The impact of the national bowel screening program in the Netherlands on detection and treatment of endoscopically unresectable benign polyps.

BACKGROUND: In January 2014, a national bowel cancer screening program started in the Netherlands. The program is being implemented in phases until 2019. Due to this program, an increase in patients referred for a colorectal resection for benign, but endoscopically unresectable polyps, is expected. So far, most resections are performed according to oncological principles despite no pre-operative histological diagnosis of malignancy. The aim of this study was to analyze the increase in referred patients during the first year of the screening program and to compare pathological results and clinical outcome of resections of patients undergoing resection for benign polyps before and after implementation of screening. METHODS: Patients referred for colorectal resection without biopsy-proven cancer between January 2009 and January December 2014 were identified from a prospectively maintained database. Patients with endoscopically macroscopic features of carcinoma were excluded. RESULTS: Seventy-six patients were included. Forty-seven patients (61.8%) were operated on in the 5 years prior to implementation of the screening program, and 29 patients (38.2%) were operated during the first year of implementation of the screening program. The overall malignancy rate before the introduction of the program was 14.1 and 6.6% after it had started (p = .469). All resections were performed laparoscopically; the conversion rate was 3.9% (n = 3). The overall mortality rate was 2.7% (n = 2), major complications (Clavien-Dindo > 3b) occurred in 11.8% (n = 9) of patients. The anastomotic leakage rate was 3.9% (n = 3). CONCLUSIONS: The number of patients referred for benign polyps tripled after introduction of the screening program. With an overall major morbidity and mortality rate of 11.8%, it seems valid to discuss whether an endoscopic excision with advanced techniques with or without laparoscopic assistance would be preferable in this patient group, accepting a 6.6% reoperation rate for additional oncological resection with lymph node sampling in patients in whom a malignancy is found on histological analysis of the complete polyp.

Colorectal anastomotic leak: delay in reintervention after false-negative computed tomography scan is a reason for concern.

BACKGROUND: Early detection of anastomotic leakage (AL) after colorectal surgery followed by timely reintervention is of crucial importance. The aim of this study was to investigate the accuracy of computed tomography (CT) imaging for AL and the effects of delay in reintervention after a false-negative CT. METHODS: All files from patients who had colorectal surgery with primary anastomoses between 2009 and 2014 were reviewed. The predictive value of CT scanning for AL was determined and correlated with short-term postoperative patient outcomes. In addition, factors predictive of false-negative scans were assessed. RESULTS: Six hundred and twenty-eight patient files were reviewed. In total, a CT scan was performed in 127 patients. Overall, leakage was seen in 49 patients (7.8%). The positive and negative predictive values were 78 and 88%, respectively. Sensitivity was 73% and specificity 91%. In patients with a true-positive CT (n = 24), reintervention followed after a median interval of 0 days (IQR 1), whereas this was 1 day (IQR 2) in the false-negative group (n = 11) (p < 0.05). This was associated with a significantly increased mortality rate (1/24 = 4.2% vs 5/11 = 45.5%) (p < 0.005), an increased length of hospital stay [median 28 days (IQR 26) vs 54 days (IQR 20) (p < 0.05)]. CONCLUSIONS: Delayed reintervention after false-negative CT scanning is associated with a high mortality rate and a significant increase in length of hospital stay.

A critical evaluation of lymph node ratio in head and neck cancer.

In head and neck squamous cell carcinoma (HNSCC), the search for better prognostic factors beyond TNM-stage is ongoing. Lymph node ratio (LNR) (positive lymph nodes/total lymph nodes) is gaining interest in view of its potential prognostic significance. All HNSCC patients at the Netherlands Cancer Institute undergoing neck dissection for lymph node metastases in the neck region between 2002 and 2012 (n = 176) were included. Based on a protocol change in specimen processing, the cohort was subdivided in two distinct consecutive periods (pre and post 2007). The prognostic value of LNR, N-stage, and number of positive lymph nodes for overall survival was assessed. The mean number of examined lymph nodes after 2007 was significantly higher (42.3) than before (35.8) (p = 0.024). The higher number concerned mostly lymph nodes in level V. The mean number of positive lymph nodes before 2007 was 3.3 vs. 3.6 after 2007 (p = 0.745). By multivariate analysis of both pre- and post-2007 cohort data, two factors remained associated with an increased hazard of dying: N2 [HR 2.1 (1.1-4.1) and 2.4 (1.0-5.8)] and >3 positive lymph nodes [HR 2.0 (1.1-3.5) and 3.1 (1.4-6.9)]. Hazard ratio for LNR >7 % was not significantly different: pre 2007 at 2.2 (1.3-3.8) and post 2007 at 2.1 (1.0-4.8, p = 0.053). In this study, changes in specimen processing influenced LNR values, but not the total number of tumor positive nodes found. Therefore, in HNSCC, the number of positive nodes seems a more reliable parameter than LNR, provided a minimum number of lymph nodes are examined.

The effect of a postoperative quality improvement program on outcomes in colorectal surgery in a community hospital.

PURPOSE: The aim of this study was to evaluate whether implementation of a comprehensive quality improvement program was associated with improved outcomes in patients undergoing oncological colorectal surgery in a non-academic, non-referral community hospital. METHODS: The quality improvement program (QIP) was introduced in January 2011 and consisted of the following interventions: (1) avoidance of postoperative nonsteriodal anti-inflammatory drugs; (2) normovolemia was pursued pre- and postoperatively; (3) non-resectional surgery if possible, in patients over 80 with ASA 3 or 4 classification; and (4) a standardized, postoperative surveillance protocol was introduced, with CRP determination day 2 and 4, and if necessary subsequent abdominal CT with rectal contrast to reduce delay in diagnosis of complications. From a prospectively maintained database of 488 patients undergoing colorectal surgery between 2009 and 2014, postoperative outcomes of patients operated before and after implementation of the program were compared. RESULTS: The severe complication rate (Clavien-Dindo >3b) decreased significantly (25.0 vs. 13.7 %; p < .001) after implementation of the QIP program. The mortality rate dropped from 8.7 to 2.6 % (p = .003). The percentage of anastomotic leakage was 9.6% before QIP implementation and 4.2% after (p = .013). Median length of hospital stay decreased from 9 (IQR 5-19) to 7 days (IQR 4-12) (p < .001). Multivariate analyses showed that surgery after implementation of the program was a strong independent predictor for less major complications (OR 0.54, 95 % CI 0.32-0.88). CONCLUSIONS: A significant decrease in major complications and mortality was observed after introduction of a relative simple quality improvement program.

The influence of nodal yield in neck dissections on lymph node ratio in head and neck cancer.

OBJECTIVES: Recent studies suggest that lymph node ratio (LNR) is a strong prognostic factor in head and neck cancer. This study aims to determine if the yield of harvested lymph nodes (LNs) influences the LNR. METHODS: The study included 522 head and neck cancer patients, undergoing 638 primary and salvage (selective) neck dissections between 2002 and 2012. Before 2007 the neck dissection specimens were macroscopically and microscopically examined by pathologists and after 2007 the macroscopic examination was performed by pathology technicians. For comparison of mean LN yields, univariate and multivariate analyses were performed. RESULTS: The mean number of LNs among 374 specimens examined by pathologists was 24 (range 0-89) vs. 32 (range 2-89) among 264 specimens examined by pathology technicians (P<.001). This caused the mean LNR in the non pre-treated patient group to drop from 11.4% to 8.7%. The counts of LNs per type of neck dissection were significantly different and increased with the number of levels involved. However, there was no linear relationship and the higher yields could be mostly ascribed to LNs in level V. The LNR varied from 8.1% to 18.4% among the different types of neck dissections. CONCLUSIONS: A significant increase in the number of harvested LNs, but a decrease in LNR was observed after introducing pathology technicians for macroscopic examination. A clear association between the extent of the dissection and the number of harvested LNs was observed. LNR appears to be strongly dependent on the harvesting protocol and the extent of the dissection.