Search

BACKGROUND: The role of laparoscopy for emergency resection of left-sided obstructive colon cancer remains unclear, especially regarding impact on survival. OBJECTIVE: This study aimed to determine short- and long-term outcomes after laparoscopic versus open emergency resection of left-sided obstructive colon cancer. DESIGN: This observational cohort study compared patients who underwent laparoscopic emergency resection to those who underwent open emergency resection between 2009 and 2016 by using 1:3 propensity-score matching. Matching variables included sex, age, BMI, ASA score, previous abdominal surgery, tumor location, cT4, cM1, multivisceral resection, small-bowel distention on CT, and subtotal colectomy. SETTING: This was a nationwide, population-based study. PATIENTS: Of 2002 eligible patients with left-sided obstructive colon cancer, 158 patients who underwent laparoscopic emergency resection were matched with 474 patients who underwent open emergency resection. INTERVENTIONS: The intervention was laparoscopic versus open emergency resection. MAIN OUTCOME MEASURES: The main outcome measures were 90-day mortality, 90-day complications, permanent stoma, disease recurrence, overall survival, and disease-free survival. RESULTS: Intentional laparoscopy resulted in significantly fewer 90-day complications (26.6% vs 38.4%; conditional OR, 0.59; 95% CI, 0.39-0.87) and similar 90-day mortality. Laparoscopy resulted in better 3-year overall survival (81.0% vs 69.4%; HR, 0.54; 95% CI, 0.37-0.79) and disease-free survival (68.3% vs 52.3%; HR, 0.64; 95% CI, 0.47-0.87). Multivariable regression analyses of the unmatched 2002 patients confirmed an independent association of laparoscopy with fewer 90-day complications and better 3-year survival. LIMITATIONS: Selection bias was the limitation that cannot be completely ruled out because of the retrospective nature of this study. CONCLUSIONS: This population-based study with propensity score-matched analysis suggests that intentional laparoscopic emergency resection might improve outcomes in patients with left-sided obstructive colon cancer compared to open emergency resection. Management of those patients in the emergency setting requires proper selection for intentional laparoscopic resection if relevant expertise is available, thereby considering other alternatives to avoid open emergency resection (ie, decompressing stoma).

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.

In patients ≥ 70 years of age with left-sided obstructive colon cancer, emergency resection should be avoided in the curative setting, and a bridge to surgery technique with Self-Expandable Metal Stent (SEMS) or a decompressing stoma should be applied. In patients70 years of age, all three options (emergency resection, SEMS or a decompressing stoma) can be considered as curative intent treatment. If the construction of a decompressing stoma and SEMS placement are both suitable bridging options, the low chance of having a stoma at any time in case of SEMS, and avoiding the risk of SEMS-related complications (i.e. perforation) in case of a stoma might be an important factor within a shared decision making process. SEMS is the preferred treatment in the palliative setting, with decompressing stoma as a valid alternative. Contraindications for SEMS are unavailability of required expertise, technical unsuitability, and when patients are under anti-angiogenic therapy (e.g. bevacizumab).

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 p = 0.005), estimated glomerular filtration rate (eGFR) ≤ 45 mL/min/1.73 m2 (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 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.

Importance: Bridge to elective surgery using self-expandable metal stent (SEMS) placement is a debated alternative to emergency resection for patients with left-sided obstructive colon cancer because of oncologic concerns. A decompressing stoma (DS) might be a valid alternative, but relevant studies are scarce. Objective: To compare DS with SEMS as a bridge to surgery for nonlocally advanced left-sided obstructive colon cancer using propensity score matching. Design, Setting, and Participants: This national, population-based cohort study was performed at 75 of 77 hospitals in the Netherlands. A total of 4216 patients with left-sided obstructive colon cancer treated from January 1, 2009, to December 31, 2016, were identified from the Dutch Colorectal Audit and 3153 patients were studied. Additional procedural and intermediate-term outcome data were retrospectively collected from individual patient files, resulting in a median follow-up of 32 months (interquartile range, 15-57 months). Data were analyzed from April 7 to October 28, 2019. Exposures: Decompressing stoma vs SEMS as a bridge to surgery. Main Outcomes and Measures: Primary anastomosis rate, postresection presence of a stoma, complications, additional interventions, permanent stoma, locoregional recurrence, disease-free survival, and overall survival. Propensity score matching was performed according to age, sex, body mass index, American Society of Anesthesiologists score, prior abdominal surgery, tumor location, pN stage, cM stage, length of stenosis, and year of resection. Results: A total of 3153 of the eligible 4216 patients were included in the study (mean [SD] age, 69.7 [11.8] years; 1741 [55.2%] male); after exclusions, 443 patients underwent bridge to surgery (240 undergoing DS and 203 undergoing SEMS). Propensity score matching led to 2 groups of 121 patients each. Patients undergoing DS had more primary anastomoses (104 of 121 [86.0%] vs 90 of 120 [75.0%], P =.02), more postresection stomas (81 of 121 [66.9%] vs 34 of 117 [29.1%], P

Colon cancer is the third most common cancer worldwide and it’s incidence is annually increasing. In the Netherlands alone, over 15.000 new cases are diagnosed each year. Most of these patients present with non-specific symptoms such as fatigue, weight loss or a changed stool pattern. Further diagnostic tests can then lead to the diagnosis of colorectal cancer. In nine to thirteen percent of patients with colorectal cancer however, acute colonic obstruction is the first symptom. The majority of patients presenting with an acute colonic obstruction are elderly and in a poor clinical condition due to several days to weeks of reduced intake and significant weight loss. Furthermore, presentation with acute colonic obstruction is associated with more advanced disease and a higher incidence of metastatic disease. These factors all contribute to an increased peri- and postoperative surgical risk. Currently, emergency resection is the most applied treatment approach, even though this procedure is associated with morbidity and mortality rates up to 60% and 22%, respectively. In high-risk patients (ASA >2 and age >70 years), mortality is even as high as 32.2%. These outcomes have prompted the search for a valid and safe alternative. This alternative has possibly been found in a bridge to surgery (BTS) approach, with the aim to achieve initial colonic decompression using a minimally invasive procedure. Hereby, the risks of colonic obstruction are addressed immediately and fecal passage is restored with the objective to reduce bowel wall distention. This creates time to optimize the patients’ condition prior to elective resection and to perform adequate tumor staging. By doing this, extensive surgery in patients with disseminated disease or unacceptable surgical risk can be avoided, since a BTS approach can then serve as a definite palliative measure. Colonic decompression as bridge to surgery can be achieved by construction of a deviating stoma (DS) or by placement of a self-expandable metallic stent (SEMS). In part one of this thesis, we focus on determining which treatment approach is best for patients with a righ-sided obstructing tumor. Currently, a bridge to surgery approach is not a standard treatment approach in these patients, even though morbidity and mortality following emergency resection is similar to those in patients with a left-sided obstruction. In part I we present evidence that a bridge to surgery approach might also benefit patient with a right-sided obstructing tumor, with more laparoscopic resections, more primary anastomosis and fewer (temporary) stoma’s. In part II we focus on left-sided tumors specifically. A bridge to surgery approach is more accepted in these patients. Especially stent placement has been extensively researched in the past years. However, data is lacking on stoma construction as a bridge to surgery approach. In part II the safety and possible advantages of this approach were studied. Both bridge to surgery approaches seem to offer the same advantages of more laparoscopic surgeries, more primary anastomosis and fewer stoma’s. In addition, stoma construction does not seem to influence long-term oncologic outcomes. Indeed, the use of this treatment approach has increased significantly in the past years. In the third and final part of this thesis we focus specifically on long-term outcomes. Especially stent placement has been associated with a negative influence on long-term oncologic outcomes. A systematic review of all literature on long-term outcomes following stent placement and a large matched analysis did not show a difference in oncologic outcome following stent placement or emergency resection. In addition, we found a higher incidence of incisional hernia’s following stoma reversal.

Item does not contain fulltext This meta-analysis aims to determine the long-term oncological outcomes of SEMS as bridge to surgery (BTS) versus emergency surgery (ES). A systematic search without restrictions was conducted, and all studies comparing SEMS with ES reporting on long-term outcomes were included. Methodological quality was assessed using the appropriate tools. Twenty-one comparative studies were selected, reporting on 1919 patients. Meta-analysis showed no significant difference regarding three- and five-year overall survival (OR = 0.85 (0.68-1.08) and OR = 1.04 (0.68-1.57), respectively), disease-free survival (OR = 0.96 (0.73-1.26) and OR = 0.86 (0.54-1.36), respectively) and local recurrence rate (OR = 1.32 (0.78-2.23)). Permanent stomas were significantly lower in the SEMS group (OR 0.49 (0.32-0.74)). Sensitivity analysis on three-year survival showed opposite outcomes, with a trend towards worse survival in the SEMS group when only RCTs are taken into account. In conclusion, when in experienced hands, SEMS placement as BTS seems oncologically safe.

Background Currently, no consensus exists on the best treatment strategy for acute malignant left-sided colonic obstruction. This systematic review and meta-analysis aims to compare the outcomes following the two surgical treatment options; primary resection versus colostomy creation as bridge to surgery. Methods This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to minimize risk of bias. Pubmed, Embase and Cochrane Library were searched for all relevant literature. Methodological quality of included studies was assessed using the MINORS criteria. Pooled odds ratios with 95% confidence intervals (95%CI) were calculated using random effects models. Results Eight comparative studies were included, reporting on 2424 patients; 1973 patients were treated with primary resection and 451 patients with colostomy construction followed by elective resection. Meta-analysis showed no significant differences between both treatment groups regarding 30-day mortality and morbidity (OR = 0.77, 95%CI 0.3-1.96 and OR = 0.76, 95%CI 0.51-1.13, respectively). However, patients treated with a colostomy followed by elective resection had significantly more primary anastomoses constructed and were less likely to be left with a permanent colostomy (OR = 0.17, 95%CI 0.11-0.26 and OR = 0.22, 95%CI 0.11-0.46, respectively). Conclusion This systematic review provides an overview of all available literature on primary resection versus colostomy creation as bridge to surgery in patients with acute LSCO. Keeping the limitations of this study in mind, we conclude that a diverting colostomy as bridge to surgery is a safe and valid alternative for primary resection. © 2015 Elsevier Ltd. All rights reserved.

Contains fulltext : 182659.pdf (Publisher’s version ) (Closed access) BACKGROUND: Traditionally, all patients with a malignant obstruction of the proximal colon (MOPC) are treated with emergency resection. However, recent data suggest that Self-expandable metallic stent (SEMS) placement could lower mortality and morbidity rates. This study therefore aimed to compare SEMS placement with emergency resection as treatment options for MOPC. METHODS: All consecutive patients that underwent SEMS placement for MOPC in the period 2004-2015 at our institution were identified. SEMS placement was the standard of care for colonic obstructions at our institution in that period. All included SEMS patients were matched (1:4) on age (+/-5 years), gender, ASA-score, tumor location, surgical approach and pTNM-stage with patients treated by emergency resection. Controls were selected from a national database that prospectively registers all patients undergoing surgery for colorectal cancer in the Netherlands. RESULTS: In total, 41 patients received SEMS placement for MOPC. In 19 patients SEMS served as a definite palliative measure and in 22 as bridge to surgery. Technical and clinical success rates of SEMS placement were 92.7% and 90.2%, respectively. No significant differences between the SEMS and emergency resection group were found regarding morbidity and mortality rates, the number of radical resections and the number of primary anastomoses. Patients treated with SEMS were, however, less likely to have a temporary stoma constructed (p = 0.04). No SEMS-related complications occurred in patients in whom SEMS was placed as bridge to surgery, whereas one stent-related perforation, three stent migrations, and five stent re-obstructions were observed in the palliative group. Three re-obstructions could be treated with re-stenting, but all other SEMS-related complications required surgical intervention. In the palliative group, SEMS complications necessitating surgery occurred in 31.6% of the patients (6/19). CONCLUSION: SEMS placement for MOPC appears to be a relatively feasible and safe alternative for emergency resection in both the curative and palliative setting.

Contains fulltext : 172022.pdf (Publisher’s version ) (Open Access) BACKGROUND: Malignant obstruction of the proximal colon (MOPC) traditionally has been treated with acute resection. However, morbidity and mortality rates following these emergency surgeries are high. Initial bowel decompression by stent placement or stoma construction has been used for distal obstructions as an alternative approach. This study evaluated whether these alternative treatment strategies could be beneficial for patients with a MOPC as well. METHODS: All patients undergoing a colonic resection for a MOPC between January 2009 and December 2013 and who were registered in the Dutch Surgical Colorectal Audit were analyzed. RESULTS: From the 49,013 patients registered in the DSCA, 1860 (3.8 %) were selected for further analysis. Acute resection was performed in 1774 patients (95.4 %), 44 patients (2.4 %) were treated with initial decompression using stent placement and resection, and 42 patients (2.3 %) with stoma construction followed by resection. Thirty-day mortality was 8.8, 2.4, and 2.4 %, respectively. Mortality was significantly lower after a bridging strategy (stent or stoma) compared with acute resection (p = 0.04). Complications following the resection occurred in 39.6% in the acute resection group and in 27.3 and 31.7% in the stent and stoma group, respectively (p = 0.167). CONCLUSIONS: Acute resection was performed in the vast majority of patients with obstructive proximal colon cancer and resulted in a 40 % morbidity and 9 % mortality rate. A bridging strategy may be a valid alternative in some of these patients, because a significantly lower postoperative mortality rate was seen in a subgroup of patients initially treated with a stent or stoma.

Contains fulltext : 172303.pdf (Publisher’s version ) (Closed access) BACKGROUND: Acute colonic decompression using a deviating colostomy (DC) or a self-expandable metal stent (SEMS) has been shown to lead to fewer complications and permanent stomas compared to acute resection in elderly patients with malignant left-sided colonic obstruction (LSCO). However, no consensus exists on which decompression method is superior, especially in patients treated with curative intend. This retrospective study therefore aimed to compare both decompression methods in potentially curable LSCO patients. METHODS: All LSCO patients treated with curative intent between 2004 and 2013 in two teaching hospitals were retrospectively identified. In one institution, a DC was the standard of care, whereas in the other all patients were treated with SEMS. RESULTS: In total, 88 eligible LSCO patients with limited disease and curative treatment options were included; 51 patients had a SEMS placed and 37 patients a DC constructed. All patients eventually underwent a subsequent elective resection. In sum, 235 patients were excluded due to benign or inoperable disease. No significant differences were found for hospital stay, morbidity, disease-free and overall survival and mortality. Major complications were seen in 13/51 (25.5 %) patients in the SEMS group and were mostly due to stent dysfunction (n = 7). Also, one stent-related perforation occurred. Major complications occurred in 4/37 (10.8 %) patients in the DC group, including abdominal sepsis (n = 3) and wound dehiscence (n = 1). Long-term complication rate was significantly higher in the DC group (29.7 vs. 9.8 %, p = 0.01), mainly due to a high incisional hernia rate. Fewer patients had a temporary colostomy following elective resection after SEMS placement (62.2 vs. 17.6 %, p < 0.01). Permanent colostomy rate was not significantly different. CONCLUSION: SEMS and DC are both effective decompression methods for curable LSCO patients with comparable short- and long-term oncological outcomes; however, more surgical procedures are performed after DC due to an increased number of temporary colostomies and incisional hernia repairs.

Contains fulltext : 152183.pdf (Publisher’s version ) (Closed access) PURPOSE: No consensus exists on the optimal treatment of acute malignant right-sided colonic obstruction (RSCO). This systematic review aims to compare procedure-related mortality and morbidity rates between primary resection and stent placement as a bridge to surgery followed by elective resection for patients with acute RSCO. METHODS: PubMed, Embase and Cochrane library were searched for all relevant literature. Primary endpoints were procedure-related mortality and morbidity. Methodological quality of the included studies was assessed using the MINORS criteria. RESULTS: Fourteen cohort studies were eligible for analysis. A total of 2873 patients were included in the acute resection group and 155 patients in the stent group. Mean mortality rate for patients who underwent acute resection with primary anastomosis was 10.8% (8.1-18.5%). Overall mortality for patients initially treated with a colonic stent followed with elective resection was 0%. Major morbidity was 23.9% (9.3-35.6%) and 0.8% (0-4.8%), respectively. Both mortality and major morbidity were significantly different. In addition, stent placement shows lower rates of anastomotic leakages (0 vs 9.1%) and fewer permanent ileostomies (0 vs 1.0%). CONCLUSION: Primary resection for patients with acute RSCO seems to be associated with higher mortality and major morbidity rates than stent placement and elective resection. In addition, stent placement resulted in fewer anastomotic leakages and permanent ileostomies. However, as no high-level studies are available on the optimal treatment of RSCO and proximal stenting is considered technically challenging, future comparative studies are warranted for the development of an evidence-based clinical decision guideline. 16 februari 2016

The reactivation of human cytomegalovirus (HCMV) poses a serious health threat to immune compromised individuals. As a treatment strategy, dendritic cell (DC) vaccination trials are ongoing. Recent work suggests that BDCA-3+ (CD141+) subset DCs may be particularly effective in DC vaccination trials. BDCA-3+ DCs had however been mostly characterized for their ability to cross-present antigen from necrotic cells. We here describe our study of human BDCA-3+ DCs in elicitation of HCMV-specific CD8+ T-cell clones. We show that Fcgamma-receptor (FcγR) antigen targeting facilitates antigen cross-presentation in several DC subsets, including BDCA-3+ DCs. FcγR antigen targeting stimulates antigen uptake by BDCA-1+ rather than BDCA-3+ DCs. Conversely, BDCA-3+ DCs and not BDCA-1+ DCs show improved cross-presentation by FcγR targeting, as measured by induced release of IFNγ and TNF by antigen-specific CD8+ T cells. FcγR-facilitated cross-presentation requires antigen processing in both an acidic endosomal compartment and by the proteasome, and did not induce substantial DC maturation. FcγRII is the most abundantly expressed FcγR on both BDCA-1+ and BDCA-3+ DCs. Furthermore we show that BDCA-3+ DCs express relatively more stimulatory FcγRIIa than inhibitory FcγRIIb in comparison with BDCA-1+ DCs. These studies support the exploration of FcγR antigen targeting to BDCA-3+ DCs for human vaccination purposes.