 s) significantly more often did not proceed with adjuvant chemotherapy than patients who scored fit on both instruments (OR = 5.10, p = 0.01). After adjustment for gender, stage, and postoperative complications, the OR decreased to 4.22 (p = 0.04). Tolerance of treatment was very high (93%) and did not differ between screening groups. CONCLUSION: Although patients who scored indicative for frailty on both the G8 and the 4MGST significantly more often did not proceed with adjuvant chemotherapy, it is still unknown whether the G8 and the 4MGST are reliable tools for identifying patients who are at high risk for severe chemotoxicity. Nonetheless, this study shows that current selection for adjuvant chemotherapy among older patients with colon cancer is safe with low rates of severe chemotoxicity.

Preoperative handgrip strength is not associated with complications and health-related quality of life after surgery for colorectal cancer.

Colorectal cancer (CRC) treatment is associated with a high morbidity which may result in a reduced health-related quality of life (HRQoL). The pre-operative measurement of handgrip strength (HGS) might be a tool to predict the patient's outcome after CRC surgery. The aim of this study was to evaluate the association of pre-operative HGS with the occurrence of postoperative complications and postoperative HRQoL. Stage I to III CRC patients ≥ 18 years were included at diagnosis. Demographic and clinical data as well as HGS were collected before start of treatment. HGS was classified as weak if it was below the gender-specific 25th percentile of our study population; otherwise HGS was classified as normal. The occurrence of postoperative complications within 30 days after surgery was collected from medical records. Cancer-specific HRQoL was measured 6 weeks after treatment using the EORTC QLQ-C30 and the EORTC QLQ-CR29 questionnaire. Of 295 patients who underwent surgical treatment for CRC, 67 (23%) patients had a weak HGS while 228 (77%) patients had normal HGS. 118 patients (40%) developed a postoperative complication. Complications occurred in 37% of patients with a weak HGS and in 41% of patients with a normal HGS (p = 0.47). After adjustment for age, sex, ASA, BMI and TNM, no significant associations between pre-operative HGS and the occurrence of postoperative complications and between HGS and HRQoL were found. We conclude that a single pre-operative HGS measurement was not associated with the occurrence of postoperative complications or post-treatment HRQoL in stage I-III CRC patients.

The low anterior resection syndrome in a reference population: prevalence and predictive factors in the Netherlands.

AIM: The low anterior resection syndrome (LARS) severely affects quality of life (QoL) after colorectal cancer surgery. There are no data about these complaints and the association with QoL in a reference population. The aim of this study was to assess LARS and the association with QoL in a reference population. METHODS: Six hundred patients who visited the outpatient clinic because of general or trauma surgical indications were asked to participate in this study. They received an invitation letter containing three validated questionnaires to assess LARS (assessed with the LARS score) and both general [European Organization for the Research and Treatment of Cancer (EORTC) QLQ-C30] and colorectal-specific (EORTC QLQ-CR29) QoL. RESULTS: Five hundred and one respondents could be included for the analyses. The median age at inclusion was 68 years and 47.3% were men. Major LARS was observed in 15% of patients (11.4% in men and 18.9% in women, P = 0.021). Women reported more urgency (P = 0.070) and incontinence for both flatus (P < 0.001) and stool (P = 0.063) compared to men. In univariate analyses, women reported major LARS significantly more often than men (OR 1.82; 95% CI 1.10-3.01). Patients with major LARS scored significantly worse in most QoL domains compared to patients with no/minor LARS. CONCLUSION: This is the first study demonstrating major LARS and the association with QoL in a reference population of patients without colorectal cancer. Our data can assist in the interpretation of LARS in past and future research about abdominal complaints after colorectal cancer surgery.

Functional bowel complaints and quality of life after surgery for colon cancer: prevalence and predictive factors.

AIM: Low anterior resection syndrome (LARS) severely affects the quality of life (QoL) of patients after surgery for rectal cancer. There are very few studies that have investigated LARS-like symptoms and their effect on QoL after colon cancer surgery. The aim of this study was to investigate the prevalence of functional abdominal complaints and related QoL after colon cancer surgery compared with patients with similar complaints after rectal cancer surgery. METHOD: All patients who underwent colorectal cancer resections between January 2008 and December 2015, and who were free of colostomy for at least 1 year, were eligible (n = 2136). Bowel function was assessed by the LARS score, QoL by the EORTC QLQ-C30 and QLQ-CR29 questionnaires. QoL was compared between the LARS score categories and tumour height categories. RESULTS: A total of 1495 patients (70.0%) were included in the analyses, of whom 1145 had a colonic and 350 a rectal tumour. Symptoms of LARS were observed in 55% after rectal cancer resection compared with 21% after colon cancer resection. Female gender (OR 1.88, CI 1.392-2.528) and a previous diverting stoma (OR 1.84, CI 1.14-2.97) were independently associated with a higher prevalence of LARS after colon cancer surgery. Patients with LARS after colon cancer surgery performed significantly worse in most QoL domains. CONCLUSION: The results of this study highlight the presence of LARS-like symptoms after surgery for colonic cancer. Patients suffering from major LARS-like symptoms after colon resection reported the same debilitating effect on their QoL as patients with major LARS after rectal resection. This should be addressed by colorectal cancer specialists in order to adequately inform patients.

Bowel dysfunction after sigmoid resection underestimated: Multicentre study on quality of life after surgery for carcinoma of the rectum and sigmoid.

AIM: The Low Anterior Resection Syndrome (LARS) severely affects quality of life (QoL) after rectal cancer surgery. There are no data about functional complaints after sigmoid cancer surgery. We investigated LARS and QoL in patients with a resection for sigmoid cancer versus patients who had surgery for rectal cancer. METHODS: 506 patients after resection for rectal or sigmoid cancer who were at least one year colostomy-free were included between January 2008 and December 2013. Bowel function was assessed by the LARS-Score. QoL was assessed by the EORTC QLQ-C30 and -CR29 questionnaires. QoL was compared between the LARS score categories and tumour height categories. RESULTS: 412 respondents (81.5%) could be included for the analyses. The median interval since treatment was 5 years, and the median age at the follow-up point was 72 years. Major LARS increased significantly with decreasing tumour height from one fifth in sigmoid carcinoma to 90% in low rectum carcinoma. Female gender (OR = 2.162; 95% CI: 1.349-3.467), postoperative temporary diverting stoma (OR = 3.457; 95% CI: 2.019-5.919) and tumours located in the middle (OR = 3.193; 95% CI: 1.696-6.010) or lower rectum (OR = 8.247; 95% CI: 1.672-40.678) were independently associated with the development of major LARS. Patients with major LARS fared significantly worse in most QOL domains. CONCLUSIONS: For the first time, we found that functional abdominal complaints after sigmoid surgery are a major problem, with a negative effect on QoL, even 5 years after treatment. Patients need to be adequately informed about these long-term complaints.

Mesh Versus Patch Repair for Epigastric and Umbilical Hernia (MORPHEUS Trial); One-Year Results of a Randomized Controlled Trial.

DESIGN: This trial is a randomized controlled, patient-blinded, multicentre, superiority trial. METHODS: All patients ≥18 years with a single, symptomatic and primary umbilical or epigastric hernia (<2 fingers) qualified for participation in the study. Flat polypropylene mesh repair was compared to patch repair (PROCEED® Ventral Patch) (PVP). The objective of this trial was to identify a superior method for umbilical and epigastric hernia repair in terms of complication rates. RESULTS: A total of 352 patients were randomized in this trial; 348 patients received the intervention (n = 177 PVP vs. n = 171 mesh). No peri-operative complications occurred. PVP placement was significantly faster compared to mesh placement (30 min, SD 11 vs. 35 min, SD 11) and was scored as an easier procedure. At 1-month follow-up, 76 patients suffered any kind of complication. There was no significant difference in the proportion of complications (24.9% for PVP and 18.7% for mesh, p = 0.195). A significant difference was seen in re-operation rate within 1 month, significantly less early re-operations in the mesh group (0.0 vs. 2.8%, p = 0.027). After 1-year follow-up, no significant differences are seen in recurrence rates (n = 13, 7.8% PVP vs. n = 5, 3.3% mesh, p = 0.08). CONCLUSIONS: Both mesh and PVP had a comparable amount of reported complications. There was a significantly higher incidence of early re-operations due to early complications in the PVP group. No differences were seen in infection rates and the need for antibiotic treatment. No significant difference was seen in the recurrence rates. REGISTRATION: This trial was registered in the Dutch Trail Registry (NTR) NTR2514NL33995.060.10. [12].

Evaluation of nutritional status as an independent predictor of post-operative complications and morbidity after gastro-intestinal surgery.

BACKGROUND: Nutritional Risk Screening-2002 (NRS-2002) and the Malnutrition Universal Screening Tool (MUST) are screening tools for nutritional risk that have also been used to predict post-operative complications and morbidity, though not all studies confirm the reliability of nutritional screening. Our study aims to evaluate the independent predictive value of nutritional risk screening in addition to currently documented medical, surgical and anesthesiological risk factors for post-operative complications, as well as length of hospital stay. METHODS: This study is a prospective observational cohort study of 129 patients undergoing elective gastro-intestinal-surgery. Patients were screened for nutritional risk upon admission using both MUST and NRS-2002 screening tools. Univariate and multivariate analyses were performed to investigate the independent predictive value of nutritional risk for post-operative complications and length of hospital stay. RESULTS: MUST ≥2 (OR 2.87; 95% CI 1.05-7.87) and peri-operative transfusion (OR 2.78; 95% CI 1.05-7.40) were significant independent predictors for the occurrence of post-operative complications. Peri-operative transfusion (HR 2.40; 95% CI 1.45-4.00), age ≥70 (HR 1.50; 95% CI 1.05-2.16) and open surgery versus laparoscopic surgery (HR 1.39; 95% CI 0.94-2.05) were independent predictors for increased length of hospital stay, whereas American Society of Anesthesiology Score (ASA) and MUST were not. CONCLUSION: Nutritional risk screening (MUST ≥2) is an independent predictor for post-operative complications, but not for increased length of hospital stay.

Long-term outcome of low perianal fistulas treated by fistulotomy: a multicenter study.

PURPOSE: Fistulotomy is considered to be the golden standard for the treatment of low perianal fistula but might have more influence on continence status than believed. This study was performed to evaluate the healing rate after a fistulotomy and to show results for continence status. METHODS: A retrospective database study was performed in one university medical center and its six affiliated hospitals. All patients treated with a fistulotomy for a low perianal fistula were identified. Healing and recurrence of the fistula were identified. Questionnaires on continence status and quality of life were mailed to all patients. RESULTS: In total, 537 patients were identified. The primary etiology of the fistulas was cryptoglandular (66.5%). Recurrence was seen in 88 patients (16.4%) resulting in a primary healing rate of 83.6%. After secondary treatment for the recurrence, another 40 patients healed. This resulted in a secondary healing rate of 90.3%. The Kaplan-Meier analysis showed that at 5 years, the healing rate was 0.81 (95% confidence interval (95% CI) 0.71-0.85). The mean Vaizey score was 4.67 (SD 4.80). Major incontinence, defined as a Vaizey score of >6, was seen in 95 (28.0%) patients. Only 26.3% of the patients had a perfect continence status (Vaizey score 0). Quality of life was not different from the general population. CONCLUSIONS: Fistulotomy seems to be associated with a healing rate of 0.81 (95% CI 0.71-0.85) after 5 years. However, major incontinence is still reported by 26.8% of patients and only 26.3% of patients had a perfect continence status.

Classical operative therapy for Zenker's diverticulum.

Zenker's diverticulum is a rare disease usually described in elderly patients. The "gold standard" is endoscopic treatment. We describe a 77-year-old patient treated by classical operative therapy. Patient history showed weight loss of 22 kilograms within a year. Physical examination showed a swelling in the neck of 7 by 2 centimeters. Gastroscopic examination demonstrated a Zenker's diverticulum, but this could not be passed with the scope. Classical surgical resection was performed with excellent results 6 months after surgery.

[Pancreas-preserving total duodenectomy due to familial adenomatous polyposis in 4 patients]. / Pancreassparende totale duodenectomie wegens familiaire adenomateuze polyposis bij 4 patiënten.

In 4 patients with familial adenomatous polyposis (FAP) and multiple severe dysplastic adenomas in the duodenum (a 42-year-old woman and 3 men aged 44, 53 and 33 years, respectively), pancreas-preserving total duodenectomy (PPTD) was carried out. In 2 of the patients, serious early post-operative complications arose (leakage and haemorrhage of the gastrojejunostomy, respectively), and 1 patient developed a late complication (attacks of pancreatitis). During the 1-5-year follow-up period, small villous adenomas were seen in the jejunum (neoduodenum) of 1 of the patients. PPTD is a technically possible procedure which allows targeted treatment to be carried out if duodenum polyps are found upon endoscopic examination.

Comparison of epineural or intramuscular nerve electrodes for stimulated graciloplasty.

OBJECTIVE: Two different techniques have been developed to stimulate the gracilis muscle when it is used in anal neosphincter reconstruction. These are direct neural stimulation and intramuscular electrode stimulation. The aim of this study was to compare these techniques. METHODS: Comparison was made of gracilis anal neosphincter reconstruction using neural stimulation (Royal London Hospital in the United Kingdom) with the intramuscular muscular method (University Hospital Maastricht in the Netherlands). The United Kingdom data were obtained from a retrospective database, whereas the Netherlands data were gathered prospectively. RESULTS: A successful outcome was achieved in 46 of 81 patients (57 percent) in London and 148 of 200 cases (74 percent) in the Maastricht study (chi-squared = 7.2; P < 0.01). There was no significant difference between the two techniques in voltage required for stimulation of the neosphincter muscle during a ten-year period. Reoperative surgery for electrode failure or dislocation was required in 21 (26 percent) patients in the London study, whereas only four (2.7 percent) of the Maastricht cases required such procedures (chi-squared = 37.8; P < 0.05). The high electrode plate failure rate in the London study was related to the source of manufacture. CONCLUSIONS: Both neural and intramuscular nerve techniques provide effective long-term stimulation of the gracilis anal neosphincter.

Hemorrhoidectomy vs. Lord's method: 17-year follow-up of a prospective, randomized trial.

PURPOSE: A prospective, randomized trial was performed between 1979 and 1981 comparing anal dilation and hemorrhoidectomy for hemorrhoidal disease at the Maastricht University Hospital. The aim of this study was to update that trial to assess long-term outcome and complications such as fecal incontinence. METHODS: A total of 138 patients with second-degree and third-degree hemorrhoids entered the study. Median follow-up was 17 (range, 8.4-18.3) years and was achieved for 118 (86 percent) patients. Group A (n = 35) underwent hemorrhoidectomy and Group B (n = 39) was treated with anal dilation and aftertreatment (original Lord's procedure), whereas Group C (n = 44) had dilation only. Fourteen of these patients died. RESULTS: Recurrent hemorrhoids were noted for 26 percent of the patients treated with hemorrhoidectomy, for 46 percent with operative dilation with the postoperative dilation program, and for 39 percent with operative dilation without the postoperative program. The percentage of repeated treatment for the three subgroups was 11, 23, and 18 percent, respectively. The continence status remained more or less the same during the first year. However, 17 years later the anal stretch procedures caused various incontinence disorders in 52 percent of these patients. Significance was found for incontinence of flatus (from 11 to 30 patients; P = 0.04) in the anal dilation groups. CONCLUSIONS: Hemorrhoidectomy can be considered to be a safe procedure for treatment of hemorrhoidal disease, with excellent long-term results. Anal dilation is associated with a high percentage of complaints of fecal incontinence. The procedure should be abandoned.

[General surgery in Paramaribo University Hospital]. / Algemene heelkunde in het Academisch Ziekenhuis Paramaribo.

Specific health problems in Surinam include high prevalence of infections, mostly gastrointestinal infections in young children, malaria and injuries due to violence. The public health care and medical and surgical training are hampered by a lack of funds, as are most things in the country. Relatively much of the surgery in Paramaribo University Hospital in 1991-1998 was performed because of complications of a diabetic foot (128.17%) and breast lesions (76.10%). No scientific research is being carried out either in the hospital or at the faculty of Anton de Kom University. Retrospective registration of operations may give a new impulse to scientific research.

General surgery in Paramaribo University Hospital

Specific health problems in Suriname include high prevalence of infections, mostly gastrointestinal infections in young children, malaria and injuries due to violence. The public health care and medical and surgical training are hampered by a lack of funds, as are most things in the country. Relatively much of the surgery in Paramaribo University Hospital in 1991-1998 was performed because of complications of a diabetic foot (128.17 percent) and breast lessions (76.10 percent). No scientific research is being carried out either in the hospital or at the Faculty of Anton de Kom University. Retrospective registration of operations may give a new impulse to scientific research. (AU)

Assessment of ischaemia of the distal part of the gracilis muscle during transposition for anal dynamic graciloplasty.

BACKGROUND: Dynamic graciloplasty is used to create a neosphincter in patients with intractable faecal incontinence. When mobilizing the distal gracilis muscle from the upper leg, the minor vascular pedicles have to be ligated. This can interfere with the vascular supply in this part of the muscle. METHODS: The arterial anatomy within the muscle was visualized by means of angiography of 11 postmortem specimens. To quantify potential acute ischaemia, blood flow in the distal gracilis muscle was measured in ten patients with laser Doppler flowmetry during mobilization of the muscle. RESULTS: Angiography showed that the main vascular pedicle and all minor pedicles drain into one and the same arterial system. After clamping of the minor vascular pedicles, blood flow (mean 25.8 (range 6.5-74.3) perfusion units) did not differ from values obtained before clamping (mean 25.4 (range 7.5-68.7) perfusion units). After a mean of 1.8 years, all muscles were vital. No correlation existed between the change in muscle blood flow and either squeeze pressure (r = -0.2) or functional outcome (r = 0.31). CONCLUSION: This study provides direct anatomical and physiological evidence of one arterial system within the gracilis muscle. It is therefore questionable whether ligation of the minor vascular pedicles is the bottleneck in human dynamic graciloplasty. An additional operation for vascular delay may be redundant. A prospective randomized clinical study should be performed to compare the functional outcome in patients with and without a delay procedure.

Dynamic graciloplasty. Complications and management.

PURPOSE: Patients with intractable fecal incontinence, in whom all other treatment failed, can be treated by dynamic graciloplasty. Good results have been reported, but this technique involves specific problems. All problems that occurred over an eight-year period are presented, and management is discussed. METHODS: Dynamic graciloplasty was performed in 67 patients with a mean follow-up of 2.7 years. All patients were monitored by physical examination, anal manometry, defecography, and electromyography at fixed intervals. All complications were noted and treated. Continence was defined as being continent to solid and liquid stools. RESULTS: The technique was successful in 52 patients (78 percent), whereas failures occurred in 15 patients (22 percent). Complications resulted from technical problems, problems with infection, and problems attributable to an abnormal physiology of the muscle or an anorectal functional imbalance. In total, 53 complications were identified in 36 patients. Most technical problems, concerning the transposition and stimulation of the gracilis muscle, could be treated. Failures were attributable to a bad contraction of the distal part of the muscle (n = 4) and perforation of the anal canal during stimulation (n = 1). In eight patients, infection of the stimulator and leads required explantation. Three patients did not regain continence after reimplantation. Apart from moderate constipation, physiologic complications were very hard to treat and resulted in failures in five patients because of overflow incontinence, soiling, a nondistending rectum, strong peristalsis, and strong constipation. In two patients, the technique failed despite a well-contracting graciloplasty; no clear reason for the failure was found. CONCLUSION: Complications associated with the technique of dynamic graciloplasty such as loss of contraction, infection, bad contraction in the distal part of the muscle, and constipation can often be prevented or treated. Difficulties related to an impaired sensation and/or motility, attributable to a congenital cause or degeneration, are impossible to treat, and this signifies that a good selection of patients is essential to prevent disappointment.

Anal dynamic graciloplasty in the treatment of intractable fecal incontinence.

BACKGROUND: In patients with intractable fecal incontinence, conventional treatment is not always successful. Dynamic graciloplasty (transposition of the gracilis muscle to the anus with the implantation of stimulating electrodes) was developed to provide such patients with functional neosphincters. We evaluated the clinical results of this new surgical approach and the effects on quality of life. METHODS: We treated 52 patients with dynamic graciloplasty. The clinical results of treatment were evaluated in an interview, by anal manometry, and by enema testing. The degree of continence was scored. To assess quality of life, four questionnaires were administered (parts 1 and 2 of the Nottingham Health Profile, the State-Trait Anxiety Inventory, and the Self-rating Depression scale). RESULTS: Among the 52 patients, 38 (73 percent) were continent after a median follow-up of 2.1 years. At 52 weeks the patients' condition had improved with respect to the median frequency of defecation (from five to two times per 24 hours, P < 0.001), the median time defecation could be postponed (from 9 seconds to 19 minutes, P = 0.012), and the median time an enema could be retained (from 0 to 180 seconds, P = 0.005). Patients in whom the technique was successful became less anxious than those in whom it failed (P = 0.002) and improved with regard to effectiveness in their occupations, ability to perform tasks around the home, personal relationships, sexual function, and social life (P = 0.01). They also became less isolated socially (P = 0.05). CONCLUSIONS: Dynamic graciloplasty is a safe and reliable technique in patients with severe incontinence and may result in a better quality of life.

Defecographic evaluation of dynamic graciloplasty for fecal incontinence.

PURPOSE: A prospective defecographic study was performed to evaluate the anorectal physiology of dynamic graciloplasty (gracilis muscle transposition and subsequent implantation of an electric stimulator) for treatment of fecal incontinence. METHODS: From November 1986 until May 1993, 38 consecutive patients with incapacitating fecal incontinence were treated with "anal dynamic graciloplasty." Defecography was performed before and after surgical procedures. Defecographic data (anorectal angle, perineal descent, anal canal length, anal canal width, and anal leakage) were correlated with respect to clinical outcome and anal manometry. RESULTS: Fecal continence was achieved in 24 patients, which correlated significantly with no leakage of barium contrast during defecography (P < 0.01, Kruskal-Wallis one-way analysis of variance). In addition, minimum anal canal width decreased from 7 mm before surgery to 1 mm after dynamic graciloplasty (P < 0.01, paired Student's t-test). CONCLUSION: Defecography is an efficient method to evaluate dynamic graciloplasty for fecal incontinence.