Prognostic significance of peritoneal tumour cells identified at surgery for colorectal cancer

Background:

The prognostic significance of intraperitoneal tumour cells (IPCs) in colorectal cancer is not clear. This study aimed to determine whether detection of IPCs could be used a prognostic marker for selecting patients at high risk of recurrence.

Methods:

The study included 226 patients with colorectal cancer who underwent elective resection. Clinical variables, including the presence of IPCs, were analysed for their prognostic significance.

Results:

Thirty‐three patients (14·6 per cent) were positive for IPCs. Univariable analysis indicated that the presence of IPCs was a significant prognostic factor in patients with stage III colorectal cancer; the 5‐year disease‐specific survival rate was 14 per cent in IPC‐positive patients versus 79 per cent in those without IPCs (P < 0·001). Multivariable analysis showed that IPC positivity was the most robust prognostic factor in stage III disease (hazard ratio 2·2; P = 0·003), whereas nodal category (N1 or N2) showed no significant association with prognosis. In addition, IPCs were associated with haematogenous recurrence (P = 0·004) rather than peritoneal or local recurrence (P = 0·077) in patients with stage III disease.

Conclusion:

The presence of IPCs is a significant prognostic factor in patients with stage III colorectal cancer. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Prognostic value of subclassification of T2 tumours in patients with gastric cancer

Background:

This study was designed to evaluate the prognostic value of tumour stage T2 subcategorization (T2a and T2b) in patients with gastric carcinoma.

Methods:

Clinicopathological details of a prospective series of patients who had radical resection of gastric adenocarcinoma in a single institution were analysed. Univariable and multivariable survival analyses were performed with the log rank test and Cox's model respectively.

Results:

Of 373 evaluable patients, 49 (13·1 per cent) had a T2a and 143 (38·3 per cent) a T2b tumour. At a median follow‐up of 35·5 months, the 5‐year overall survival rate was 73 and 31·1 per cent for patients with T2a and T2b lesions respectively (P < 0·001). On multivariable analysis, T stage remained an independent prognostic factor. Compared with T1a, the mortality risk for patients with T1b (hazard ratio (HR) 1·00; P = 0·992) and T2a (HR 0·97; P = 0·916) tumours was similar; by contrast, the risk of death associated with T2b (HR 1·81; P = 0·031) and T3 (HR 1·89; P = 0·038) lesions was significantly greater than for T1a tumours.

Conclusion:

Subclassification of T2 tumours should be undertaken routinely in order to stratify patients with gastric cancer more accurately in terms of their mortality risk. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Systematic review and meta‐analysis of interferon after curative treatment of hepatocellular carcinoma in patients with viral hepatitis

Background:

A combined antiviral and tumoricidal effect of interferon (IFN) is assumed to occur after resection or ablation of hepatocellular carcinoma (HCC).

Methods:

An electronic search of the Medline, Embase and Central databases from January 1998 to October 2007 was conducted to identify randomized controlled trials evaluating adjuvant effects of IFN after curative treatment of HCC. A meta‐analysis was performed to estimate the effects of IFN on 2‐year outcome.

Results:

Seven trials enrolling a total of 620 patients were included in the meta‐analysis. Adjuvant treatment with IFN significantly reduced the 2‐year mortality rate after curative treatment of HCC, with a pooled risk ratio of 0·65 (95 per cent confidence interval 0·52 to 0·80); P < 0·001) in absence of any significant heterogeneity (I² = 0 per cent, P = 0·823 for χ²). The effect on reduction of tumour recurrence was less pronounced but still significant (pooled risk ratio 0·86 (95 per cent c.i. 0·76 to 0·97); P = 0·013). IFN had to be discontinued in 8–20 per cent of patients.

Conclusion:

IFN has a significant beneficial effect after curative treatment of HCC in terms of both survival and tumour recurrence. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Meta‐analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer

Background

Studies comparing upfront surgery with neoadjuvant treatment in pancreatic cancer may report only patients who underwent resection and so survival will be skewed. The aim of this study was to report survival by intention to treat in a comparison of upfront surgery versus neoadjuvant treatment in resectable or borderline resectable pancreatic cancer.

Methods

MEDLINE, Embase and the Cochrane Library were searched for studies reporting median overall survival by intention to treat in patients with resectable or borderline resectable pancreatic cancer treated with or without neoadjuvant treatment. Secondary outcomes included overall and R0 resection rate, pathological lymph node rate, reasons for unresectability and toxicity of neoadjuvant treatment.

Results

In total, 38 studies were included with 3484 patients, of whom 1738 (49·9 per cent) had neoadjuvant treatment. The weighted median overall survival by intention to treat was 18·8 months for neoadjuvant treatment and 14·8 months for upfront surgery; the difference was larger among patients whose tumours were resected (26·1 versus 15·0 months respectively). The overall resection rate was lower with neoadjuvant treatment than with upfront surgery (66·0 versus 81·3 per cent; P < 0·001), but the R0 rate was higher (86·8 (95 per cent c.i. 84·6 to 88·7) versus 66·9 (64·2 to 69·6) per cent; P < 0·001). Reported by intention to treat, the R0 rates were 58·0 and 54·9 per cent respectively (P = 0·088). The pathological lymph node rate was 43·8 per cent after neoadjuvant therapy and 64·8 per cent in the upfront surgery group (P < 0·001). Toxicity of at least grade III was reported in up to 64 per cent of the patients.

Conclusion

Neoadjuvant treatment appears to improve overall survival by intention to treat, despite lower overall resection rates for resectable or borderline resectable pancreatic cancer. PROSPERO registration number: CRD42016049374.     

Minimal‐access colorectal surgery is associated with fewer adhesion‐related admissions than open surgery

Background:

This study aimed to describe national intermediate‐term admission rates for incisional hernia or clinically apparent adhesions following colorectal surgery, and to compare rates following laparoscopic and open approaches.

Methods:

Patients undergoing primary colorectal resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Subsequent inpatient admissions were extracted for up to 3 years after the initial operation or to the end of the study period. Outcomes examined were admissions with a diagnosis of, or operative interventions for, incisional hernia or adhesions.

Results:

A total of 187 148 patients were included between 2002 and 2008, with median follow‐up of 31·8 (interquartile range 13·1–35·3) months. Some 8885 (4·7 per cent) of these patients were admitted with a diagnosis of, or underwent a repair of, an incisional hernia. In multiple regression analysis, use of laparoscopy was not a predictor of operative intervention for incisional hernia (odds ratio 1·09, 95 per cent confidence interval (c.i.) 0·99 to 1·21; P = 0·083). Some 15 125 (8·1 per cent) of the patients were admitted with a diagnosis of adhesions or had a procedure for division of adhesions. Overall, 3·5 per cent (6637 of 187 148) of patients underwent adhesiolysis. Patients selected for a laparoscopic procedure had lower rates of admission for adhesions (6·3 per cent (692 of 11 013) for laparoscopic versus 8·2 per cent (14 433 of 176 135) for open surgery; P < 0·001) and reintervention for adhesions (2·8 per cent (305 of 11 013) versus 3·6 per cent (6325 of 176 135) respectively; P < 0·001) than those undergoing an open procedure. In multiple regression analysis, patients selected for a laparoscopic procedure had lower subsequent intervention rates for adhesions (odds ratio 0·80, 95 per cent c.i. 0·71 to 0·90; P < 0·001).

Discussion:

Patients undergoing colorectal resection who are selected for the laparoscopic approach have a lower risk of developing clinically significant adhesions. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Mismatch repair protein expression in Amsterdam II criteria-positive patients in Taiwan

Background:

Hereditary non‐polyposis colorectal cancer (HNPCC) is characterized genetically by germline mutations in DNA mismatch repair (MMR) genes. Immunohistochemistry (IHC) has high sensitivity and specificity for identifying MMR‐deficient tumours. This study investigated the clinical presentations and frequency of HNPCC in Taiwan by combined Amsterdam II criteria (AC‐II) and IHC.

Methods:

In 1995–2003, 7108 patients with primary colorectal cancer registered in Chang Gung Memorial Hospital's Colorectal Cancer Registry were screened using AC‐II. Tumour specimens were analysed for MMR protein expression by IHC, and relevant clinicopathological details were documented.

Results:

Some 83 patients fulfilled the AC‐II. Clinicopathologically, 43 patients (52 per cent) had proximal tumours, ten (12 per cent) had poorly differentiated cancers, 17 (20 per cent) had mucinous adenocarcinoma and 51 (61 per cent) had stage I–II tumours. Seventeen patients developed second primary colonic and extracolonic cancers over a mean 7·2‐year follow‐up. Immunohistochemically, 58 patients were MMR protein deficient. They had a significantly earlier age of onset (P < 0·001), more proximal tumour location (P = 0·002), less advanced tumour stage (P = 0·008) and more second primary cancers (P = 0·017) compared with MMR‐competent patients.

Conclusion:

These data show significant differences in clinical features between MMR protein‐deficient and MMR competent subgroups. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Risk of recurrence and death in patients with breast cancer after delayed deep inferior epigastric perforator flap reconstruction

Background

Postmastectomy reconstruction using a deep inferior epigastric perforator (DIEP) flap is increasingly being performed in patients with breast cancer. The procedure induces extensive tissue trauma, and it has been hypothesized that the release of growth factors, angiogenic agonists and immunomodulating factors may reactivate dormant micrometastasis. The aim of the present study was to estimate the risk of breast cancer recurrence in patients undergoing DIEP flap reconstruction compared with that in patients treated with mastectomy alone.

Methods

Each patient who underwent delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013, was compared with up to four controls with breast cancer who did not receive a DIEP flap. The control patients were selected using incidence density matching with respect to age, tumour and nodal status, neoadjuvant therapy and year of mastectomy. The primary endpoint was breast cancer‐specific survival. Survival analysis was carried out using Kaplan–Meier survival estimates and Cox proportional hazard regression analysis.

Results

The analysis included 250 patients who had 254 DIEP flap reconstructions and 729 control patients. Median follow‐up was 89 and 75 months respectively (P = 0·053). Breast cancer recurrence developed in 50 patients (19·7 per cent) in the DIEP group and 174 (23·9 per cent) in the control group (P = 0·171). The 5‐year breast cancer‐specific survival rate was 92·0 per cent for patients with a DIEP flap and 87·9 per cent in controls (P = 0·032). Corresponding values for 5‐year overall survival were 91·6 and 84·7 per cent (P < 0·001). After adjustment for tumour and patient characteristics and treatment, patients without DIEP flap reconstruction had significantly lower overall but not breast cancer‐specific survival.

Conclusion

The present findings do not support the hypothesis that patients with breast cancer undergoing DIEP flap reconstruction have a higher rate of breast cancer recurrence than those who have mastectomy alone.     

Two‐year results of the randomized clinical trial DILALA comparing laparoscopic lavage with resection as treatment for perforated diverticulitis

Background

Traditionally, perforated diverticulitis with purulent peritonitis was treated with resection and colostomy (Hartmann's procedure), with inherent complications and risk of a permanent stoma. The DILALA (DIverticulitis – LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) and other randomized trials found laparoscopic lavage to be a feasible and safe alternative. The medium‐term follow‐up results of DILALA are reported here.

Methods

Patients were randomized during surgery after being diagnosed with Hinchey grade III perforated diverticulitis at diagnostic laparoscopy. The primary outcome was the proportion of patients with one or more secondary operations from 0 to 24 months after the index procedure in the laparoscopic lavage versus Hartmann's procedure groups. The trial was registered as ISRCTN82208287.

Results

Forty‐three patients were randomized to laparoscopic lavage and 40 to Hartmann's procedure. Patients in the lavage group had a 45 per cent reduced risk of undergoing one or more operations within 24 months (relative risk 0·55, 95 per cent c.i. 0·36 to 0·84; P = 0·012) and had fewer operations (ratio 0·51, 95 per cent c.i. 0·31 to 0·87; P = 0·024) compared with those in the Hartmann's group. No difference was found in mean number of readmissions (1·37 versus 1·50; P = 0·221) or mortality between patients randomized to laparoscopic lavage or Hartmann's procedure. Three patients in the lavage group and nine in the Hartmann's group had a colostomy at 24 months.

Conclusion

Laparoscopic lavage is a better option for perforated diverticulitis with purulent peritonitis than open resection and colostomy.     

Surgical treatment of hepatocellular carcinoma associated with the metabolic syndrome

Background:

The incidence of metabolic syndrome‐associated hepatocellular carcinoma (MS‐HCC) is increasing. However, the results following liver resection in this context have not been described in detail.

Methods:

Data for all patients with metabolic syndrome as a unique risk factor for HCC who underwent liver resection between 2000 and 2011 were retrieved retrospectively from an institutional database. Pathological analysis of the underlying parenchyma included fibrosis and non‐alcoholic fatty liver disease activity score. Patients were classified as having normal or abnormal underlying parenchyma. Their characteristics and outcomes were compared.

Results:

A total of 560 resections for HCC were performed in the study interval. Sixty‐two patients with metabolic syndrome, of median age 70 (range 50–84) years, underwent curative hepatectomy for HCC, including 32 major resections (52 per cent). Normal underlying parenchyma was present in 24 patients (39 per cent). The proportion of resected HCCs labelled as MS‐HCC accounted for more than 15 per cent of the entire HCC population in more recent years. Mortality and major morbidity rates were 11 and 58 per cent respectively. Compared with patients with normal underlying liver, patients with abnormal liver had increased rates of mortality (0 versus 18 per cent; P = 0·026) and major complications (13 versus 42 per cent; P = 0·010). In multivariable analysis, a non‐severely fibrotic yet abnormal underlying parenchyma was a risk factor for major complications (hazard ratio 5·66, 95 per cent confidence interval 1·21 to 26·52; P = 0·028). The 3‐year overall and disease‐free survival rates were 75 and 70 per cent respectively, and were not influenced by the underlying parenchyma.

Conclusion:

HCC in patients with metabolic syndrome is becoming more common. Liver resection is appropriate but carries a high risk, even in the absence of severe fibrosis. Favourable long‐term outcomes justify refinements in the perioperative management of these patients. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Variations in locoregional therapy in postmenopausal patients with early breast cancer treated in different countries

Background:

The Tamoxifen and Exemestane Adjuvant Multinational (TEAM) trial is an international randomized trial evaluating the efficacy and safety of exemestane, alone or following tamoxifen. The large number of patients already recruited offered the opportunity to explore locoregional treatment practices between countries.

Methods:

Patients were enrolled in Belgium, France, Germany, Greece, Ireland, Japan, the Netherlands, the UK and the USA. The core protocol had minor differences in eligibility criteria between countries, reflecting variations in national guidelines and practice regarding adjuvant endocrine therapy.

Results:

Between 2001 and 2006, 9779 patients of mean(s.d.) age 64(9) years were randomized. Some 58·4 per cent had T1 tumours (range between countries 36·8–75·9 per cent; P < 0·001) and 47·3 per cent were axillary node positive (range 25·9–84·6 per cent; P < 0·001). Independent factors for type of breast surgery were country, age, tumour status and calendar year of surgery. After breast‐conserving surgery, radiotherapy was given to 93·2 per cent of patients, 86·0 per cent in the USA and 100 per cent in France. Axillary lymph node dissection was performed in 82·0 (range 74·6–99·1) per cent.

Conclusion:

Despite international consensus guidelines, wide global variations were observed in treatment practices of early breast cancer. There should be further efforts to optimize locoregional treatment for breast cancer worldwide. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Randomized clinical trial of early versus delayed temporary stoma closure after proctectomy

Background:

Temporary faecal diversion is recommended with a low colorectal, coloanal or ileoanal anastomosis (LA). This randomized study evaluated early (EC; 8 days) versus late (LC; 2 months) closure of the temporary stoma.

Methods:

Patients undergoing rectal resection with LA were eligible to participate. If there was no radiological sign of anastomotic leakage after 7 days, patients were randomized to EC or LC. The primary endpoints were postoperative morbidity and mortality 90 days after the initial resection.

Results:

Some 186 patients were analysed. There were no deaths within 90 days and overall morbidity rates were similar in the EC and LC groups (31 versus 38 per cent respectively; P = 0·254). Overall surgical complication (both 15 per cent; P = 1·000) and reoperation (both 8 per cent; P = 1·000) rates were similar, but wound complications were more frequent after EC (19 versus 5 per cent; P = 0·007). Small bowel obstruction (3 versus 16 per cent; P = 0·002) and medical complications (5 versus 15 per cent; P = 0·021) were more common with LC. Median (range) hospital stay was reduced by EC (16 (6–59) versus 18 (9–262) days; P = 0·013).

Conclusion:

Early stoma closure is feasible in selected patients, with reduced hospital stay, bowel obstruction and medical complications, but a higher wound complication rate. Registration number: NCT00428636 ( http://www.clinicaltrials.gov ). Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Peritoneal lavage cytology in patients with oesophagogastric adenocarcinoma

Background:

The aim of the study was to determine the value of performing peritoneal lavage cytology during laparoscopy in the management of oesophagogastric adenocarcinoma.

Methods:

Laparoscopy combined with peritoneal cytology was performed in patients with potentially resectable oesophagogastric adenocarcinoma. Macroscopic peritoneal findings at laparoscopy and the presence of free peritoneal tumour cells were recorded. All patients were followed to death or the census point. Patients with overt peritoneal disease or positive cytology were offered palliative chemotherapy, subject to performance status.

Results:

Forty‐eight (18·8 per cent) of 255 patients had overt peritoneal metastases at staging laparoscopy. Fifteen (7·2 per cent) of the remaining 207 patients had positive cytology; these patients had a median (95 per cent confidence interval) survival of 13 (3·1 to 22·9) months, versus 9 (7·4 to 10·6) months for those with overt peritoneal metastases (P = 0·517). Of patients receiving chemotherapy, those without overt metastases had a slight survival advantage over patients with metastases (median 15 (10·8 to 19·2) versus 9 (7·4 to 10·7) months; P = 0·045).

Conclusion:

Positive peritoneal cytology in the absence of overt peritoneal metastases is not uncommon in oesophagogastric adenocarcinoma. It is a marker of poor prognosis even in the absence of overt peritoneal metastases. Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Extent of liver resection for hilar cholangiocarcinoma

Background:

The extent of liver resection for hilar cholangiocarcinoma (HC) remains controversial despite extensive studies. The aim of this study was to determine the safety and efficacy of minor and major hepatectomy, selected by predetermined criteria in patients with HC.

Methods:

From 2000 to 2007, 187 patients with HC were studied prospectively; 138 patients underwent resection with curative intent. Minor hepatectomy was performed in 93 patients with Bismuth–Corlette type I, II or III HC without hepatic arterial or portal venous invasion, and major hepatectomy in 45 patients with type III HC with hepatic arterial or portal venous invasion, or type IV HC.

Results:

Overall mortality and morbidity rates were 0 and 29·7 per cent respectively, and the bile leak rate was 1·4 per cent. Actuarial 1‐, 3‐ and 5‐year survival rates were 87, 54 and 34 per cent respectively in the minor liver resection group, and 80, 42 and 27 per cent for major resection (P = 0·300).

Conclusion:

Minor liver resection for HC, selected by predetermined criteria, had good results. Major liver resection, which had a higher operative morbidity rate than minor resection, should be reserved for Bismuth–Corlette type III HC with vascular invasion, or type IV HC. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Differences in outcomes of oesophageal and gastric cancer surgery across Europe

Background:

In several European countries, centralization of oesophagogastric cancer surgery has been realized and clinical audits initiated. The present study was designed to evaluate differences in resection rates, outcomes and annual hospital volumes between these countries, and to analyse the relationship between hospital volume and outcomes.

Methods:

National data were obtained from cancer registries or clinical audits in the Netherlands, Sweden, Denmark and England. Differences in outcomes were analysed between countries and between hospital volume categories, adjusting for available case‐mix factors.

Results:

Between 2004 and 2009, 10 854 oesophagectomies and 9010 gastrectomies were registered. Resection rates in England were 18·2 and 21·6 per cent for oesophageal and gastric cancer respectively, compared with 28·5–29·9 and 41·4–41·9 per cent in the Netherlands and Denmark (P < 0·001). The adjusted 30‐day mortality rate after oesophagectomy was lowest in Sweden (1·9 per cent). After gastrectomy, the adjusted 30‐day mortality rate was significantly higher in the Netherlands (6·9 per cent) than in Sweden (3·5 per cent; P = 0·017) and Denmark (4·3 per cent; P = 0·029). Increasing hospital volume was associated with a lower 30‐day mortality rate after oesophagectomy (odds ratio 0·55 (95 per cent confidence interval 0·42 to 0·72) for at least 41 versus 1–10 procedures per year) and gastrectomy (odds ratio 0·64 (0·41 to 0·99) for at least 21 versus 1–10 procedures per year).

Conclusion:

Hospitals performing larger numbers of oesophagogastric cancer resections had a lower 30‐day mortality rate. Differences in outcomes between several European countries could not be explained by differences in hospital volumes. To understand these differences in outcomes and resection rates, with reliable case‐mix adjustments, a uniform European upper gastrointestinal cancer audit with recording of standardized data is warranted. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Recovery after ultrasound‐guided foam sclerotherapy compared with conventional surgery for varicose veins

Background:

The advantages of minimally invasive alternatives such as ultrasound‐guided foam sclerotherapy (UGFS) over conventional surgery for the treatment of varicose veins include lower morbidity and faster recovery times. The aim was to compare morbidity, analgesia use, and time to return to driving and work following UGFS with those reported after conventional surgery for varicose veins.

Methods:

Patients who had UGFS or surgery for varicose veins were sent a questionnaire 4 weeks after treatment.

Results:

A total of 332 (84·9 per cent) of 391 patients who had UGFS and 53 (56 per cent) of 94 who had surgery returned a questionnaire. The groups were similar in terms of age, sex, and the proportion who had treatment of bilateral or recurrent veins. Patients who had surgery were more likely to have significant bruising (44 versus 7·2 per cent; P < 0·001) and pain (17 versus 5·5 per cent; P = 0·001). After UGFS, 43·2 per cent of patients returned to work within 24 h compared with none who had surgery (P < 0·001). Patients who had UGFS were more likely to return to driving within 4 days (P = 0·014).

Conclusion:

UGFS was associated with less pain and analgesia requirement, time off work and quicker return to driving. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Nationwide trends in the incidence and outcome of patients with gastrointestinal stromal tumour in the imatinib era

Background

The incidence, treatment and outcome of patients with newly diagnosed gastrointestinal stromal tumour (GIST) were studied in an era known for advances in diagnosis and treatment.

Methods

Nationwide population‐based data were retrieved from the Netherlands Cancer Registry. All patients with GIST diagnosed between 2001 and 2012 were included. Primary treatment, defined as any treatment within the first 6–9 months after diagnosis, was studied. Age‐standardized incidence was calculated according to the European standard population. Changes in incidence were evaluated by calculating the estimated annual percentage change (EAPC). Relative survival was used for survival calculations with follow‐up available to January 2017.

Results

A total of 1749 patients (54·0 per cent male and median age 66 years) were diagnosed with a GIST. The incidence of non‐metastatic GIST increased from 3·1 per million person‐years in 2001 to 7·0 per million person‐years in 2012; the EAPC was 7·1 (95 per cent c.i. 4·1 to 10·2) per cent (P < 0·001). The incidence of primary metastatic GIST was 1·3 per million person‐years, in both 2001 and 2012. The 5‐year relative survival rate increased from 71·0 per cent in 2001–2004 to 81·4 per cent in 2009–2012. Women had a better outcome than men. Overall, patients with primary metastatic GIST had a 5‐year relative survival rate of 48·2 (95 per cent c.i. 42·0 to 54·2) per cent compared with 88·8 (86·0 to 91·4) per cent in those with non‐metastatic GIST.

Conclusion

This population‐based nationwide study found an incidence of GIST in the Netherlands of approximately 8 per million person‐years. One in five patients presented with metastatic disease, but relative survival improved significantly over time for all patients with GIST in the imatinib era.     

Impact of postoperative morbidity on long‐term survival after oesophagectomy

Background:

Oesophageal malignancy is a disease with a poor prognosis. Oesophagectomy is the mainstay of curative treatment but associated with substantial morbidity and mortality. Although mortality rates have improved, the incidence of perioperative morbidity remains high. This study assessed the impact of postoperative morbidity on long‐term outcomes.

Methods:

A prospective database was designed for patients undergoing oesophagectomy for malignancy from 1998 to 2011. An observational cohort study was performed with these data, assessing intraoperative technical complications, postoperative morbidity and effects on overall survival.

Results:

Some 618 patients were included, with a median follow‐up of 51 months for survivors. The overall complication rate was 64·6 per cent (399 of 618), with technical complications in 124 patients (20·1 per cent) and medical complications in 339 (54·9 per cent). Technical complications were associated with longer duration of surgery (308 min versus 293 min in those with no technical complications; P = 0·017), greater operative blood loss (448 versus 389 ml respectively; P = 0·035) and longer length of stay (22 versus 13 days; P < 0·001). Medical complications were associated with greater intraoperative blood loss (418 ml versus 380 ml in those with no medical complications; P = 0·013) and greater length of stay (16 versus 12 days respectively; P < 0·001). Median overall and disease‐free survival were 41 and 43 months. After controlling for age, tumour stage, resection margin, length of tumour, adjuvant therapy, procedure type and co‐morbidities, there was no effect of postoperative complications on disease‐specific survival.

Conclusion:

Technical and medical complications following oesophagectomy were associated with greater intraoperative blood loss and a longer duration of inpatient stay, but did not predict disease‐specific survival. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Systematic review and meta-analysis of outcomes following pathological complete response to neoadjuvant chemoradiotherapy for rectal cancer

Background:

Following neoadjuvant chemoradiotherapy (CRT) and interval proctectomy, 15–20 per cent of patients are found to have a pathological complete response (pCR) to combined multimodal therapy, but controversy persists about whether this yields a survival benefit. This systematic review evaluated current evidence regarding long‐term oncological outcomes in patients found to have a pCR to neoadjuvant CRT.

Methods:

Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The systematic review included all original articles reporting long‐term outcomes in patients with rectal cancer who had a pCR to neoadjuvant CRT, published in English, from January 1950 to March 2011.

Results:

A total of 724 studies were identified for screening. After applying inclusion and exclusion criteria, 16 studies involving 3363 patients (1263 with pCR and 2100 without) were included (mean age 60 years, 65·0 per cent men). Some 73·4 per cent had a sphincter‐saving procedure. Mean follow‐up was 55·5 (range 40–87) months. For patients with a pCR, the weighted mean local recurrence rate was 0·7 (range 0–2·6) per cent. Distant failure was observed in 8·7 per cent. Five‐year overall and disease‐free survival rates were 90·2 and 87·0 per cent respectively. Compared with non‐responders, a pCR was associated with fewer local recurrences (odds ratio (OR) 0·25; P = 0·002) and less frequent distant failure (OR 0·23; P < 0·001), with a greater likelihood of being alive (OR 3·28; P = 0·001) and disease‐free (OR 4·33, P < 0·001) at 5 years.

Conclusion:

A pCR following neoadjuvant CRT is associated with excellent long‐term survival, with low rates of local recurrence and distant failure. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Outcome of surgery for rectovaginal fistula due to Crohn's disease

Background:

This study examined the outcome of surgery for symptomatic Crohn's rectovaginal fistula (RVF) and assessed the effect of therapy with antibody against tumour necrosis factor (TNF) on healing.

Methods:

Fifty‐six patients with Crohn's disease underwent surgery for a RVF between January 1993 and December 2006. Outcome analysis was performed in February 2008 in relation to the surgical procedures used and the effect of anti‐TNF treatment.

Results:

Four patients with a healed fistula still had a stoma at final follow‐up for other reasons and were excluded from the analysis. Fistula closure was achieved in 81 per cent of the remaining 52 patients. Primary and secondary surgical success rates were 56 and 57 per cent respectively. The primary healing rate was similar in patients who received anti‐TNF treatment before the first operation (12 of 18 patients) and those who did not (19 of 34). In univariable analysis, duration of Crohn's disease (P = 0·037) and previous extended colonic resection (P < 0·001) were significantly related to failure of primary surgery, but only the latter remained significant in multivariable analysis (P < 0·001). Late recurrence developed in four patients.

Conclusion:

Fistula closure was achieved in most patients, but more than one operation was often required. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Meta‐analysis of risk of developing malignancy in congenital choledochal malformation

Background

Choledochal malformations comprise various congenital cystic dilatations of the extrahepatic and/or intrahepatic biliary tree. Choledochal malformation is generally considered a premalignant condition, but reliable data on the risk of malignancy and optimal surgical treatment are lacking. The objective of this systematic review was to assess the prevalence of malignancy in patients with choledochal malformation and to differentiate between subtypes. In addition, the risk of malignancy following cystic drainage versus complete cyst excision was assessed.

Methods

A systematic review of PubMed and Embase databases was performed in accordance with the PRISMA statement. A meta‐analysis of the risk of malignancy following cystic drainage versus complete cyst excision was undertaken in line with MOOSE guidelines. Prevalence of malignancy was defined as the rate of biliary cancer before resection, and malignant transformation as new‐onset biliary cancer after surgery.

Results

Eighteen observational studies were included, reporting a total of 2904 patients with a median age of 36 years. Of these, 312 in total developed a malignancy (10·7 per cent); the prevalence of malignancy was 7·3 per cent and the rate of malignant transformation was 3·4 per cent. Patients with types I and IV choledochal malformation had an increased risk of malignancy (P = 0·016). Patients who underwent cystic drainage had an increased risk of developing biliary malignancy compared with those who had complete cyst excision, with an odds ratio of 3·97 (95 per cent c.i. 2·40 to 6·55).

Conclusion

The risk of developing malignancy among patients with choledochal malformation was almost 11 per cent. The malignancy risk following cystic drainage surgery was four times higher than that after complete cyst excision. Complete surgical resection is recommended in patients with choledochal malformation.