Background
Although self‐expandable metal stent (SEMS) placement as bridge to surgery (BTS) in patients with left‐sided obstructing colonic cancer has shown promising short‐term results, it is used ...infrequently owing to uncertainty about its oncological safety. This population study compared long‐term oncological outcomes between emergency resection and SEMS placement as BTS.
Methods
Through a national collaborative research project, long‐term outcome data were collected for all patients who underwent resection for left‐sided obstructing colonic cancer between 2009 and 2016 in 75 Dutch hospitals. Patients were identified from the Dutch Colorectal Audit database. SEMS as BTS was compared with emergency resection in the curative setting after 1 : 2 propensity score matching.
Results
Some 222 patients who had a stent placed were matched to 444 who underwent emergency resection. The overall SEMS‐related perforation rate was 7·7 per cent (17 of 222). Three‐year locoregional recurrence rates after SEMS insertion and emergency resection were 11·4 and 13·6 per cent (P = 0·457), disease‐free survival rates were 58·8 and 52·6 per cent (P = 0·175), and overall survival rates were 74·0 and 68·3 per cent (P = 0·231), respectively. SEMS placement resulted in significantly fewer permanent stomas (23·9 versus 45·3 per cent; P < 0·001), especially in elderly patients (29·0 versus 57·9 per cent; P < 0·001). For patients in the SEMS group with or without perforation, 3‐year locoregional recurrence rates were 18 and 11·0 per cent (P = 0·432), disease‐free survival rates were 49 and 59·6 per cent (P = 0·717), and overall survival rates 61 and 75·1 per cent (P = 0·529), respectively.
Conclusion
Overall, SEMS as BTS seems an oncologically safe alternative to emergency resection with fewer permanent stomas. Nevertheless, the risk of SEMS‐related perforation, as well as permanent stoma, might influence shared decision‐making for individual patients.
The disease‐free and overall survival of patients with left‐sided obstructive colonic cancer treated with either emergency resection or stent placement and elective resection was compared using a propensity score‐matched analysis. No difference was found in any of the oncological outcome measures. Patients treated with stent placement, however, had significantly fewer permanent stomas.
Self‐expandable metal stent oncologically safe
Acute resection for left-sided obstructive colon carcinoma is thought to be associated with higher mortality risk than a bridge to surgery approach using decompressing stoma or self-expandable metal ...stent, but prediction models are lacking.
Determine the influence of treatment strategy on mortality within 90-days from first intervention using a prediction model in patients presenting with left-sided obstructive colon carcinoma.
A national multicenter cohort study, using data of a prospective national audit.
The study was performed in 75 Dutch hospital.
Patients were included if they underwent a resection with curative intent for left-sided obstructive colon carcinoma between 2009 and 2016.
First intervention was either acute resection, bridge to surgery with self-expandable metallic stent, or bridge to surgery with decompressing stoma.
The main outcome measure was 90-day mortality after first intervention. Risk factors were identified using multivariable logistic analysis. Subsequently a risk model was developed.
In total 2395 patients were included, with first intervention consisting of acute resection in 1848 (77%) patients, stoma as bridge to surgery in 332 (14%) patients, and stent as bridge to surgery in 215 (9%) patients. Overall, 152 patients (6.3%) died within 90-days from first intervention. A decompressing stoma was independently associated with a lower 90-day mortality risk (HR: 0.27, CI: 0.094-0.62). Other independent predictors for mortality were age, ASA classification, tumor location, and index levels of serum creatinine and C-reactive protein. The constructed risk model had an area under the curve of 0.84 (CI: 0.81-0.87).
Only patients that underwent surgical resection were included.
Treatment strategy had a significant impact on 90-day mortality. A decompressing stoma considerably lowers the risk of mortality, especially in older and frail patients. A risk model was developed, which needs further external validation. See Video Abstract at http://links.lww.com/DCR/B975.
Background
Controversy exists on emergency setting as a risk factor for peritoneal metastases (PM) in colon cancer patients. Data in patients with obstruction are scarce. The aim of this study was to ...determine the incidence of synchronous and metachronous PM, risk factors for the development of metachronous PM, and prognostic implications within a large nationwide cohort of left-sided obstructive colon cancer (LSOCC).
Methods
Patients with LSOCC treated between 2009 and 2016 were selected from the Dutch ColoRectal Audit. Additional treatment and long-term outcome data were retrospectively collected from original patient files in 75 hospitals in 2017.
Results
In total, 3038 patients with confirmed obstruction and without perforation were included. Synchronous PM (at diagnosis or < 30 days postoperatively) were diagnosed in 148/2976 evaluable patients (5.0%), and 3-year cumulative metachronous PM rate was 9.9%. Multivariable Cox regression analyses revealed pT4 stage (HR 1.782, 95% CI 1.191–2.668) and pN2 stage (HR 2.101, 95% CI 1.208–3.653) of the primary tumor to be independent risk factors for the development of metachronous PM. Median overall survival in patients with or without synchronous PM was 20 and 63 months (
p
< 0.001) and 3-year overall survival of patients that did or did not develop metachronous PM was 48.1% and 77.0%, respectively (
p
< 0.001).
Conclusion
This population based study revealed a 5.0% incidence of synchronous peritoneal metastases in patients who underwent resection of left-sided obstructive colon cancer. The subsequent 3-year cumulative metachronous PM rate was 9.9%, with advanced tumor and nodal stage as independent risk factors for the development of PM.
To demonstrate that splenic artery embolization (SAE) is more cost-effective than splenectomy from a societal perspective in the Netherlands.
Patient-level data obtained from the SPLENIQ study were ...used to populate a health economic model and were supplemented with expert opinion when necessary. Propensity score matching was used to correct for baseline differences in injury severity scores. The health economic model consisted of 3 health states (complications after intervention, SAE failure, and recovery) and a dead state. Model outcomes were incremental quality-adjusted life years (QALYs) and incremental costs of SAE over splenectomy. The Dutch health economic guidelines were followed. The model used a lifetime time horizon. Uncertainty was assessed using probabilistic sensitivity analysis and scenario analyses.
Patients undergoing SAE had a higher life expectancy than patients undergoing splenectomy. Incremental QALYs were 3.1 (mostly explained by difference in life expectancy), and incremental costs were €34,135 (explained by costs related to medical consumption and lost productivity in additional life years), leading to an incremental cost-effectiveness ratio of €11,010 per QALY. SAE was considered cost-effective in >95% of iterations using a threshold of €20,000 per QALY.
SAE results in more QALYs than splenectomy. Intervention costs for SAE are lower than that for splenectomy, but medical consumption and productivity costs in later years are higher for SAE due to better survival. SAE was found to be cost-effective compared with splenectomy under appropriate Dutch cost-effectiveness thresholds.
Purpose
A substantial part (21–35%) of defunctioning stomas created during resection for colorectal cancer will never be reversed. Known risk factors for non-closure are age, peri- or postoperative ...complications, comorbidity, and tumor stage. However, studies performed to identify these risk factors mostly focus on rectal cancer and include both preoperative and postoperative factors. This study aims to identify preoperative risk factors for non-reversal of intended temporary stomas created during acute resection of left-sided obstructive colon cancer (LSOCC) with primary anastomosis.
Methods
All patients who underwent emergency resection for LSOCC with primary anastomosis and a defunctioning stoma between 2009 and 2016 were selected from the Dutch ColoRectal Audit, and additional data were collected in the local centers. Multivariable analysis was performed to identify independent preoperative factors for non-closure of the stoma.
Results
A total of 155 patients underwent acute resection for LSOCC with primary anastomosis and a defunctioning stoma. Of these, 51 patients (32.9%) did not have their stoma reversed after a median of 53 (range 7–104) months of follow-up. In multivariable analysis, hemoglobin < 7.5 mmol/L (odds ratio (OR) 4.79, 95% confidence interval (95% CI) 1.60–14.38,
p
= 0.005), estimated glomerular filtration rate (eGFR) ≤ 45 mL/min/1.73 m
2
(OR 4.64, 95% CI 1.41–15.10,
p
= 0.011), and metastatic disease (OR 6.12, 95% CI 2.35–15.94,
p
< 0.001) revealed to be independent predictors of non-closure.
Conclusions
Anemia, impaired renal function, and metastatic disease at presentation were found to be independent predictors for non-reversal of intended temporary stomas in patients who underwent acute resection for LSOCC. In patients who have an increased risk of non-reversal, the surgeon should consider a Hartmann’s procedure.
As research continues to highlight the risks involved in handling antineoplastic drugs, the health services are giving increased attention to safety measures. In order to establish what protective ...measures nursing staff employ and what they know about antineoplastic drugs, a survey was carried out in The Netherlands. The questions were based on the self-study modules by Dunne and the (American) Oncology Nursing Society. A total of 1,373 questionnaires were distributed in 10 hospitals. Of these, 824 were returned, which represents a response rate of 60%. Over two-thirds (68%) of the nursing staff reported that they were involved, on a daily or weekly basis, in caring for patients being treated with antineoplastic drugs. In the view of 94% of the nurses, protective measures are effective. While administering antineoplastic drugs, 91% of the respondents said that they wore gloves, 21% said that they wore a gown, 18% wore a mask, and 3% used goggles. While handling excreta, fewer nurses applied safety measures. Thirty-nine percent of the respondents knew that latex gloves offer a greater degree of protection than PVC gloves. It appeared that there was not one Dutch hospital whose guidelines for the safe handling of antineoplastic material were completely up-to-date and that nurses do not always follow the guidelines established.
Surgical site infections (SSI's) are associated with severe morbidity, mortality and increased health care costs in vascular surgery.
To implement a bundle of care in vascular surgery and measure the ...effects on the overall and deep-SSI's rates.
Prospective, quasi-experimental, cohort study.
A prospective surveillance for SSI's after vascular surgery was performed in the Amphia hospital in Breda, from 2009 through 2011. A bundle developed by the Dutch hospital patient safety program (DHPSP) was introduced in 2009. The elements of the bundle were (1) perioperative normothermia, (2) hair removal before surgery, (3) the use of perioperative antibiotic prophylaxis and (4) discipline in the operating room. Bundle compliance was measured every 3 months in a random sample of surgical procedures and this was used for feedback.
Bundle compliance improved significantly from an average of 10% in 2009 to 60% in 2011. In total, 720 vascular procedures were performed during the study period and 75 (10.4%) SSI were observed. Deep SSI occurred in 25 (3.5%) patients. Patients with SSI's (28,5±29.3 vs 10.8±11.3, p<0.001) and deep-SSI's (48.3±39.4 vs 11.4±11.8, p<0.001) had a significantly longer length of hospital stay after surgery than patients without an infection. A significantly higher mortality was observed in patients who developed a deep SSI (Adjusted OR: 2.96, 95% confidence interval 1.32-6.63). Multivariate analysis showed a significant and independent decrease of the SSI-rate over time that paralleled the introduction of the bundle. The SSI-rate was 51% lower in 2011 compared to 2009.
The implementation of the bundle was associated with improved compliance over time and a 51% reduction of the SSI-rate in vascular procedures. The bundle did not require expensive or potentially harmful interventions and is therefore an important tool to improve patient safety and reduce SSI's in patients undergoing vascular surgery.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective Long-term results of precuffed expanded polytetrafluoroethylene (ePTFE) grafts used for peripheral bypass surgery are lacking. The aim of this study was to obtain the long-term outcomes of ...precuffed ePTFE grafts compared with autologous saphenous vein (ASV) grafts used in patients with peripheral arterial disease (PAD). Methods A single-institution retrospective study of precuffed ePTFE and ASV graft performances in patients with PAD was undertaken between January 2004 and December 2012. Five-year primary patency, secondary patency, and limb salvage rates were determined by Kaplan-Meier analyses. Results A total of 467 bypass grafts were included in this study (169 precuffed ePTFE grafts and 298 ASV grafts). Secondary patency rates of ePTFE vs ASV at 1 and 5 years, respectively, were as follows: for 134 supragenicular femoropopliteal bypasses, 60% and 27% vs 89% and 85% ( P < .05); for 190 infragenicular femoropopliteal bypasses, 40% and 25% vs 86% and 79% ( P < .05); and for 84 femorocrural bypasses, 30% and 14% vs 50% and 50% ( P < .05). Five-year limb salvage rates of ePTFE vs ASV for supragenicular femoropopliteal bypasses were 82% vs 94% ( P = .16); for infragenicular femoropopliteal bypasses, 41% vs 92% ( P < .05); and for femorocrural bypasses, 43% vs 64% ( P = .06). Conclusions ASV bypasses are still the first-choice conduit in peripheral bypass surgery performed in patients with PAD. Precuffed ePTFE bypasses are acceptable alternatives in the absence of adequate autologous vein.
Abstract
The European H2020 project, entitled “effective Container inspection at BORDer control points” (C-BORD), aims to develop a framework of Non-Intrusive Inspection (NII) technologies,
for ...containers and large-volume freight at the EU borders. In this article the first results of the
field trials of the Rapidly Relocatable Tagged Neutron Inspection System (RRTNIS) are reported.
The tests were carried out at the customs administration of the Netherlands' (DCA) facility in the
seaport of Rotterdam, the Netherlands. For the tests mock-up cargo containers were prepared. The containers were analyzed using the whole set of NII subsystems of the C-BORD framework. Each container underwent a session of subsequent scans with all the subsystems, in order to realistically
reproduce the normal flow of inspections at the customs facility. The RRTNIS was tested under these realistic conditions, as well. The system was able to separate and identify the target materials, in mock-up containers, and improve the state-of-the-art in terms of the detected quantities.
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