Experiences and needs of partners as informal caregivers of patients with major low anterior resection syndrome: A qualitative study.

PURPOSE: After treatment, many rectal cancer survivors are confronted with ongoing bowel problems, called low anterior resection syndrome. The cancer diagnosis and treatment poses a burden on informal caregivers and results in higher levels of psychological distress and loneliness which is persistent after treatment as well. Our study aimed to investigate the experiences and needs of partners as informal caregivers of patients with major low anterior resection syndrome. METHODS: A ground theory study was conducted. Semi-structured interviews with partners as informal caregivers of patients with major low anterior syndrome were performed in three hospitals between 2017 and 2019. In the first phase, maximum variation sampling was used and later theoretical sampling. Data analysis was done using the constant comparative method and investigators triangulation. RESULTS: Twenty partners as informal caregivers were interviewed until data saturation. Low anterior resection syndrome of their partner was overwhelming and they failed to live a normal life. They had the feeling that they stood at the side-line and partly because of that felt lonely. Partners experienced three levels of loneliness: because of their changed own life, the changed life of their partner and the changed life in the environment. CONCLUSION: Low anterior resection syndrome has a large impact on the lives of partners as informal caregivers and induces loneliness at three levels. It is key that the HCPs of the interdisciplinary team understand this impact. A clinical nurse specialist/oncology nurse navigator could help in alleviate that burden by addressing both patients' and partners' needs.

The trajectory of hope and loneliness in rectal cancer survivors with major low anterior resection syndrome: A qualitative study.

PURPOSE: Rectal cancer survivors are often confronted with long-term bowel function impairment, called low anterior resection syndrome. This has a large impact on patients' lives. The aim was to explore the experiences of patients with major low anterior resection syndrome with a specific focus on hope and loneliness. METHODS: A grounded theory approach was used. Individual semi-structured interviews (n = 28) were performed between 2017 and 2019. Patients were recruited in three hospitals and a call was distributed in two patients' organizations. During data analysis, the constant comparative method and investigators' triangulation was used. RESULTS: Hope was important at different stages in the trajectory. After treatment patients hoped to pick up their previous life. Confrontation with low anterior resection syndrome was unexpected and patients hoped to manage it through trial and error. They lost hope if further improvement was absent. At that turning point some tried to accept the new lifestyle, others pushed their boundaries and some opted for a permanent stoma. Loneliness presented itself in several layers. Patients experience loneliness due being toilet-bound, changes in their lives and activities outside their homes and the impact on their family life. CONCLUSION: Assessment of the impact on patients' lives and tailored counselling is possible if healthcare professionals gain more insight into the different layers of loneliness and where the patient is located in the trajectory of hope.

Experiences and needs of patients with rectal cancer confronted with bowel problems after stoma reversal: A systematic review and thematic-synthesis.

PURPOSE: After the reversal of the temporary stoma, rectal cancer survivors are often confronted with bowel complaints largely impacting on their quality of life. This systematic review aims to identify and synthesise the experiences and needs of patients with rectal cancer confronted with bowel problems after stoma reversal. METHODS: A systematic search was performed through Pubmed, CINAHL and Web of Science. Only studies with a qualitative design were included in this review. Quality assessment was done by the critical appraisal skill programme (CASP) Qualitative Studies Checklist. A thematic-synthesis was performed. RESULTS: Of 2713 identified papers, 10 were included in this systematic review. Two general themes were identified: 'experiences and needs about bowel function before surgery' and 'experiences and needs afterwards'. Before restoration of continuity patients had to cope with the temporary stoma, and they felt uncertain about what to expect. Patients indicated that the timing of providing information was crucial but varied. Bowel problems after surgery had a physical and emotional impact on patients' family life. They were also confronted with shame and stigma. Patients were happy to be alive and cancer free but were hopeful that the bowel problems would resolve. They used several strategies to manage and cope with these symptoms. Peers and healthcare professionals proved valuable resources of support. CONCLUSION: Rectal cancer survivors experience ongoing bowel problems after treatment. Patients describe experiences and needs before rectal cancer surgery and afterwards when confronting with bowel problems. Follow-up care should be organised proactively and focus on management strategies and emotional support.

Impact of low anterior resection syndrome (LARS) on the quality of life and treatment options of LARS - A cross sectional study.

PURPOSE: The purpose of this study was to assess the relationship between the low anterior resection syndrome (LARS) and quality of life (QOL). Furthermore, in patients with major LARS, therapeutic management options were explored. METHODS: A cohort of surviving patients, who underwent a low anterior resection for rectal cancer after long course of radiochemotherapy, were identified. These patients were treated in Ghent University Hospital between 2006 and 2016. QOL was assessed using the European Organization for Research and Treatment of Cancer Quality Of Life questionnaire-C30 and the bowel function using the LARS-score. The relationship between LARS and QOL was analysed. Patients with major LARS (≥30 points) were contacted to explore their therapeutic management of LARS. RESULTS: 69% of the participants had major LARS. QOL was closely associated with LARS. Significant differences were found between those with and without LARS in the global health status (p ≤ 0.001) and in the following functional scales: physical (p ≤ 0.001), role (p ≤ 0.001), cognitive (p = 0.04) and social (p ≤ 0.001). Patients with major LARS experienced more diarrhea (p ≤ 0.001), fatigue (p = 0.002), insomnia (p ≤ 0.001) and pain (p = 0.02), compared to patient with no/minor LARS. Most patients tried dietary regimens (71%), medication (71%) and incontinence material (63.8%) in an attempt to manage their LARS and found some of them useful. The level of the anastomosis (low) was a significant risk factor for major LARS (p=0.03). CONCLUSION: More than half of the patients in this cohort still suffered from major LARS. Patients confronted with major LARS had a lower QOL than patients with no/minor LARS. Currently, there is no gold standard for the management of LARS. Patients manage it through trial and error.

Safety and preliminary efficacy of electrostatic precipitation during pressurized intraperitoneal aerosol chemotherapy (PIPAC) for unresectable carcinomatosis.

INTRODUCTION: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) was recently introduced to treat unresectable peritoneal metastases. Adding an electrostatic field may enhance charged droplet precipitation and tissue penetration, resulting in improved anticancer efficacy. We report for the first time its safety and preliminary efficacy. MATERIALS AND METHODS: Patients underwent PIPAC combined with an electrostatic field, using the Ultravision™ apparatus. Adverse events were scored with the Common Terminology Criteria. Treatment response was assessed after more than one PIPAC, using clinical symptoms, tumor markers, CT imaging and histological regression. RESULTS: Forty-eight patients (median age, 61 y) with diverse primary tumors underwent 135 procedures (median per patient, 3). Most (65.2%) were treated as outpatient. Twenty-eight (58.3%) patients received concomitant chemotherapy. The most frequent treatment-related toxicities were anemia (grade 1 to 3, 13 [9.6%]), ileus (grade 1 to 3, 5 [3.7%]), anorexia (grade 1 to 3, 6 [4.4%]), nausea (grade 1 to 3, 5 [3.7%]) and vomiting (grade 1 to 3, 7 [5.2%]). There was no grade 4 or 5 morbidity. Twenty (41.7%) patients did not complete three treatments, mainly because of disease progression (n = 13). After two procedures, there were one responder and 8 non-responders. After three treatments, we observed 11 responders, two patients with stable disease, and 15 non-responders. All but one patient with therapy response received simultaneous chemotherapy. CONCLUSION: Electrostatic precipitation during PIPAC is well tolerated and safe. After three procedures and concomitant chemotherapy, response or stable disease is achieved in approximately half of cases. These findings warrant prospective trials in homogeneous patient cohorts.

The Belgian Association for Study of the Liver Guidance Document on the Management of Adult and Paediatric Non-Alcoholic Fatty Liver Disease.

Non-Alcoholic Fatty Liver Disease (NAFLD) is highly prevalent and associated with considerable liver-related and non-liverrelated morbidity and mortality. There is, however, a lot of uncertainty on how to handle NAFLD in clinical practice. The current guidance document, compiled under the aegis of the Belgian Association for the Study of the Liver by a panel of experts in NAFLD, from a broad range of different specialties, covers many questions encountered in daily clinical practice regarding diagnosis, screening, therapy and follow-up in adult and paediatric patients. Guidance statements in this document are based on the available evidence whenever possible. In case of absence of evidence or inconsistency of the data, guidance statements were formulated based on consensus of the expert panel. This guidance document is intended as a help for clinicians (general practitioners and all involved specialties) to implement the most recent evidence and insights in the field of NAFLD within a Belgian perspective.

Serum vascular cell adhesion molecule-1 predicts significant liver fibrosis in non-alcoholic fatty liver disease.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide and is strongly associated with obesity, dyslipidemia and insulin resistance. NAFLD often presents as simple steatosis (NAFL) but can progress to non-alcoholic steatohepatitis (NASH) and fibrosis. Current non-invasive biomarkers are not tailored to identify significant (⩾F2) fibrosis, although recent guidelines recommend a stringent follow-up of this patient population. We and others have reported on the role of pathological angiogenesis in the pathogenesis of NAFLD, highlighting pro-angiogenic factors as potential diagnostic markers. OBJECTIVE: To investigate the applicability of angiogenic and endothelial dysfunction markers as non-invasive diagnostic tools for NASH or NASH-associated fibrosis in obese patients. METHODS: In a prospective cross-sectional study, male patients undergoing bariatric surgery (n=61) and control patients (n=35) were recruited. Serum protein levels and visceral adipose tissue gene expression of endothelial dysfunction and angiogenic markers were analyzed by multiplex bead-based assay and quantitative RT-PCR, respectively. For validation, we recruited a second cohort of patients undergoing bariatric surgery (n=40) and a cohort of NAFLD patients from our outpatient clinic (n=30). RESULTS: We identified serum vascular cell adhesion molecule-1 (VCAM-1) as an independent predictor for ⩾F2 fibrosis (median 14.0 vs 8.7 ng ml-1 in patients with and without significant fibrosis; P<0.0001) with an area under the receiver-operating characteristics (AUROC) curve of 0.80. The cutoff point of 13.2 ng ml-1 showed a sensitivity of 80% and specificity of 83%. In line with these results, VCAM-1 visceral adipose tissue gene expression was also elevated in patients with fibrosis (P=0.030). In the bariatric surgery and clinical validation cohorts, VCAM-1 displayed similar AUROCs of 0.89 and 0.85, respectively. CONCLUSIONS: VCAM-1 levels are able to accurately predict significant (⩾F2) fibrosis in NAFLD patients.

Metabolic surgery in patients over 60 years old: short- and long-term results.

PURPOSE: Laparoscopic Roux-en-Y gastric bypass can treat obesity related comorbidities and can prolong life expectancy. It remains unclear whether this type of surgery is also indicated in obese patients with advanced age. MATERIALS AND METHODS: In this retrospective monocentric study, we investigated the morbidity and outcomes of weight and metabolic control of bariatric surgery in patients older than 60 years and compared these findings with those of younger patients. RESULTS: At 18 months after RY gastric bypass, weight losses of respectively 30 ± 11% and 34 ± 9% of total initial body weight were measured in the older and younger patients (p < 0.05). After 12 months, HbA1c dropped below 6.5% in 89% of patients younger and in 81% of patients older than 60 (p = 0.11). There was no mortality in either group, but there were significantly more complications and there was a longer hospital stay in the older patients. CONCLUSION: RY gastric bypass comes with a significantly higher morbidity and hospital stay in older patients, but weight loss and improvement of DM are similar as in the younger patients.

Effect of neoadjuvant radiation dose on surgical and oncological outcome in locally advanced esophageal cancer.

INTRODUCTION: Neoadjuvant chemoradiation (CRT) confers a survival benefit in locally advanced esophageal cancer. The optimal dose of radiotherapy remains undefined. METHODS: From a prospective database, we identified patients who received CRT followed by Ivor Lewis esophagectomy. Surgical complications, pathological response, and oncological outcome were compared between patients who received a radiotherapy (RT) dose of 36 Gy (group 1) versus a dose of > 40 Gy (group 2). RESULTS: 147 patients were evaluated : 109 received 36 Gy, while 38 received 41-50 Gy. Mean age was 61 ± 9 years (84% male). Median hospital stay was 16 days. Anastomotic leakage occurred in 4.0%. Pulmonary complications occurred in 41.8%, neither being influenced by RT dose. Complete resection (R0) was achieved in 95% (group 1) and 100% (group 2), P = 0.3. Pathological complete response (pCR) was observed in 19% (group 1) and 37% (group 2), P = 0.04. Local recurrence developed in 9% in group 1, and 3% in group 2 (P = 0.3), but regional recurrence developed significantly higher in the low dose group (28% vs 3%, P < 0.001). Metastatic recurrence occurred in 48% in group 1 and 13% in group 2 (P < 0.001). CONCLUSIONS: In patients with locally advanced esophageal cancer a higher RT dose does not affect surgical outcome, enhances pCR rate, and reduces the locoregional and metastatic recurrence risk.

Effect of Neoadjuvant Radiation Dose on Surgical and Oncological Outcome in Locally Advanced Esophageal Cancer.

INTRODUCTION: Neoadjuvant chemoradiation (CRT) confers a survival benefit in locally advanced esophageal cancer. The optimal dose of radiotherapy remains undefined. METHODS: From a prospective database, we identified patients who received CRT followed by Ivor Lewis esophagectomy. Surgical complications, pathological response, and oncological outcome were compared between patients who received a radiotherapy (RT) dose of 36 Gy (group1) versus a dose of > 40 Gy (group 1). RESULTS: 147 patients were evaluated: 109 received 36 Gy, while 38 received 41-50Gy. Mean age was 61 ± 9 years (84% male). Median hospital stay was 16 days. Anastomotic leakage occurred in 4.0%. Pulmonary complications occurred in 41.8%, neither being influenced by RT dose. Complete resection (R0) was achieved in 95% (group 1) and 100% (group 2), P = 0.3. Pathological complete response (pCR) was observed in 19% (group 1) and 37% (group 1), P = 0.04. Local recurrence developed in 9% in group 1, and 3% in group 2 (P = 0.3), but regional recurrence developed significantly higher in the low dose group (18% vs 3%, P < 0.001). Metastatic recurrence occurred in 48% in group 1 and 13% in group 1 (P < 0.001). CONCLUSIONS: In patients with locally advanced esophageal cancer a higher RT dose does not affect surgical outcome, enhances pCR rate, and reduces the locoregional and metastatic recurrence risk.

Training models in laparoscopy: a systematic review comparing their effectiveness in learning surgical skills.

BACKGROUND: Surgery has traditionally been learned on patients in the operating room, which is time-consuming, can have an impact on the patient outcomes, and is of variable effectiveness. As a result, surgical training models have been developed, which are compared in this systematic review. METHODS: We searched Pubmed, CENTRAL, and Science Citation index expanded for randomised clinical trials and randomised cross-over studies comparing laparoscopic training models. Studies comparing one model with no training were also included. The reference list of identified trials was searched for further relevant studies. RESULTS: Fifty-eight trials evaluating several training forms and involving 1591 participants were included (four studies with a low risk of bias). Training (virtual reality (VR) or video trainer (VT)) versus no training improves surgical skills in the majority of trials. Both VR and VT are as effective in most studies. VR training is superior to traditional laparoscopic training in the operating room. Outcome results for VR robotic simulations versus robot training show no clear difference in effectiveness for either model. Only one trial included human cadavers and observed better results versus VR for one out of four scores. Contrasting results are observed when robotic technology is compared with manual laparoscopy. CONCLUSION: VR training and VT training are valid teaching models. Practicing on these models similarly improves surgical skills. A combination of both methods is recommended in a surgical curriculum. VR training is superior to unstructured traditional training in the operating room. The reciprocal effectiveness of the other models to learn surgical skills has not yet been established.

Effect of perfusion temperature on glucose and electrolyte transport during hyperthermic intraperitoneal chemoperfusion (HIPEC) with oxaliplatin.

INTRODUCTION: Hyperthermic intraperitoneal chemoperfusion (HIPEC) with oxaliplatin is increasingly used in patients with carcinomatosis from colorectal cancer. For reasons of chemical stability, oxaliplatin can only be administered in a dextrose (D5%) solution, and this causes peroperative glucose and electrolyte shifts. Here, we examined the influence of perfusion temperature on glucose and electrolyte transport, metabolic shifts, and surgical morbidity. METHODS: Patients with carcinomatosis underwent cytoreduction and HIPEC using oxaliplatin (460 mg/m(2) in D5%, open abdomen) during 30 min at 39°-41 °C. Intraperitoneal (IP) temperature was measured at three locations using thermocouple probes. The area under the temperature versus time curve (AUCt) was calculated using the trapezoid rule. The influence of perfusion temperature on surgical outcome was assessed using linear regression models and the Mann Whitney U test where appropriate. RESULTS: From July 2005 until March 2011, 145 procedures were performed in 139 patients with a diagnosis of CRC (70%), pseudomyxoma peritonei (11%), ovarian cancer (10%), or miscellaneous peritoneal malignancies (9%). Postoperative mortality and major morbidity were 1.4% and 26%, respectively. Higher perfusion temperature was related to more pronounced changes in serum glucose (P = 0.058), sodium (P = 0.017), and lactate (P < 0.001). The median duration of nasogastric drainage was 5 days, and this was unrelated to perfusion temperature (P = 0.76). The GI fistula rate and reoperation rate were 12.4% and 16.5% respectively; neither was related to perfusion temperature. CONCLUSIONS: In patients undergoing HIPEC with oxaliplatin, perfusion temperature exacerbates peroperative metabolic shifts but does not affect surgical outcome.

Life-threatening side effects of malabsorptive procedures in obese patients necessitating conversion surgery: a review of 17 cases.

BACKGROUND: Malabsorptive surgery (MAS) can cause huge weight loss but is also known for its serious side effects. We investigated whether conversion surgery is an effective treatment for MAS-induced complications. METHODS: We searched our hospital database for patients who underwent conversion surgery after MAS. Any complication was recorded till time of conversion. The conversion techniques and their effect on the course of the patients were analyzed and compared to the situation after MAS. RESULTS: We identified 17 patients who suffered a wide range of complications after biliopancreatic diversion (BPD) (n = 11), biliopancreatic diversion with duodenal switch (BPD-DS) (n = 4), or distal gastric bypass (D-GBP) (n = 2). After a (mean +/- SD) period of 6.0 +/- 3.6 years the MAS was either converted to a gastric bypass (GBP) in 6 patients or an elongation of the common limb (ECL) in 9 patients. Two conversions were atypical. After a (mean +/- SD) follow-up of 2.4 +/- 2.5 years the majority of blood test results improved. The incidence of most complaints diminished except abdominal discomfort, critical illness polyneuropathy, need for total parenteral nutrition (TPN), wheelchair dependency, and asthenia. One patient died of irreversible liver failure after 3 liver transplantations. Two patients died of cachexia. The preferred conversion technique is still unclear. CONCLUSIONS: MAS can cause invalidating and life-threatening side effects. If there are signs of incipient deterioration in organ function and/or nutritional status, conversion surgery should not be delayed. Although we have the impression that early conversion causes better outcome, many patients experience lifelong postoperative complications.

Long-term results of a prospective study on laparoscopic adjustable gastric banding for morbid obesity.

BACKGROUND: The objective of this study was to study the long-term outcome of adjustable gastric banding in the treatment of morbid obesity. In Europe, the preference for gastric band has declined in favor of Roux-Y-gastric bypass. METHODS: This is a follow-up of a prospective study on a large cohort of patients after laparoscopic gastric banding (LAGB) for morbid obesity. RESULTS: Complete data were collected on 656 patients (88%) from a cohort of 745 patients. After a median follow-up of 95 months (range 60-155), the mean BMI dropped from 41.0 ± 7.3 to 33.2 ± 7.1 kg/m², with a 46.2 ± 36.5% excess weight loss (EWL). A more than 50% EWL was achieved in 44% of patients. The band was still in place in 77.1% of patients; conversion to gastric bypass after band removal was carried out in 98 (14.9%) patients, while a simple removal was done in only 52 (7.9%) patients. Band removal was more likely in women and patients with a higher BMI. CONCLUSIONS: After LAGB, band removal was necessary for complications or insufficient weight loss in 24% of patients. Nearly half of the patients achieved a more than 50% EWL, but in 88%, a more than 10% EWL was observed. LAGB can achieve an acceptable weight loss in some patients, but the failure in one out of four patients does not allow proposing it as a first-line option for the treatment of obesity.

Prognostic value of the lymph node ratio in stage III colorectal cancer: a systematic review.

BACKGROUND: Although nodal invasion represents one of the most powerful prognostic indicators in colorectal cancer, marked heterogeneity exists within stage III patients. Recently, the lymph node ratio (LNR), defined as the ratio of the number of positive nodes over the total number of examined nodes, was proposed to stratify outcome in stage III patients. METHODS: A systematic search was performed for studies examining the prognostic significance of the LNR in colon or rectal cancer. Individual studies were assessed for methodological quality and summary data extracted. Hazard ratios from multivariate analyses were entered in a fixed-effects meta-analysis model. RESULTS: In total, 16 studies were identified including 33,984 patients with stage III colon or rectal cancer. In all identified studies, the LNR was identified as an independent prognostic factor in patients with stage III cancer of the colon or rectum. The prognostic separation obtained by the LNR was superior to that of the number of positive nodes (N stage). The pooled hazard ratios for overall and disease-free survival were 2.36 (95% confidence interval, 2.14-2.61) and 3.71 (95% confidence interval, 2.56-5.38), respectively. CONCLUSIONS: The LNR allows superior prognostic stratification in stage III colorectal cancer and should be validated in prospective studies.

Defining the optimal therapy sequence in synchronous resectable liver metastases from colorectal cancer: a decision analysis approach.

INTRODUCTION: Approximately 5%-20% of colorectal cancer (CRC) patients present with synchronous potentially resectable liver metastatic disease. Preclinical and clinical studies suggest a benefit of the 'liver first' approach, i.e. resection of the liver metastasis followed by resection of the primary tumour. A formal decision analysis may support a rational choice between several therapy options. METHODS: Survival and morbidity data were retrieved from relevant clinical studies identified by a Web of Science search. Data were entered into decision analysis software (TreeAge Pro 2009, Williamstown, MA, USA). Transition probabilities including the risk of death from complications or disease progression associated with individual therapy options were entered into the model. Sensitivity analysis was performed to evaluate the model's validity under a variety of assumptions. RESULTS: The result of the decision analysis confirms the superiority of the 'liver first' approach. Sensitivity analysis demonstrated that this assumption is valid on condition that the mortality associated with the hepatectomy first is < 4.5%, and that the mortality of colectomy performed after hepatectomy is < 3.2%. CONCLUSION: The results of this decision analysis suggest that, in patients with synchronous resectable colorectal liver metastases, the 'liver first' approach is to be preferred. Randomized trials will be needed to confirm the results of this simulation based outcome.

Laparoscopic repair of parastomal hernias: a multi-centre retrospective review and shift in technique.

PURPOSE: To describe the reasons for a shift in our technique of laparoscopic repair of parastomal hernias towards repair with a non-slit mesh. Our initial results with repair using meshes with a keyhole had high recurrence rates. METHODS: We performed a multi-centre retrospective study focusing on complications and recurrences. Data were gathered retrospectively from the medical records. The last follow-up date was the latest clinical examination by the surgeon. Recurrences were diagnosed clinically or by CT scan performed for oncological follow-up in cancer patients. RESULTS: From September 2001 till May 2007, twenty-four patients with a symptomatic parastomal hernia were treated laparoscopically. No major intra- or postoperative complications were encountered. We had no conversions, no enterotomies and the overall postoperative morbidity was 8.4% (2/24). During a mean follow-up of 21.2 months, ten recurrences or 41.7% (10/24) have been diagnosed. In patients treated with a "keyhole technique" recurrence rate was 72.7% (8/11) with a mean follow-up of 30.7 months. In patients treated with a "modified Sugarbaker technique" recurrence rate was 15.4% (2/13) with a mean follow-up of 14.0 months. CONCLUSIONS: We found laparoscopic parastomal hernia repair could be performed with few complications. We abandoned the "keyhole techniques" because of a high recurrence rate. We currently use a "modified Sugarbaker technique" with promising early results.

Surgery and intracavitary chemotherapy for peritoneal carcinomatosis from colorectal origin.

A subset of patients with colorectal cancer (CRC) develops synchronous or metachronous isolated peritoneal disease. The development of peritoneal carcinomatosis (PC) can be conceptualized as a series of well defined steps including cell shedding, adhesion to mesothelial cells and underlying matrix, and invasion of submesothelial tissue. Surgical cytoreduction combined with hyperthermic intraperitoneal chemoperfusion (HIPEC) has evolved as the standard of care in patients with mucinous appendiceal tumors including the pseudomyxoma peritonei syndrome. Recently, this approach was extended to patients with peritoneal carcinomatosis (PC) from non appendiceal CRC. In this review, we discuss the biological rationale, clinical methods, and oncological outcomes associated with cytoreduction and intracavitary chemotherapy in CRC patients suffering from peritoneal disease spread.

Open, preperitoneal hernia repair with the Kugel patch: a prospective, multicentre study of 450 repairs.

BACKGROUND: The Kugel patch inguinal hernia repair is a relatively new, open, minimally invasive procedure using a preperitoneal approach. METHOD: Prospective multicentre case series of 450 consecutive Kugel patch repairs. Recurrence rates and persistent inguinal pain after at least 1 year as well as short-term outcomes were studied. RESULTS: After a follow-up of 18 months, eight recurrences (1.9%) were found, and persisting inguinal pain was reported in 15 patients (3.5%). The mean operation time and hospital stay were 20 +/- 9 min and 19 +/- 1.3 h respectively. Less than 1% of patients planned for an ambulatory treatment needed prolonged hospitalisation. Analgesics were used for 3 +/- 2 days. Paracetamol was the only painkiller used in 69% of patients, and 13% did not take any painkiller at all. Half of all patients returned to their daily activities after 9 days and half of the employed patients returned to work after 14 days. CONCLUSION: The Kugel patch repair is a quick technique with a low recurrence rate and good patient comfort. It offers the advantages of a preperitoneal inguinal hernia repair without the need for general anaesthesia or expensive laparoscopic equipment.