In the Netherlands, use of neoadjuvant radiotherapy for rectal cancer declined after guideline revision in 2014. This decline is thought to affect the clinical nature and treatability of locally ...recurrent rectal cancer (LRRC). Therefore, this study compared two national cross-sectional cohorts before and after the guideline revision with the aim to determine the changes in treatment and survival of LRRC patients over time.
Patients who underwent resection of primary rectal cancer in 2011 (n = 2094) and 2016 (n = 2855) from two nationwide cohorts with a 4-year follow up were included. Main outcomes included time to LRRC, synchronous metastases at time of LRRC diagnosis, intention of treatment and 2-year overall survival after LRRC.
Use of neoadjuvant (chemo)radiotherapy for the primary tumour decreased from 88.5% to 60.0% from 2011 to 2016. The 3-year LRRC rate was not significantly different with 5.1% in 2011 (n = 114, median time to LRRC 16 months) and 6.3% in 2016 (n = 202, median time to LRRC 16 months). Synchronous metastasis rate did not significantly differ (27.2% vs 33.7%, p = 0.257). Treatment intent of the LRRC shifted towards more curative treatment (30.4% vs. 47.0%, p = 0.009). In the curatively treated group, two-year overall survival after LRRC diagnoses increased from 47.5% to 78.7% (p = 0.013).
Primary rectal cancer patients in 2016 were treated less often with neoadjuvant (chemo)radiotherapy, while LRRC rates remained similar. Those who developed LRRC were more often candidate for curative intent treatment compared to the 2011 cohort, and survival after curative intent treatment also improved substantially.
•In 2016 less primary rectal cancer patients were treated with neoadjuvant (chemo)radiotherapy.•The LRRC rate remained the same between 2011 and 2016.•In 2016 LRRC patients were more often candidate for curative treatment.•In 2016 LRRC patients received full course chemoradiotherapy more often.•Survival of curatively treated LRRC patients increased significantly over time.
Abstract Purpose The aims of this study were to investigate the effectiveness of cone beam computed tomography (CBCT) compared to panoramic radiography (PR), prior to mandibular third molar removal, ...in reducing patient morbidity, and to identify risk factors associated with inferior alveolar nerve (IAN) injury. Material and methods This multicentre, randomised, controlled trial was performed at three centres in the Netherlands. Adults with an increased risk for IAN injury, as diagnosed from PR, were included in the study. In one arm of the study, patients underwent an additional CBCT prior to third molar surgery. In a second arm of the study, no additional radiographs were acquired. The primary outcome measure was the number of patient-reported altered sensations 1 week after surgery. As secondary outcome measures, the number of patients with objective IAN injury, with long-term (>6 months) IAN injury, the occurrence of other postoperative complications, the Oral Health Related Quality of Life–14 (OHIP-14) questionnaire responses, postoperative pain (visual analogue scale score), duration of surgery, number of emergency visits, and number of missed days of work or study were scored. Results A total of 268 patients with 320 mandibular third molars were analysed according to the intention-to-treat principle. The overall incidence of IAN injury 1 week after surgery was 6.3%. No significant differences between CBCT and PR for temporary IAN injury ( p = 0.64) and all other secondary outcomes were registered. A lingual position of the mandibular canal (MC) and narrowing, in which the diameter of the MC lumen was decreased at the contact area between the MC and the roots, were significant risk factors for temporary IAN injury. Conclusion Although CBCT is a valuable diagnostic adjunct for identification of an increased risk for IAN injury, the use of CBCT does not translate into a reduction of IAN injury and other postoperative complications, after removal of the complete mandibular third molar. In these selected cases of a high risk for IAN injury, an alternative strategy, such as monitoring or a coronectomy, might be more appropriate. ( http://clinicaltrials.gov , NCT02071030 ).
Abstract The purpose of this prospective observational study was to evaluate whether cone beam CT (CBCT) is a useful tool for analyzing the fracture line in a bilateral sagittal split osteotomy ...(BSSO). The patient group consisted of 40 consecutive patients (9 males and 31 females) with a mandibular hypoplasia who underwent a BSSO advancement (Hunsuck modification; n = 80 splits) between September 2006 and July 2008. The mean age at the time of surgery was 34 years (range 17–61 years). A newly developed lingual split scale was used to categorize the path of the fracture line on the lingual side of the ramus based on one-day postoperative data sets reconstructed from CBCT data. Although all splits (n = 80) were performed according to the standardized protocol, only 51% of the fracture lines run according to the Hunsuck's description, whereas 33% ran through the mandibular canal and 16% split otherwise. The split pattern was influenced by the length of the medial osteotomy (p = 0.01). In conclusion, 3D imaging is a useful tool for analyzing the surgical outcome of a BSSO and has the potential to provide substantial data on the position of the proximal segments as a result of the lingual fracture line.
Aim
The construction of a new coloanal anastomosis (CAA) following anastomotic leakage after low anterior resection (LAR) is challenging. The available literature on this topic is scarce. The aim of ...this two‐centre study was to determine the clinical success and morbidity after redo CAA.
Method
This retrospective cohort study included all patients with anastomotic leakage after LAR for rectal cancer who underwent a redo CAA between 2010 and 2014 in two tertiary referral centres. Short‐ and long‐term morbidity were analysed, including both anastomotic leakage and permanent stoma rates on completion of follow‐up.
Results
A total of 59 patients were included, of whom 45 (76%) were men, with a mean age of 59 years (SD ± 9.4). The median interval between index and redo surgery was 14 months interquartile range (IQR) 8–27. The median duration of follow‐up was 27 months (IQR 17–36). The most frequent complication was anastomotic leakage of the redo CAA occurring in 24 patients (41%), resulting in a median of three reinterventions (IQR 2–4) per patient. At the end of follow‐up, bowel continuity was restored in 39/59 (66%) patients. Fourteen (24%) patients received a definitive colostomy and six (10%) still had a diverting ileostomy. In a multivariable model, leakage of the redo CAA was the only risk factor for permanent stoma (OR 0.022; 95% CI 0.004–0.122).
Conclusion
Redo CAA is a viable option in selected patients with persisting leakage after LAR for rectal cancer who want their bowel continuity restored. However, patients should be fully informed about the relatively high morbidity and reintervention rates.
Aim
The high morbidity associated with radical resection for rectal cancer is an incentive for surgeons to adopt strategies aimed at organ preservation, particularly for early disease. There are a ...number of different approaches to achieve this. In this study we have collated current national and international guidelines to produce a synopsis to support this changing practice.
Method
The PubMed, Embase, Trip, National Guideline Clearinghouse and BMJ Best Practice databases were interrogated. Guidelines published before 2010 were excluded. The AGREE‐II tool was used for quality assessment.
Results
Twenty‐four guidelines were drawn from 2278 potential publications. A consensus exists for local excision for ‘low‐risk’ T1 rectal cancer but there is no agreement on how to stratify the risk of treatment failure. There is a low level of agreement for rectal preservation for more advanced disease, but when mentioned it is recommended for unfit patients or in the context of a clinical trial. Guidelines are inconsistent with respect to surveillance in node‐negative disease and after complete response to chemoradiotherapy.
Conclusion
According to current guidelines and consensus statements, organ preservation for rectal cancer beyond low‐risk T1 is still considered experimental and only indicated in patients who are unsuitable for radical surgery. Follow‐up strategies and cN0 staging deserve attention, highlighting the need for high‐quality clinical trials.
Abstract Osteoid osteoma is a benign bone tumour with self-limiting growth potential occurring in any part of the body. Two rare cases of a pathologically proven osteoid osteoma invading the ...temporomandibular joint (TMJ) are reported herein. This article also reviews the cases of osteoid osteoma of the craniofacial complex reported in the English-language literature to date. Although the clinical presentation of osteoid osteoma in the jaw differs from that of osteoid osteoma in the more common locations, the radiographic features are similar. In both cases presented, computed tomography revealed a small round osseous lesion with sharp margins in the TMJ. Bone scintigraphy was performed in order to differentiate the lesions from other osseous lesions. Both patients underwent surgical excision of the lesion with immediate relief of the pain. The importance of early recognition of the clinical and imaging characteristics of an osteoid osteoma of the TMJ is emphasized, in order to prevent misdiagnosis and avoid discouraging therapies.
Background: This retrospective cohort study evaluated the longitudinal three-dimensional cranial shape developments and the secondary treatment aspects after endoscopically assisted craniosynostosis ...surgery (EACS) with helmet therapy and open cranial vault reconstruction (OCVR) for scaphocephaly. Methods: Longitudinally collected three-dimensional photographs from scaphocephaly patients and healthy infants were evaluated. Three-dimensional cranial shape measurements and growth maps were compared between the groups over time. Secondary treatment aspects were compared for the treatment groups. Results: Both surgical techniques showed their strongest changes directly after surgery, with mean parietal three-dimensional growths up to 10 mm. At age 24 months, comparison of head shapes showed mean three-dimensional differences less than ±2 mm, with OCVR resulting in a lower vertex and longer cranial length when compared with EACS. At 48 months of age, no measurements were significantly different between treatment groups. Only the total head volume was somewhat larger in the male EACS group at age 48 months ( P = 0.046). Blood loss in EACS (mean, 18 mL; range, 0 to 160 mL) was lower than in OCVR (mean, 100 mL; range, 15 to 300 mL; P < 0.001). Median length of stay after surgery was shorter for EACS (mean, 2 days; range, 1 to 5 days) compared with OCVR (mean, 5 days; range, 3 to 8 days; P < 0.001). Conclusions: The authors conclude that EACS for scaphocephaly shows equal craniometric results at age 48 months and has a better surgery profile compared with OCVR. Early diagnostics and referral for suspected scaphocephaly to allow EACS is therefore recommended. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Aim: Transanal endoscopic microsurgery (TEM) is used for the resection of large rectal adenomas and well or moderately differentiated T1 carcinomas. Due to difficulty in preoperative staging, final ...pathology may reveal a carcinoma not suitable for TEM. Although completion total mesorectal excision is considered standard of care in T2 or more invasive carcinomas, this completion surgery is not always performed. The purpose of this article is to evaluate the outcome of patients after TEM-only, when completion surgery would be indicated. Methods: In this retrospective multicenter, observational cohort study, outcome after TEM-only (n = 41) and completion surgery (n = 40) following TEM for a pT2–3 rectal adenocarcinoma was compared. Results: Median follow-up was 29 months for the TEM-only group and 31 months for the completion surgery group. Local recurrence rate was 35 and 11% for the TEM-only and completion surgery groups respectively. Distant metastasis occurred in 16% of the patients in both groups. The 3-year overall survival was 63% in the TEM-only group and 91% in the completion surgery group respectively. Three-year disease-specific survival was 91 versus 93% respectively. Conclusions: Although local recurrence after TEM-only for pT2–3 rectal cancer is worse compared to the recurrence that occurs after completion surgery, disease-specific survival is comparable between both groups. The lower unadjusted overall survival in the TEM-only group indicates that TEM-only may be a valid alternative in older and frail patients, especially when high morbidity of completion surgery is taken into consideration. Nevertheless, completion surgery should always be advised when curation is intended.
Abstract In this study, cone beam computed tomography (CBCT) and three dimensional (3D) stereophotogrammetry are used to compare the 3D skeletal and soft tissue changes caused by a bilateral sagittal ...split osteotomy (BSSO) 1 year after a mandibular advancement. Eighteen consecutive patients with a hypoplastic mandible were treated with a BSSO according to the Hunsuck modification. Preoperatively and 1 year postoperatively, a CBCT scan was acquired and a 3D photograph. The pre- and postoperative CBCT scans were matched using voxel based registration. After registration, the mandible could be segmented in the pre- and postoperative scans. The preoperative scan was subtracted from the postoperative scan, resulting in the hard tissue difference. To investigate the soft tissue changes, the pre- and postoperative 3D photographs were registered using surface based registration. After registration the preoperative surface could be subtracted from the postoperative surface, resulting in the overall volumetric difference. As expected, a correlation between mandibular advancent and volumetric changes of the hard tissues was found. The correlation between advancement and soft tissues was weak. The labial mental fold stretched after surgery. This study proved that using 3D imaging techniques it is possible to document volumetric surgical changes accurately and objectively.
The implementation of augmented reality (AR) in image-guided surgery (IGS) can improve surgical interventions by presenting the image data directly on the patient at the correct position and in the ...actual orientation. This approach can resolve the switching focus problem, which occurs in conventional IGS systems when the surgeon has to look away from the operation field to consult the image data on a 2-dimensional screen. The Microsoft HoloLens, a head-mounted AR display, was combined with an optical navigation system to create an AR-based IGS system. Experiments were performed on a phantom model to determine the accuracy of the complete system and to evaluate the effect of adding AR. The results demonstrated a mean Euclidean distance of 2.3 mm with a maximum error of 3.5 mm for the complete system. Adding AR visualization to a conventional system increased the mean error by 1.6 mm. The introduction of AR in IGS was promising. The presented system provided a solution for the switching focus problem and created a more intuitive guidance system. With a further reduction in the error and more research to optimize the visualization, many surgical applications could benefit from the advantages of AR guidance.
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