Laparoscopic mesh removal for chronic postoperative inguinal pain following endoscopic hernia repair: a cohort study on the effect on pain.

PURPOSE: Chronic postoperative inguinal pain (CPIP) after pre-peritoneal hernia repair is rare but may be severely invalidating. Mesh may be a contributing factor to the development of CPIP. International guidelines acknowledge mesh removal as a treatment option for CPIP after open repair, but experience in laparoscopic mesh removal is limited. Surgeons are hesitant to remove pre-peritoneal meshes because of fear of operative complications. This observational study describes risks and effectiveness of laparoscopic mesh removal in patients with CPIP after endoscopic inguinal hernia repair. METHODS: Questionnaires and operative findings of consecutive patients undergoing a laparoscopic mesh removal for CPIP between August 2014 and February 2019 in the center for groin pain were prospectively recorded. Long-term efficacy was determined using pre and postoperative questionnaires on pain and quality of life. RESULTS: Forty-four patients were included (37 males, median age 51 years). Complete or sufficient pain relief was reported in every two out of three patients (68%) and quality of life improved significantly. Intraoperative findings included wrinkled mesh (n = 19), meshoma (n = 14) and infected mesh (n = 1). Surprisingly, over half of the meshes (n = 23) did not fully cover the groin, with three clear recurrent hernias. Intraoperative complications included two bladder injuries. One patient undergoing removal of 3 meshes on one side developed a necrotic testicle. During follow-up, three patients developed a recurrent hernia requiring open surgery. CONCLUSION: Laparoscopic mesh removal is safe and effective in selected patients with CPIP after endoscopic hernia repair. We believe that this technique should be adopted by dedicated hernia surgeons.

Metabolic syndrome; associations with adverse outcome after colorectal surgery. A systematic review and meta-analysis.

BACKGROUND: Increasing evidence shows that patients with Metabolic Syndrome (MetS) are at risk for adverse outcome after abdominal surgery. The aim of this study was to investigate the impact of MetS and preoperative hyperglycemia, as an individual component of MetS, on adverse outcome after colorectal surgery. METHODS: A literature review was systematically performed according to the PRISMA guidelines. Inclusion criteria were observational studies that evaluated the relationship between MetS or preoperative hyperglycemia and outcomes after colorectal surgery (i.e. any complication, severe complication defined as Clavien-Dindo grade ≥ III, anastomotic leakage, surgical site infection, mortality and length of stay). RESULTS: Six studies (246.383 patients) evaluated MetS and eight studies (9.534 patients) reported on hyperglycemia. Incidence rates of MetS varied widely from 7% to 68% across studies. Meta-analysis showed that patients with MetS are more likely to develop severe complications than those without MetS (RR 1.62, 95% CI 1.01-2.59). Moreover, a non-significant trend toward increased risks for any complication (RR 1.35, 95% CI 0.91-2.00), anastomotic leakage (RR 1.67, 95% CI 0.47-5.93) and mortality (RR 1.19, 95% CI 1.00-1.43) was found. Furthermore, preoperative hyperglycemia was associated with an increased risk of surgical site infection (RR 1.35, 95% CI 1.01-1.81). CONCLUSION: MetS seem to have a negative impact on adverse outcome after colorectal surgery. As a result of few studies meeting inclusion criteria and substantial heterogeneity, evidence is not conclusive. Future prospective observational studies should improve the amount and quality in order to verify current results.

Comparing practice and outcome of laparoscopic liver resection between high-volume expert centres and nationwide low-to-medium volume centres.

BACKGROUND: Based on excellent outcomes from high-volume centres, laparoscopic liver resection is increasingly being adopted into nationwide practice which typically includes low-medium volume centres. It is unknown how the use and outcome of laparoscopic liver resection compare between high-volume centres and low-medium volume centres. This study aimed to compare use and outcome of laparoscopic liver resection in three leading European high-volume centres and nationwide practice in the Netherlands. METHOD: An international, retrospective multicentre cohort study including data from three European high-volume centres (Oslo, Southampton and Milan) and all 20 centres in the Netherlands performing laparoscopic liver resection (low-medium volume practice) from January 2011 to December 2016. A high-volume centre is defined as a centre performing >50 laparoscopic liver resections per year. Patients were retrospectively stratified into low, moderate- and high-risk Southampton difficulty score groups. RESULTS: A total of 2425 patients were included (1540 high-volume; 885 low-medium volume). The median annual proportion of laparoscopic liver resection was 42.9 per cent in high-volume centres and 7.2 per cent in low-medium volume centres. Patients in the high-volume centres had a lower conversion rate (7.4 versus 13.1 per cent; P < 0.001) with less intraoperative incidents (9.3 versus 14.6 per cent; P = 0.002) as compared to low-medium volume centres. Whereas postoperative morbidity and mortality rates were similar in the two groups, a lower reintervention rate (5.1 versus 7.2 per cent; P = 0.034) and a shorter postoperative hospital stay (3 versus 5 days; P < 0.001) were observed in the high-volume centres as compared to the low-medium volume centres. In each Southampton difficulty score group, the conversion rate was lower and hospital stay shorter in high-volume centres. The rate of intraoperative incidents did not differ in the low-risk group, whilst in the moderate-risk and high-risk groups this rate was lower in high-volume centres (absolute difference 6.7 and 14.2 per cent; all P < 0.004). CONCLUSION: High-volume expert centres had a sixfold higher use of laparoscopic liver resection, less conversions, and shorter hospital stay, as compared to a nationwide low-medium volume practice. Stratification into Southampton difficulty score risk groups identified some differences but largely outcomes appeared better for high-volume centres in each risk group.

Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation.

BACKGROUND: Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME. METHODS: Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence. RESULTS: The implementation cohort of 120 patients had a median follow up of 21·9 months. Short-term outcomes included a positive circumferential resection margin rate of 5·0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10·0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15·2(7·0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5·6 per cent (4·0 per cent after excluding the first 10 procedures at each centre). CONCLUSION: TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.

ANTECEDENTES: La escisión total del mesorrecto por vía transanal (Transanal Total Mesorectal Excision, TaTME) se ha propuesto como abordaje quirúrgico en pacientes con cáncer de recto medio e inferior. La técnica TaTME se ha introducido en los Países Bajos mediante un proceso de formación estructurado que incluye la supervisión. Este estudio evaluó el porcentaje de recidiva local durante la fase de implementación de TaTME. MÉTODOS: Se recogieron los resultados oncológicos de los primeros 10 procedimientos realizados mediante TaTME en cada uno de los 12 centros participantes como parte de una auditoría externa de implementación del procedimiento. Se reunió una cohorte más amplia de pacientes procedentes de 4 centros para analizar los efectos de la curva de aprendizaje. El criterio de valoración principal fue la presencia de recidiva locorregional. RESULTADOS: La cohorte de implementación de 120 pacientes tuvo una mediana de seguimiento de 21,9 meses. Los resultados a corto plazo incluyeron una tasa del margen de resección circunferencial positivo del 5% y una tasa de fuga anastomótica del 17,4%. La tasa global de recidiva local en la cohorte de implementación fue del 10% (12/120) con un intervalo medio de recidiva de 15,2 (DE 7) meses. El patrón de recidiva local fue multifocal en 8 de 12 casos (67%). En la cohorte ampliada (n = 266), la tasa global de recidiva fue del 5,6% (4,0%, excluyendo a los primeros 10 pacientes). CONCLUSIÓN: TaTME se asoció con un porcentaje de recidiva local multifocal que puede relacionarse con una ejecución subóptima, más que con la técnica en sí. Se recomienda una supervisión prolongada, la optimización de la técnica para evitar la diseminación tumoral, así como un control de calidad.

Cardiac overscreening hip fracture patients.

BACKGROUND: The aim of this study was to prospectively investigate the adherence to the American College of Cardiology (ACC) and the American Heart Association guidelines for perioperative assessment of patients with hip fracture in daily clinical practice and how this might affect outcome. METHODS: This prospective cohort study from Maastricht University Medical Centre included 166 hip fracture patients within a 3-year inclusion period. The preoperative cardiac screening and adherence to the ACC/AHA guideline were analyzed. Cardiac risk was classified as low, intermediate and high risk. Secondary outcome measurements were delay to surgery, perioperative complications and in-hospital, 30-day, 1-year and 2-year mortality. RESULTS: According to the ACC/AHA guideline, 87% of patients received correct preoperative cardiac screening. The most important reason for incorrect preoperative cardiac screening was overscreening (> 90%). Multivariate analysis showed that a cardiac consultation (p = 0.003) and overscreening (p = 0.02) as significant predictors for increased delay to surgery, while age, sex, previous cardiac history and preoperative mobility were not. High risk patients had in comparison with low risk patients a significantly higher relative risk ratio for in-hospital mortality (RR 6, 95% CI 2-17). Multivariate analysis showed that a previous cardiac history and increased delay to surgery were predictors for early mortality. High age and previous cardiac history were risk factors for late mortality. CONCLUSION: Preoperative cardiac screening for hip fracture patients in adherence to the ACC/AHA guideline is associated with a diminished use of preoperative resources. Overscreening leads to greater delay to surgery, which poses a risk for perioperative complications and early mortality. LEVEL OF EVIDENCE: II.

Histological examination of the gallbladder following routine cholecystectomy? A selective analysis is justified.

BACKGROUND: It was hitherto common practice to analyse each removed gallbladder for the presence of gall bladder cancer (GBC) although this approach may be questioned. The aim of this study was to determine whether a policy of selective histopathological analysis (Sel-HPA) is oncologically safe and cost effective. METHODS: This retrospective study was conducted in a single Dutch teaching hospital. Immediately following cholecystectomy, the surgeon decided on the basis of inspection and palpation whether histological examination was indicated. The Dutch Comprehensive Cancer Organisation (IKNL) registry was used to identify the number of GBC during this time period. RESULTS: Of 2271 patients who underwent a cholecystectomy in our institution between January 2012 and December 2017, 1083 (47.7%) were deemed indicated for histopathological analysis. Sixteen pathological gallbladders (1.5%) were identified in that period (intestinal metaplasia, n = 3; low grade dysplasia n = 7; carcinoma n = 6). During follow-up, no patient was found to have GBC recurrence in the population whose gallbladder was not sent for pathology (52.3%, n = 1188, median 49 months of follow up). The percentage of gallbladders that were analysed decreased over the six years of observation from 83% to 38%. Our policy of Sel-HP saved over €65 000. CONCLUSIONS: A policy of selective histopathology after cholecystectomy is oncologically safe and reduces costs.

Selective Histological Examination After Cholecystectomy: An Analysis of Current Daily Practice in The Netherlands.

BACKGROUND: The 2016 Dutch national guidelines on handling of a removed gallbladder for cholelithiasis proposes a selective histopathologic policy (Sel-HP) rather than routine policy (Rout-HP). The aim of this study was to determine the current implementation of the present guideline and the daily practice of Sel-HP. METHODS: Surgeons who were engaged in gallbladder surgery in the Netherlands and were involved in local hospitals' gallbladder protocols completed a questionnaire study regarding gallbladder policy, between December 2017 and May 2018. Data were analyzed using standard statistics. RESULTS: A 100% response rate was obtained (n = 74). Approximately 64% of all gallbladders (n = 22,500) were examined microscopically. Sixty-nine (93.2%) hospitals confirmed they were aware of the new guidelines, and 56 (75.7%) knew the guideline was adjusted in favor of Sel-HP. Half of the hospitals (n = 35, 47.3%) had adopted a Sel-HP, and 39 (52.7%) a Rout-HP. Of the 39 hospitals who had a Rout-HP, 36 were open to a transition to a Sel-HP although some expressed the need for more evidence on safety or novel guidelines. CONCLUSIONS: The current implementation of the 2016 Dutch guideline advising a selective microscopic analysis of removed gallbladders for gallstone disease is suboptimal. Evidence demonstrating safety and cost-effectiveness of an on demand histopathological examination will aid in the implementation process.

Outcome of Surgical Inspection of the Gallbladder in Relation to Final Pathology.

INTRODUCTION: Routine histopathologic gallbladder examination after cholecystectomy has been a point of discussion. The aim of this study was to evaluate the macroscopic examination by the surgeon in relation to the final histology. METHODS: A prospective study was conducted to investigate the practice of macroscopic gallbladder examination by a surgeon compared to routine histopathology by a pathologist. All consecutive cholecystectomies were included between November 2009 and February 2011. RESULTS: A total of 319 consecutive cholecystectomies were performed. Of all macroscopic examinations, the surgeon identified 62 gallbladders with macroscopic abnormalities, ranging from polyps to wall thickening or ulcers. In 55 (17.2%) cases, the surgeon judged that further examination of the specimen by the pathologist could possibly lead to additional and relevant findings. There was a strong agreement between the surgeon and the pathologist concerning the macroscopic examination (κappa = 0.822). The surgeon and the pathologist had disagreement on the macroscopic examination of 18 gallbladders, without clinical consequences for the patient. DISCUSSION: The present prospective study shows that the surgeon should be able to select those gallbladders needing a microscopic gallbladder examination. Potentially, about 80% of this kind of routine histology can be reduced.

Low radiographic muscle density is associated with lower overall and disease-free survival in early-stage colorectal cancer patients.

BACKGROUND: In cancer patients with a poor prognosis, low skeletal muscle radiographic density is associated with higher mortality. Whether this association also holds for early-stage cancer is not very clear. We aimed to study the association between skeletal muscle density and overall mortality among early-stage (stage I-III) colorectal cancer (CRC) patients. Furthermore, we investigated the association between skeletal muscle density and both CRC-specific mortality and disease-free survival in a subset of the study population. METHODS: Skeletal muscle density was assessed in 1681 early-stage CRC patients, diagnosed between 2006 and 2015, using pre-operative computed tomography images. Adjusted Cox proportional hazard models were used to evaluate the association between muscle density and overall mortality, CRC-specific mortality and disease-free survival. RESULTS: The median follow-up time was 48 months (range 0-119 months). Low muscle density was detected in 39% of CRC patients. Low muscle density was significantly associated with higher mortality (low vs. normal: adjusted HR 1.91, 95% CI 1.53-2.38). After stratification for comorbidities, the association was highest in patients with ≥ 2 comorbidities (HR 2.11, 95% CI 1.55-2.87). Furthermore, low skeletal muscle density was significantly associated with poorer disease-free survival (HR 1.68, 95% CI 1.14-2.47), but not with CRC-specific mortality (HR 1.68, 95% CI 0.89-3.17) in a subset of the study population. CONCLUSION: In early-stage CRC patients, low muscle density was significantly associated with higher overall mortality, and worse disease-free survival.

What you should know about the low anterior resection syndrome - Clinical recommendations from a patient perspective.

INTRODUCTION: Functional bowel complaints, referred to as Low Anterior Resection Syndrome (LARS), are common after sphincter-saving surgical procedures and have a severe impact on quality of life (QoL). Care for LARS patients is complex and surgeons underestimate or misinterpret its associated symptoms. This study aimed to explore the impact of LARS from a patient perspective facilitating the construction of a set of recommendations improving current care stratagems. METHODS: In a non-academic Dutch teaching hospital, three focus group sessions were conducted with 16 patients (males = 50%) who had undergone colorectal surgery between 2012 and 2017. A trained moderator orchestrated patient-discussion regarding illness perception and health-care needs. Transcripts were analysed using inductive content analysis. RESULTS: Three themes were identified: illness perception, preoperative care and postoperative supportive care. Specific attention and screening for LARS is deemed necessary for breaking the taboo surrounding it. Extension of preoperative counselling on the normal postoperative course, including ways to optimize social support, were identified as crucial. After discharge, patients experienced a lack of supportive care regarding functional complaints and did not know who to counsel. In addition, they felt intrinsically motivated to actively prepare for surgery, i.e. by participating in prehabilitation programs. CONCLUSION: Exploring perspectives in LARS patients resulted in the identification of potential improvements in current care pathways. Recommendations on ways to improve information provision, screening of LARS and methods to intervene in the gap of supportive care after discharge are presented. We recommend to implement these measures as QoL of patients undergoing colorectal cancer surgery may be improved.

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.

Systematic review of exercise training in colorectal cancer patients during treatment.

Colorectal cancer surgery results in considerable postoperative morbidity, mortality and reduced quality of life. As many patients will undergo additional (neo)adjuvant therapy, it is imperative that each individual optimize their physical function. To elucidate the potential of exercise in patient optimization, we investigated the evidence for an exercise program before and after surgical treatment in colorectal cancer patients. A systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions, the guidelines of the Physical Therapy Journal and the PRISMA guidelines. No literature pertaining to exercise training during preoperative neoadjuvant treatment was found. Seven studies, investigating the effects of regular exercise during adjuvant chemotherapy for patients with colorectal cancer or a mixed population, were identified. A small effect (effect size (ES) 0.4) of endurance/interval training and strength training (ES 0.4) was found in two studies conducted in patients with colorectal and gastrointestinal cancer. In five studies that included a mixed population of cancer patients, interval training resulted in a large improvement (ES 1.5; P≤.05). Endurance training alone was found to increase both lower extremity strength and endurance capacity. The effects of strength training in the lower extremity are moderate, whereas, in the upper extremity, the increase is small. There is limited evidence available on exercise training during treatment in colorectal cancer patients. One study concluded exercise therapy may be beneficial for colorectal cancer patients during adjuvant treatment. The possible advantages of training during neoadjuvant treatment may be explored by prehabilitation trials.

Laparoscopic mesh removal for otherwise intractable inguinal pain following endoscopic hernia repair is feasible, safe and may be effective in selected patients.

BACKGROUND: Laparoscopic inguinal hernia repair is preferred over an open technique because of reduced recovery time, favorable cost effectiveness, and less chronic postoperative inguinal pain. Nevertheless, some patients develop a nociceptive inguinal pain syndrome possibly related to the presence of the mesh. This is the first study describing feasibility, safety, and effectiveness of laparoscopic mesh removal in patients with chronic pain after endoscopic hernia repair. METHODS: Pre- and intraoperative data of chronic pain patients scheduled for endoscopic mesh removal were prospectively collected by a standard evaluation form. Long-term efficacy was determined using pain scores, patient satisfaction, and quality of life questionnaire. A Wilcoxon signed-rank test was used to determine significant differences between pre- and postoperative pain scores. RESULTS: Fourteen patients were studied (11 males, median 52 years). Median operating time was 103 min. Conversion to open surgery was not required. One intraoperatively recognized bladder laceration was laparoscopically closed. Otherwise, no intraoperative or postoperative complications occurred. Eight months postoperatively (median), pain scores had dropped from eight to four (p < 0.01). Satisfaction was good or excellent in ten patients. A recurrent hernia developed in two patients requiring an open mesh repair in one. CONCLUSIONS: Laparoscopic mesh removal is a feasible, safe, and effective option in selected patients with chronic groin pain after endoscopic hernia repair in the hands of an experienced surgeon.

Randomized clinical trial of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study).

BACKGROUND: Laparoscopic left lateral sectionectomy (LLLS) has been associated with shorter hospital stay and reduced overall morbidity compared with open left lateral sectionectomy (OLLS). Strong evidence has not, however, been provided. METHODS: In this multicentre double-blind RCT, patients (aged 18-80 years with a BMI of 18-35 kg/m2 and ASA fitness grade of III or below) requiring left lateral sectionectomy (LLS) were assigned randomly to OLLS or LLLS within an enhanced recovery after surgery (ERAS) programme. All randomized patients, ward physicians and nurses were blinded to the procedure undertaken. A parallel prospective registry (open non-randomized (ONR) versus laparoscopic non-randomized (LNR)) was used to monitor patients who were not enrolled for randomization because of doctor or patient preference. The primary endpoint was time to functional recovery. Secondary endpoints were length of hospital stay (LOS), readmission rate, overall morbidity, composite endpoint of liver surgery-specific morbidity, mortality, and reasons for delay in discharge after functional recovery. RESULTS: Between January 2010 and July 2014, patients were recruited at ten centres. Of these, 24 patients were randomized at eight centres, and 67 patients from eight centres were included in the prospective registry. Owing to slow accrual, the trial was stopped on the advice of an independent Data and Safety Monitoring Board in the Netherlands. No significant difference in median (i.q.r.) time to functional recovery was observed between laparoscopic and open surgery in the randomized or non-randomized groups: 3 (3-5) days for OLLS versus 3 (3-3) days for LLLS; and 3 (3-3) days for ONR versus 3 (3-4) days for LNR. There were no significant differences with regard to LOS, morbidity, reoperation, readmission and mortality rates. CONCLUSION: This RCT comparing open and laparoscopic LLS in an ERAS setting was not able to reach a conclusion on time to functional recovery, because it was stopped prematurely owing to slow accrual. Registration number: NCT00874224 ( https://www.clinicaltrials.gov).

Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together.

BACKGROUND: Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation. METHODS: Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies). RESULTS: The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL. CONCLUSION: Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.

Is current perioperative practice in hepatic surgery based on enhanced recovery after surgery (ERAS) principles?

BACKGROUND: The worldwide introduction of multimodal enhanced recovery programs has also changed perioperative care in patients who undergo liver resection. This study was performed to assess current perioperative practice in liver surgery in 11 European HPB centers and compare it to enhanced recovery after surgery (ERAS) principles. METHODS: In each unit, 15 consecutive patients (N = 165) who underwent hepatectomy between 2010 and 2012 were retrospectively analyzed. Compliance was classified as "full," "partial," or "poor" whenever ≥ 80, ≥ 50, or <50 % of the 22 ERAS protocol core items were met. The primary study end point was overall compliance with the ERAS core program per unit and per perioperative phase. RESULTS: Most patients were operated on for malignancy (91 %) and 56 % were minor hepatectomies. The median number of implemented ERAS core items was 9 (range = 7-12) across all centers. Compliance was partial in the preoperative (median 2 of 3 items, range = 1-3) and perioperative phases (median 5 of 10 items, range: 4-7). Median postoperative compliance was poor (median 2 of 9 items, range = 0-4). A statistically significant difference was observed between median length of stay and median time to recovery (7 vs. 5 days, P < 0.001). CONCLUSION: Perioperative care among centers that perform liver resections varied substantially. In current HPB surgical practice, some elements of the ERAS program, e.g., preoperative counselling and minimal fasting, have already been implemented. Elements in the perioperative phase (avoidance of drains and nasogastric tube) and postoperative phase (early resumption of oral intake, early mobilization, and use of recovery criteria) should be further optimized.

Quality of life of older rectal cancer patients is not impaired by a permanent stoma.

BACKGROUND: The current study was undertaken to investigate the impact of a stoma on the HRQL with a special focus on age. MATERIALS AND METHODS: Using the Eindhoven Cancer Registry, rectal cancer patients diagnosed between 1998 and 2007 in 4 hospitals were identified. All patients underwent TME surgery. Survivors were approached to complete the SF-36 and EORTC QLQ-C38 questionnaires. HRQL scores of the four groups, stratified by stoma status (stoma/no stoma) and age at operation (<70 and ≥ 70), were compared. The SF-36 and the QLQ-CR38 sexuality subscale scores of the survivors were compared with an age- and sex-matched Dutch norm population. RESULTS: Median follow-up of 143 patients was 3.4 years. Elderly had significantly worse physical function (p = 0.0003) compared to younger patients. Elderly (p = 0.005) and patients without a stoma (p = 0.009) had worse sexual functioning compared to younger patients and patients with a stoma. Older males showed more sexual dysfunction (p = 0.01) when compared to younger males. In comparison with the normative population, elderly with a stoma had worse physical function (p < 0.01), but slightly better mental health (p < 0.05). Elderly without a stoma had better emotional role function (p < 0.01), and younger patients had worse sexual functioning and enjoyment (both p < 0.0001). CONCLUSIONS: Older patients with a stoma have comparable HRQL to older patients without a stoma or the normative population, indicating the feasibility of a permanent stoma for elderly patients with a low situated rectal carcinoma. The negative impact of treatment on sexual functioning as found in the current study calls for further attention to alleviate this problem in sexually active patients.

Gallbladder cancer, a vanishing disease?

OBJECTIVE: Gallbladder cancer (GBC) is a rare gastrointestinal malignancy. A retrospective population-based study was conducted to evaluate trends in incidence, treatment, and outcome of GBC in the latter three decades in the south of the Netherlands. METHODS: All patients diagnosed with GBC diagnosed in the Dutch Eindhoven Cancer Registry area between 1975 and 2008 were included (n = 659). Trend analyses were conducted for treatment and survival. RESULTS: During this time period, standardized incidence in females and males plummeted from 4.5 to 0.7 and from 2.0 to 0.4 per 100,000 inhabitants, respectively. Resection rates decreased from 74.3 to 53.4 %. Chemotherapy and radiotherapy rates did not change and were used sparingly. Five-year survival remained stable (10 %) over time. CONCLUSION: The age-standardized incidence of GBC declined drastically over the last three decades. An increasing number of early cholecystectomies for gallstones may play a role. Parallel to the decreasing incidence of stomach cancer, the effective treatment of Helicobacter pylori may also have resulted in a lowered incidence of GBC.

Risk factors for conversion during laparoscopic cholecystectomy - experiences from a general teaching hospital.

BACKGROUND AND AIMS: Laparoscopic cholecystectomy (LC) is the gold standard for treating symptomatic cholelithiasis. Conversion, however, is sometimes necessary. The aim of this study was to determine predictive factors of conversion in patients undergoing LC for various indications in elective and acute settings in a general teaching hospital. MATERIAL AND METHODS: A retrospective analysis was performed on 972 consecutive patients who underwent a laparoscopic cholecystectomy in Máxima Medical Centre in Veldhoven, the Netherlands, from January 2000 till January 2006. Recorded data were sex, age, indication for LC, conversion to open cholecystectomy, reason for conversion, performing surgeon, co-morbidity, type of complication, length of hospital stay and 30-day mortality. RESULTS: Conversion to open cholecystectomy was performed in 121 patients (12%). The most frequent reasons for conversion were infiltration/fibrosis of Calot's triangle (30%) and adhesions (27%). In the multivariate analyses male gender (OR 1.67, 95% CI 1.07-2.59), age >65 years (OR 2.10, 95% CI 1.32-3.34), acute cholecystitis (OR 11.8, 95% CI 6.98-20.1), recent acute cholecystitis (OR 4.71, 95% CI 2.42-9.18) and recent obstructive jaundice (OR 20.6, 95% CI 4.52-94.1) were independent predictive factors for conversion. CONCLUSIONS: Male gender, age >65 years, (recent) acute cholecystitis and recent obstructive jaundice are independent predictive risk factors for conversion. By appreciating these risk factors for conversion, preoperative patient counselling can be improved.