Athletes treated for inguinal-related groin pain by endoscopic totally extraperitoneal (TEP) repair: long-term benefits of a prospective cohort

PURPOSE

Inguinal-related groin pain (IRGP) in athletes is a multifactorial condition, posing a therapeutic challenge. If conservative treatment fails, totally extraperitoneal (TEP) repair is effective in pain relief. Because there are only few long-term follow-up results available, this study was designed to evaluate effectiveness of TEP repair in IRGP-patients years after the initial procedure.

METHODS

Patients enrolled in the original, prospective cohort study (TEP-ID-study) were subjected to two telephone questionnaires. The TEP-ID-study demonstrated favorable outcomes after TEP repair for IRGP-patients after a median follow-up of 19 months. The questionnaires in the current study assessed different aspects, including, but not limited to pain, recurrence, new groin-related symptoms and physical functioning measured by the Copenhagen Hip and Groin Outcome Score (HAGOS). The primary outcome was pain during exercise on the numeric rating scale (NRS) at very long-term follow-up.

RESULTS

Out of 32 male participants in the TEP-ID-study, 28 patients (88%) were available with a median follow-up of 83 months (range: 69-95). Seventy-five percent of athletes were pain free during exercise (p < 0.001). At 83 months follow-up, a median NRS of 0 was observed during exercise (IQR 0-2), which was significantly lower compared to earlier scores (p <0.01). Ten patients (36%) mentioned subjective recurrence of complaints, however, physical functioning improved on all HAGOS subscales (p <0.05).

CONCLUSION

This study demonstrates the safety and effectivity of TEP repair in a prospective cohort of IRGP-athletes, for whom conservative treatment had failed, with a follow-up period of over 80 months.

Health-related quality-of-life trajectories during/after surgery and adjuvant chemotherapy in patients with colon cancer

PURPOSE

This study aims to evaluate quality of life trajectory during the first year after surgical treatment in patients with resectable primary colon cancer.

METHODS

Patients with resectable primary colon cancer diagnosed between 2013 and 2019 who received surgical treatment and adjuvant chemotherapy if indicated were selected from the Prospective Dutch ColoRectal Cancer cohort study (PLCRC). Health-related quality of life (HR-QoL) was assessed using EORTC-QLQ-C30 questionnaire before surgery, and three and twelve months after surgery. HR-QoL scores varied between 0 and 100 and outcomes were compared according to age (< 70 years, ≥ 70 years), comorbidity (yes, no) and treatment type (adjuvant chemotherapy, surgical treatment only). The extent of resilience, defined as a recovery of HR-QoL to baseline level after a clinically relevant decline in HR-QoL at months, was calculated twelve months post-surgery.

RESULTS

For all 458 patients, the mean age was 66.4 years (SD 9.5), 40% were aged 70 years and older and 68% were men. Baseline level of HR-QoL summary score was relatively high with a mean of 87.9 (SD 11.5), and did not significantly differ between older and younger patients. The strongest decline of HR-QoL compared to baseline was observed at three months with a gradual recovery over time. Fourteen percent of all patients were non-resilient or showed a late decline at twelve months post-surgery. Compared to younger patients, older patients who received adjuvant chemotherapy were less resilient (respectively, 53 and 32%, p = 0.07) and at risk of a late decline in HR-QoL 1 year post-surgery (respectively, 3% versus 16%, p = 0.02). Comorbidity status had no significant impact on the HR-QoL trajectory.

CONCLUSION

Colon cancer treatment was associated with a decline in HR-QoL three months post-surgery, but most patients return to baseline level within twelve months. Still, particularly older patients who received adjuvant chemotherapy were less resilient and at risk of a late decline in HR-QoL. These data could help in patients counselling regarding colon cancer treatment.

Quality of life in elderly patients with an ostomy - a study from the population-based PROFILES registry

AIM

Ostomies are being placed frequently in surgically treated elderly patients with colorectal cancer (CRC). An insight into the (potential) impact of ostomies on quality of life (QoL) could be useful in patient counselling as well as in the challenging shared treatment decision-making.

METHOD

Patients with CRC diagnosed between 2000 and 2009 and registered in the population-based Eindhoven Cancer Registry received a QoL questionnaire (EORTC QLQ-C30) in 2010. In addition, QoL was compared with an age- and sex-matched normative population.

RESULTS

The study included 2299 CRC patients, of whom 494 had an ostomy. No differences were found in reported ostomy-related problems between patients aged ≤65, 66-75 and ≥76 years. Ostomy patients aged 66-75 and ≥76 years reported significantly lower physical functioning compared with those without an ostomy. In the elderly (those aged ≥76 years) ostomates reported a worse physical and social functioning compared with the normative population. All these differences were of small clinical relevance. The impact of an ostomy seems to be more prominent in younger (≤75 years old) ostomates, as they experience more functional limitations and a decrease in global health status compared with younger nonostomy patients and the normative population.

CONCLUSION

Although elderly (≥76 years old) patients with an ostomy report significantly more limitations in functioning compared with a normative population and elderly CRC patients without an ostomy, the clinical relevance of this finding is limited. In contrast, the impact of an ostomy is more prominent in younger patients. Thus, age itself is not a reason for withholding an ostomy.

Nationwide comprehensive gastro-intestinal cancer cohorts: the 3P initiative

BACKGROUND

The increasing sub-classification of cancer patients due to more detailed molecular classification of tumors, and limitations of current trial designs, require innovative research designs. We present the design, governance and current standing of three comprehensive nationwide cohorts including pancreatic, esophageal/gastric, and colorectal cancer patients (NCT02070146). Multidisciplinary collection of clinical data, tumor tissue, blood samples, and patient-reported outcome (PRO) measures with a nationwide coverage, provides the infrastructure for future and novel trial designs and facilitates research to improve outcomes of gastrointestinal cancer patients.

MATERIAL AND METHODS

All patients aged ≥18 years with pancreatic, esophageal/gastric or colorectal cancer are eligible. Patients provide informed consent for: (1) reuse of clinical data; (2) biobanking of primary tumor tissue; (3) collection of blood samples; (4) to be informed about relevant newly identified genomic aberrations; (5) collection of longitudinal PROs; and (6) to receive information on new interventional studies and possible participation in cohort multiple randomized controlled trials (cmRCT) in the future.

RESULTS

In 2015, clinical data of 21,758 newly diagnosed patients were collected in the Netherlands Cancer Registry. Additional clinical data on the surgical procedures were registered in surgical audits for 13,845 patients. Within the first two years, tumor tissue and blood samples were obtained from 1507 patients; during this period, 1180 patients were included in the PRO registry. Response rate for PROs was 90%. The consent rate to receive information on new interventional studies and possible participation in cmRCTs in the future was >85%. The number of hospitals participating in the cohorts is steadily increasing.

CONCLUSION

A comprehensive nationwide multidisciplinary gastrointestinal cancer cohort is feasible and surpasses the limitations of classical study designs. With this initiative, novel and innovative studies can be performed in an efficient, safe, and comprehensive setting.

The impact of an ostomy on older colorectal cancer patients: a cross-sectional survey

BACKGROUND

Ostomies are being placed in 35 % of patients after colorectal cancer surgery. As decision-making regarding colorectal surgery is challenging in the older patients, it is important to have insight in the potential impact due to ostomies.

METHODS

An internet-based survey was sent to all members with registered email addresses of the Dutch Ostomy Patient Association.

RESULTS

The response rate was 49 %; 932 cases were included of whom 526 were aged <70 years old ("younger respondents"), 301 were aged between 70 and 79 years old ("the elderly"), and 105 were aged ≥80 years old ("oldest old"). Ostomy-related limitations were similar in the different age groups, just as uncertainty (8-10 %) and dependency (18-22 %) due to the ostomy. A reduced quality of life was experienced least in the oldest old group (24 % vs 37 % of the elderly and 46 % of the younger respondents, p < 0.001). Over time, a decrease of limitations and impact due to the ostomy was observed.

CONCLUSION

Older ostomates do not experience more limitations or psychosocial impact due to the ostomy compared to their younger counterparts. Over the years, impact becomes less distinct. Treatment decision-making is challenging in the older colorectal cancer patients but ostomy placement should not be withheld based on age alone.

[Colorectal cancer surgery in the oldest Dutch patients: retrospective analysis of two national databases covering 2011 and 2012]

OBJECTIVE

Adequate decision-making concerning elderly patients with colorectal cancer requires accurate information regarding the risks of treatment. We analysed the post-operative outcomes and survival following colorectal resections in the oldest old patients (≥ 85 years old).

DESIGN

Retrospective study.

METHOD

We analysed the data from 2011 and 2012 of all patients with colorectal carcinoma, stage I-III, from two national databases, namely the Dutch Surgical Colorectal Audit registry (DSCA) and the Netherlands Cancer Registry (NKR).

RESULTS

The study included over 1200 elderly patients. The postoperative complication rate was 41%. The frequency of cardiopulmonary complications rose rapidly with age, from 11% in those < 70 years to 38% in those aged > 85 years. The postoperative 30-day mortality rate was 10% for the oldest old patients, whereas it was 14% after three months, 24% after one year and 36% after two years. After correction for expected mortality in the general population, excess mortality for the oldest old was 12% in the first year and 3% in the second year.

CONCLUSION

For patients aged ≥ 85 years who undergo surgical resection for colorectal carcinoma, high rates of cardiopulmonary complications and excess mortality in the first year after surgery are observed. We propose that these data could be analysed together with information regarding individual patients' health status, to enable optimisation of future decision-making regarding potential surgical intervention in elderly patients.

Non-surgical complications after laparoscopic and open surgery for colorectal cancer - A systematic review of randomised controlled trials

BACKGROUND

Cardiac and pulmonary complications account for a large part of postoperative mortality, especially in the growing number of elderly patients. This review studies the effect of laparoscopic surgery for colorectal cancer on short term non-surgical morbidity.

METHODS

A literature search was conducted to identify randomised trials on laparoscopic compared to open surgery for colorectal cancer with reported cardiac or pulmonary complications.

RESULTS

The search retrieved 3302 articles; 18 studies were included with a total of 6153 patients. Reported median or mean age varied from 56 years to 72 years. The percentage of included patients with ASA-scores ≥ 3 ranged from 7% to 38%. Morbidity was poorly defined. Overall reported incidence of postoperative cardiac complications was low for both laparoscopic and open colorectal resection (median 2%). There was a trend towards fewer cardiac complications following laparoscopic surgery (OR 0.66, 95% CI 0.41-1.06, p = 0.08), and this effect was most marked for laparoscopic colectomy (OR 0.28, 95% CI 0.11-0.71, p = 0.007). Incidence of pulmonary complications ranged from 0 to 11% and no benefit was found for laparoscopic surgery, although a possible trend was seen in favour of laparoscopic colectomy (OR 0.78, 95% CI 0.53-1.13, p = 0.19). Overall morbidity rates varied from 11% to 69% with a median of 33%.

CONCLUSION

Although morbidity was poorly defined, for laparoscopic colectomies, significantly less cardiac complications occurred compared with open surgery and a trend towards less pulmonary complications was observed. Subgroup analysis from two RCTs suggests that elderly patients benefit most from a laparoscopic approach based on overall morbidity rates.

Representation of the elderly in trials of laparoscopic surgery for colorectal cancer

AIM

Most patients with colorectal cancer are elderly, but there are few data on the optimal surgical treatment for this age group and most studies are observational. We have reviewed the characteristics of randomized trials reporting laparoscopic surgery for colorectal cancer to determine the degree to which the elderly are represented.

METHOD

A search was conducted of the NIH clinical trial registry and the ISRCTN register for randomized trials on laparoscopic surgery for colorectal cancer. Trial characteristics and end-points were extracted from the registry website and supplemented by published results where available.

RESULTS

Of 52 trial protocols the majority did not state any restrictions regarding cardiac [40 (77%)] or pulmonary function [41 (79%)]. More than half [30 (58%)] had no restrictions regarding American Society of Anesthesiologists score. Twenty-three (44%) trials excluded the elderly either simply on age or by comorbidity or organ function. When an upper age limit was set, half of the studies had no restriction regarding organ function, indicating that chronological age rather than physical condition was taken as the reason for exclusion. In 45 (86%) of the trials the average age of participants was < 70 years, and no details of concurrent disease were given.

CONCLUSION

Participation of the elderly in trials of laparoscopic surgery for colorectal cancer is very limited. This should be remedied in future trials if adequate information on the majority of patients with colorectal cancer is to be obtained.

[Symptomatic gallstone disease: an indication for surgery]

Three patients, men in the ages of 58, 66 and 56 years, respectively, had experienced 'warning colics' a considerable time before gallstone complications or severe recurrent colic. Ultrasonographically proven gallstones had not led to cholecystectomy. The 58-year-old man died of sepsis due to infected pancreatic necrosis; the other men underwent laparoscopic cholecystectomy, after which they recovered fully. Approximately 10-5% of the adult Dutch population have gallstones, but only 10% will develop symptoms. The annual risk for developing complicated gallstone disease is 1-2% in asymptomatic gallstone carriers. Of patients admitted with complicated gallstone disease, 58% have had prior 'warning colics'. Complicated gallstone disease can be prevented by timely treatment after recognition of warning colics. Cholecystectomy is indicated in patients with intermittent upper-abdominal pain and proven gallstones or sludge.