Laparoscopic peritoneal lavage versus sigmoidectomy for perforated diverticulitis with purulent peritonitis: three-year follow-up of the randomised LOLA trial

Background

This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.

Methods

Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.

Results

Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.

Conclusion

Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.

Graphical abstract

The value of a dedicated multidisciplinary expert panel to assess treatment strategy in patients suffering from colorectal cancer liver metastases

BACKGROUND

For patients with colorectal cancer liver metastases (CRLM), local treatment is the only treatment with curative intent. The majority of patients with CRLM are however evaluated in multidisciplinary teams of colorectal cancer specialists often lacking expertise in local treatment of liver tumors. The aim of this study was therefore to assess the value of a dedicated multidisciplinary panel consisting of hepatobiliary surgeons and interventional radiologists for patients suffering from liver-only CRLM.

METHODS

Patients diagnosed with liver-only CRLM in 2016 were identified in a tertiary referral hospital, and two of the referring hospitals in the Netherlands. Diagnostic imaging was independently reviewed by a panel of four hepatobiliary surgeons and two interventional radiologists to re-evaluate treatment strategy retrospectively. If two or more panelists assessed all lesions eligible for resection and/or ablation, patients were deemed eligible for local treatment with curative intent. Interrater reliability between hepatobiliary surgeons was assessed through intraclass correlation coefficient (ICC) and weighted Cohen's kappa.

RESULTS

Diagnostic imaging of 61 patients with liver-only metastases were reviewed. Local treatment strategies appeared feasible in 40/61 (65.6%) patients. Five out of 25 patients (20.0%) initially assigned to systemic therapy were deemed eligible for upfront local treatment with curative intent (p = 0.015). In this subgroup, interrater reliability between hepatobiliary surgeons was substantial (ICC: 0.704, 95% CI: 0.536-0.838, n = 25).

CONCLUSION

Assessment of treatment strategy by a dedicated multidisciplinary panel including liver experts may result in an increased number of patients eligible for potentially curative treatment and reduce undertreatment of patients suffering from liver-only CRLM.

Stage I-II non-small-cell lung cancer treated using either stereotactic ablative radiotherapy (SABR) or lobectomy by video-assisted thoracoscopic surgery (VATS): outcomes of a propensity score-matched analysis

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) lobectomy and stereotactic ablative radiotherapy (SABR) are both used for early-stage non-small-cell lung cancer. We carried out a propensity score-matched analysis to compare locoregional control (LRC).

PATIENTS AND METHODS

VATS lobectomy data from six hospitals were retrospectively accessed; SABR data were obtained from a single institution database. Patients were matched using propensity scores based on cTNM stage, age, gender, Charlson comorbidity score, lung function and performance score. Eighty-six VATS and 527 SABR patients were matched blinded to outcome (1:1 ratio, caliper distance 0.025). Locoregional failure was defined as recurrence in/adjacent to the planning target volume/surgical margins, ipsilateral hilum or mediastinum. Recurrences were either biopsy-confirmed or had to be PET-positive and reviewed by a tumor board.

RESULTS

The matched cohort consisted of 64 SABR and 64 VATS patients with the median follow-up of 30 and 16 months, respectively. Post-SABR LRC rates were superior at 1 and 3 years (96.8% and 93.3% versus 86.9% and 82.6%, respectively, P = 0.04). Distant recurrences and overall survival (OS) were not significantly different.

CONCLUSION

This retrospective analysis found a superior LRC after SABR compared with VATS lobectomy, but OS did not differ. Our findings support the need to compare both treatments in a randomized, controlled trial.

Cryosurgery of tumor tissue causes endotoxin tolerance through an inflammatory response

INTRODUCTION

Earlier reports on animal studies showed inhibition of secondary tumor growth and metastases after cryoablation, probably mediated by an inflammatory response. In this study enhancement of this inflammatory response and its possible additive antitumor effect is evaluated in a mouse tumor model.

MATERIALS AND METHODS

Mice received two subcutaneously implanted C--26B tumors on, respectively, day 0 (thigh) and day 7 (flank). The thigh tumor was treated by either cryoablation or resection. In addition the animals received a single dose of lipopolysaccharide (LPS) or anti-IL10 together with, or two days after, surgical treatment. The growth of the flank tumor was followed and plasma levels of IL-1 alpha and TNF-alpha were measured.

RESULTS

Compared to excision of the primary tumor, cryosurgery clearly induced inhibition of secondary tumor growth while plasma levels of TNF (0.09) and IL-1 (0.06) were significantly elevated after cryosurgery when compared to excision (TNF 0.0, IL-1 0.03; p < 0.01). Administration of LPS two days after cryosurgery did not lead to extra inhibition of secondary tumor growth, even at high doses. Remarkably, dose--response studies with LPS administered two days after treatment showed a high mortality at a dose of 200 micrograms (75%) in the excision group while mortality in the cryo-treated group was 13% (p < 0.02). Mortality was directly related to cytokine levels that were significantly higher in the excision group (TNF 3.60, IL-1 0.30) when compared to the cryo-treated group (TNF 1.0, IL-10.15; p < 0.01). In contrast, when 25 micrograms LPS was given at the same time as treatment of the primary tumor either by cryosurgery or excision, mortality in the cryo-treated group (85%) was higher than in the excision group (14%, p < 0.05). Again mortality was related to post-treatment cytokine levels which now were significantly higher in the cryo-treated animals (TNF 1.30, IL-10.35) than in animals treated by excision (TNF 0.60, IL-10.10; p < 0.01). Administration of anti IL-10 did not lead to extra tumor growth inhibition.

CONCLUSION

These experiments confirm the hypothesis that cryosurgery leads to a systemic inflammatory response. This reaction can lead to the inhibition of tumor growth. Administration of LPS after cryosurgery does not lead to an extra anti-tumor response; animals appear to become endotoxin tolerant. Adversely, when LPS is administered together with cryosurgery, the animals are extremely sensitive to LPS. These findings are in accordance with the clinical observation of cryoshock after cryoablation of liver metastases.