Evaluation of the Introduction of a Colorectal Bundle in Left Sided Colorectal Resections (EvaCol): Study Protocol of a Multicentre, Observational Trial

Purpose:

Overall complication and leak rates in colorectal surgery showed only minor improvements over the last years and remain still high. While the introduction of the WHO Safer Surgery Checklist has shown a reduction of overall operative mortality and morbidity in general surgery, only minor attempts have been made to improve outcomes by standardizing perioperative processes in colorectal surgery. Nevertheless, a number of singular interventions have been found reducing postoperative complications in colorectal surgery. The aim of the present study is to combine nine of these measures to a catalogue called colorectal bundle (CB). This will help to standardize pre-, intra-, and post-operative processes and therefore eventually reduce complication rates after colorectal surgery.

Methods:

The study will be performed among nine contributing hospitals in the extended north-western part of Switzerland. In the 6-month lasting control period the patients will be treated according to the local standard of each contributing hospital. After a short implementation phase all patients will be treated according to the CB for another 6 months. Afterwards complication rates before and after the implementation of the CB will be compared.

Discussion:

The overall complication rate in colorectal surgery is still high. The fact that only little progress has been made in recent years underlines the relevance of the current project. It has been shown for other areas of surgery that standardization is an effective measure of reducing postoperative complication rates. We hypothesize that the combination of effective, individual components into the CB can reduce the complication rate.

Trial registration:

Registered in ClinicalTrials.gov on 11/03/2020; NCT04550156.

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Improved quality of colon cancer surveillance after implementation of a personalized surveillance schedule

BACKGROUND

Early detection of recurrence through surveillance after curative surgery for primary colon cancer is recommended. We previously reported inadequate quality of surveillance among patients operated for colon cancer. These poor results led to the introduction of a personalized surveillance schedule. This study reassesses the quality of surveillance after the introduction of the personalized schedule.

PATIENTS AND METHODS

A total of 93 patients undergoing curative surgery for colon cancer between January 2009 and December 2014 (prospective data registration) were included in this retrospective single-center cohort study. Written informed consent was given by all patients. Compliance with surveillance was compared with national guidelines, as well as with the previous results and analyzed depending on where surveillance was conducted (general practitioner or outpatient clinic).

RESULTS

Adherence to surveillance was higher when performed by oncologists compared to general practitioners with an odds ratio (OR), 6.03 (95%CI: 3.41-10.67, P = .001). Compared with the previous study, adherence to surveillance was significantly higher in the later cohort with an OR = 4.55 (95%CI: 2.50-8.33, P < 0.001).

CONCLUSION

This study demonstrates that the implementation of a personalized surveillance schedule improves adherence to recommendations and that awareness can be increased with this simple measure.

Lymph node ratio is inferior to pN-stage in predicting outcome in colon cancer patients with high numbers of analyzed lymph nodes

Background

The lymph node ratio (LNR), i.e. the number of positive lymph nodes (LN) divided by the total number of analyzed LN, has been described as a strong outcome predictor in node-positive colon cancer patients. However, most published analyses are constrained by relatively low numbers of analyzed LN. Therefore, the objective of the present study was to evaluate the prognostic impact of LNR in colon cancer patients with high numbers of analyzed LN.

Methods

One hundred sixty-six colon cancer patients underwent open colon resection. All node-positive patients were analyzed for this study. The number of analyzed LN, of positive LN, the disease-free (DFS) and overall survival (OS) time were prospectively recorded. Patients were dichotomously allocated to a high or a low LNR-group, respectively, with the median LNR (0.125) as a cut-off value. Median follow-up was 34.3 months.

Results

Fifty-eight patients (34.9%) were node-positive. The median number of analyzed LN was 23 (range 8–54). DFS and OS were significantly shorter in pN2 vs pN1 patients (p < 0.001, and p = 0.001, respectively), and in LNR high vs low patients (p = 0.032, and p = 0.034, respectively). pN2 (vs pN1) disease showed hazard ratios (HR) of 6.2 (p < 0.001), and 6.8 (p < 0.005; for DFS and OS, respectively), while LNR high (vs low) showed HR of 3.0 (p =0.041), and 4.5 (p = 0.054).

Conclusions

LNR is a reasonable outcome predictor in node-positive colon cancer patients. However, LNR is inferior to pN-stage in predicting survival in patients with high number of harvested lymph nodes.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0417-0) contains supplementary material, which is available to authorized users.

On the hydrogen-graphene layers interactions, relevance to the onboard storage problem

Empirical evaluations of fundamental characteristics of the physical and chemical interaction of hydrogen with graphene layers in different kinds of graphite and novel carbonaceous nanomaterials of graphene layer structure have been carried out. This was done by using the approaches of the thermodynamics of reversible and irreversible processes for analysis of the adsorption, absorption, diffusion, the temperature-programmed desorption (TPD) and other experimental data and comparing such analytical results with first-principles calculations. Such an analysis of a number of the known experimental and theoretical data has shown a real possibility of the multilayer specific adsorption (intercalation) of hydrogen between graphene layers in novel carbonaceous nanomaterials. This is of relevance for solving the bottle-neck problem of the hydrogen on-board storage in fuel-cell-powered vehicles, and other technical applications.

Sentinel lymph node procedure leads to upstaging of patients with resectable colon cancer: results of the Swiss prospective, multicenter study sentinel lymph node procedure in colon cancer

BACKGROUND

The value of the sentinel lymph node (SLN) procedure in colon cancer patients remains a matter of debate. The objective of this prospective, multicenter trial was 3-fold: to determine the identification rate and accuracy of the SLN procedure in patients with resectable colon cancer; to evaluate the learning curve of the SLN procedure; and to assess the extent of upstaging due to the SLN procedure.

METHODS

One hundred seventy-four consecutive colon cancer patients were enrolled onto this prospective trial. They underwent an intraoperative SLN procedure with isosulfan blue 1% injected peritumorally followed by open standard colon resection with oncologic lymphadenectomy. Three levels of each SLN were stained with hematoxylin and eosin (H&E) and immunostained with the pancytokeratin marker AE1/AE3 if H&E was negative.

RESULTS

SLN identification rate and accuracy were 89.1% and 83.9%, respectively. SLN were significantly more likely to contain tumor infiltrates than non-SLN (P < 0.001). Both SLN identification rate (P = 0.021) and the sensitivity of the procedure (P = 0.043) significantly improved with experience. The use of immunohistochemistry in SLN resulted in an upstaging of 15.4% (16 of 104) stage I and II patients considered node-negative in initial H&E analysis.

CONCLUSIONS

The SLN procedure for colon cancer has good identification and accuracy rates, which further improve with increasing experience. Most importantly, the SLN procedure results in upstaging of >15% of node-negative patients. The potential advantage of performing the SLN procedure appears to be particularly important in these patients because they may potentially benefit from adjuvant therapy.

Tumornachsorge nach potentiell kurativerResektion eines Karzinoms

Als Tumornachsorge wird die strukturierte, regelmäßige Kontrolle asymptomatischer Patientinnen und Patienten nach potentiell kurativer Therapie eines Karzinoms bezeichnet. Das in der Schweiz gültige Nachsorgeschema nach kolorektalem Karzinom basiert auf Konsensusempfehlungen der Schweizerischen Gesellschaft für Gastroenterologie. Durch die Nachsorge können Lokalrezidive und neu aufgetretene Fernmetastasen früher und somit häufiger in einem Stadium entdeckt werden, in welchem eine kurative Therapie noch möglich ist. Die Nachsorgeempfehlungen beim Mammakarzinom legen das Schwergewicht auf das Lokalgeschehen, da Fernmetastasen viel seltener als beim kolorektalen Karzinom noch kurativ angehbar sind. Unabhängig von der Tumorentität sollte die Nachsorge interdisziplinär unter der Führung einer koordinierenden Stelle durchgeführt werden. Die mit der Nachsorge betrauten Ärztinnen und Ärzte sollten sich der Wichtigkeit dieser anspruchsvollen Aufgabe bewusst sein.

Anti-Mullerian hormone confirms the novel classification of female functional androgenization including polycystic ovary syndrome

OBJECTIVE

Functional androgenization (FA) can be divided into five groups corresponding to the predominant organ pathology as recently shown by our group: functional cutaneous androgenization (FCA, skin) and FA syndrome (FAS) I (ovary, lean individual), II (adrenal gland), III (ovary, fat tissue, pancreas, and hyperinsulinemia), and IV (residual FA dysfunctions). Group-specific clusters are based on primary variables such as LH, testosterone, DHEAS, sex hormone-binding globulin (SHBG), body mass index (BMI), glucose, insulin, and enlarged polyfollicular ovaries. Because anti-Müllerian hormone (AMH) positively correlates with the antral follicle count, its relevance as an additional primary variable for classifying FA was investigated.

DESIGN

In this study, 178 patients with FA were consecutively enrolled and classified into the five FA groups as described earlier and 30 women with regular menstrual cycles served as control.

METHODS

Primary variables and serum AMH were analyzed in the early follicular phase.

RESULTS

FA patients showed significantly elevated AMH levels (11.1±6.7 ng/ml) versus control (3.0±2.0 ng/ml; P<.0001). AMH was significantly increased in groups FAS I (15.6±5.8 ng/ml) and FAS III (11.6±6.6 ng/ml) compared with groups FCA (7.0±3.8 ng/ml), FAS II (5.05±3.0 ng/ml), and FAS IV (6.9±4.6 ng/ml) and correlated positively (P<.0001) with LH (r=0.538) and testosterone (r=0.368). In regression and multivariate analyses, AMH was not dependent on SHBG, DHEAS, BMI, glucose, or insulin. In receiver operating characteristic analysis, 9.21 ng/ml AMH showed 90% specificity with 71.2% sensitivity for the diagnosis of the two ovarian FA groups, FAS I and III.

CONCLUSION

AMH confirms the novel stratification system and constitutes a useful primary variable in the algorithm of FA classification.

On physical nanoscale aspects of compatibility of steels with hydrogen and natural gas

The possibilities of effective solutions of relevant technological problems are considered based on the analysis of fundamental physical aspects, elucidation of the nano-structural mechanisms and interrelations of aging and hydrogen embrittlement of materials (steels) in the hydrogen industry and gas-main industries. The adverse effects which these mechanisms and processes have on the service properties and technological lifetime of materials are analyzed. The concomitant fundamental process of formation of carbohydride-like and other segregation nanostructures at dislocations (with the segregation capacity 1 to 1.5 orders of magnitude greater than in the widely used Cottrell 'atmosphere' model) and grain boundaries is discussed in the context of how these nanostructures affect technological processes (aging, hydrogen embrittlement, stress corrosion damage, and failure) and the physicomechanical properties of the metallic materials (including the technological lifetimes of pipeline steels).

Analytical review on the hydrogen multilayer intercalation in carbonaceous nanostructures: relevance for development of super-adsorbents for fuel-cell-powered vehicles

The analytical consideration of some recent experimental and theoretical data on the hydrogen on-board storage problem shows the necessity and economical expediency of carrying out further basic studies and initiating a constructive discussion on the physical key-note aspects ("open questions") of the hydrogen sorption by carbon-based nanomaterials: Especially, on the hydrogen multilayer intercalation in carbonaceous nanostructures, their relevance for the development of super-adsorbents for fuel-cell-powered vehicles, i.e., storage materials, which satisfy most of the U.S. DOE targets. It is consistent with the U. S. National Academies' recent recommendations and manifestations of the critical situation of the hydrogen storage problem.

Carcinoma of the stomach. Why are we falling to improve survival?

Review of 298 cases of primary gastric malignancy from 1958 to 1978 revealed 265 cases of adenocarcinoma. Overall 5-year survival rate was a disappointing 5.5%, which was less than the earlier series of Oschner Clinic (7.5%). Curative resections produced a five-year survival rate of 26%. Patients presented with advanced disease; 84% had Stage III or IV disease at time of initial observation. The introduction of fiberoptic endoscopy during this period greatly enhanced the accuracy of preoperative diagnosis of tissue-proven cancer from 6% before fiberoptic to 58% since. Worldwide experience is much better, with overall five-year survival rate of 17.9%. Excellent survival statistics from Japanese studies reflect both the effects of mass surveying and early surgery and the prevalence of superficial spreading type of cancer. Improvement of results in this country will require more aggressive evaluation and earlier surgical intervention.

Cancer of the stomach

Carcinoma of the stomach, although its incidence is decreasing in the United States, is still a fatal disease. The results today are actually no better than they were 30 years ago because we are still making late diagnoses. In order to improve our results in the treatment of cancer of the stomach, we must perform fiberoptic gastroscopy in individuals over age 40 who have gastric complaints that do not respond readily to conservative medical therapy. At the time of endoscopy, multiple biopsies of gastric mucosa must be taken. Only in this way can early enough diagnoses be made to increase the survival rate in gastric carcinoma.

The relative merits of temporary gastrostomy and nasogastric suction of the stomach

Nasogastric suction is usually employed for gastric decompression because of its ease of application. However, it is associated with greater discomfort and more complications than temporary gastrostomy, especially in the young, the elderly, those who smoke, and those in whom prolonged decompression is necessary.

Aging

Aging, a wearing-out process which affects everything inanimate and animate, is accelerated by abuse of decelerated by care. The psychologic reaction of aging persons vary considerably. The concept of growing older is much more satisfactory and pleasant than the concept of being old, since the former is applicable to everyone regardless of age whereas the latter carries a finite significance as deterioration progresses. Chronologic age is much less important than biologic age. The desideratum is not longevity but rather a long, useful and meaningful life. Although heredity is of importance in longevity, it is a factor over which at present we have no control. However, we can influence the aging process according to whether we care for or abuse the body. The principal factors in accelerated aging, in order of importance, are: 1) tobacco use (particularly cigarette smoking), 2) lack of exercise, and 3) obesity. Conversely, abstinence from tobacco, exercise within tolerance, and avoidance of obesity not only decelerate aging but result in a better quality of life.

Appraising current therapy for breast cancer; 1. surgery

Breast cancer is an extremely unpredictable type of lesion, due in part to its hormone dependence. Although minimal resection may suffice for those patients with great host resistance, radical or modified radical mastectomy is the treatment of choice unless distant metastases are evident.

Diseases of the breast

As a result of health education programs that have stressed self-examination and the importance of early diagnosis and treatment, less than 5 percent of breast lesions seen in clinical practice today are malignant. Nevertheless, breast cancer is the leading cause of deaths due to cancer in women and the second most common breast lesion. Chronic cystic mastitis, the most common breast lesion seen in women, can often be treated conservatively by aspirating the cystic fluid. Close follow-up is necessary so that if carcinoma develops, it can be treated early. Carcinoma is unpredictable but not hopeless. Although controversy exists regarding treatment, radical mastectomy is still the preferred treatment in most cases. Other breast diseases include adenofibroma, a common lesion requiring excisional biopsy for positive diagnosis; nipple discharge, which should be carefully examined cytologically; and relatively rare breast lesions, including intraductal papilloma, adenosis, traumatic fat necrosis, and cystosarcoma phylloides.