Time interval between self-expandable metal stent placement or creation of a decompressing stoma and elective resection of left-sided obstructive colon cancer

Background The optimal timing of resection after decompression of left-sided obstructive colon cancer is unknown. Revised expert-based guideline recommendations have shifted from an interval of 5-10 days to approximately 2 weeks following self-expandable metal stent (SEMS) placement, and recommendations after decompressing stoma are lacking. We aimed to evaluate the recommended bridging intervals after SEMS and explore the timing of resection after decompressing stoma. Methods This nationwide study included patients registered between 2009 and 2016 in the prospective, mandatory Dutch ColoRectal Audit. Additional data were collected through patient records in 75 hospitals. Only patients who underwent either SEMS placement or decompressing stoma as a bridge to surgery were selected. Technical SEMS failure and unsuccessful decompression within 48 hours were exclusion criteria. Results 510 patients were included (182 SEMS, 328 decompressing stoma). Median bridging interval was 23 days (interquartile range [IQR] 13-31) for SEMS and 36 days (IQR 22-65) for decompressing stoma. Following SEMS placement, no significant differences in post-resection complications, hospital stay, or laparoscopic resections were observed with resection after 11-17 days compared with 5-10 days. Of SEMS-related complications, 48% occurred in patients operated on beyond 17 days. Compared with resection within 14 days, an interval of 14-28 days following decompressing stoma resulted in significantly more laparoscopic resections, more primary anastomoses, and shorter hospital stays. No impact of bridging interval on mortality, disease-free survival, or overall survival was demonstrated. Conclusions Based on an overview of the data with balancing of surgical outcomes and timing of adverse events, a bridging interval of approximately 2 weeks seems appropriate after SEMS placement, while waiting 2-4 weeks after decompressing stoma further optimizes surgical conditions for laparoscopic resection with restoration of bowel continuity

Positron Emission Tomography in Staging of Esophageal Cancer

Curative treatment of patients with esophageal cancer mainly depends on the stage of disease. Until now, surgical resection is the only curative option in patients with locoregional stage of the disease, but is accompanied by substantial morbidity and even mortality. Patients with distant metastases (M1) or local invasion of adjacent vital structures by the primary tumor (T4) are beyond cure. These patients may benefit from less invasive methods, including stenting, external radiation and/or brachytherapy for palliation. The primary aim in staging of esophageal cancer is to assess the prognosis in order to select those patients who may benefit from surgery. Therefore, several techniques are employed to stage these patients. During the last decade, preoperative noninvasive staging modalities have improved. Computed Tomography (CT) of thorax and abdomen has been the first-line method to determine local resectability and metastatic spread for many years. Later, Endoscopic Ultrasound (EUS) was introduced and has become the most reliable method of identifying the depth of primary tumor invasion and to assess regional and distant lymph node involvement, particularly in combination with fine-needle aspiration (FNA). Recently, 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) has been gaining acceptance in the detection of distant metastatic disease. This thesis discusses several aspect of PET in staging patients with cancer of the esophagus or gastroesophageal junction. In chapter 2, the literature concerning staging esophageal cancer with FDG-PET was systematically reviewed. FDG-PET was found to have moderate sensitivity and specificity in the detection of locoregional lymph node metastases, with considerable heterogeneity across the included studies. In the detection of distant nodal and hematogenous metastases, FDG-PET has reasonable sensitivity and specificity, with a lower degree of heterogeneity. As M stage determines patient management, we feel that the potential contribution of FDG-PET to staging should carry more weight than its role in N staging when deciding whether or not to implement FDG-PET in the standard preoperative work-up of patient with esophageal cancer. Chapter 3 describes a systematic review of CT, EUS and FDG-PET for the response assessment to neoadjuvant therapy in patients with esophageal cancer. Single slice CT scanning to assess the response to neoadjuvant therapy in esophageal cancer is inaccurate and therefore not recommended. EUS and FDG-PET have equivalent accuracy. EUS can identify patients who have achieved a pathological response, but is not always feasible during or shortly after chemoradiation and therefore not routinely used for therapy response assessment. FDG-PET, measuring alterations in tissue metabolism, seems a promising noninvasive tool for neoadjuvant therapy response assessment in esophageal cancer. In chapter 4, the impact of FDG-PET on the rate of unnecessary surgical explorations is investigated. This study shows a substantial rate of unnecessary surgery in patients suitable for curative treatment mainly because of distant metastases. Improvement of preoperative staging, especially by implementation of FDG-PET, may have reduced the rate of unnecessary surgery to approximately 20%. Chapter 5 describes the additional value of FDG-PET after a state-of-the-art conventional staging and the additional costs related to FDG-PET. FDG-PET improves the selection for potentially curative surgery, especially in stage III-IV esophageal cancer patients. However its yield after extensive conventional staging including EUS-FNA and multidetector CT is limited. The additional costs of FDG-PET were not compensated by the cost reduction of prevented surgery. Chapter 6 discusses the clinical importance of synchronous neoplasms, which are detected on FDG-PET that was obtained for the preoperative staging of esophageal cancer patients. FDG-PET may detect unexpected synchronous primary neoplasms in patients with esophageal cancer. Sites of suspected metastases should be confirmed histologically before treatment, as synchronous neoplasms can mimic metastatic disease. In chapter 7, the possible pitfalls of FDG-PET are described. This study demonstrates the pitfalls of staging esophageal cancer with FDG-PET due to the occurrence of false-positive results. We should remember that FDG is not a tumor-specific substance, and that false-positive results may occur as a result of increased glucose metabolism in benign lesions. This study shows that PET still has to be used complementary to conventional staging methods. From these observations, it is clear that positive findings on FDG-PET must be confirmed by pathological examination, whenever possible, before denying patients from surgery with curative intent. Besides imaging, FDG-PET offers the opportunity for quantification of FDG uptake in the primary tumor. Chapter 8 discusses the role of the standardized uptake value (FDG) in the assessment of prognosis in esophageal cancer. SUV analysis should be performed because a high SUV seems to be related with advanced stages of esophageal carcinoma, irresectability and therefore with poorer prognosis. However, SUV is not useful as an independent predictor of survival in patients with esophageal cancer. Since esophagectomy is the only potentially curative option, survival is strongly predicted by the eligibility for surgery. In chapter 9, the new tracer 18F-fluoro-3’deoxy-3’-L-fluorothymidine (FLT) is investigated in a feasibility study. At present, 18F-FDG is the tracer of choice for the staging of esophageal cancer. FLT seems to be more tumor specific. Despite the lower incidence of false-positive results with 18F-FLT, false-negative results will increase by using 18F-FLT, which is a major disadvantage for the staging of esophageal cancer.

Slowly resorbable biosynthetic mesh: 2-year results in VHWG grade 3 hernia repair

Introduction: Information on the long-term performance of biosynthetic meshes is scarce. This study analyses the performance of biosynthetic mesh (Phasix™) over 24 months. Methods: A prospective, international European multi-center trial is described. Adult patients with a Ventral Hernia Working Group (VHWG) grade 3 incisional hernia larger than 10 cm2, scheduled for elective repair, were included. Biosynthetic mesh was placed in sublay position. Short-term outcomes included 3-month surgical site occurrences (SSO), and long-term outcomes comprised hernia recurrence, reoperation, and quality of life assessments until 24 months. Results: Eighty-four patients were treated with biosynthetic mesh. Twenty-two patients (26.2%) developed 34 SSOs, of which 32 occurred within 3 months (primary endpoint). Eight patients (11.0%) developed a hernia recurrence. In 13 patients (15.5%), 14 reoperations took place, of which 6 were performed for hernia recurrence (42.9%), 3 for mesh infection (21.4%), and in 7 of which the mesh was explanted (50%). Compared to baseline, quality of life outcomes showed no significant difference after 24 months. Despite theoretical resorption, 10.7% of patients reported presence of mesh sensation in daily life 24 months after surgery. Conclusion: After 2 years of follow-up, hernia repair with biosynthetic mesh shows manageable SSO rates and favorable recurrence rates in VHWG grade 3 patients. No statistically significant improvement in quality of life or reduction of pain was observed. Few patients report lasting presence of mesh sensation. Results of biosynthetic mesh after longer periods of follow-up on recurrences and remodeling will provide further valuable information to make clear recommendations. Trial registration: Registered on clinicaltrials.gov (NCT02720042), March 25, 2016