Transanal total mesorectal excision: how are we doing so far?

Aim This subgroup analysis of a prospective multicentre cohort study aims to compare postoperative morbidity between transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME). Method The study was designed as a subgroup analysis of a prospective multicentre cohort study. Patients undergoing TaTME or LaTME for rectal cancer were selected. All patients were followed up until the first visit to the outpatient clinic after hospital discharge. Postoperative complications were classified according to the Clavien–Dindo classification and the comprehensive complication index (CCI). Propensity score matching was performed. Results In total, 220 patients were selected from the overall prospective multicentre cohort study. After propensity score matching, 48 patients from each group were compared. The median tumour height for TaTME was 10.0 cm (6.0–10.8) and for LaTME was 9.5 cm (7.0–12.0) (P = 0.459). The duration of surgery and anaesthesia were both significantly longer for TaTME (221 vs 180 min, P < 0.001, and 264 vs 217 min, P < 0.001). TaTME was not converted to laparotomy whilst surgery in five patients undergoing LaTME was converted to laparotomy (0.0% vs 10.4%, P = 0.056). No statistically significant differences were observed for Clavien–Dindo classification, CCI, readmissions, reoperations and mortality. Conclusion The study showed that TaTME is a safe and feasible approach for rectal cancer resection. This new technique obtained similar postoperative morbidity to LaTME

Second and third look laparoscopy in pT4 colon cancer patients for early detection of peritoneal metastases; the COLOPEC 2 randomized multicentre trial

Background: Approximately 20–30% of patients with pT4 colon cancer develop metachronous peritoneal metastases (PM). Due to restricted accuracy of imaging modalities and absence of early symptoms, PM are often detected at a stage in which only a quarter of patients are eligible for curative intent treatment. Preliminary findings of the COLOPEC trial (NCT02231086) revealed that PM were already detected during surgical re-exploration within tw

Induction chemotherapy followed by chemoradiotherapy versus chemoradiotherapy alone as neoadjuvant treatment for locally recurrent rectal cancer: study protocol of a multicentre, open-label, parallel-arms, randomized controlled study (PelvEx II)

Background A resection with clear margins (R0 resection) is the most important prognostic factor in patients with locally recurrent rectal cancer (LRRC). However, this is achieved in only 60 per cent of patients. The aim of this study is to investigate whether the addition of induction chemotherapy to neoadjuvant chemo(re)irradiation improves the R0 resection rate in LRRC. Methods This multicentre, international, open-label, phase III, parallel-arms study will enrol 364 patients with resectable LRRC after previous partial or total mesorectal resection without synchronous distant metastases or recent chemo- and/or radiotherapy treatment. Patients will be randomized to receive either induction chemotherapy (three 3-week cycles of CAPOX (capecitabine, oxaliplatin), four 2-week cycles of FOLFOX (5-fluorouracil, leucovorin, oxaliplatin) or FOLFORI (5-fluorouracil, leucovorin, irinotecan)) followed by neoadjuvant chemoradiotherapy and surgery (experimental arm) or neoadjuvant chemoradiotherapy and surgery alone (control arm). Tumours will be restaged using MRI and, in the experimental arm, a further cycle of CAPOX or two cycles of FOLFOX/FOLFIRI will be administered before chemoradiotherapy in case of stable or responsive disease. The radiotherapy dose will be 25 × 2.0 Gy or 28 × 1.8 Gy in radiotherapy-naive patients, and 15 × 2.0 Gy in previously irradiated patients. The concomitant chemotherapy agent will be capecitabine administered twice daily at a dose of 825 mg/m2 on radiotherapy days. The primary endpoint of the study is the R0 resection rate. Secondary endpoints are long-term oncological outcomes, radiological and pathological response, toxicity, postoperative complications, costs, and quality of life. Discussion This trial protocol describes the PelvEx II study. PelvEx II, designed as a multicentre, open-label, phase III, parallel-arms study, is the first randomized study to compare induction chemotherapy followed by neoadjuvant chemo(re)irradiation and surgery with neoadjuvant chemo(re)irradiation and surgery alone in patients with locally recurrent rectal cancer, with the aim of improving the number of R0 resections

Operative notes do not reflect reality in laparoscopic cholecystectomy

Background: Operative notes represent an essential element in safe patient care and should therefore be clear and accurate. This comparative study examined whether operative notes accurately represented the laparoscopic cholecystectomy (LC) as performed. Methods: Nine Dutch teaching and non-teaching hospitals were invited to record 20 successive LCs each and to collect the corresponding operative notes. The main outcome measures were overall differences and correspondence between video recordings and notes based on the Dutch guideline for LC and the occurrence of iatrogenic gallbladder perforation. A comparison was made of the cumulative results of recordings and operative notes, and individual recordings were compared with the corresponding notes. Results: Seven hospitals participated in the study; 125 video recordings and operative notes were fully analysed. Recordings showed more steps of the procedure than did notes. Individual comparisons showed significant differences (P <= 0.001) between the recording and the corresponding note for the steps 'Introducing trocars under vision', 'Condition of the gallbladder', 'Critical view of safety' and 'Removing first and second trocar under vision'. Iatrogenic gallbladder perforation with spilled bile occurred in 31 patients (24.8 per cent), and was both recorded and reported in 29 patients. Iatrogenic gallbladder perforation with spilled bile and spilled stones occurred in 15 patients (12.0 per cent), and was recorded and reported in 11 patients. Conclusion: Operative notes do not adequately represent the actual LCs performed as they describe fewer important procedural steps. It is suggested that operative notes should include video recordings

Association between socioeconomic status, surgical treatment and mortality in patients with colorectal cancer

Background: High socioeconomic status is associated with better survival in colorectal cancer (CRC). This study investigated whether socioeconomic status is associated with differences in surgical treatment and mortality in patients with CRC. Methods: Patients diagnosed with stage I-III CRC between 2005 and 2010 in the Eindhoven Cancer Registry area in the Netherlands were included. Socioeconomic status was determined at a neighbourhood level by combining the mean household income and the mean value of the housing. Results: Some 4422 patients with colonic cancer and 2314 with rectal cancer were included. Patients with colonic cancer and high socioeconomic status were operated on with laparotomy (70.7 versus 77.6 per cent; P = 0.017), had laparoscopy converted to laparotomy (15.7 versus 29.5 per cent; P = 0.008) and developed anastomotic leakage or abscess (9.6 versus 12.6 per cent; P = 0.049) less frequently than patients with low socioeconomic status. These differences remained significant after adjustment for patient and tumour characteristics. In rectal cancer, patients with high socioeconomic status were more likely to undergo resection (96.3 versus 93.7 per cent; P = 0.083), but this was not significant in multivariable analysis (odds ratio (OR) 1.44, 95 per cent confidence interval 0.84 to 2.46). The difference in 30-day postoperative mortality in patients with colonic cancer and high and low socioeconomic status (3.6 versus 6.8 per cent; P < 0 001) was not significant after adjusting for age, co-morbidities, emergency surgery, and anastomotic leakage or abscess formation (OR 0.90, 0.51 to 1.57). Conclusion: Patients with CRC and high socioeconomic status have more favourable surgical treatment characteristics than patients with low socioeconomic status. The lower 30-day postoperative mortality found in patients with colonic cancer and high socioeconomic status is largely explained by patient and surgical factors