Predicting the survival of patients with small bowel neuroendocrine tumours: comparison of 3 systems.

Neuroendocrine tumours (NET) are clinically challenging due to their unpredictable behaviour. Nomograms, grading and staging systems are predictive tools with multiple roles in clinical practice, including patient prognostication. The NET nomogram allocates scores for various clinicopathological parameters, calculating percentage estimates for 5- and 10-year disease-specific survival of patients with small bowel (SB) NET. We evaluated the clinical utility of three prognostic systems in 70 SB NET patients: the NET nomogram, the World Health Organisation (WHO)/European Neuroendocrine Tumour Society (ENETS) grading system and the American Joint Commission on Cancer (AJCC)/Union Internationale Contre le Cancer (UICC) TNM staging method. Using Kaplan-Meier methodology, neither the WHO/ENETS grade (P = 0.6) nor the AJCC/UICC stage (P = 0.276) systems demonstrated significant differences in patient survival in the cohort. The NET nomogram was well calibrated to our data set, displaying favourable prediction accuracy. Harrel's C-index for the nomogram (a measure of predictive power) was 0.65, suggesting good prediction ability. On Kaplan-Meier analyses, there were significant differences in patient survival when stratified into nomogram score-based risk groups: low-, medium- and high-risk tumours were associated with median estimated survivals of 156, 129 and 112 months, respectively (P = 0.031). Our data suggest that a multivariable analysis-based NET nomogram may be clinically useful for patient survival prediction. This study identifies the limitations of the NET nomogram and the imperfections of other currently used single or binary parameter methodologies for assessing neuroendocrine disease prognosis. The future addition of other variables to the NET nomogram will likely amplify the accuracy of this personalised tool.

Role of Staging in Patients with Small Intestinal Neuroendocrine Tumours.

Small bowel neuroendocrine tumours are the commonest malignancy arising in the small intestine and have substantially increased in incidence in recent decades. Patients with small bowel neuroendocrine tumours commonly develop lymph node and/or distant metastases. Here, we examine the role of staging in 84 surgically treated patients with small bowel neuroendocrine tumours, comparing diagnostic information yielded from morphological, functional and endoscopic modalities. Furthermore, we correlate pre-operative staging with intra-operative findings in a sub-cohort of 20 patients. The vast majority of patients had been histologically confirmed to have low-grade (Ki-67 <2%) disease; however, lymph node and distant metastases were observed in 74 (88.1%) and 51 (60.7%) of patients at presentation, respectively. Liver metastases were evident in 48 (57.1%) patients, with solely peritoneal and bone metastases observed in 2 (2.4%) and 1 (1.2%) patients, respectively. Forty patients (47.6%) received multimodal treatment. In our sub-cohort analysis, pre-operative imaging understaged disease in 14/20 (70%) when compared with intra-operative findings. In patients with multifocal primary tumours and miliary liver metastases, no imaging modality was able to detect entire disease spread. Overall, presently available imaging modalities heavily underestimate disease stage, with meticulous intra-operative abdominal examination being superior to any imaging technology. Multimodal treatment has an important role in prolonging survival.

Cold-Plasma Coagulation on the Surface of the Small Bowel Is Safe in Pigs.

INTRODUCTION: Surgical treatment in patients with peritoneal carcinomatosis is often limited by the extent of small bowel involvement. We investigated the results of the application of cold-plasma coagulation on the surface of the small bowel. METHODS: After permission by the federal government of Schleswig-Holstein, 8 female pigs underwent a laparoscopy and cold-plasma coagulation on the small bowel with different energy levels. Cold plasma is generated by high-frequency energy that is directed through helium gas. After 12 to 18 days a laparotomy was done and the abdomen was inspected for peritonitis, fistula, or other pathology. RESULTS: Perioperative morbidity was low with transient diarrhea in 1 pig and loss of appetite for 1 day in another pig. We saw 1 interenteric fistula that was clinically not apparent after accidently prolonged application of cold-plasma coagulation (6 seconds instead of 2 seconds) with the highest energy level of 100 W. We did not observe any mortality. The depth of necrosis after application of different energy levels was dependent on the generator energy. We observed statistically significant differences between the different energy levels (20 W vs 10 W [P = .014], 75 W vs 50 W [P = .011]). The comparison of the necrosis depths after the application of 100 W and 75 W almost reached statistical significance (P = .059). We observed distinct interenteric adhesions as a result of the coagulation. DISCUSSION: The application of cold-plasma coagulation on the surface of vital bowel in pigs is safe. We would recommend against the use of the highest energy level of 100 W before more clinical data are available.

Survival of diabetes patients with major amputation is comparable to malignant disease.

INTRODUCTION: Almost all studies on diabetic foot syndrome focused on prevention of amputation and did not investigate long-term prognosis and survival of patients as a primary outcome parameter. METHODS: We did a retrospective cohort study including 314 patients who had diabetic foot syndrome and underwent amputation between December 1995 and January 2001. RESULTS: A total of 48% of patients received minor amputation (group I), 15% only major amputation (group II) and 36% initially underwent a minor amputation that was followed by a major amputation (group III). Statistically significant differences were observed in comparison of the median survival of group I to group II (51 vs. 40 months; p = 0.016) and of group II to group III (40 vs. 55 months; p = 0.003). DISCUSSION: The prognosis of patients with major amputation due to diabetic foot syndrome is comparable to patients with malignant diseases. Vascular interventions did not improve the individual prognosis of patients.

Conversion of laparoscopic surgery for perforated peptic ulcer: a single-center study.

PURPOSE: A perforated peptic ulcer can be managed laparoscopically in selected patients. The purpose of this study was to evaluate whether conversion of emergency laparoscopy is inferior to primary median laparotomy in terms of postoperative morbidity and mortality. METHODS: We analyzed patients who underwent laparoscopic or open surgery for a perforated peptic ulcer at the Department of Surgery, University of Schleswig-Holstein, Campus Luebeck between January, 1996 and December, 2010. Perforations were graded according to the Boey classification, a preoperative risk-scoring system. RESULTS: Conversion to laparotomy was necessary in 20 of the 45 patients who underwent laparoscopic surgery (CG); therefore, laparoscopic operations were completed in 25 patients (LG). The third patient cohort comprised 139 patients who underwent primary laparotomy (OG). Overall minor morbidity was significantly lower (p = 0.048) in the LG patients than in the OG patients, whereas no significant differences were found in major morbidity and mortality, particularly between the OG and CG. CONCLUSION: Patients' suitability for laparoscopic management should be decided on according to Boey's clinical scoring system. Our findings demonstrated that conversion from laparoscopy to laparotomy was not associated with elevated postoperative morbidity or mortality versus initial laparotomy. Therefore, emergency operations may be commenced laparoscopically in selected patients, especially considering the postoperative advantages of this approach.

Spontaneous and non-spontaneous bleeding complications in patients with oral vitamin K antagonist therapy.

PURPOSE: The aim of the study was to evaluate potential differences between patients with spontaneous and non-spontaneous bleeding episodes during treatment with vitamin K antagonists which mainly resulted in compartment syndromes. METHODS: The population in this study comprised 116 patients who suffered at least one bleeding complication which required surgical treatment during therapy with an oral vitamin K antagonist. The patients were treated between September 2001 and July 2008. RESULTS: Significant differences were observed between the two patient groups with regard to the presence of renal failure, arterial hypertension, and diabetes mellitus, which occurred more frequently in patients with spontaneous bleeding. Also, significantly more patients with spontaneous bleedings developed compartment syndrome that needed emergency operation. Overall mortality was 9.6 %, was associated with multiorgan failure in all patients, and was not different between the two patient groups. CONCLUSIONS: The identification of high-risk patients before treatment with an oral vitamin K antagonist is of major importance. The existence of over-anticoagulation syndrome and compartment syndrome is associated with significant mortality and morbidity and should not be underestimated.

Outcome and management of invasive candidiasis following oesophageal perforation.

The regular colonisation of the oesophagus with a Candida species can, after oesophageal perforation, result in a contamination of the mediastinum and the pleura with a Candida species. A patient cohort of 80 patients with oesophageal perforation between 1986 and 2010 was analysed retrospectively. The most common sources with positive results for Candida were mediastinal biopsies and broncho-alveolar secretions. Candida species were detected in 30% of the patients. The mortality rate was 41% in patients with positive microbiology results for Candida, whereas it was 23% in the remaining patient cohort. This difference did not reach statistical significance (P = 0.124). Mortality associated with oesophageal perforation was attributed mainly to septic complications, such as mediastinitis and severe pneumonia. During the study period we observed a shift towards non-albicans species that were less susceptible or resistant to fluconazole. In selected patients with risk factors as immunosuppression, granulocytopenia and long-term intensive-care treatment together with the finding of Candida, an antimycotic therapy should be started. A surgical approach offers the possibility to obtain deep tissue biopsies. The antimycotic therapy should start with an echinocandin, as the resistance to fluconazole is growing and to cover non-albicans Candida species, too.

Influence of second or multiple tumours on the prognosis of patients with colorectal cancer.

BACKGROUND: Colorectal cancer is one of the most common forms of cancer in the Western world. A wide variety of prognostic factors for colorectal cancer have been identified. There is, however, a paucity of literature addressing the influence of multiple primary carcinomas on prognosis. We conducted the present study in order to investigate the influence of second or multiple primary tumours on the prognosis of colorectal cancer patients. PATIENTS AND METHODS: From 1992 to 2005, 1500 patients underwent surgery for colorectal cancer at the University Hospital of Luebeck. Of these, 276 patients (19%) had multiple primary malignant tumours. We performed statistical analyses only on patients who underwent surgery with curative intent in order to minimise additional prognostic factors. The patients were divided into groups according to the time of multiple primary tumour occurrence. Data were analysed for various variables. RESULTS: We did not detect any significant differences in survival either between the various groups or between patients with and without multiple primary tumours. CONCLUSION: The presence of multiple primary carcinomas is not an independent prognostic factor in patients with an index tumour of the colorectum. Multiple primary tumours are thus not necessarily associated with a poorer outcome and patients should receive curative intent surgery and appropriate follow-up care.

Complicated jejunal diverticulitis: a challenging diagnosis and difficult therapy.

BACKGROUND/AIM: In contrast to diverticulosis of the colon, jejunal diverticulosis is a rare entity that often becomes clinically relevant only after exacerbations occur. The variety of symptoms and low incidence make this disease a difficult differential diagnosis. PATIENTS AND METHODS: Data from all patients who were treated in our surgical department for complicated jejunal diverticulitis, that is, gastrointestinal hemorrhage or a diverticula perforation were collected prospectively over a 6-year period (January 2004 to January 2010) and analyzed retrospectively. RESULTS: The median age among the 9 patients was 82 years (range: 54-87). Except for 2 cases (elective operation for a status postjejunal peridiverticulitis and a re-perforation of a diverticula in a patient s/p segment resection with free perforation), the diagnosis could only be confirmed with an exploratory laparotomy. Perforation was observed in 5 patients, one of which was a retroperitoneal perforation. The retroperitoneal perforation was associated with transanal hemorrhage. Hemodynamically relevant transanal hemorrhage requiring transfusion were the reason for an exploratory laparotomy in 2 further cases. In one patient, the hemorrhage was the result of a systemic vasculitis with resultant gastrointestinal involvement. A singular jejunal diverticulum caused an adhesive ileus in one patient. The extent of jejunal diverticulosis varied between a singular diverticulum to complete jejunal involvement. A tangential, transverse excision of the diverticulum was carried out in 3 patients. The indication for segment resection was made in the case of a perforation with associated peritonitis (n=4) as well as the presence of 5 or more diverticula (n=2). Histological analysis revealed chronic pandiverticulitis in all patients. Median operating time amounted to 142 minutes (range: 65-210) and the median in-hospital stay was 12 days (range: 5-45). Lethality was 0%. Major complications included secondary wound closure after s/p repeated lavage and bilateral pleural effusions in one case. Signs of malabsorption as the result of a short bowel syndrome were not observed. Minor complications included protracted intestinal atony in 2 cases and pneumonia in one case. Median follow-up was 6 months (range: 1-18). CONCLUSION: Complicated jejunal diverticulitis often remains elusive preoperatively due to its unspecific clinical presentation. A definitive diagnosis can often only be made intraoperatively. The resection of all diverticula and/or the complete diverticula-laden segment is the goal in chronic cases. The operative approach chosen (tangential, transverse excision vs segment resection) should be based on the extent of the jejunal diverticulosis as well as the intraoperative findings.

The application of cold-plasma coagulation on the visceral pleura results in a predictable depth of necrosis without fistula generation.

A technique for the safe transfer of electric energy to the pulmonary surface for the potential evaporation of malignant tumours is non-existent to date. By conducting the current study, we wanted to generate data on the potential beneficiary effects and complications of using cold-plasma coagulation on the pulmonary surface. Cold-plasma coagulation was applied to the pulmonary surface in eight female mini-pigs via a thoracoscopic access. After 12 days, we performed a re-thoracoscopy on the contralateral side. After a further 12 days, we performed a median sternotomy and did cold-plasma coagulation on previously untreated areas of either lung. No pulmonary fistulas were detected. In two of the eight pigs, we found a localized chronic pneumonia. None of the pigs died during the course of the study. Morbidity was also low with two pigs refusing food intake, one pig with dyspnoea after difficult intubation and one pig coughing. All events were self-limited and occurred only on post-operative Day 1. The treatment effect was almost linear and correlated to the generator energy applied. The differences between the effects reached statistical significance (P < 0.05). The application of cold-plasma coagulation to the pulmonary surface is safe in pigs. A potential clinical application of this technique is treatment of malignant pleural mesothelioma.

Multivisceral and standard resections in colorectal cancer.

PURPOSE: The current study was designed to identify prognostic factors for long-term survival in patients with advanced colorectal cancer in a consecutive cohort. METHODS: A total of 123 patients were operated because of T4 colorectal cancer between 1 January 2002 and 31 December 2008 in the Clinic of Surgery, UK-SH Campus Luebeck. RESULTS: A total of 78 patients underwent a multivisceral resection. The postoperative morbidity was elevated in the patient group with multivisceral resections (34.6% vs. 26.7%). Nevertheless, we detected no significant differences concerning 30 days mortality (7.7% vs. 8.9%; p = 0.815). The main prognostic factor that reached significance in the multivariate analysis was the possibility to obtain a R0 resection (p < 0.0001) resulting in a 5-year survival rate of 55% for patients with curative resection. There were no statistically significant differences in 5-year survival between multivisceral and non-multivisceral resections (p = 0.608). Also we were not able to detect any significant differences for cancer of colonic or rectal origin (p = 0.839), for laparoscopic vs. open procedures (p = 0.610), and for emergency vs. planned operations (p = 0.674). Moreover, the existence of lymph node metastases was not a predictive factor concerning survival as there was no difference between patients with and without lymph node metastases (p = 0.658). CONCLUSIONS: Multivisceral resections are associated with the same 5-year survival as standard resections. Therefore, the aim to perform a R0 resection should always be the main goal in surgery for colorectal cancer. In planned operations, a laparoscopic approach is justified in selected patients.