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ABSTRACT: BACKGROUND: Breast-conserving therapy, consisting of lumpectomy and adjuvant radiotherapy, is considered standard treatment for early-stage breast cancer. One of the most important risk factors of local recurrence is the presence of positive surgical margins following lumpectomy. We aimed to develop and validate a predictive model (nomogram) to predict for positive margins following the first attempt at lumpectomy as a preoperative tool for clinical decision-making. METHODS: Patients with clinical T1-2N0-1Mx-0 histology-proven invasive breast carcinoma who underwent BCT throughout the North-East region of The Netherlands between June 2008 and July 2009 were selected from the Netherlands Cancer Registry (n = 1185). Results from multivariate logistic regression analyses served as the basis for development of the nomogram. Nomogram calibration and discrimination were assessed graphically and by calculation of a concordance index, respectively. Nomogram performance was validated on an external independent dataset (n = 331) from the University Medical Center Groningen. RESULTS: The final multivariate regression model included clinical, radiological, and pathological variables. Concordance indices were calculated of 0.70 (95% CI: 0.66-0.74) and 0.69 (95% CI: 0.63-0.76) for the modeling and the validation group, respectively. Calibration of the model was considered adequate in both groups. A nomogram was developed as a graphical representation of the model. Moreover, a web-based application (http://www.breastconservation.com) was build to facilitate the use of our nomogram in a clinical setting. CONCLUSION: We developed and validated a nomogram that enables estimation of the preoperative risk of positive margins in breast-conserving surgery. Our nomogram provides a valuable tool for identifying high-risk patients who might benefit from preoperative MRI and/or oncoplastic surgery.
Breast (Edinburgh, Scotland) 02/2013; · 2.09 Impact Factor
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ABSTRACT: AIM: Reported incidence rates of colorectal anastomotic leakage (AL) vary between 2.5 and 20%. There is little information on late anastomotic leakage (LAL).. The aim of this study was to determine the incidence of LAL after colorectal resection. METHOD: All patients undergoing colorectal resection with primary anastomosis between January 2004 and October 2009 at the University Medical Center Groningen were included. LAL was defined as anastomotic leakage diagnosed >30 days after surgery. RESULTS: One-hundred and forty-one patients were analysed. Indications for surgery included both benign and malignant conditions. The incidence of early anastomotic leakage (EAL) within 30 days after surgery was 13%. The LAL rate was 6%. Eighty-nine percent of patients with EAL underwent relaparotomy compared with 44% for LAL (p= 0.02). CONCLUSION: One third of all anastomotic leakages were diagnosed >30 days after surgery. Of these, 44% underwent relaparotomy. Patients with leakage diagnosed within 30 days after surgery were more likely to undergo relaparotomy. Late anastomotic leakage is a significant problem after colorectal surgery. © 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.
Colorectal Disease 02/2013; · 2.93 Impact Factor
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ABSTRACT: BACKGROUND: The follow-up of patients treated for colorectal liver metastases (CRLM) is not standardized. The accuracy of an increase in carcinoembryonic antigen (CEA) levels for finding recurrences after treatment for CRLM is compared in this retrospective cohort study with the accuracy of routine imaging modalities of liver and chest. METHODS: Data from all patients in follow-up after intentionally curative treatment for CRLM from 1990 to 2010 were analyzed. All patients underwent the same follow-up schedule. The way in which recurrences became apparent (i.e., CEA increase, routine imaging, or both) was registered. The specificity and sensitivity of increases in CEA before finding recurrent disease were calculated by receiver operating characteristic (ROC) curves. An economic evaluation of the cost per resectable tumor recurrence was performed. RESULTS: ROC curves showed that a significant CEA increase was defined as a 25 % increase from the previous value. Recurrences were detected in 46 % of the procedures through CEA increase concomitant with positive imaging, in 23 % through CEA increase without positive findings on routine imaging, and in 31 % through positive imaging without an increase in CEA. The resectability of recurrences did not differ between triggers. Cost per curable recurrence was 2,196 for recurrences found via CEA alone and 6,721 for recurrences found with imaging and CEA. CONCLUSIONS: In the follow-up of patients after liver surgery for CRLM, a 25 % increase in CEA serum level can accurately detect recurrences, but routine imaging is indispensable. In patients with CRLM, we advocate both CEA monitoring and imaging in the follow-up after liver surgery.
Annals of Surgical Oncology 09/2012; · 4.17 Impact Factor
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ABSTRACT: The present paper is a first evaluation of the use of "CEAwatch", a clinical support software system for surgeons for the follow-up of colorectal cancer (CRC) patients. This system gathers Carcino-Embryonic Antigen (CEA) values and automatically returns a recommendation based on the latest values.
Consecutive patients receiving follow-up care for CRC fulfilling our in- and exclusion criteria were identified to participate in this study. From August 2008, when the software was introduced, patients were asked to undergo the software-supported follow-up. Safety of the follow-up, experiences of working with the software, and technical issues were analyzed.
245 patients were identified. The software-supported group contained 184 patients; the control group contained 61 patients. The software was safe in finding the same amount of recurrent disease with fewer outpatient visits, and revealed few technical problems. Clinicians experienced a decrease in follow-up workload of up to 50% with high adherence to the follow-up scheme.
CEAwatch is an efficient software tool helping clinicians working with large numbers of follow-up patients. The number of outpatient visits can safely be reduced, thus significantly decreasing workload for clinicians.
BMC Medical Informatics and Decision Making 03/2012; 12:14. · 1.48 Impact Factor
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ABSTRACT: After primary treatment for breast cancer, patients are recommended to use hospital follow-up care routinely. Long-term data on the utilization of this follow-up care are relatively rare.
Information regarding the utilization of routine hospital follow-up care was retrieved from hospital documents of 662 patients treated for breast cancer. Utilization of hospital follow-up care was defined as the use of follow-up care according to the guidelines in that period of time. Determinants of hospital follow up care were evaluated with multivariate analysis by generalized estimating equations (GEE).
The median follow-up time was 9.0 (0.3-18.1) years. At fifth and tenth year after diagnosis, 16.1% and 33.5% of the patients had less follow-up visits than recommended in the national guideline, and 33.1% and 40.4% had less frequent mammography than recommended. Less frequent mammography was found in older patients (age > 70; OR: 2.10; 95%CI: 1.62-2.74), patients with comorbidity (OR: 1.26; 95%CI: 1.05-1.52) and patients using hormonal therapy (OR: 1.51; 95%CI: 1.01-2.25).
Most patients with a history of breast cancer use hospital follow-up care according to the guidelines. In older patients, patients with comorbidity and patients receiving hormonal therapy yearly mammography is performed much less than recommended.
BMC Cancer 06/2011; 11:279. · 3.01 Impact Factor
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ABSTRACT: This study examined associations between the degree of self-disclosure and changes in depressive symptoms in couples coping with colorectal cancer.
Sixty-four newly diagnosed patients and their partners completed a measure of depressive symptoms (Center of Epidemiologic Studies Depression Scale) 3 and 9 months postdiagnosis. Furthermore, approximately 2 months after the first assessment, they engaged in a cancer-related conversation in which the patient was asked to introduce a concern. Each partner's verbalizations of emotions, thoughts, and wishes (i.e., self-disclosures) were coded by independent observers.
Patients who reported more depressive symptoms at baseline showed more self-disclosures. Mutual self-disclosure was not associated with lower levels of depressive symptoms in patients and partners as compared with one-sided self-disclosure or low disclosure in both patients and partners. It is important to note that decreases in depressive symptoms over time were least prominent in couples in which the partner disclosed a lot whereas the patient disclosed little.
These results suggest that mere disclosure of emotions and thoughts to one's intimate partner is not beneficial in reducing distress. Partners' self-disclosure toward patients who disclose few emotions and concerns even appears to be harmful both for patients and partners, given that it reduces the decrease of depressive symptoms over time. If there is a mismatch in the need for self-disclosure within couples, partners with a strong need to talk about their emotions and concerns may be recommended to confide in someone else in their social network or to consult a health care professional.
Health Psychology 06/2011; 30(6):753-62. · 3.87 Impact Factor
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ABSTRACT: The TME trial investigated the value of preoperative short-term radiotherapy in combination with total mesorectal excision (TME). Long-term results are reported after a median follow-up of 12 years.
Between Jan 12, 1996, and Dec 31, 1999, 1861 patients with resectable rectal cancer without evidence of distant disease were randomly assigned to TME preceded by 5 × 5 Gy radiotherapy or TME alone (ratio 1:1). Randomisation was based on permuted blocks of six with stratification according to centre and expected type of surgery. The primary endpoint was local recurrence, analysed for all eligible patients who underwent a macroscopically complete local resection.
10-year cumulative incidence of local recurrence was 5% in the group assigned to radiotherapy and surgery and 11% in the surgery-alone group (p<0·0001). The effect of radiotherapy became stronger as the distance from the anal verge increased. However, when patients with a positive circumferential resection margin were excluded, the relation between distance from the anal verge and the effect of radiotherapy disappeared. Patients assigned to radiotherapy had a lower overall recurrence and when operated with a negative circumferential resection margin, cancer-specific survival was higher. Overall survival did not differ between groups. For patients with TNM stage III cancer with a negative circumferential resection margin, 10-year survival was 50% in the preoperative radiotherapy group versus 40% in the surgery-alone group (p=0·032).
For all eligible patients, preoperative short-term radiotherapy reduced 10-year local recurrence by more than 50% relative to surgery alone without an overall survival benefit. For patients with a negative resection margin, the effect of radiotherapy was irrespective of the distance from the anal verge and led to an improved cancer-specific survival, which was nullified by an increase in other causes of death, resulting in an equal overall survival. Nevertheless, preoperative short-term radiotherapy significantly improved 10-year survival in patients with a negative circumferential margin and TNM stage III. Future staging techniques should offer possibilities to select patient groups for which the balance between benefits and side-effects will result in sufficiently large gains.
The Dutch Cancer Society, the Dutch National Health Council, and the Swedish Cancer Society.
The lancet oncology 06/2011; 12(6):575-82. · 14.47 Impact Factor
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ABSTRACT: Delirium is one of the most serious complications in hospitalized elderly, with incidences ranging from 3-56%. The objective of this meta-analysis was two-fold, first to investigate if interventions to prevent delirium are effective and second to explore which factors increase the effectiveness of these interventions.
An electronic search was carried out on articles published between January 1979 and July 2009. Abstracts were reviewed, data were extracted and methodologic quality was assessed by two independent reviewers. Effect sizes of the interventions were expressed as ORs (odds ratios) and 95%CIs (confidence intervals). A random effect model was used to provide pooled ORs. To explore which factors increase the effectiveness of the interventions, ORs were stratified for several factors.
Sixteen relevant studies were found. Overall the included studies showed a positive result of any intervention to prevent delirium (pooled OR: 0.64; 95%CI: 0.46-0.88). The largest effect was seen in studies on populations with an incidence of delirium above 30% in the control group (pooled OR: 0.34; 95%CI: 0.16-0.71 versus 0.76; 95%CI: 0.60-0.97).
Interventions to prevent delirium are effective. Interventions seem to be more effective when the incidence of delirium in the population under study is above 30%. To maximize the options for a cost-effective strategy of delirium prevention it might be useful to offer an intervention to a selected population.
International Journal of Geriatric Psychiatry 05/2011; 26(5):441-50. · 2.42 Impact Factor
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ABSTRACT: This longitudinal study has examined the associations between perceived supportive and unsupportive spousal behavior and changes in distress in couples coping with cancer. We tested whether people relatively low in their sense of personal control were more responsive to spousal supportive and unsupportive behavior than were people relatively high in personal control. Patients with colorectal cancer and their partners (n = 70) completed questionnaires at two assessment points: 3 (at baseline) and 9 months (at follow-up) after the diagnosis. We assessed perceived spousal supportive (SSL) and unsupportive (SSL-N) behavior, sense of personal control (Pearlin & Schooler's Mastery), and depressive symptoms (CES-D) in both patients and partners. Multilevel analysis (MLwiN) was used to examine changes in distress over time in a dyadic context. Patients and partners who perceived more spousal support reported less distress over time, but this only applied to those relatively low in personal control. Moreover, partners who perceived more unsupportive spousal behavior reported more distress, again only if they were relatively low in personal control. Patients and partners relatively high in personal control reported relatively low levels of distress, regardless of spousal behavior. In conclusion, people relatively low in personal control may be more adversely affected by unsupportive behavior and benefit more from supportive behavior than people relatively high in personal control.
Journal of Family Psychology 04/2011; 25(2):310-8. · 1.66 Impact Factor
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ABSTRACT: Advanced colorectal cancer (CRC), either locally advanced, metastasized (mCRC) or both, is present in a relevant proportion of patients. The chances on curation of advanced CRC are continuously improving with modern multi-modality treatment options. For incurable CRC the focus lies on palliation of symptoms, which is not necessarily a resection of the primary tumor. Both situations motivate adequate staging before treatment in CRC. This prospective observational study evaluates the outcomes after the introduction of routine staging with abdominal CT before treatment.
In a prospective observational study of 612 consecutive patients (2007-2009), the ability of abdominal CT to find liver metastases (LM), peritoneal carcinomatosis (PC) and T4 stage in colon cancer (CC) was analysed.
Advanced CRC was present in 58% of patients, mCRC in 31%. The ability to find LM was excellent (99%), cT4 stage CC good (86%) and PC poor (33%). In the group of surgical patients with emergency presentations, the incidences of both mCRC (51%) and locally advanced colon cancer (LACC) (69%) were higher than in the elective group (20% and 26% respectively). Staging tended to be omitted more often in the emergency group (35% versus 12% in elective surgery).
The strengths of staging with abdominal CT are to find LM and LACC, however it fails in diagnosing PC. On grounds of the incidence of advanced CRC, staging is warranted in patients with emergency presentations as well.
BMC Cancer 01/2011; 11:433. · 3.01 Impact Factor
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ABSTRACT: Routine physical examination is recommended in follow up guidelines for women with a history of breast cancer. The objective of this paper is to assess the contribution of routine physical examination in addition to mammography in the early diagnosis of breast cancer recurrences.
The medical follow-up documents of 669 patients were reviewed. 127 contra-lateral breast cancers (CBCs) and 58 loco-regional recurrences (LRRs) in 163 patients were included. The additional contribution of routine physical examination over mammography was evaluated with the proportions of CBCs or LRRs detected by physical examination alone. χ(2) tests were used to compare the difference of contribution of physical examination among subgroups.
Seven (6%) out of 127 CBCs and 13 (22%) out of 58 LRRs were detected by routine physical examination alone. Six LRRs (17%; 6/35) were in patients after breast conserving surgery and seven LRRs (30%; 7/23) in patients after mastectomy. There was a trend that the contribution of physical examination is higher in women under 60 years of age in the detection of CBCs (9%; 5/57) and LRRs (28%, 8/29) than in women over 60 years of age (CBCs:3%; 2/70 and LRRs:17%, 5/29; χ(2)=3.090, P=0.079).
Twenty-two percent of loco regional breast cancer recurrences would have been detected later without physical examination. Routine physical examination may be most valuable for women with a history of breast cancer younger than 60 years at follow-up visit.
European journal of cancer (Oxford, England: 1990) 12/2010; 47(5):676-82. · 4.12 Impact Factor
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ABSTRACT: Selection of patients with anal cancer for groin irradiation is based on tumor size, palpation, ultrasound, and fine needle cytology. Current staging of anal cancer may result in undertreatment in small tumors and overtreatment of large tumors. This study reports the feasibility of the sentinel lymph node biopsy (SLNB) in patients with anal cancer and whether this improves the selection for inguinal radiotherapy.
A total of 50 patients with squamous anal cancer were evaluated prospectively. Patients without a SLNB (n = 29) received irradiation of the inguinal lymph nodes based on lymph node status, tumor size, and location of the primary tumor. Inguinal irradiation treatment in patients with a SLNB was based on the presence of metastases in the SLN.
SLNs were found in all 21 patients who underwent a SLNB. There were 5 patients (24%) who had complications after SLNB and 7 patients (33%) who had a positive SLN and received inguinal irradiation. However, 2 patients with a tumor-free SLN and no inguinal irradiation developed lymph node metastases after 12 and 24 months, respectively.
We conclude that SLNB in anal cancer is technically feasible. SLNB can identify those patients who would benefit from refrain of inguinal irradiation treatment and thereby reducing the incidence of unnecessary inguinal radiotherapy. However, because of the occurrence of inguinal lymph node metastases after a tumor-negative SLNB, introduction of this procedure as standard of care in all patients with anal carcinoma should be done with caution to avoid undertreatment of patient who otherwise would benefit from inguinal radiotherapy.
Annals of Surgical Oncology 10/2010; 17(10):2656-62. · 4.17 Impact Factor
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Wenli Lu,
Michael Schaapveld,
Liesbeth Jansen,
Emad Bagherzadegan,
Marko Mirza Sahinovic,
Peter C Baas,
Leo M H C Hanssen,
Hans C J van der Mijle,
Jan D Brandenburg, Theo Wiggers,
Geertruida H De Bock
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ABSTRACT: To determine the contribution of surveillance mammography to the early detection of metachronous contralateral breast cancer (MCBC) and to assess its impact on the survival of breast cancer patients with relation to compliance.
Breast cancer patients (5589) were identified using files from the regional cancer registry of the Comprehensive Cancer Centre North Netherlands (CCCN Groningen, The Netherlands). The programme sensitivity and the impact on prognosis of follow-up mammography with relation to compliance were evaluated in 114 patients who developed MCBC during hospital follow-up.
The cumulative MCBC incidence rate at year 10 was 3.4% (95% CI: 2.8-4.0%). The programme sensitivity of surveillance mammography was 59.6% (95% CI: 50.6-68.7). In patients who complied with annual mammography, sensitivity was increased to 70.8% (95% CI: 61.7-80.0). Patients with MCBCs detected by routine mammography have better survival rates than patients with MCBCs detected by other means (HR: 3.18; 95% CI: 1.59-6.34). Though there was a trend towards improved survival in patients being compliant with regular clinical follow-up (HR: 1.69; 95% CI: 0.72-3.96), this was not the case for patients being compliant with annual mammography (HR:1.02; 95% CI:0.50-2.09).
Mammography is a valuable tool for the early detection of MCBC during hospital follow-up of breast cancer patients and is probably beneficial to survival. The utilisation of follow-up surveillance in breast cancer patients and its potential impact on survival deserve further investigation.
European journal of cancer (Oxford, England: 1990) 10/2009; 45(17):3000-7. · 4.12 Impact Factor
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ABSTRACT: Anastomotic leakage is associated with increased morbidity and mortality. However, there is no accurate tool to predict its occurrence. We evaluated the predictive value of visible light spectroscopy (VLS), a novel method to measure tissue oxygenation [saturated O(2) (StO(2) )], for anastomotic leakage of the colon and the rectum.
Oxygen saturation in the bowel was measured in 77 colorectal resections. The anastomosis was between 2 and 30 cm (mean 13 cm) from the anal verge. The oxygen saturation was measured in the colon and rectum before and after anastomosis construction. This was compared with a reference measurement in the caecum. Data on postoperative complications were prospectively collected.
Anastomotic leakage occurred in 14 (18%) patients. When compared with a leaking anastomosis, normal anastomoses showed rising O(2) values during the operation (mean StO(2) 72.1 ± 9.0-76.7 ± 8.0 vs 73.9 ± 7.9-73.1 ± 7.4) (P ≤ 0.05). There were also higher StO(2) values in the caecum compared with those which ultimately leaked (73.6 ± 5.7 normal anastomoses, 69.6 ± 5.6 anastomotic leaks) (P ≤ 0.05). Both StO(2) values were predictive of anastomotic leakage.
Tissue oxygenation O(2) appears to be a potentially useful means of predicting anastomotic leakage after colorectal anastomosis.
Colorectal Disease 08/2009; 12(10):1018-25. · 2.93 Impact Factor
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ABSTRACT: The purposes of this study were to assess whether multislice CT can identify tumors having a free or involved circumferential margin, to investigate the additional role of multislice CT as a "one-stop shopping" staging tool for staging nodal and distant metastases.
A total of 250 patients with adenocarcinoma of the rectum underwent multislice CT scans of the chest and abdomen before undergoing total mesorectal excision. The scans were scored by two teams. The main outcome was yes/no involvement of the mesorectal fascia. Histology was taken as the standard for determining the involvement.
The overall sensitivity for predicting an involved mesorectal fascia was 74.2 percent and the overall specificity was 93.9 percent. The overall sensitivity for low tumors was 65.6 percent and the overall specificity was 81.5 percent. The overall sensitivity for mid-/high rectal tumors was 76.1 percent and the overall specificity was 96.3 percent. The interobserver agreement was substantial (kappa 0.695). The overall sensitivity for the prediction of liver metastases was 64.3 percent and the overall specificity was 94.4 percent with kappa 0.82. The accuracy in predicting lymph node metastases was low.
Multislice CT can be used for the assessment of mesorectal fascia involvement in primary rectal cancer, especially those located in the middle rectum and the high rectum; however, in the prediction of an involved margin of tumors located in the distal rectum, the accuracy of multislice CT falls short.
Diseases of the Colon & Rectum 06/2009; 52(5):928-34. · 3.13 Impact Factor
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ABSTRACT: The impact of the reported number of lymph nodes at pathologic examination of colon specimens on survival was studied.
The data of 2,281 patients with localized colon cancer were retrospectively reviewed. The effect of tumor characteristics and surgical and pathologic factors on the number of lymph nodes and examined lymph node numbers on nodal status and survival were analyzed.
The number of examined nodes increased with T stage, left-sided tumors, and mucinous morphology, but decreased with age. The proportion of node-positive patients increased with a larger number of nodes. A high number of examined nodes and high T stage affected nodal status. The five-year overall survival was 51.3 percent for node-positive patients vs. 68.2 percent for node-negative patients. Node-negative patients had a significantly higher five-year crude and relative survival when more lymph nodes were examined. This was not found for the node-positive group and for all patients combined.
T stage, localization, and patient age were predictive for the number of nodes examined. A higher number of examined nodes was associated with an increase in node positivity. The survival benefit can be explained by stage migration. Eventually this may lead to an overall survival benefit, as more patients are classified as node-positive, and therefore will receive adjuvant therapy.
Diseases of the Colon & Rectum 03/2009; 52(2):260-7. · 3.13 Impact Factor
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ABSTRACT: The potential contribution of psychological and anatomical changes to sexual dysfunction in female patients following short-term preoperative radiotherapy (5 x 5 Gy) and total mesorectal excision (TME) is not clear. Aim. In this study we assessed female sexual dysfunction in patients who underwent radiotherapy and TME for rectal cancer.
Genital arousal was assessed using vaginal videoplethysmography.
Sexual functioning was examined in four patients who had rectal cancer and underwent radiotherapy and TME. All investigations were done at least 15 months after treatment. The results were compared with an age-matched group of 18 healthy women.
The patients and healthy controls showed comparable changes in vaginal vasocongestion during sexual arousal, though three out of four patients showed a lower mean spectral tension (MST) of the vaginal pulse compared with healthy controls. Subjective sexual arousal was equivalent between the two groups.
In this study the changes of genital and subjective sexual arousal after erotic stimulus condition between patients and healthy controls were not different, though lower MST of the vaginal pulse was found in three out of four patients compared with healthy women. Additional work, however, must be performed to clarify the mechanisms of sexual dysfunction following treatment of rectal cancer.
Journal of Sexual Medicine 09/2008; 6(4):1045-53. · 3.55 Impact Factor
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ABSTRACT: In primary hyperparathyroidism the gamma probe is effective, but its role in secondary hyperparathyroidism is unclear. We investigated the utility of the probe in the surgical management of secondary and tertiary hyperparathyroidism.
The value of the probe in guiding resection of parathyroids was determined prospectively in 29 patients with secondary or tertiary hyperparathyroidism. Resected tissues with radioactivity of greater than 20% as compared with the wound bed was considered hyperfunctional parathyroid and was confirmed histologically.
The probe was helpful in guiding resection in 13% of the hyperplastic glands, including ectopic glands and those not detected preoperatively. The gamma probe confirmed the presence of hyperfunctional parathyroid after resection with a sensitivity and specificity of 97% and 92%, respectively.
The probe is particularly useful in confirming the presence of hyperfunctional parathyroids after resection. It also is useful in identifying ectopic localizations, but its value is limited in guiding surgery for secondary or tertiary disease.
American journal of surgery 08/2008; 196(1):13-8. · 2.36 Impact Factor
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ABSTRACT: To explore new methods for intraoperative evaluation of tissue oxygenation, we evaluated the use of visible light spectroscopy as a predictor of anastomotic strength in an experimental model with ischemic murine colon anastomoses.
Male rats (n = 34) were divided into 2 groups (ischemia and nonischemia). In the ischemia group the arteries of the distal colon were ligated until tissue oxygen saturation (StO2) dropped below 55%. A segment of the proximal part of the colon was resected until a well-perfused area was reached and an anastomosis was performed. In the nonischemia group, resection of a segment of descending colon and a colon anastomosis was performed. The animals were sacrificed on the 3rd or 7th postoperative d. The anastomosis was tested for bursting pressure and breaking strength.
After ligation of the relevant mesenteric arteries, StO2 of the distal part of the colon decreased (54.6% SD 6.4% versus 71.2% SD 7.4%, P <or= 0.05). On the 3rd or 7th postoperative d StO2 had normalized. Adhesion score in the ischemia group was higher compared to the nonischemia group (1.6 versus 0.4, P <or= 0.05). There were no differences in bursting pressure between both groups. Breaking strength was lower in the ischemia group on the 3rd postoperative d (162.3 SD 47.3 versus 212.6 SD 41.2, P <or= 0.05).
Ischemia can intraoperatively accurately be detected by visible light spectroscopy. Partially ischemic anastomoses showed more adhesions and diminished breaking strength in the early phase of healing, whereas bursting pressure was not affected. Low StO2 of a distal colon anastomosis appeared to be a risk factor for anastomotic dehiscence at d 3 and beyond.
Journal of Surgical Research 05/2008; 152(2):288-95. · 2.25 Impact Factor
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Koen C M J Peeters,
Corrie A M Marijnen,
Iris D Nagtegaal,
Elma Klein Kranenbarg,
Hein Putter, Theo Wiggers,
Harm Rutten,
Lars Pahlman,
Bengt Glimelius,
Jan Willem Leer,
Cornelis J H van de Velde
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ABSTRACT: To investigate the efficacy of preoperative short-term radiotherapy in patients with mobile rectal cancer undergoing total mesorectal excision (TME) surgery.
Local recurrence is a major problem in rectal cancer treatment. Preoperative short-term radiotherapy has shown to improve local control and survival in combination with conventional surgery. The TME trial investigated the value of this regimen in combination with total mesorectal excision. Long-term results are reported after a median follow-up of 6 years.
One thousand eight hundred and sixty-one patients with resectable rectal cancer were randomized between TME preceded by 5 x 5 Gy or TME alone. No chemotherapy was allowed. There was no age limit. Surgery, radiotherapy, and pathologic examination were standardized. Primary endpoint was local control.
Median follow-up of surviving patients was 6.1 year. Five-year local recurrence risk of patients undergoing a macroscopically complete local resection was 5.6% in case of preoperative radiotherapy compared with 10.9% in patients undergoing TME alone (P < 0.001). Overall survival at 5 years was 64.2% and 63.5%, respectively (P = 0.902). Subgroup analyses showed significant effect of radiotherapy in reducing local recurrence risk for patients with nodal involvement, for patients with lesions between 5 and 10 cm from the anal verge, and for patients with uninvolved circumferential resection margins.
With increasing follow-up, there is a persisting overall effect of preoperative short-term radiotherapy on local control in patients with clinically resectable rectal cancer. However, there is no effect on overall survival. Since survival is mainly determined by distant metastases, efforts should be directed towards preventing systemic disease.
Annals of Surgery 12/2007; 246(5):693-701. · 7.49 Impact Factor
