Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial

PURPOSE

The extent of lymph node dissection appropriate for gastric cancer is still under debate. We have conducted a randomized trial to compare the results of a limited (D1) and extended (D2) lymph node dissection in terms of morbidity, mortality, long-term survival and cumulative risk of relapse. We have reviewed the results of our trial after follow-up of more than 10 years.

PATIENTS AND METHODS

Between August 1989 and June 1993, 1,078 patients with gastric adenocarcinoma were randomly assigned to undergo a D1 or D2 lymph node dissection. Data were collected prospectively, and patients were followed for more than 10 years.

RESULTS

A total of 711 patients (380 in the D1 group and 331 in the D2 group) were treated with curative intent. Morbidity (25% v 43%; P <.001) and mortality (4% v 10%; P =.004) were significantly higher in the D2 dissection group. After 11 years there is no overall difference in survival (30% v 35%; P =.53). Of all subgroups analyzed, only patients with N2 disease may benefit of a D2 dissection. The relative risk ratio for morbidity and mortality is significantly higher than one for D2 dissections, splenectomy, pancreatectomy, and age older than 70 years.

CONCLUSION

Overall, extended lymph node dissection as defined in this study generated no long-term survival benefit. The associated higher postoperative mortality offsets its long-term effect in survival. For patients with N2 disease an extended lymph node dissection may offer cure, but it remains difficult to identify patients who have N2 disease. Morbidity and mortality are greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age. Extended lymph node dissections may be of benefit if morbidity and mortality can be avoided.

Prospective evaluation of anorectal function after total mesorectal excision for rectal carcinoma with or without preoperative radiotherapy

OBJECTIVE

Anorectal function is greatly disturbed after rectal surgery with or without radiotherapy (RT). To clarify the underlying mechanisms, we designed a prospective study to evaluate the effect of RT and surgery on anorectal function and clinical outcome of patients with a rectal carcinoma.

METHODS

Thirty-four patients with a rectal carcinoma participated in this study. They filled out a symptom questionnaire and underwent anal manometry, anal and rectal mucosal electrosensitivity testing, and a rectal barostat, before surgery, 4 and 12 months postoperatively. Thirteen patients were lost to follow-up, 14 underwent surgery alone (total mesorectal excision [TME]), and seven also received RT (RT + TME).

RESULTS

Functional outcome was disappointing in both groups, with at 4 months a significantly higher defecation frequency after RT + TME as compared with TME. Anal sphincter function and rectal sensitivity to pressure-controlled distention were not affected by either treatment. Rectal compliance, however, was significantly reduced after RT + TME at 4 and 1 2 months, resulting in lower rectal volumes at the thresholds for first sensation and desire to defecate. Rectal but not anal mucosal electrosensitivity was higher after TME + RT.

CONCLUSIONS

Anorectal function after rectal surgery with or without RT is greatly hampered because of a decreased rectal compliance. After 12 months, partial improvement is shown, especially in the absence of RT.

Prospective evaluation of anorectal function after total mesorectal excision for rectal carcinoma with or without preoperative radiotherapy

OBJECTIVE

Anorectal function is greatly disturbed after rectal surgery with or without radiotherapy (RT). To clarify the underlying mechanisms, we designed a prospective study to evaluate the effect of RT and surgery on anorectal function and clinical outcome of patients with a rectal carcinoma.

METHODS

Thirty-four patients with a rectal carcinoma participated in this study. They filled out a symptom questionnaire and underwent anal manometry, anal and rectal mucosal electrosensitivity testing, and a rectal barostat, before surgery, 4 and 12 months postoperatively. Thirteen patients were lost to follow-up, 14 underwent surgery alone (total mesorectal excision [TME]), and seven also received RT (RT + TME).

RESULTS

Functional outcome was disappointing in both groups, with at 4 months a significantly higher defecation frequency after RT + TME as compared with TME. Anal sphincter function and rectal sensitivity to pressure-controlled distention were not affected by either treatment. Rectal compliance, however, was significantly reduced after RT + TME at 4 and 1 2 months, resulting in lower rectal volumes at the thresholds for first sensation and desire to defecate. Rectal but not anal mucosal electrosensitivity was higher after TME + RT.

CONCLUSIONS

Anorectal function after rectal surgery with or without RT is greatly hampered because of a decreased rectal compliance. After 12 months, partial improvement is shown, especially in the absence of RT.

What is the benefit of preoperative sperm preservation for patients who undergo restorative proctocolectomy for benign diseases?

PURPOSE

In patients with benign colorectal diseases undergoing a restorative proctocolectomy with an ileal pouch-anal anastomosis, semen cryopreservation seems rational to enable the possibility of procreation in case surgery leads to sexual disorders or impotence. The aim of this study was to determine the preoperative and postoperative semen quality in patients undergoing ileal pouch-anal anastomosis. In addition, the study sought to determine the incidence of surgery-induced sexual dysfunction to evaluate the economic efficiency of semen cryopreservation as compared with alternatives such as microsurgical epididymal sperm aspiration.

METHODS

Preoperative and postoperative semen analyses were offered to 97 patients with ileal pouch-anal anastomosis with benign colorectal diseases since 1989. The direct costs of the semen cryopreservation program were determined and compared with those of alternatives.

RESULTS

In 34 of 40 consecutive patients with ileal pouch-anal anastomosis who made use of preoperative semen preservation, normal sperm concentrations, motility, and morphology were found. Mean semen characteristics of all 23 patients who returned for postoperative analysis were not different from preoperative values, but they were for total sperm number. Two patients developed temporary retrograde ejaculation postoperatively. None of the preserved semen samples was used, thus semen cryopreservation benefited none of these patients. The total costs of semen cryopreservation are between 2.2 and 5 times higher than the costs for one microsurgical epididymal sperm aspiration procedure.

CONCLUSIONS

Preoperative semen cryopreservation in patients undergoing ileal pouch-anal anastomosis because of benign colorectal diseases is quite feasible. However, most likely because of improved surgical techniques and the increasing number of effective alternatives, preoperative semen cryopreservation in patients with ileal pouch-anal anastomosis is no longer cost effective.

Quality of life after total colectomy with ileorectal anastomosis or proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis

BACKGROUND

Knowledge of postoperative health status is important in decision-making about the type of operation necessary in patients with familial adenomatous polyposis (FAP). This study compared the quality of life (QoL) between patients with an ileorectal anastomosis (group 1) and those with an ileal pouch-anal anastomosis (group 2).

METHODS

QoL was assessed with both a generic questionnaire (Short Form-36 Health Survey; SF-36) and a disease-specific questionnaire (European Organization for Research and Treatment of Cancer Colorectal QoL Questionnaire; EORTC QLQ-CR38). The SF-36 consists of 36 items representing eight generic health domains, and the EORTC QLQ-CR38 comprises 38 items representing disease-specific health domains. Both questionnaires were distributed among 323 patients with FAP known at the Dutch Polyposis Registry who had previously undergone either operation. The results of the SF-36 were compared with the scores of age- and sex-matched respondents from the general population.

RESULTS

Some 279 patients (86 per cent), 161 in group 1 and 118 in group 2, completed the questionnaire. Generic and disease-specific QoL was the same for groups 1 and 2. The SF-36 scores of both groups were significantly lower than those of the general population.

CONCLUSION

There were no differences with respect to health status between patients in groups 1 and 2, and preference for either procedure cannot be based on QoL.

[Proctocolectomy with an ileal pouch-anal anastomosis; results from 100 consecutive patients in the Academic Medical Center at Amsterdam, 1994-1999]

OBJECTIVE

To evaluate the results of proctocolectomy with creation of an ileac pouch anal anastomosis (IPAA).

DESIGN

Retrospective.

METHOD

Of the 100 patients in whom an IPAA procedure was performed in the period 1994/'99 in the Department of Surgery of the Academic Medical Centre, Amsterdam, the Netherlands, data were collected on the complications: in the patients with a follow-up of over 12 months the functional results were studied.

RESULTS

The group comprised 48 males and 52 females with a mean age of 36.3 years (range: 15-62). Preoperative diagnoses were ulcerative colitis (n = 84), familial polyposis coli (12), slow transit obstipation (2), Hirschsprung's disease (1) and Muir-Torre syndrome (1). Median operating time was 2.3 h, peroperative blood and fluid loss 500 ml and median hospital stay 15 days. There was no mortality. Ten patients had a loop ileostomy formation, in 6 because of postoperative complications. A total of 30 patients developed postoperative complications, peroperatively or during follow-up 10 of those patients needed a relaparotomy. After 12 months 1 pouch had to be excised and 2 patients still had a loop ileostomy due to postoperative complications. In 56 patients with at least 12 months follow-up, median 24-hour stool frequency was 6. Eighty-nine per cent of these patients were satisfied or highly satisfied with the overall outcome.

CONCLUSION

A proctocolectomy with IPAA formation is a safe procedure with good functional results.

Functional outcome after colectomy and ileorectal anastomosis compared with proctocolectomy and ileal pouch-anal anastomosis in familial adenomatous polyposis

OBJECTIVE

To compare the long-term functional results of ileorectal anastomosis (IRA) with those of ileal pouch-anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP).

SUMMARY BACKGROUND DATA

In patients with FAP, hundreds of colorectal adenomas develop, and the patient will die of colorectal cancer if left untreated. The surgeon must choose between colectomy with IRA and restorative proctocolectomy with IPAA. One factor crucial to decision making is the functional outcome after either procedure. To date, studies on this issue have reported conflicting results and have been based on small series of patients.

METHODS

To assess various functional variables, a questionnaire was sent to 323 patients with FAP who underwent either IRA or IPAA and who were registered at the Netherlands Foundation for the Detection of Hereditary Tumors. The overall response rate was 86%; the responders comprised 161 patients who underwent IRA and 118 patients who underwent IPAA.

RESULTS

Patients who underwent IRA scored significantly better for daytime and nighttime stool frequency, soiling, occasional passive incontinence, flatus and feces discrimination, stool consistency, and need for antidiarrheal medication. There was no difference with regard to perianal irritation, episodes of bowel discomfort, or dietary restrictions. The functional results according to the aggregate score of the Gastro-Intestinal Functional Outcome Scale, where the items specified above were integrated (0 indicating a poor and 100 a good overall function), were significantly better in patients with an IRA (74.5) than in patients with an IPAA (66.0) (p < 0.01).

CONCLUSION

The functional outcome after IRA is significantly better than after IPAA. On the basis of these results, IRA might still be considered in patients with a mild phenotypic expression of the disease in the rectum.

Cumulative risk of developing polyps or malignancy at the ileal pouch-anal anastomosis in patients with familial adenomatous polyposis

Restorative proctocolectomy with an ileal pouch-anal anastomosis is performed in an increasing number of patients with familial adenomatous polyposis (FAP). Two techniques are currently used to construct an ileal pouch-anal anastomosis: (1) a double-stapled anastomosis between the pouch and the anal canal and (2) mucosectomy with a hand-sewn ileoanal anastomosis at the dentate line. Although this procedure is thought to abolish the risk of colorectal adenoma, an increasing number of case reports have been published concerning the development of adenoma at the anastomotic site. The purpose of this study was to evaluate the overall cumulative risk of developing adenomatous polyps after ileal pouch-anal anastomosis and to compare the cumulative risk after either anastomotic technique. A total of 126 consecutive FAP patients undergoing a restorative proctocolectomy were identified from polyposis registries in The Netherlands, Denmark, Italy, Germany, and New York. Life-table analysis was used to calculate the cumulative risk of developing polyps in 97 patients with at least 1 year of endoscopic follow-up (median 66 months, range 12 to 188 months). A double-stapled anastomosis was used in 35 patients, whereas in 62 patients a hand-sewn anastomosis with a mucosectomy was performed. In 13 patients polyps developed at the anastomotic site, four with severe and four with moderate dysplasia. None of the patients developed a carcinoma at the anastomotic site. The cumulative risk of developing a polyp at the anastomotic site was 8% (95% confidence interval 2% to 14%) at 3.5 years and 18% (95% confidence interval 8% to 28%) at 7 years, respectively. The risk of developing a polyp at the anastomotic site within 7 years was 31% for patients with a double-stapled vs. 10% for patients with a hand-sewn anastomosis with mucosectomy (P = 0.03 [log-rank test]). Because FAP patients undergoing a restorative proctocolectomy with either a double-stapled or hand-sewn anastomosis have a substantial risk of developing adenomatous polyps at the anastomotic site, lifelong endoscopic surveillance is mandatory in both groups.

Total mesorectal excision (TME) with or without preoperative radiotherapy in the treatment of primary rectal cancer. Prospective randomised trial with standard operative and histopathological techniques. Dutch ColoRectal Cancer Group

OBJECTIVE

To document local recurrence in primary rectal cancer when standardised techniques of surgery, radiotherapy, and pathology are used, and to investigate whether the local recurrence rate after total mesorectal excision permits the omission of adjuvant short term preoperative radiotherapy.

DESIGN

Prospective randomised study.

SETTING

Dutch (n = 80), English (n = 1), German (n = 1), Swedish (n = 9), and Swiss (n = 1) hospitals.

SUBJECTS

The first 500 randomised Dutch patients with primary rectal cancer.

MAIN OUTCOME MEASURES

Local recurrence, survival, operation-related factors, specific pathological tumour characteristics, short and long term morbidity, and quality of life.

RESULTS

Between January 1996 and April 1998, 871 Dutch and 94 other patients were randomised. Our feasibility analysis shows that cooperation between and within the participating disciplines goes well. With regard to the surgical part, this can be confirmed by the large number of operations attended by consultant surgeons (58%). The number of abdominoperineal resections appeared to be low (30%), as did the percentage of lateral margins involved (13%). The rate of adverse effects of radiotherapy was acceptable. Apart from a larger operative blood loss and a higher infective complication rate in the irradiated group, no significant differences were found with regard to morbidity and mortality between the randomised groups.

CONCLUSIONS

The accrual of our trial is going well and it is feasible; short term preoperative radiotherapy is safe even in combination with TME.

Extended lymph-node dissection for gastric cancer

BACKGROUND

Curative resection is the treatment of choice for gastric cancer, but it is unclear whether this operation should include an extended (D2) lymph-node dissection, as recommended by the Japanese medical community, or a limited (D1) dissection. We conducted a randomized trial in 80 Dutch hospitals in which we compared D1 with D2 lymph-node dissection for gastric cancer in terms of morbidity, postoperative mortality, long-term survival, and cumulative risk of relapse after surgery.

METHODS

Between August 1989 and July 1993, a total of 996 patients entered the study. Of these patients, 711 (380 in the D1 group and 331 in the D2 group) underwent the randomly assigned treatment with curative intent, and 285 received palliative treatment. The procedures for quality control included instruction and supervision in the operating room and monitoring of the pathological results.

RESULTS

Patients in the D2 group had a significantly higher rate of complications than did those in the D1 group (43 percent vs. 25 percent, P<0.001), more postoperative deaths (10 percent vs. 4 percent, P= 0.004), and longer hospital stays (median, 16 vs. 14 days; P<0.001). Five-year survival rates were similar in the two groups: 45 percent for the D1 group and 47 percent for the D2 group (95 percent confidence interval for the difference, -9.6 percent to +5.6 percent). The patients who had R0 resections (i.e., who had no microscopical evidence of remaining disease), excluding those who died postoperatively, had cumulative risks of relapse at five years of 43 percent with D1 dissection and 37 percent with D2 dissection (95 percent confidence interval for the difference, -2.4 percent to +14.4 percent).

CONCLUSIONS

Our results in Dutch patients do not support the routine use of D2 lymph-node dissection in patients with gastric cancer.

Carney's triad

The purpose of this study is to provide an overview of cases of Carney's triad and to discuss the clinical implications of this diagnosis. A search was made of the English-language literature for original articles, reviews and abstracts addressing Carney's triad. A new patient was described and added to the number of known patients. In literature 40 patients were found with a complete or incomplete triad. There exists no agreement on the pathology and possible common origin of these tumours. Directions are given for diagnostics and therapy. The diagnosis of Carney's triad has specific clinical implications that make a good knowledge of this syndrome mandatory.

Imaging of estrogen receptors in primary and metastatic breast cancer patients with iodine-123-labeled Z-MIVE

PURPOSE

To evaluate the feasibility of noninvasive imaging of estrogen receptors (ERs) in primary and metastatic breast cancer with the iodine-123-labeled ER-specific ligand cis-11beta-methoxy-17alpha-iodovinylestradiol-17beta (Z-[123I]MIVE) using conventional nuclear medicine techniques.

PATIENTS AND METHODS

Z-[123I]MIVE planar scintigraphy and single-photon emission computed tomography (SPECT) were performed in 12 patients with proven primary breast cancer and 13 patients with proven or from other imaging modalities evident bone, liver, lung, pleura and/or lymph node metastases. The results were compared with those of ER immunohistochemistry (IHC). Blocking studies with the antiestrogen tamoxifen were performed to test whether Z-[123I]MIVE tumor uptake was ER-mediated.

RESULTS

Planar imaging showed uptake in 11 of 12 primary carcinomas. ER IHC performed for nine of these was positive. For the planar scintigraphy-negative patient, SPECT was faintly positive, but ER IHC negative (agreement, 90%). In nine of 13 metastatic patients, planar scintigraphy was positive. The agreement between the results of ER IHC on the original primary tumor and of Z-[123I]MIVE scintigraphy was 82%. Specificity of tumor Z-[123I]MIVE uptake was established by complete blockade of uptake by tamoxifen, except in two patients who showed progressive disease. Z-[123I]MIVE scintigraphy also enabled discriminating metastases from confounding nonmalignant abnormalities of the bone scan.

CONCLUSION

Z-[123I]MIVE scintigraphy shows high sensitivity and specificity for the detection of ER-positive breast cancer. This may have impact on diagnostic possibilities and therapeutic management. Since ER imaging shows the functional status, addressing known intratumoral and intertumoral ER heterogeneity, it may improve the characterization of disease and the selection of patients who may benefit from hormonal therapy.

Complications of an implantable venous access device (Port-a-Cath) during intermittent continuous infusion of chemotherapy

In 149 patients, treated with intermittent continuous infusion of different chemotherapeutic agents, 169 Port-a-Caths were implanted by qualified surgeons and residents in training. The peri- and postoperative complications of implantation of the Port-a-Cath system and the complications during treatment were retrospectively analysed. The Port-a-Cath was in situ for a total of 36247 days (median 181, range 1-1332). Of the 169 catheters, major complications occurred during treatment, with infection in 4 patients (2.4%), occlusion in 3 (1.8%), thrombosis in 8 (4.7%), extravasation in 8 (4.7%) and migration in 3 (1.8%). The peri- and postoperative complication rate was low, although pneumothorax occurred in 6 patients (3.6%). In 25 patients (14.8%) the Port-a-Cath had to be explanted due to complications. It can be concluded that continuous infusion of chemotherapy via a Port-a-Cath system is a relatively safe procedure, although major complications do occur. The experience of the surgeon could not be related to the complications.

Intermittent continuous infusion of ifosfamide and 5-fluorouracil in patients with advanced adenocarcinoma of the pancreas

BACKGROUND

In advanced adenocarcinoma of the pancreas treatment with 5-fluorouracil (5-FU) or ifosfamide results in response rates of approximately 20%. Continuous infusion of these drugs is on many grounds theoretically attractive and may therefore offer advantages over bolus or short-term infusion.

PATIENTS AND METHODS

Sixteen patients with advanced adenocarcinoma of the pancreas with progressive measurable disease and no previous chemotherapy entered the study. After implantation of a subcutaneous infusion chamber patients were treated on days 1-12 with ifosfamide (1.0 g/m2/day) and 5-FU (300 mg/m2/day) as a continuous intravenous infusion using a portable infusion pump. Mesna (1.0 g/m2/day) was added as uroprotective agent from day 1-14. Courses were repeated every 4 weeks.

RESULTS

Fifteen of the 16 patients were evaluable for response. One partial response was observed (response rate 7% [95% CI: 0%-32%]). Toxicity occurred in 64% of the courses. Dose limiting toxic effects were grade 3 nausea/vomiting (WHO) in 3 patients, grade 2 mucositis in 1 patient and grade 4 leukopenia in 1 patient.

CONCLUSION

Intermittent continuous infusion with ifosfamide, mesna and 5-FU is feasible on an outpatient basis. Although continuous infusion of ifosfamide may have a more favorable toxicity profile, the combination of 5-FU and ifosfamide in this schedule is no more effective than bolus or short-term infusion.

Intermittent continuous infusion of 5-fluorouracil and low dose oral leucovorin in patients with gastrointestinal cancer: relationship between plasma concentrations and clinical parameters

Modulation of 5-fluorouracil (5-FU) by leucovorin and continuous infusion of 5-FU can both result in enhanced therapeutic efficacy. The main objective of this study was to determine the maximum tolerated dose (MTD) of oral leucovorin in combination with continuous infusion of 5-FU for 14 days every 4 weeks at a dose of 300 mg/m2/day in 30 patients with gastrointestinal cancer. The MTD of oral leucovorin was established at 10 mg/day. Dose-limiting toxicities were mucositis, diarrhoea and hand-foot syndrome. Plasma leucovorin concentrations were below the detection limit of the assay (< 0.5 microM). Plasma 5-FU concentrations varied considerably from 0.06 to 11.3 microM. A relation between toxicity, response and plasma concentration of 5-FU could not be established. Our data may indicate that even very low plasma concentrations of leucovorin are able to modulate 5-FU. In 17 patients with colorectal cancer the response rate was 24% (95% CI: 7-50%), which is comparable to other treatment schedules with leucovorin or to continuous infusion of 5-FU alone.

Delayed postoperative emptying after esophageal resection is dependent on the size of the gastric substitute

BACKGROUND

Delayed emptying of the gastric substitute is a common problem after resection and reconstruction of the esophagus. The occurrence of postoperative delayed gastric emptying in patients undergoing resection and reconstruction of the esophagus was studied with regard to the type and size of gastric substitute and the execution of a pyloroplasty.

STUDY DESIGN

From 1983 to 1994, one hundred fifty-five patients underwent resection of the esophagus, with a hospital mortality rate of 7 percent. The inability to resume a diet of solid food within one week after a normal esophagography was defined as delayed gastric emptying. One hundred forty patients were studied; group 1, substitution with whole stomach with (1a, n = 9) and without (1b, n = 31) pyloroplasty; group 2, substitution with distal two-thirds stomach with (2a, n = 20) or without (2b, n = 45) pyloroplasty; and group 3, tubulized stomach without pyloroplasty (n = 35).

RESULTS

Delayed gastric emptying was seen in 38 percent (15 of 40) of patients in group 1 (1a, 44 percent; 1b, 37 percent), in 14 percent (nine of 65) of patients in group 2 (1a, 10 percent; 2b, 15 percent), and in 3 percent (one of 35) of patients in group 3. The differences between patients in group 1 and group 2, and between patients in group 1 and group 3 were significantly different (p < 0.05).

CONCLUSIONS

The type of gastric remnant used for reconstruction is an important determinant of postoperative gastric emptying. Pyloroplasty does not prevent delayed gastric emptying after esophageal substitution.

Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients

For patients with gastric cancer deemed curable the only treatment option is surgery, but there is disagreement about whether accompanying lymph-node dissection should be limited to the perigastric nodes (D1) or should extend to regional lymph nodes outside the perigastric area (D2). We carried out a multicentre randomised comparison of D1 and D2 dissection. 1078 patients were randomised (539 to each group). 26 allocated D1 and 56 allocated D2 were found not to satisfy eligibility criteria (histologically confirmed adenocarcinoma of the stomach without clinical evidence of distant metastasis). Each of the remainder was attended by one of eleven supervising surgeons who decided whether curative resection was possible and, if so, assisted with the allocated procedure. Among the 711 patients (380 D1, 331 D2) judged to have curable lesions, D2 patients had a higher operative mortality rate than D1 patients (10 vs 4%, p = 0.004) and experienced more complications (43 vs 25%, p < 0.001). They also needed longer postoperative hospital stays (median 25 [range 7-277] vs 18 [7-143] days, p < 0.001). Morbidity and mortality differences persisted in almost all subgroup analyses. While we await survival results, D2 dissection should not be used as standard treatment for western patients.

Risk of residual rectal mucosa after proctocolectomy and ileal pouch-anal reconstruction with the double-stapling technique. Postoperative endoscopic follow-up study

PURPOSE

This study was designed to assess the risk of retained rectal mucosa after proctocolectomy and ileal pouch-anal anastomosis with the double-stapling technique.

METHODS

A total of 113 patients underwent proctocolectomy with an ileal pouch-anal reconstruction. In 57 patients the anastomosis between pouch and proximal anal canal was performed using the double-stapling technique. In 26 patients the procedure was carried out without a protecting ileostomy. Of the remaining 31 patients with a proximal ileostomy, 15 underwent endoscopy six weeks postoperatively. Circular biopsies were taken just distal from the pouch-anal anastomosis.

RESULTS

Histologic examination revealed rectal mucosa in at least one biopsy in 7 of 15 patients. At follow-up (mean 18 months) no (distal) pouchitis was clinically noticed. In one patient with familial polyposis, a few polyps, distal of the anastomosis, had to be endoscopically removed.

CONCLUSIONS

Double-stapled ileal pouch-anal anastomosis has a considerable risk of residual rectal mucosa, because of combined linear transection and circular stapling with bilateral dog-ear formation of rectal mucosa. Residual rectal mucosa did not seem to influence clinical results at follow-up.

Role of extended lymph node dissection in the treatment of gastrointestinal tumours: a review of the literature

Over recent decades the long-term survival of patients operated on for gastrointestinal cancer has shown little if any improvement, despite sometimes aggressive surgical procedures and a significant fall in postoperative mortality.

BACKGROUND

We went through the literature to see if there were any eventual effects of extended lymph node dissection or survival.

METHODOLOGY

We reviewed recent literature on the different types of gastrointestinal cancer.

RESULTS

Japanese centres report excellent results when wide local excision is combined ith systematic extended lymph node dissection, especially in gastric and oseophageal cancer. The overall 5-year survival of over 50% for the large number of patients undergoing gastric resection for cancer seems to demonstrate convincingly the value of the extended lymphadenectomy. All oriental studies are uncontrolled, as are most reports from Western countries. The role of extended lymphadenectomy is therefore far from certain. The results from two randomized studies (British Medical Research Council and Dutch Gastric Cancer Trial) are awaited. It is evident from these prospective studies that the procedure adds a considerable operative risk. From non-randomized studies there is evidence that extended lymph node dissection in the treatment of pancreatic cancer might be of benefit to patients with small stage I and II tumours. In the treatment of proximal bile duct cancer the main goal of surgery is optimal relief of biliary obstruction. Whether there will ever be a role for extensive lymphadenectomy is doubtful. The extent of the surgical procedure in the treatment of gallbladder cancer is related to the depth of tumour infiltration. Extended resections are only recommended for patients with stage II to IV tumours. Extended lateral pelvic node dissection in the treatment of rectal cancer is demonstrated in Japanese retrospective studies to induce considerable urogenital problems, whereas the risk for local recurrence is still present.

CONCLUSIONS

No firm conclusions can be drawn based on data as available from the studied literature. Trial results will have to be awaited. Specific subgroups such as gastric and rectal cancer might benefit from these more extensive procedures.

Surgical treatment of pulmonary metastases from soft tissue sarcomas: a retrospective study in The Netherlands

Sixty-seven of 87 patients with soft tissue sarcoma underwent complete resection of the metastases in the lung. In this retrospective study, follow-up was for a median of 24 months. The 5-year overall, crude and disease-free survival was 38%, 45%, and 41%, respectively. Twenty-seven (40%) patients developed a recurrence in the lung. Of the six prognostic variables, the only factor significantly related to disease-free survival was grade. It is concluded that surgery for lung metastases of soft tissue sarcoma should be considered as standard therapy when preoperative evaluation predicts a complete resection. By adding chemotherapy to surgery, an improvement of prognosis probably can be achieved.

[Surgical treatment of anorectal disorders in 32 HIV-seropositive patients]

OBJECTIVE

To describe the presentation and surgical treatment of anorectal pathology in HIV seropositive patients.

DESIGN

Retrospective study.

SETTING

Department of surgery, University Medical Centre, Amsterdam, the Netherlands.

METHODS

Retrospective review of the records of 32 HIV seropositive patients surgically treated for anorectal pathology in 1985-1992.

RESULTS

The 32 patients, homosexual males, had a total of 46 diagnoses for which they underwent 49 surgical interventions. Sixteen patients had an anorectal ulcer (14 in the anal canal, 2 in the distal rectum); 7 were treated by local excision and 9 with additional advancement of the anal mucosa; there were 4 and 2 recurrences, respectively. Ten patients had a perianal abscess; 5 a fistula, 2 of whom initially presented with a metastatic abscess in liver and brain. Eight patients had perianal warts, which in 2 cases showed severe dysplasia and in one an infiltrating carcinoma. Five patients presented primarily with a malignancy (3 with squamous cell carcinoma of the anus, 1 with cloacogenic carcinoma, 1 with non-Hodgkin lymphoma distally in the rectum). Twelve patients died within 6 months after the first operation.

CONCLUSION

In choosing therapy for anorectal disorders, the limited survival of HIV seropositive patients, especially those with an advanced stage of AIDS should be considered. Surgical treatment can improve the quality of life in these patients.

Dermal angiosarcoma of the breast: a complication of primary radiotherapy?

A 70-year-old female developed recurrent disease following radiotherapy for primary inoperable breast cancer 5.5 years previously. Salvage mastectomy was performed. Pathology revealed recurrent breast cancer, along with a second primary malignancy, a dermal angiosarcoma. Radical excision of recurrent angiosarcoma failed. Irradiation combined with hyperthermia showed good palliation. The angiosarcoma's possible relation to the initial radiotherapy is discussed.

External radiotherapy and extrahepatic bile duct cancer

The hospital records of patients with extrahepatic bile duct cancer who where treated surgically between 1968 and 1983 were reviewed. Of 55 patients, 16 (29%) received radiotherapy after surgery. The total dose given ranged from 40 to 60 Gy. Median follow-up time for analysis was 4.0 months and lasted until January 1988. The overall median survival was 4 months (range 0-36), that of the irradiated patients was 16 months (range 2-36), and that of the 39 patients who were not irradiated was 3 months (range 0-32). When the 13 post operative deaths were excluded the median survival was 4 months. Radiotherapy did not cause any severe complications. No firm conclusion about the role of radiotherapy can be drawn from these data because the patients were not randomly chosen to receive radiotherapy and selection was therefore biased. We conclude that most patients with extrahepatic bile duct cancer still die of locoregional disease. Effective adjuvant treatments are needed and should be evaluated in prospective randomized trials.

Leiomyosarcoma of large and small veins: clinical findings and results of treatment in six patients

Vascular leiomyosarcomas are rare malignant tumours originating from the media of the vessel wall. Six patients (five women and one man, aged 44-66 years) have been treated for a vascular leiomyosarcoma located in the inferior vena cava (three patients), the suprarenal, the external iliac and an antecubital vein. In four patients, the tumour was large and extended beyond the vessel wall giving rise to a retroperitoneal mass. In two patients the tumour was confined to the inner wall of respectively a large and small vein, occluding the lumen; the former was in the inferior vena cava and the latter in an antecubital vein. Block resection was performed in all patients. The tumours showed mitotic indices ranging from 6-32 mitoses/10 high power fields. The five patients with retroperitoneal tumours received additional radiotherapy varying from 50.00-70.00 Gy, on the basis of either macroscopic residual tumour or indefinite radicality. One of these five patients developed distant metastases within 2.5 years without local recurrence, the other four had no evidence of recurrence at follow-up, 3-7 years (mean 4.2 years) after surgery. The results illustrate the role of adjuvant radiotherapy in the control of local recurrence, when resection in this type of tumour proves to be either non-radical or totally radical.

[Ileo-anal anastomosis with ileum reservoir]

Ileo-anal anastomosis with an ileal pouch is a reasonable alternative for patients with ulcerative colitis and adenomatous polyposis coli. The type of the reservoir, the length of the rectal cuff and the level of the anastomosis are still topics of discussion. This operation was performed in 41 patients. A modified J-reservoir (B-reservoir) was constructed in 34 patients in an attempt to improve the function of the neorectum. Twenty patients underwent inter-sphincteric freeing of the rectum and subsequent resection without leaving a rectal cuff. Although this procedure is associated with a considerable morbidity, the ultimate result is satisfactory.

[Periampullary carcinoma as a second primary tumor following a previously treated adenocarcinoma of the colon]

Three patients are presented who developed periampullary carcinoma after colectomy for adenocarcinoma. The combination of colonic carcinoma and periampullary carcinoma is rare, although wellknown in patients with colonic polyposis or Gardner's syndrome. Perhaps genetic research might help select patients with a high risk of developing multiple carcinomas in the gastrointestinal tract. The five-year survival rate for periampullary carcinoma after subtotal colectomy is higher than for pancreatic carcinoma.

Multifocal rhabdomyoma of the neck. Report of a case studied by fine-needle aspiration, light and electron microscopy, histochemistry, and immunohistochemistry

A 32-year-old Caucasian man presented with a tumor in the right side of the neck. Preoperative fine-needle aspiration showed large multinucleated cells with abundant granular cytoplasm that were consonant with the features of a granular cell tumor. At surgery, two separate tumors were found. Histologically, the tumor proved to be an adult rhabdomyoma, the 11th such multifocal case reported. The striated muscle origin of this benign tumor was confirmed by immunohistochemical and ultrastructural studies. The tumor cells were desmin-, myoglobin-, and actin-positive. They showed variable numbers of thick and thin filaments, as well as hypertrophic Z-band material. Histochemical studies showed the presence of basophilic muscle cells, vesicular nuclei, ragged red fibers, and diffuse acid phosphatase positivity. These features, together with the absence of actual muscle cell proliferation and the assumption that the mass of the tumor could be explained by the enormous swelling of the muscle cells, lead us to conclude that an adult rhabodomyoma is merely the result of a process of disorderly degeneration and regeneration rather than a real neoplasm or a hamartomatous lesion.

Ileal pouch-anal anastomosis without rectal muscular cuff

Twenty patients underwent proctocolectomy followed by an ileal pouch-anal anastomosis. The rectum was mobilized in the intersphincteric plane and transected at the level of the dentate line. As a consequence, a rectal cuff, which is considered by some to be important for the maintenance of anal continence, was not left behind. All patients were continent. Manometric data demonstrated no difference compared to a group of 21 patients with a conventional mucosectomy. Nearly half of the patients in both groups had a positive recto-anal inhibitory reflex. As a rectal cuff is not essential for maintaining continence, the receptors of the rectoanal inhibitory reflex are probably located outside the rectal wall.

Intestinal endocrine cells in radiation enteritis

In this study, the intestinal endocrine cells were investigated in 13 surgical specimens affected by radiation enteritis. Endocrine cells were studied by means of Grimelius' silver staining and immunostaining for chromogranin, a general marker of endocrine cells. Positively stained cells were quantified by counting their number per unit length of muscularis mucosa. Results in radiation enteritis were compared with matched control specimens by using Student's t test. Chromogranin immunostaining showed a statistically significant increase of endocrine cells in radiation enteritis specimens compared with controls both in small and large intestine (ileum, 67.5 +/- 23.5 cells per unit length of muscularis mucosa in radiation enteritis versus 17.0 +/- 6.1 in controls; colon, 40.9 +/- 13.7 cells per unit length of muscularis mucosa in radiation enteritis versus 9.5 +/- 4.1 in controls--p less than 0.005 in both instances). Increase of endocrine cells was demonstrated also by Grimelius' staining; however, without reaching statistical significance. It is not clear whether or not the increase of endocrine cells in radiation enteritis reported in this study is caused by a hyperplastic response or by a sparing phenomenon. We should consider that increased endocrine cells, when abnormally secreting their products, may be involved in some of the clinical features of radiation enteropathy. In addition, as intestinal endocrine cells produce trophic substances to the intestine, their increase could be responsible for the raised risk of developing carcinoma of the intestine in long standing radiation enteritis.

Long-term follow-up after colectomy and ileorectal anastomosis in familial adenomatous polyposis coli. Is there still a place for the procedure?

Forty-four patients with familial adenomatous polyposis coli treated with colectomy and ileorectal anastomosis were studied. Mean age at operation was 27 years. The mean follow-up period was 10 years (median 8 years). Three patients (7%) developed rectal cancer 1, 4, and 24 years after the initial operation, respectively. Proctectomy with ileostomy was performed in one patient, and 7 patients underwent a conversion to an ileoanal procedure for an increasing number of rectal polyps in the rectum stump. Although frequent bowel actions and episodes of diarrhea were common findings in patients after colectomy and ileorectal anastomosis, almost all patients (96%) were more or less satisfied with their quality of life after the procedure. On the basis of our results and the results reported in the literature, colectomy with ileorectal anastomosis is still the operation of choice in selected patients with familial adenomatous polyposis coli. An initial ileal pouch - anal anastomosis, or a conversion to such a procedure after colectomy and ileorectal anastomosis is indicated, depending on the number and size of rectal polyps.

One-stage colectomy and ileorectal anastomosis for complete left-sided obstruction of the colon

Fourteen patients with complete left-sided obstruction of the colon were treated by a one-stage emergency colectomy and primary ileorectal anastomosis. One patient died from anastomotic leakage. In selected patients the method should be considered as an alternative to the staged procedure.

Increased populations of endocrine cells in Crohn's ileitis

Hyperplasia of nerves has been described previously in Crohn's disease. To determine whether similar alteration of the enteric endocrine system occurs, endocrine cells of the ileal epithelium were quantified in typical cases of the disease. In the ileum from patients with Crohn's disease, there was an increase in the endocrine cell population, as visualised by immunostaining of chromogranin. Quantification of endocrine cell numbers showed significant increases in both macroscopically uninvolved (i.e. histologically normal) (35.0 +/- 3.8, cells per unit length of muscularis mucosae mean +/- SEM, P less than 0.05) and involved (44.5 +/- 5.5, P less than 0.01) Crohn's disease samples, compared with normal controls (23.7 +/- 3.4). Although individual types of endocrine cell showed slight increases in Crohn's samples, only the enterochromaffin cells in abnormal bowel showed a significantly greater population (normal controls 10.5 +/- 2.3; involved Crohn's 21.3 +/- 4.4, P less than 0.05).

The Hartmann procedure: its role in acute complicated diverticulitis

A retrospective study of 38 patients with Hartmann procedure for acute complicated diverticulitis. Two patients died. Continuity was restored in 30 patients (30/36). With the present mortality (2/38) and a rather low morbidity, the Hartmann procedure can be recommended in acute complicated diverticulitis.

Kimura's disease in the spermatic cord, an unusual site of a rare tumor

Kimura's disease is a rare, but well-defined clinical and histologic entity, classified under the term angiolymphoid hyperplasia with eosinophilia. A patient with a tumor in the spermatic cord is described, presenting a unique case of Kimura's disease involving the spermatic cord.

Henri Hartmann, lord of the Hôtel-Dieu

As assistant to Professor Terrier, Henri Hartmann (1860-1952) completed his surgical training at the Hôpital Bichat in Paris, where he was later to become Chief-Surgeon. In 1909 he was appointed Professor of Surgery in the Faculty of Medicine, and in 1914 he became head of the surgical clinic of the Hôtel-Dieu in Paris. It was in 1921 that Hartmann proposed the operation that thereafter was to bear his name. He reported on two patients with an obstructive carcinoma of the sigmoid colon, who, after having received a proximal colostomy, underwent resection with closure of the rectal stump as cul de sac. The operative procedure is described in Hartmann's book Chirurgie du rectum, which was published in 1931. Hartmann retired in 1930, greatly respected both in his own country and abroad.

Primary closure of the perineum and vacuum drainage after abdominoperineal excision

From retrospective study of the case records of 62 consecutive patients from whom 58 underwent abdominoperineal rectal excision for malignant or inflammatory bowel disease, it was found that management with primary closed perineum and closed pelvic peritoneum with closed vacuum drainage results in 84% primary perineal healing and short hospitalization. Perineal wounds were healed in 93% of patients within one month. Adequate exclusion of three sepsis promoting factors, e.g. dead space, devitalized tissue and micro-organisms should preclude perineal sepsis. The need for precise positioning of a large bore vacuum drain, Ch. 27, through a preoperatively determined stab-wound on the medial side of the thigh is stressed. To guarantee optimal drainage a three-stage procedure is required in a one-team management. The procedure is well tolerated as a palliation; patients with pre-existing massive perineal sepsis should be excluded.

Pre-operative whole-gut irrigation with mannitol

Whole-gut irrigation preceded by oral mannitol administration as a method of preoperative bowel preparation was studied in 58 patients. Our results did not confirm the advantages described in the literature. Irrigation time, irrigation fluid volume, patient acceptability and the quality of bowel preparation were not improved, compared to our earlier studies with saline alone. Fluid retention was considerably diminished after mannitol preparation. A significant increase in postoperative septic complications was observed. Disadvantages and possible hazards of mannitol administration are discussed. Mannitol cannot be recommended as a safe and useful adjunct in whole-gut irrigation.