International Expert Consensus on Defining Textbook Oncologic Outcomes in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Peritoneal Metastasis

BACKGROUND

Textbook oncologic outcome (TOO) is a composite metric shown to correlate with improved survival after curative intent oncologic procedures. Despite increasing use among disciplines in surgical oncology, no consensus exists for its definition in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

STUDY DESIGN

An international consensus-based study employed a Delphi methodology to achieve agreement. Fifty-four senior surgeons from the peritoneal surface malignancies field received a questionnaire comprising TOO parameters divided into 3 surgical domains: operative, short-term, and long-term postoperative outcomes. Two online meetings with participants defined the new criteria. Consensus was achieved when 75% of agreement rate was reached. Clinical data of patients who underwent CRS and HIPEC for colorectal peritoneal metastasis between 2010 and 2022 from 1 designated center (Sheba Medical Center) were collected, the consensus definition applied and outcomes analyzed.

RESULTS

Thirty-eight surgeons (70%) participated. Expert consensus TOO parameters for colorectal peritoneal metastasis CRS and HIPEC included the absence of unplanned reoperations during 30 days postoperation, absence of severe postoperative complications (Clavien-Dindo ≥III), absence of unplanned readmissions during 30 days postoperation, 90-day postoperative mortality, and absence of contraindications for chemotherapy within 12 weeks from operation, and included the achievement of complete cytoreduction (CC0). The study cohort consisted of 251 patients, and 151 (60%) met TOO criteria. Patients who achieved TOO had significantly better overall survival (median 67.5 months, 95% CI) vs patients who did not achieve TOO (median 44.6 months, 95% CI, p < 0.001) and significantly improved disease-free survival (median, 12 months, 95% CI, vs 9 months, 95% CI, p = 0.01).

CONCLUSIONS

Achievement of TOO as defined by consensus statement is associated with improved survival.

Perioperative and Oncological Outcomes of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Metastasis of Rectal Origin

BACKGROUND

The peritoneum is a common metastatic site of colorectal cancer (CRC) and associated with worse oncological outcomes. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been shown to improve outcomes in selected patients. Studies have demonstrated significant difference in survival of patients with primary colon and rectal tumors both in local and in metastatic setting; but only few assessed outcomes of CRS/HIPEC for rectal and colon tumors. We studied the perioperative and oncological outcomes of patients undergoing CRS/HIPEC for rectal cancer.

METHODS

A retrospective analysis of a prospectively maintained database between 2009 and 2021 was performed.

RESULTS

199 patients underwent CRS/HIPEC for CRC. 172 patients had primary colon tumors and 27 had primary rectal tumors. Primary rectal location was associated with longer surgery (mean 4.32, hours vs 5.26 h, p = 0.0013), increased blood loss (mean 441cc vs 602cc, p = 0.021), more blood transfusions (mean 0.77 vs 1.37units, p = 0.026) and longer hospitalizations (mean 10 days vs 13 days, p = 0.02). Median disease-free survival (DFS) was shorter in rectal primary group; 7.03 months vs 10.9 months for colon primaries (p = 0.036). Overall survival was not statistically significant; 53.2 months for rectal and 60.8 months for colon primary tumors. Multivariate analysis indicated origin (colon vs rectum) and Peritoneal Cancer Index to be independently associated with DFS.

CONCLUSIONS

Patients with rectal carcinoma undergoing CRS/HIPEC for peritoneal metastasis had worse peri-operative and oncological outcomes. Overall survival was excellent in both groups. This data may be used for risk stratification when considering CRS/HIPEC for patients with rectal primary.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Outcomes of diverting loop ileostomy reversal in the elderly: a case-control study

BACKGROUND

Although diverting loop ileostomy (DLI) reversal is considered to be a relatively simple procedure, it is not immune from major morbidity. We aimed to compare outcomes of DLI reversal between elderly and non-elderly patients.

METHODS

Retrospective review of all patients who underwent DLI reversal at a single tertiary medical centre between 2010 and 2020. The elderly group consisted of patients 70 or older compared to a control group of those younger than 70 years.

RESULTS

During the study period, 307 patients underwent DLI reversal. Of these, 76 patients were in the elderly group (mean age 75.6) and 231 in the control group (mean age 55.3). The groups were comparable in terms of mean time interval between the creation of the ileostomy and reversal (242 versus 255 days, respectively, P = 0.5), choice between stapled and hand-sewn anastomoses (97.4% stapled anastomosis versus 93.1%, P = 0.086), median post-operative length of stay (5 days in both, P = 0.086), rates of post-operative complications (26.3% versus 26.8%, P = 0.99), severe complications (5.3% versus 6.9%, P = 0.81) and 30-day readmission rates (13.2% versus 10.8%, P = 0.58). Multivariate analysis found the time interval between the creation of the stoma and its reversal to be the only significant risk factor for major post-operative morbidity. Age was not found to be correlated with post-operative morbidity.

CONCLUSION

The outcomes of loop ileostomy reversal in elderly patients are similar to non-elderly patients. Efforts should be made to decrease the time interval between the creation of the stoma and its reversal as this is a significant risk factor for major post-operative morbidity.

5205Electrocardiographic predictors of appropriate implantable cardioverter defibrillator therapies in patients with tetralogy of Fallot

Background

The electrocardiogram (ECG) is widely available and may contribute to a better risk stratification for sudden cardiac death in patients with tetralogy of Fallot. QRS duration has been consistently associated with outcomes, with a lack of specificity for sudden mortality and a relatively low predictive value. New markers such as QRS fragmentation and vectocardiographic parameters have been recently suggested.

Purpose

To identify ECG predictors of appropriate therapies in patients with tetralogy of Fallot and implantable cardioverter defibrillator (ICD).

Methods

The DAI-T4F study is a large ongoing national French registry including all patients with tetralogy of Fallot and ICD (NCT03837574). Information have been collected prospectively since 2010 with annual update. Baseline patient characteristics and clinical events during the follow-up were analyzed with central adjudication. Cox proportional hazard models were used to identify factors associated with appropriate ICD therapies.

Results

A total of 134 patients (median age 41.7 years, 70.7% males) were enrolled. During a median (IQR) follow-up of 6.1 (2.7–10.2) years, 59 (44.0%) patients received at least one appropriate ICD therapy, giving annual incidence of 5.5% and 7.1% in primary and secondary prevention, respectively (p=0.058). Overall, QRSd ≥180ms (p=0.073), QRS fragmentation (p=0.052), and QRS vector magnitude (vm, p=0.327) were not significantly associated with appropriate ICD therapies, whereas QRS fragmentation in right leads (HR=1.7, 95% CI: 1.1–2.9, p=0.039) and the association of QRSd ≥180ms and overall QRS fragmentation (HR=1.9, 95% CI: 1.1–3.4, p=0.036) were associated with an increased risk of appropriates ICD therapies. In patients with ICD for primary prevention (47 patients, 35.1%), 53.8% had QRS fragmentation, 48.6% had decreased QRS vm, and 41.0% had QRSd ≥180ms. In this group, while non-sustained ventricular tachycardia (NSVT) considered isolated was not associated with ventricular events during follow-up (p=0.069), respective combinations with QRSd ≥180 ms (HR=7.2, 95% CI: 1.6–32.7, p=0.011), QRS fragmentation (HR=3.8, 95% CI: 1.2–12.4, p=0.025), or decreased QRS vm (HR=3.6, 95% CI: 1.1–12.1, p=0.042) were all associated with a higher incidence of appropriate ICD therapies. Positive predictive value and negative predictive value were 0.33 and 0.85, 0.58 and 0.74, and 0.36 and 0.84 in patients with NSVT and QRS ≥180ms, NSVT and QRS fragmentation, and NSVT and decreased QRS vm, respectively.

Conclusions

Our findings highlight that cumulative risk score derived from ECG may contribute to improve risk stratification in patients with tetralogy of Fallot, in particular QRS fragmentation and QRS vm in association with QRS duration and other traditional risk factors.

[Electromechanical mapping of myocardial ischemia in coronary occlusion in the pig]

The NOGA-Biosense catheter-based mapping technique has been well studied experimentally in infarction model. However, chronic myocardial ischemia with this new device has not been well explored. Thus, the aim of our study was to assess electromechanical changes in a pig aneroid constricor model. To achieved this aim, ten pigs were studied 21 days after the implantation of an aneroid constrictor around the circumflex artery. Coronary reserve assess by intracoronary Doppler flow wire was reduced in the ischemic lateral area (ILA) compared with the nonischemic zone (NIZ) (1.3 +/- 0.1 in the ILA vs. 2.3 +/- 0.2 in the NSZ; p < 0.01). TM echocardiography was used to evaluate myocardial regional contractility under basal condition and after stress induced by rapid atrial pacing. In stress state, the ischemic zone showed an impaired contractility compared with basal state (wall thickening, 32.7 +/- 7.4% vs. 59.7 +/- 8.6%; p < 0.05) whereas the non ischemic zone did not (53.8 +/- 7.6% vs. 60.8 +/- 10.1%; p = ns). Constrast echography showed a decrease in contrast intensity in subendocardium of the ila compared with the niz (46.2 +/- 16.6 vs. 99.2 +/- 35.6; p = 0.03) in pacing. Ventricular mapping quantified unipolar (UV). bipolar (BV) voltage potentials and endocardial local shortening (LLS) in 9 left ventricular regions. In basal state, electrical potentials were preserved in both zones (UV: 9.1 +/- 1.8 mV in the ischemic vs 11.3 +/- 3.6 mV in the non ischemic zone; p = ns; BV: 4.2 +/- 1.1 mV in the ILA vs. 3.9 +/- 1.5 mV; p = ns). In contrast, LLS was significantly lower in the ischemic compared with non ischemic zone (6.4 +/- 5.4% vs. 17.9 +/- 3.0%, p < 0.001). In conclusion, ventricular mapping with the NOGA-Biosense system can identify the ischemic myocardium. In this pig model, the association of a preserved electrical activity and an impaired mechanical activity characterizes the ischemic myocardium. These findings could be interesting in this model in regard of the new developments of the system in particular in the field of angiogenesis.

[Atrial flutter with 1/1 nodo-ventricular conduction with amiodarone. From physiopathology to diagnosis]

Atrial flutter with 1/1 nodo-ventricular conduction is a classical complication of Vaughan-Williams's Class I antiarrhythmic drugs. The increase of the flutter cycle and weak action of the antiarrhythmic on the atrioventricular node leads to 1/1 conduction of atrial depolarisation to the ventricles. In view of their marked action on the atrioventricular node, this type of pro-arrhythmic effect is very unexpected with Class III antiarrhythmics. The authors report 7 cases of 1/1 atrial flutter with oral amiodarone observed between 1994 and 2001. The patients were 6 men and 1 woman with an average age of 58 +/- 14 years. Four of them had underlying cardiac disease; none were hyperthyroid. The initial arrhythmia was 2/1 atrial flutter (n = 4), 1/1 atrial flutter (n = 2) and atrial fibrillation (n = 1). Treatment was preventive with doses of 400 mg/day associated with carvedilol in one patient and 200 mg/day in another. The other five patients all received loading doses of 9200 +/- 2400 mg over 10 +/- 4 days. The symptoms were palpitations (n = 2) associated in one patient with hypotension, one syncope, one near syncope and one cardiogenic shock. The ventricular cycle of the 1/1 flutter was 287 +/- 33 ms. The QRS duration was 136 +/- 35 ms with ventricular tachycardia-like appearances in 3 cases. An adrenergic trigger factor was noted in 5 patients. One patient required emergency cardioversion. The authors discuss the physiopathology of 1/1 flutter and theoretical diagnostic methods are proposed. In conclusion, amiodarone does not always prevent the occurrence of 1/1 nodo-ventricular conduction in atrial flutter.

[Implantable defibrillators. Sudden death: high risk]

INCIDENCE

The incidence of sudden death remains high. The basic causes are related to ischemic heart disease and heart failure. Automatic defibrillation is the best treatment, as first conceived and implanted by Mirovski twenty years ago. MARKERS OF RISK OF SUDDEN DEATH: Left ventricular dysfunction, functional class and spontaneous and induced ventricular hyperexcitability identify a high-risk population.

THERAPEUTIC APPROACH

Drug treatments used in the post infarction period or for heart failure (beta-blockers, converting enzyme inhibitors and amiodarone) have demonstrated a certain efficacy in preventing sudden death. However, different therapeutic trials comparing the efficacy of defibrillators and drug treatments have demonstrated the 20 to 46% superiority of defibrillation in terms of reduced mortality.

[Implantable defibrillators. Role of the defibrillator in treatment and prevention of sudden death]

PROVEN EFFICACY

Several studies have demonstrated that implantable defibrillators improve survival in patients with a very high risk of sudden death. INDICATIONS FOR PRIMARY PREVENTION: The most obvious indication is for young patients with severe recurrent rhythm disorders and generally good left ventricular function. However, most of the candidates have severe left ventricular dysfunction due to post infarction ischemia or dilated cardiomyopathy who develop syncopal or hemodynamically poorly tolerated ventricular tachycardia or who have survived a first episode of sudden death. PROPHYLACTIC INDICATIONS: Automatic defibrillation should be proposed for patients with factors of risk of sudden death such as left ventricular dysfunction or infarction sequelae.

Functional trans-inactivation of insulin receptor kinase by growth-inhibitory angiotensin II AT2 receptor

The present study demonstrates negative intracellular cross-talk between angiotensin II type 2 (AT2) and insulin receptors. AT2 receptor stimulation leads to inhibition of insulin-induced extracellular signal-regulated protein kinase (ERK2) activity and cell proliferation in transfected Chinese hamster ovary (CHO-hAT2) cells. We show that AT2 receptor interferes at the initial step of insulin signaling cascade, by impairing tyrosine phosphorylation of the insulin receptor (IR) beta-chain. AT2-mediated inhibition of IR phosphorylation is insensitive to pertussis toxin and is also detected in neuroblastoma N1E-115 and pancreatic acinar AR42J cells that express endogenous receptors. We present evidence that AT2 receptor inhibits the autophosphorylating tyrosine kinase activity of IR, with no significant effect on insulin binding properties. AT2-mediated inactivation of IR does not mainly involve tyrosine dephosphorylation by vanadate-sensitive tyrosine phosphatases nor serine/threonine phosphorylation by protein kinase C. As a consequence of IR inactivation, AT2 receptor inhibits tyrosine phosphorylation of insulin receptor substrate-1 (IRS-1) and signal-regulatory protein (SIRPalpha1) and prevents subsequent association of both IRS-1 and SIRPalpha1 with Src homology 2 (SH2)-containing tyrosine phosphatase SHP-2. Our results thus demonstrate functional trans-inactivation of IR kinase by G protein-coupled AT2 receptor, illustrating a novel mode of negative communication between two families of membrane receptors.

[Mapping and radiofrequency ablation in different forms of right peri-atriotomy flutter]

Peri-atriotomy flutter is a possible complication of surgical atriotomy. This tachycardia in an indication for radiofrequency ablation. The aim of this study was to determine the mechanism of the flutter, evaluate the possibility of mapping and the role of radiofrequency ablation in its treatment. Eleven patients with a mean age of 45 years (26-70) were referred for ablation of atrial flutter observed on average 15 years after surgical atriotomy. In 7 patients (Group I), the ECG appearances before the procedure were that of a rare flutter. Endocavitary mapping showed a circuit limited to the free wall of the right atrium with a posterior caudo-cranial and an anterior cranio-caudal front. A series of radiofrequency applications joining the atriotomy scar to the inferior vena cava interrupted the flutter in all patients and created a bidirectional block around the atriotomy. In 4 patient (Group II), the ECG appearances were that of a common flutter. A series of radiofrequency ablations in the cavo-tricuspid isthmus led to sudden change in polarity of the F wave in all patients. Repeat mapping then showed a peri-atriotomy circuit identical to that described in Group I. The whole was interpreted as a figure-of-eight circuit. The primary success rate was 100%. There were no complications but the early recurrence rate remained high. This preliminary experience confirms the value of radiofrequency ablation in the treatment of peri-atriotomy flutter and shows ECG polymorphism related to a figure-of-eight reentry circuit.

Angiotensin II type 2 receptors mediate inhibition of mitogen-activated protein kinase cascade and functional activation of SHP-1 tyrosine phosphatase

Angiotensin II type 2 (AT2) receptors are involved in the inhibition of cell proliferation as well as in apoptosis and neuronal differentiation, through intracellular signalling pathways that remain poorly defined. The present study examines the effect of AT2-receptor stimulation on growth-factor-induced pathways leading to the activation of mitogen-activated protein (MAP) kinases. In N1E-115 neuroblastoma cells, AT2 receptors inhibit the activity of MAP kinases induced by serum as well as by epidermal growth factor. The inhibitory effect of angiotensin II (Ang II) is rapid and transient, and affects both ERK1 and ERK2 (extracellular signal-related protein kinase) isoforms of the enzyme. AT2-mediated MAP kinase inactivation is not sensitive to pertussis toxin or okadaic acid, but involves a vanadate-sensitive protein tyrosine phosphatase (PTP). Expression of MAP kinase phosphatase-1 (MKP-1) is not significantly modified upon AT2-receptor activation, and insensitivity to actinomycin D also rules out transcriptional induction of other MKPs as a possible mechanism for AT2-mediated inactivation of MAP kinases. In addition, we report here that both in N1E-115 cells and in Chinese hamster ovary cells expressing recombinant human AT2 receptors, Ang II rapidly stimulates the catalytic activity of SHP-1, a soluble PTP that has been implicated in termination of signalling by cytokine and growth-factor receptors. These findings thus demonstrate functional negative cross-talk between heptahelical AT2 receptors and receptor tyrosine kinases, and suggest that SHP-1 tyrosine phosphatase is an early transducer of the AT2 receptor signalling pathway.

Rotational coronary atherectomy with adjunctive balloon angioplasty: evaluation of lumen enlargement by quantitative angiographic analysis

To evaluate the mechanisms of lumen enlargement and the respective contributions of rotational coronary atherectomy (RA) and adjunctive percutaneous transluminal coronary balloon angioplasty (PTCA), serial measurements were recorded in 70 consecutive patients by quantitative coronary angiography before RA, after RA, after adjunctive PTCA, and 24 hours later. Minimal luminal diameter (MLD) increased from 0.85 +/- 0.31 mm to 1.42 +/- 0.27 mm (p < 0.001) after RA and to 2.20 +/- 0.46 mm (p < 0.001) after PTCA. Minimal luminal area (MLA) increased from 0.64 +/- 0.50 mm2 to 1.63 +/- 0.60 mm2 (p < 0.001) after RA and to 3.97 +/- 1.68 mm2 (p < 0.001) after PTCA. Both 24-hour MLD and MLA showed a trend toward reduced values (2.07 +/- 0.45 mm and 3.52 +/- 1.70 mm2, respectively) when compared with immediate results after PTCA. The absolute gains in MLD after RA and after PTCA were 0.56 +/- 0.24 mm and 0.79 +/- 0.38 mm, respectively (p < 0.01). The absolute gains in MLA after RA and after PTCA were 0.99 +/- 0.49 mm2 and 2.34 +/- 1.41 mm2, respectively (p < 0.001). The respective contributions of RA and PTCA are highly variable, but in general, balloon dilatation accounts for most of the gain in lumen area and therefore is not an adjunctive but a primary technique.

[Epidermotropic eccrine carcinoma. Apropos of a case with ultrastructural examination]

Pinkus and Mehregan's epidermotropic eccrine carcinoma shows particular clinico-pathological characteristics which makes it different from the other cutaneous epitheliomas. A case observed on a 81 year old woman is reported. The initial lesion consisted of an ulcerating tumor on the calf, then followed by multiple verrucous papules eruption around it. Within a few weeks, many other verrucous tumors occurred on the upper part of the leg while a lymphedema was developing. One year after the initial lesion has been noticed, the patient died of metastases in distant organs. From a histological point of view, the tumor corresponded to a squamous cell carcinoma that was slightly keratinizing, Bowenoïd epidermotropic, with dermal involvement too. Features of duct formation were identified within solid nests of neoplastic cells, tumor emboli were seen in the lymphatics. The ultra-structural study made it evident that the tonofilaments were precarious in neoplastic cells; the cytoplasm contained glycogen. The inter-cellular bridges and desmosomes were scanty and micro-villi were noted. The latter confirm the sudoral nature of these cells. For Pinkus and Mehregan, this type of tumor originates in the acrosyringium, but we think that a contiguous segment of the sudoral duct must also be probably concerned. The spreading of the epidermotropic eccrine carcinoma occurs in the teguments themselves in a uncommon way. The tumor re-appears from the dermal lymphatic channels. The lymphatic involvement is the main characteristic of this cutaneous carcinoma, verified by metastases existing in distant organs.