Evaluation of National Surgical Practice for Lateral Lymph Nodes in Rectal Cancer in an Untrained Setting.

BACKGROUND: Involved lateral lymph nodes (LLNs) have been associated with increased local recurrence (LR) and ipsi-lateral LR (LLR) rates. However, consensus regarding the indication and type of surgical treatment for suspicious LLNs is lacking. This study evaluated the surgical treatment of LLNs in an untrained setting at a national level. METHODS: Patients who underwent additional LLN surgery were selected from a national cross-sectional cohort study regarding patients undergoing rectal cancer surgery in 69 Dutch hospitals in 2016. LLN surgery consisted of either 'node-picking' (the removal of an individual LLN) or 'partial regional node dissection' (PRND; an incomplete resection of the LLN area). For all patients with primarily enlarged (≥7 mm) LLNs, those undergoing rectal surgery with an additional LLN procedure were compared to those  undergoing only rectal resection. RESULTS: Out of 3057 patients, 64 underwent additional LLN surgery, with 4-year LR and LLR rates of 26% and 15%, respectively. Forty-eight patients (75%) had enlarged LLNs, with corresponding recurrence rates of 26% and 19%, respectively. Node-picking (n = 40) resulted in a 20% 4-year LLR, and a 14% LLR after PRND (n = 8; p = 0.677). Multivariable analysis of 158 patients with enlarged LLNs undergoing additional LLN surgery (n = 48) or rectal resection alone (n = 110) showed no significant association of LLN surgery with 4-year LR or LLR, but suggested higher recurrence risks after LLN surgery (LR: hazard ratio [HR] 1.5, 95% confidence interval [CI] 0.7-3.2, p = 0.264; LLR: HR 1.9, 95% CI 0.2-2.5, p = 0.874). CONCLUSION: Evaluation of Dutch practice in 2016 revealed that approximately one-third of patients with primarily enlarged LLNs underwent surgical treatment, mostly consisting of node-picking. Recurrence rates were not significantly affected by LLN surgery, but did suggest worse outcomes. Outcomes of LLN surgery after adequate training requires further research.

Primary care access to radiology: Characteristics of trauma patients referred to the emergency department.

RATIONALE, AIMS AND OBJECTIVES: Low-urgent Emergency Department (ED) attendances are a known contributing factor to ED crowding. In the Netherlands, general practitioners (GPs) have direct access to radiology facilities during office hours. Patients with radiographically confirmed traumatic injuries are subsequently referred to the ED. We analysed these ED trauma patients' characteristics, provided treatments and ED discharge diagnoses to identify the possibility of alternative care pathways. METHODS: Single-centre retrospective observational study of trauma patients referred to the ED by the radiology department during office hours (January 2017-December 2017). Data were obtained from patient records. Descriptive statistics were used to analyse the extracted data. RESULTS: A total of 662 patients were included. The median age was 42 years (range: 1-100, interquartile range (IQR): 15-63) and patients presented to the ED with a median delay of 1 day (range: 0-112 days, IQR: 0-5). Most patients were referred for injuries involving the upper extremities (61.5%) and lower extremities (30%). A total of 48 additional diagnoses were made in the ED. The majority of injuries was classified as 'minor' (29.5%) or 'moderate' (68.3%) on the Abbreviated Injury Scale (AIS). The median length of stay in the ED was 65 min (range: 7-297 min, IQR: 43-102). CONCLUSION: Most patients presented with low acuity injuries and often with a notable delay to the ED. This suggests that the majority of these patients do not necessarily need ED treatment, which may provide an opportunity to counter ED crowding.

The added clinical value of performing CT colonography in patients with obstructing colorectal carcinoma.

BACKGROUND: A small percentage of incomplete optical colonoscopies (OCs) are the result of an obstructing tumor. According to current guidelines, CT colonography (CTC) is performed to prevent missing a synchronous tumor. The aim of this study was to evaluate how frequently a synchronous tumor was found on CTC and how often this led to a change in the surgical plan. METHODS: In this retrospective study, a total of 267 patients underwent CTC after an incomplete OC as a result of an obstructing colorectal carcinoma (CRC). Among them, 210 patients undergoing surgery met the inclusion criteria and were included in the analysis. The OC report, CTC report and surgical report of these patients were retrospectively evaluated for the presence of synchronous tumors using surgery and post-operative colonoscopy as the gold standard. RESULTS: Six of the 210 patients (2.9%) showed signs of a synchronous CRC proximal to the obstructing tumor on CTC. In three of these patients, a synchronous CRC was confirmed during surgery. All these tumors caused a change in the surgical plan. Three out of the six tumors found on CTC were found to be large, non-malignant polyps. All these polyps were located in the same segment as the obstructing tumor and therefore did not alter the surgical plan. CONCLUSION: In patients with obstructing CRC, the frequency of synchronous CRCs proximal to this lesion is low. Performing a CTC leads to a change in surgical plan based on the presence of these synchronous tumors in 1.4% of the cases. CTC should be employed as a one-stop shop in patients with an obstructing CRC.

Sigmoid cancer versus chronic diverticular disease: differentiating features at CT colonography.

PURPOSE: To retrospectively identify morphologic findings at computed tomographic (CT) colonography that are the most reliable in the differentiation of masslike chronic diverticular disease from sigmoid carcinoma in a large patient cohort. MATERIALS AND METHODS: This study was approved by the institutional review boards. The need for signed consent was waived for this retrospective study. The cohort consisted of 212 patients (mean age, 68 years; 113 women, 99 men) with focal masslike findings in the sigmoid colon at CT colonography, representing chronic diverticular disease (n = 97) or sigmoid carcinoma (n = 115). CT colonography studies were scored according to presence or absence of potential discriminators by a panel of four readers in consensus. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated, and multivariate analysis was performed. RESULTS: Absence of diverticula in the affected segment showed high NPV and PPV (0.95 and 0.93, respectively). Also, shoulder phenomenon showed a high NPV (0.92) and PPV (0.75). Segment length of 10 cm or less (NPV, 0.85; PPV, 0.61) and destroyed mucosal folds (NPV, 1.00; PPV, 0.62) had a high NPV but a low PPV. Although segments affected by carcinoma often showed straightened and eccentric growth patterns, no thick fascia sign, and more and larger local-regional lymph nodes (all P < .05), NPV was insufficient for discrimination (NPV ≤ 0.66). Combination of absence of diverticula and presence of shouldering showed a high diagnostic certainty (93%). CONCLUSION: Carcinoma is best differentiated from masslike diverticular disease by the absence of diverticula in the affected segment and the presence of shoulder phenomenon.

Prospective evaluation of the added value of imaging within the Dutch National Diagnostic Appendicitis Guideline--do we forget our clinical eye?

BACKGROUND: Annually 16,000 appendectomies are performed in the Netherlands, of which 15-20% are negative. In 2010, to reduce this unacceptable percentage of superfluous appendectomies, the Dutch Association for Surgery introduced the 'Appendicitis Guideline'. This guideline recommends the use of imaging. In this observational prospective study the added value of imaging in everyday clinical practice is evaluated. METHODS: All patients with suspected appendicitis were included at the emergency department of a Dutch teaching hospital during the period from September 2011 to May 2012 (n = 350; 237 adults and 113 children under 18 years). Adherence to the guideline was evaluated. RESULTS: 75 Patients (21%) were not referred for imaging because of a low suspicion or alternative diagnosis. In 16 patients (5%) the guideline was not followed. Of the 259 patients (74%) who underwent ultrasonography, 105 (30%) also underwent computed tomography (CT). 127 appendectomies were performed, showing appendicitis in 112 patients (88%); 15 appendectomies (12%) were negative. In the latter group, 12 were performed after false positive imaging results, and 3 following inconclusive imaging results. CONCLUSION: When using imaging in the diagnosis of appendicitis, the percentage of negative appendectomies remains close to the percentage declared as unacceptable by the publishers of the guideline.

[CT colonography as first-line diagnostic procedure in patients with bowel symptoms]. / CT-colografie als eerstelijnsdiagnosticum bij patiënten met darmklachten.

OBJECTIVE: To investigate in how many patients with bowel or abdominal complaints, referred by the primary care physician (PCP) for exclusion of colorectal carcinoma (CRC), the more invasive colonoscopy could be avoided on the basis of the findings of CT colonography. DESIGN: Retrospective, descriptive. METHODS: All consecutive patients who underwent CT colonography in our centre on the request of their PCP from December 2006 to June 2009 were included. Demographic and referral data were collected. CT colonography results were described according to the 'CT Colonography Reporting and Data System'. We also investigated how many patients had to undergo colonoscopy in the 6 months following CT colonography. RESULTS: 398 patients (154 men and 244 women) with a median age of 61 years (range: 22-91) were included. Follow-up colonoscopy was indicated by CT colonography in 30 patients (7.5%) for suspected colorectal carcinoma, polyps > 10 mm, or 3 or more polyps 6-9 mm in size. In 33 patients (8.3%) follow-up colonoscopy or CT colonography was indicated for 1 or 2 polyps 6-9 mm in size, or suspicious lesions. 11 of these patients (2.8%) underwent colonoscopy. In 335 patients (84.2%) polyps > 6 mm or malignancies could be excluded. 18 of these patients (4.5%) still had a colonoscopy. In total, colonoscopy was spared in 341 patients (85.7%). Significant or potentially significant extra-colonic pathological abnormalities were found in 63 patients (15.8%). CONCLUSION: Our results support the theory that in the vast majority of patients with low or moderate suspicion of CRC referred by their PCP, invasive colonoscopy could be avoided, because CRC and polyps could be excluded by CT colonography. CT colonography could be a valuable additional diagnostic tool in primary care.