Minimally Invasive versus Open Approach for Right-Sided Colectomy: A Study in 12,006 Patients from the Dutch Surgical Colorectal Audit.

BACKGROUND: There is ongoing debate whether laparoscopic right colectomy is superior to open surgery. The purpose of this study was to address this issue and arrive at a consensus using data from a national database. METHODS: Patients who underwent elective open or laparoscopic right colectomy for colorectal cancer during the period 2009-2013 were identified from the Dutch Surgical Colorectal Audit. Complications that occurred within 30 days after surgery and 30-day mortality rates were calculated and compared between open and laparoscopic resection. RESULTS: In total, 12,006 patients underwent elective open or laparoscopic surgery for right-sided colorectal cancer. Of these, 6,683 (55.7%) underwent open resection and 5,323 (44.3%) underwent laparoscopic resection. Complications occurred within 30 days after surgery in the laparoscopic group in 26.1% of patients and in 32.1% of patients in the open group (p < 0.001). Thirty-day mortality was also significantly lower in the laparoscopic group (2.2 vs. 3.6% p < 0.001). CONCLUSION: In this non-randomized, descriptive study conducted in the Netherlands, open right colectomy seems to have a higher risk for complications and mortality as compared to laparoscopic right colectomy, even after correction for confounding factors.

Hospital Teaching Status and Patients' Outcomes After Colon Cancer Surgery.

BACKGROUND AND OBJECTIVES: It is increasingly accepted that quality of colon cancer surgery might be secured by combining volume standards with audit implementation. However, debate remains about other structural factors also influencing this quality, such as hospital teaching status. This study evaluates short-term outcomes after colon cancer surgery of patients treated in general, teaching or academic hospitals. METHODS: All patients (n = 23,593) registered in the Dutch Colorectal Audit undergoing colon cancer surgery between 2011 and 2014 were included. Patients were divided into groups based on teaching status of their hospital. Main outcome measures were serious complications, failure to rescue (FTR) and 30-day or in-hospital mortality. Multivariate logistic regression models on these outcome measures and with hospital teaching status as primary determinant were used, adjusted for case-mix, year of surgery and hospital volume. RESULTS: Patients treated in teaching and academic hospitals showed higher adjusted serious complication rates, compared to patients treated in general hospitals (odds ratio 1.25 95% CI [1.11-1.39] and OR 1.23 [1.05-1.46]). However, patients treated in teaching hospitals had lower adjusted FTR rates than patients treated in general hospitals (OR 0.63 [0.44-0.89]). However, for all outcomes there was considerable between-hospitals variation within each type of teaching status. CONCLUSION: On average, patients treated in general hospitals had lower serious complication rates, but patients treated in teaching hospitals had more favorable FTR rates. Given the hospital variation within each hospital teaching type, it is possible to deliver excellent care regardless of the hospital teaching type.

The value of intramural vascular invasion in colorectal cancer - a systematic review and meta-analysis.

Extramural venous invasion (EMVI) is a well-known prognostic factor in colorectal cancer (CRC). Vascular invasion within the bowel wall, intramural vascular invasion (IMVI), has received less attention and its incidence and prognostic importance in CRC is not completely known. A systematic literature search was performed focusing on the impact of IMVI in CRC. Data were analysed using Review Manager version 5.3 on incidence and clinical endpoints local recurrence, 5-year cancer-specific survival (CSS) and 5-year overall survival (OS). Meta-analysis was performed in terms of risk ratios (RR) and hazard ratios (HR) with 95% confidence interval (95% CI). Of the initial 1199 papers identified by our search strategy, 20 were included in this meta-analysis. Of the 8078 included patients, 1008 patients had IMVI (12.5%). Studies that re-examined histological slides showed a higher incidence of IMVI compared to studies extracting IMVI from pathology reports (17.6 versus 7.7%, P < 0.001). Detection of IMVI increased significantly with the use of additional staining (22.9 versus 12.3%, P < 0.001). IMVI was associated with a decreased CSS HR: 1.6, 95% CI 1.2-2.2 in multivariate analysis). A borderline significant effect was observed for IMVI on local recurrence (RR: 1.5, 95% CI: 0.98-2.3) and OS (RR: 1.2, 95% CI: 1.0-1.4). In conclusion, despite the limited number of studies, there is a clear association with outcome in the presence of IMVI. This warrants more attention to this under-reported prognostic factor.

[A 84-year-old woman with an abnormality in her breast]. / Een 84-jarige vrouw met een afwijking in de mamma.

A 84-year-old woman with a medical history of breast cancer in her left breast was referred to the Department of Surgery with a palpable mass in her right breast. Histological examination of a biopsy of the mass showed a fibroadenoma. These benign lesions of the breast are rare in elderly patients.

The Influence of Hospital Volume on Circumferential Resection Margin Involvement: Results of the Dutch Surgical Colorectal Audit.

UNLABELLED: This population-based study evaluates the association between hospital volume and CRM (circumferential resection margin) involvement, adjusted for other confounders, in rectal cancer surgery. A low hospital volume (<20 cases/year) was independently associated with a higher risk of CRM involvement (odds ratio=1.54; 95% CI: 1.12-2.11). OBJECTIVE: To evaluate the association between hospital volume and CRM (circumferential resection margin) involvement in rectal cancer surgery. BACKGROUND: To guarantee the quality of surgical treatment of rectal cancer, the Association of Surgeons of the Netherlands has stated a minimal annual volume standard of 20 procedures per hospital. The influence of hospital volume has been examined for different outcome variables in rectal cancer surgery. Its influence on the pathological outcome (CRM) however remains unclear. As long-term outcomes are best predicted by the CRM status, this parameter is of essential importance in the debate on the justification of minimal volume standards in rectal cancer surgery. METHODS: Data from the Dutch Surgical Colorectal Audit (2011-2012) were used. Hospital volume was divided into 3 groups, and baseline characteristics were described. The influence of hospital volume on CRM involvement was analyzed, in a multivariate model, between low- and high-volume hospitals, according to the minimal volume standards. RESULTS: This study included 5161 patients. CRM was recorded in 86% of patients. CRM involvement was 11% in low-volume group versus 7.7% and 7.9% in the medium- and high-volume group (P≤0.001). After adjustment for relevant confounders, the influence of hospital volume on CRM involvement was still significant odds ratio (OR) = 1.54; 95% CI: 1.12-2.11). CONCLUSIONS: The outcomes of this pooled analysis support minimal volume standards in rectal cancer surgery. Low hospital volume was independently associated with a higher risk of CRM involvement (OR = 1.54; 95% CI: 1.12-2.11).

Reduced Circumferential Resection Margin Involvement in Rectal Cancer Surgery: Results of the Dutch Surgical Colorectal Audit.

BACKGROUND: The circumferential resection margin (CRM) is a significant prognostic factor for local recurrence, distant metastasis, and survival after rectal cancer surgery. Therefore, availability of this parameter is essential. Although the Dutch total mesorectal excision trial raised awareness about CRM in the late 1990s, quality assurance on pathologic reporting was not available until the Dutch Surgical Colorectal Audit (DSCA) started in 2009. The present study describes the rates of CRM reporting and involvement since the start of the DSCA and analyzes whether improvement of these parameters can be attributed to the audit. METHODS: Data from the DSCA (2009-2013) were analyzed. Reporting of CRM and CRM involvement was plotted for successive years, and variations of these parameters were analyzed in a funnelplot. Predictors of CRM involvement were determined in univariable analysis and the independent influence of year of registration on CRM involvement was analyzed in multivariable analysis. RESULTS: A total of 12,669 patients were included for analysis. The mean percentage of patients with a reported CRM increased from 52.7% to 94.2% (2009-2013) and interhospital variation decreased. The percentage of patients with CRM involvement decreased from 14.2% to 5.6%. In multivariable analysis, the year of DSCA registration remained a significant predictor of CRM involvement. CONCLUSIONS: After the introduction of the DSCA, a dramatic improvement in CRM reporting and a major decrease of CRM involvement after rectal cancer surgery have occurred. This study suggests that a national quality assurance program has been the driving force behind these achievements.

Uncommon cause of pneumoperitoneum.

Free intraperitoneal air is thought to be pathognomonic for perforation of a hollow viscus. Here, we present a patient with pain in the upper left quadrant, a mild fever and leukocytosis. Free air was suggested under the left diaphragm but during the explorative laparotomy no signs of gastric or diverticular perforation were seen. Further exploration and revision of the computed tomography revealed a perforated splenic abscess. Splenic abscesses are a rare clinical entity. Presenting symptoms are often non-specific and include upper abdominal pain, recurrent or persistent fever, nausea and vomiting, splenomegaly, leukocytosis and left lower chest abnormalities. Predisposing conditions can be very divergent and include depressed immunosuppressed state, metastatic or contiguous infection, splenic infarction and trauma. Splenic abscess should therefore be considered in a patient with fever, left upper abdominal pain and leukocytosis. Moreover, our case shows that splenic abscess can present in an exceptional way without clear underlying aetiology and should even be considered in the presence of free abdominal air.

[Acute obstructive colon carcinoma and liver metastases: how to treat?]. / Acuut obstruerend coloncarcinoom én levermetastasen: hoe te behandelen?

BACKGROUND: The incidence of patients who present with acute obstructive colon carcinoma and synchronous liver metastases is increasing. CASE DESCRIPTION: Two men aged 70 and 71 both had acute obstructive colon carcinoma with synchronous liver metastases. Both patients underwent successful stent placement that solved the colonic obstruction. Five weeks later the first patient underwent an elective surgical procedure at which both the colon carcinoma and the liver metastases were resected. The second patient had more widespread metastases and first received chemotherapy. After six courses of chemotherapy the liver metastases became resectable and he underwent a two-stage liver resection with a left-sided hemicolectomy. CONCLUSION: These cases illustrate that placing a stent can be an alternative to an acute operation, and thus can save the patient from an emergency laparotomy with creation of a stoma that needs closure afterwards. In addition stent placement is a good starting point for an intended curative treatment trajectory, also in the setting of synchronous liver metastases accompanying the acute obstructive carcinoma.

Case-control breast cancer study of MALDI-TOF proteomic mass spectrometry data on serum samples.

We introduce mass spectrometry proteomic research for diagnosis from a clinical perspective, with special reference to early-stage breast cancer detection. The nature of SELDI and MALDI mass spectrometric measurement is discussed. We explain how the mass spectral data arising from this technology may be viewed as a new data type. Some of the properties of the data are discussed and we show how such spectra may be interpreted. Sample preprocessing for mass spectrometry is introduced and a literature review of research in clinical proteomics is presented. Finally, we provide a detailed description of the study design on the breast cancer case-control study which is investigated in this special issue.

MALDI-TOF serum protein profiling for the detection of breast cancer.

BACKGROUND: Proteomic expression profiling has been suggested as a potential tool for the early diagnosis of cancer and other diseases. The objective of our study was to assess the feasibility of this approach for the detection of breast cancer. MATERIALS AND METHODS: In a randomized block design pre-operative serum samples obtained from 78 breast cancer patients and 29 controls were used to generate high-resolution MALDI-TOF protein profiles. The spectra generated using C8 magnetic beads assisted mass spectrometry were smoothed, binned and normalized after baseline correction. Linear discriminant analysis with double cross-validation, based on principal component analysis, was used to classify the protein profiles. RESULTS: A total recognition rate of 99%, a sensitivity of 100%, and a specificity of 97.0% for the detection of breast cancer were shown. The area under the curve of the classifier was 98.3%, which demonstrates the separation power of the classifier. The first 2 principal components account for most of the between- group separation. CONCLUSIONS: Double cross-validation showed that classification could be attributed to actual information in the protein profiles rather than to chance. Although preliminary, the high sensitivity and specificity indicate the potential usefulness of serum protein profiles for the detection of breast cancer.

Detection of colorectal cancer using MALDI-TOF serum protein profiling.

Serum protein profiling is a promising approach for classification of cancer versus non-cancer samples. The objective of our study was to assess the feasibility of mass spectrometry based protein profiling for the discrimination of colorectal cancer (CRC) patients from healthy individuals. In a randomized block design, pre-operative serum samples obtained from 66 colorectal cancer patients and 50 controls were used to generate MALDI-TOF protein profiles. After pre-processing of the spectra, linear discriminant analysis with double cross-validation was used to classify protein profiles. A total recognition rate (92.6%), sensitivity (95.2%) and specificity (90.0%) for the detection of CRC were shown. The area under the curve of the classifier was 97.3%, and demonstrated the high, significant separation power of the classifier. Double cross-validation shows that classification can be attributed to information in the protein profile. Although preliminary, the high sensitivity and specificity indicate the potential usefulness of serum protein profiles for the detection of colorectal cancer.

Reliability of human serum protein profiles generated with C8 magnetic beads assisted MALDI-TOF mass spectrometry.

Protein profiling with mass spectrometry is a promising approach for classification and identification of biomarkers; however, there is debate about measurement quality and reliability. Here, we present a pipeline for preprocessing, statistical data analysis and presentation. Serum samples of 16 healthy individuals are used to generate protein profiles with high-resolution MALDI-TOF after isolation of peptides with C8 magnetic beads. Analysis of variance was performed after binning, baseline correction and normalization of the mean spectra. Relative variations in the spectra are expressed as coefficient of variation, which depending on the respective preanalytical variation parameter investigated, was found to range between 0.15 and 0.67 in this study. With this novel method, the reproducibility of our protein profiling procedure could be quantified. We showed that circadian rhythm and the number of freeze-thaw cycles had relatively limited influence on serum protein profiles, whereas the period between collection and serum centrifugation had a more pronounced effect.