Laparoscopic ventral mesh rectopexy in the oldest old is safe: the race is run.

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVMR) is considered to be the gold standard for managing rectal prolapse. Nevertheless, concerns have been expressed about the use of this procedure in elderly patients. The aim of the current study was to examine the perioperative safety of primary LVMR operations in the oldest old in comparison to younger individuals and to assess our hospital policy of offering LVMR to all patients, regardless of age and morbidity. METHODS: A retrospective study analysed demographic information, operation notes, meshes utilised, operation times, lengths of hospital stay (LOS) and American Society of Anesthesiologists (ASA) scores of patients who underwent LVMR at Elisabeth-TweeSteden Hospital between 2012 and 2023. RESULTS: Eighty-seven female patients underwent LVMR. Nineteen patients were 80 years of age or older (OLD group); the remaining 65 patients were under the age of 80 (YOUNG group). The difference between the groups in terms of age was statistically significant. ASA scores were not significantly different. No mortality was observed. There was no statistically significant difference between the groups in terms of LOS, operation time or morbidity. Moreover, the postoperative morbidity profile was excellent in both groups. CONCLUSION: LVMR seems to be a safe operation for the "oldest old" patients with comorbidity, despite a single-centre, retrospective trial with limited follow-up. The present study suggests abandoning the dogma that "frail patients with rectal prolapse are not suitable for laparoscopic ventral mesh rectopexy."

Internal Hernia After Laparoscopic Gastric Bypass Without Preventive Closure of Mesenteric Defects: a Single Institution's Experience.

BACKGROUND: Internal herniation (IH) is a well-known complication after laparoscopic gastric bypass (LGB). Diagnosing and managing IH can be challenging. This retrospective cohort study aimed to achieve a greater understanding of symptomatology, diagnostic tools, complications, risk of IH recurrence, and symptom relief in IH patients. METHODS: We included patients who underwent LGB surgery at our institution between 2011 and 2015. Mesenteric defects were not preventively closed during LGB. We focused on LGB patients who underwent surgical intervention(s) for suspected IH during a 7-year study period. We studied patient characteristics, (predictive) symptoms and signs, abdominal imaging, operative findings, post-operative course, and risk of (recurrent) IH. RESULTS: A total of 1588 patients were included. In total, 243 patients underwent IH-related diagnostic laparoscopy. Radiating pain to the back (OR 2.45, p = .03), post-prandial pain (OR 3.23, p = .00), and leukocytosis (OR 15.53, p = .01) were identified as predictors of IH. The estimated risk of IH-related diagnostic laparoscopy was 16% at 3 years post-LGB, and the risk of confirmed IH was 12%. The estimated risk of diagnostic laparoscopy for suspected recurrent IH was 10% at 5 years post-LGB. In patients who underwent secondary mesenteric defects closure, post-operative symptom relief was reported in 84%. CONCLUSION: This study demonstrates a considerable risk of developing IH after LGB without preventive closure of the mesenteric defects. We emphasize the value of diagnostic laparoscopy to achieve symptom relief in patients with suspicion of IH. Preoperative diagnosis of IH can be improved by being watchful of specific symptoms and signs which can predict the intra-operative presence of IH.

Simultaneous Large Paraesophageal Hernia Repair and Laparoscopic Roux-en-Y Gastric Bypass: a Single Institution's Experience.

This study reviews a single institution's experience with simultaneous (redo) laparoscopic Roux-en-Y gastric bypass (LRYGB) and primary large paraesophageal hernia (PEH) repair. A retrospective review was done of all 13 patients who underwent simultaneous LRYGB and large PEH repair between February 2014 and December 2017 at our institution. All patients had a large type III or IV PEH. All patients underwent primary crural repair, without the use of a reinforcing mesh. No patients underwent additional surgery for obstruction of the gastric pouch or for symptomatic recurrence of PEH. No mortality was reported. Our study highlights that simultaneous primary large PEH repair and primary or redo LRYGB is safe and feasible.

Laparoscopic repair of perineal hernia after abdominoperineal excision.

PURPOSE: Perineal hernia is a challenging complication after abdominoperineal excision (APE) of the rectum. Surgical repair can be accomplished using challenging abdominal or transperineal approaches. A laparoscopic repair using a Proceed mesh might be an easy and effective alternative. METHODS: We describe a multi-center case-series of twelve patients with a symptomatic perineal hernia treated by laparoscopic mesh repair. A cone-shaped 10 × 15 cm Proceed Mesh was tacked to the promontory or sacrum and sutured to the pelvic sidewalls and the anterior peritoneum. RESULTS: Twelve patients underwent laparoscopic repair of their perineal hernia. Four men and eight women presented with a symptomatic perineal hernia after abdominoperineal excision between 2008 and 2013 and underwent a laparoscopic repair with a Proceed mesh. The median age at presentation was 53 years (range 39-68 years). The mean total theater time was 119 min (range 75-200 min). No conversion to an open procedure was needed. No early complications where seen. The mean hospital stay was 2.25 days (range 1-4 days). Three patients showed recurrence, of whom two had a defect in the middle of the proceed mesh, one had a defect anterior to the previous perineal hernia. All 3 patients underwent a redo-laparoscopic repair with mesh. CONCLUSION: In this case series we present an alternative approach for the surgical repair of perineal hernias. Based on our experience, perineal hernia after APE can be repaired safely and effectively using the described laparoscopic technique.

Efficacy of follow-up after surgical treatment of colorectal liver metastases.

PURPOSE: There is an increasing tendency for an aggressive approach to colorectal liver metastases (CLM), even as second stage procedures after initial hepatic resection. This study assesses the efficacy of intensive follow-up after resection of CLM. PATIENTS AND METHODS: Hundred and three patients, operated on for CLM, were followed for disease recurrence. Outcome measures were time and imaging modality that revealed recurrence, performed treatment for recurrence, and overall survival. RESULTS: After hepatic resection, 1- and 3-year overall survival (OS) rates were 91% and 50%, the disease-free survival rates 63% and 45%. Seventy-four patients developed recurrent disease during follow-up. Resection of recurrence was performed in 25 patients. OS of this group was 51 months. Patients with recurrence treated by chemotherapy had an OS of 34 months. In case of recurrence, 70% was observed within 12 months, 92% within 24 months. CT appeared to be far a very useful surveillance modality, directing surgical treatment in 19 asymptomatic patients. DISCUSSION: Follow-up of patients after surgical treatment of CLM proves worthwhile, resulting in meaningful re-operations in a quarter of all patients that underwent hepatic resection for CLM.

Computer-based decision making in medicine: A model for surgery of colorectal liver metastases.

AIMS: Seeking the best available treatment for patients with colorectal liver metastases may be complex due to the interpretation of many variables. In this study conjoint analysis is used to develop a decision model to help clinicians selecting patients eligible for surgery of liver metastases. METHODS: Patient and tumor characteristics decisive for surgery of colorectal liver metastases were selected from literature. A factorial design was used to construct virtual patient cases by balanced combinations of these characteristics. Surgeons experienced in liver surgery (n=25) were asked to give their advised treatment (resection and/or local ablation, or chemotherapy). Different tumor and patient variables were weighted in the analysis for their contribution to treatment choices. RESULTS: Patient's age, the involvement of lobes and location of metastases in relation to large vessels were most important for treatment decisions. The number of metastases, size of the lesions, presence of resectable extrahepatic disease and time interval from primary tumor to metastases proved of less importance. Based on the analysis a computer-based decision model was designed. CONCLUSION: Conjoint analysis can be a valuable tool in clinical decision making. The computer-based decision model can assist clinicians in defining which patient should be referred for liver surgery.

Quality of life after surgical treatment of colorectal liver metastases.

BACKGROUND: The surgical approach to colorectal liver metastases is becoming increasingly aggressive. The aim of this prospective study was to evaluate the impact of surgery on health-related quality of life (HRQoL) of patients with colorectal liver metastases. METHODS: HRQoL data from 97 patients with colorectal liver metastases were analysed. Sixty patients (group 1) had surgical treatment of the liver metastases. Seventeen patients (group 2) were shown to have inoperable disease at laparotomy. Twenty outpatients with inoperable disease were included as a control group (group 3). Two validated HRQoL instruments, the European Organization for Research and Treatment of Cancer Core questionnaire (QLQ C-30) and the EuroQol-5D, were applied. RESULTS: By 2 weeks after operation patients in group 1 showed a clear overall deterioration in HRQoL, but after 3 months most HRQoL scores had returned to baseline levels. At 2 weeks after surgery there was clear deterioration in almost all HRQoL domains in group 2, and several symptoms were still being reported at 3 months. Patients in group 3 showed hardly any deterioration in HRQoL over the 3 months. CONCLUSION: The fast recovery of HRQoL, generally within 3 months, justifies an aggressive surgical approach to colorectal liver metastases. However, careful preoperative evaluation is crucial to avoid needless laparotomy, considering the ongoing deteriorated HRQoL of group 2.

Efficacy of fluorine-18-deoxyglucose positron emission tomography in detecting tumor recurrence after local ablative therapy for liver metastases: a prospective study.

PURPOSE: The aims of this prospective study were to investigate the potential role of fluorine-18-deoxyglucose (FDG) positron emission tomography (PET) in determining the efficacy of the local tumor ablative process and to determine the added value of FDG-PET in the detection of tumor recurrence during follow-up. PATIENTS AND METHODS: Twenty-three patients with unresectable colorectal liver metastases were followed up after local ablative therapy consisting of a standard protocol including FDG-PET scanning, computed tomography (CT) scanning, and carcinoembryonic antigen measurements. The mean follow-up period was 16 months (range, 10 to 21 months). RESULTS: Ninety-six lesions was treated, 56 by local ablative treatment. Within 3 weeks after local ablative treatment, 51 lesions became photopenic on FDG-PET, while five lesions (in five patients) showed persistent activity on FDG-PET. In four of five FDG-PET-positive lesions, a local recurrence developed during follow-up; one FDG-PET-positive lesion turned out to be an abscess. None of the FDG-PET-negative lesions developed a local recurrence during a mean follow-up period of 16 months. During follow-up, 11 patients showed recurrence in the liver outside of the treated area. In all cases, previously negative FDG-PET scans became positive. Extrahepatic recurrence was encountered in nine patients during follow-up; FDG-PET showed all nine cases of tumor recurrence. There was one false-positive FDG-PET caused by an intra-abdominal abscess. In all patients, the time point of detection of recurrence by FDG-PET was considerably earlier than the detection by CT. CONCLUSION: FDG-PET seems to have a significant impact in measuring treatment efficacy directly after local ablative therapy. Furthermore, FDG-PET has an added value in patient follow-up because it reveals recurrences earlier than conventional diagnostic modalities.

Value of positron emission tomography with [F-18]fluorodeoxyglucose in patients with colorectal liver metastases: a prospective study.

PURPOSE: To assess prospectively the value of fluor-18-deoxyglucose (FDG) positron emission tomography (PET), in addition to conventional diagnostic methods (CDM), as a staging modality in candidates for resection of colorectal liver metastases. PATIENTS AND METHODS: In 51 patients analyzed for resection of colorectal liver metastases, clinical management decisions were recorded after a complete work-up with CDM. Afterward, FDG-PET scans were performed and any change of clinical management according to FDG-PET results was carefully documented. Discordances between FDG-PET and CDM results were identified and related to the final diagnosis by histopathology, intraoperative findings, and follow-up. RESULTS: In 10 (20%) out of 51 patients, clinical management decisions based on CDM were changed after FDG-PET findings were known. FDG-PET detected unresectable pulmonary (n = 5) and hepatic metastases (n = 1) and ruled out extrahepatic (n = 2) and hepatic disease (n = 2). Due to FDG-PET, eight patients were spared unwarranted liver resection or laparotomy and two other patients were identified as candidates for liver resection. When the results of FDG-PET were regarded as decisive in a retrospective analysis, potential change of management was 29% (15 patients). FDG-PET and CDM showed discordant extrahepatic results in 11 patients (22%) and discordant hepatic results in eight patients (16%). Compared with CDM, FDG-PET resulted in true upstaging (n = 11), true downstaging (n = 5), false upstaging (n = 1), and false downstaging (n = 2). The detection rate of liver metastases on a lesion basis was generally better for computed tomography than for FDG-PET (80% v 65%); this was related to tumor size. CONCLUSION: FDG-PET as a complementary staging method improves the therapeutic management of patients with colorectal liver metastases, especially by detecting unsuspected extrahepatic disease.

Quality of life as an outcome measure in surgical oncology.

BACKGROUND: There is a growing interest in assessing the impact of a disease and the effect of a treatment on a patient's life, expressed as health-related quality of life (HRQoL). HRQoL assessment can provide essential outcome information for cancer surgery. METHODS: The core of this review is derived from a literature search of the Medline database. RESULTS: Three types of HRQoL instrument can be distinguished: generic, disease specific and symptom specific. There are criteria against which HRQoL instruments may be evaluated. The instrument chosen must be reliable, valid and sensitive to change. CONCLUSION: HRQoL measurement may be useful in identifying the optimal surgical procedure. It may also be of help in deciding whether surgery in patients with limited life expectancy should still be considered. No HRQoL instrument fits all the recommended conditions or is suitable in all clinical situations. Using the appropriate instrument is essential to arrive at valid and clinically meaningful outcome measures.