Feasibility and Safety of Laparoscopic D2 Gastrectomy in Combination with Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in Patients with Gastric Cancer at High Risk of Recurrence-The PIPAC-OPC4 Study

BACKGROUND

Patients with gastric adenocarcinoma (GAC) are at high risk of peritoneal recurrence despite perioperative chemotherapy and radical resection. This study evaluated feasibility and safety of laparoscopic D2 gastrectomy in combination with pressurized intraperitoneal aerosol chemotherapy (PIPAC).

METHODS

This was a prospective, controlled bi-institutional study in patients with GAC at high risk of recurrence treated with PIPAC with cisplatin and doxorubicin (PIPAC C/D) after laparoscopic D2 gastrectomy. High risk was defined as a poorly cohesive subtype with predominance of signet-ring cells, clinical stage ≥ T3 and/or ≥ N2, or positive peritoneal cytology. Peritoneal lavage fluid was collected before and after resection. Cisplatin (10.5 mg/m²) and doxorubicin (2.1 mg/m²) were aerosolized after anastomosis (flow 0.5-0.8 ml/s, maximum pressure 300 PSI). Treatment was feasible and safe if ≤ 20% had Dindo-Clavien ≥ 3b surgical complications or CTCAE ≥ 4 medical adverse events within 30 days. Secondary outcomes were length of stay (LOS), peritoneal lavage cytology, and completion of postoperative systemic chemotherapy.

RESULTS

Twenty-one patients were treated with a D2 gastrectomy and PIPAC C/D. The median age was 61 years (range 24-76), there were eleven female patients, and 20 patients had preoperative chemotherapy. There was no mortality. Two patients had grade 3b complications that were potentially related to PIPAC C/D (one anastomotic leakage, and one late duodenal blow-out). One patient had severe neutropenia, and nine patients had moderate pain. The LOS was 6 days (4-26). One patient had positive peritoneal lavage cytology before resection, and none were positive after. Fifteen patients had postoperative chemotherapy.

CONCLUSIONS

Laparoscopic D2 gastrectomy in combination with PIPAC C/D is feasible and safe.

Treatment of Peritoneal Metastasis with Pressurized Intraperitoneal Aerosol Chemotherapy: Results from the Prospective PIPAC-OPC2 Study

BACKGROUND

Pressurized Intraperitoneal Aerosol chemotherapy (PIPAC) is a local treatment for peritoneal metastasis (PM). Prospective data are scarce and evaluation of treatment response remains difficult. This study evaluated the use of the Peritoneal Regression Grading score (PRGS) and its prognostic value.

PATIENTS AND METHODS

This was a prospective, controlled phase II trial in patients with PM from gastrointestinal, gynaecological, hepatopancreatobiliary, primary peritoneal, or unknown primary cancer. Patients in performance status 0-1, with a non-obstructed gastrointestinal tract, and a maximum of one extraperitoneal metastasis were eligible. Colorectal or appendiceal PM had PIPAC with oxaliplatin, other primaries had PIPAC with cisplatin and doxorubicin. Biopsies were taken at each PIPAC and evaluated using the PRGS. Quality-of-life questionnaires were reported at baseline and after three PIPACs.

RESULTS

One hundred ten patients were treated with 336 PIPACs (median 3, range 1-12). One hundred patients had prior palliative chemotherapy and 45 patients received bidirectional treatment. Complete or major histological response to treatment (PRGS 1-2) was observed in 38 patients (61%) who had three PIPACs, which was the only independent prognostic factor in a multivariate analysis. The median overall survival (mOS) from PIPAC 1 was 10 months, while patients with PM from gastric, colorectal, and pancreatic cancer had a mOS of 7.4, 16.7, and 8.2 months, respectively. Global health scores were significantly reduced, but patients were less fatigued, nauseated, constipated, and had better appetite after three PIPACs.

CONCLUSIONS

PIPAC with oxaliplatin or cisplatin and doxorubicin was able to induce a major or complete histological response during three PIPACs, which may provide significant prognostic information, both at baseline and after treatment.

Bleeding after percutaneous coronary intervention and selection of candidates for long-term dual antithrombotic treatment

Background

The European Society of Cardiology recommends addition of a second antithrombotic drug (a P2Y12 inhibitor or rivaroxaban 2.5 mg twice daily) on top of aspirin in selected patients with chronic coronary syndrome (CCS) at high residual risk of ischemic events. However, this treatment increases bleeding risk, and identifying subsets of patients with the most favorable trade-off between ischemic and bleeding risk thus is essential. We hypothesized that patients undergoing percutaneous coronary intervention (PCI) who tolerate subsequent dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) without any bleeding complications selected themselves as candidates for prolonged dual antithrombotic therapy.

Methods and results

We included 30,531 patients with CCS treated with dual antiplatelet therapy after first-time PCI with a drug-eluting stent in Western Denmark (3.5 million inhabitants) from 1999 to 2018. Of these, 1,220 (4%) were hospitalized for bleeding within one year after PCI (bleeders) and 29,311 (96%) were not (non-bleeders). Patients were followed for maximum nine years (median follow-up 5.4 years). Bleeders had an increased nine-year risk of death (adjusted hazard ratio [aHR] 1.54, 95% CI 1.37–1.73) and hospitalization for bleeding (aHR 2.53, 95% CI 2.20–2.90). These associations were particularly strong for women. Looking at types of bleeding, the strongest predictors of death were gastrointestinal bleeding, cerebral bleeding, and anemia due to bleeding. Risks of myocardial infarction and ischemic stroke did not differ between bleeders and non-bleeders (Table). We then stratified non-bleeders according to their thromboembolic risk using the CHADS-P2A2RC score – a validated clinical risk prediction model developed to estimate thromboembolic risk in patients without atrial fibrillation. Non-bleeders with a high estimated thromboembolic risk (CHADS-P2A2RC score ≥4) had higher nine-year risks of myocardial infarction (hazard ratio [HR] 1.88, 95% CI 1.78–2.07), ischemic stroke (HR 3.02, 95% CI 2.66–3.43), hospitalization for bleeding (HR 1.98, 95% CI 1.81–2.16) and, in particular, death (HR 4.48, 95% CI 4.21–4.77) than non-bleeders with a low-to-moderate predicted risk (CHADS-P2A2RC score <4).

Conclusions

Patients with CCS experiencing a bleeding event during the first year after first-time PCI had a substantially higher long-term risk of death and recurrent bleeding, but not a higher risk of ischemic events. Therefore, bleeding events during the first year after PCI may guide the preclusion of selected patients from long-term dual antithrombotic therapy. Among non-bleeders, the risk of ischemic events rose proportionately more than the risk of bleeding when comparing high-risk with low-risk patients. This is an important finding for clinicians, for whom accurate identification of patients at highest risk of ischemic events is an essential step in treatment allocation.

Funding Acknowledgement

Type of funding sources: None.

Coronary artery disease is a stronger predictor of mortality than left ventricular ejection fraction among newly diagnosed patients with heart failure

Background

Heart failure (HF) prevalence remains high and prognosis is poor despite improvements in both medical treatment and implantation of primary prophylactic implantable cardioverter-defibrillator (ICD) and cardiac resynchronisation therapy (CRT) devices. At present, classification of HF and treatment algorithms are determined by the left ventricular ejection fraction (LVEF). However, in patients with LVEF <50% and newly diagnosed HF, evidence remains sparse as to whether LVEF per se or presence of CAD provide independent prognostic information on mortality.

Methods

Using the Western Denmark Heart Registry, we identified newly diagnosed patients with HF and LVEF 10–49% undergoing first-time coronary angiography (CAG) from 2003 to 2016 referred due to HF. Patients were stratified by LVEF (10–35% vs. 36–49%, according as to whether primary prophylactic ICD and CRT treatment should be considered) and presence of coronary artery disease (CAD). Maximum follow-up was 10 years. We estimated 10-year cumulative incidence of death and calculated hazard ratios (HR) adjusted for relevant comorbidities and risk factors.

Results

Of 154,186 Western Danish residents undergoing CAG, 3,620 patients had HF and LVEF 10–49%. Among these, 2,780 (77%) patients had LVEF 10–35% and 840 (23%) patients had LVEF 36–49%. CAD was present in 1,592 (44%) patients.

There was a potential association in 10-year mortality when comparing patients with HF and LVEF 36–49% to those with LVEF 10–35% (37.3% vs. 42.1%, HR 1.15; 95% CI 0.99–1.34) (Figure 1A), with point estimates of mortality ranging from being 1% reduced to 24% increased. This result was not strongly influenced by the presence of CAD (HR 1.11; 95% CI 0.91–1.35) or absence of CAD (HR 1.24; 95% CI 0.97–1.57) (Figure 1B). There was no trend between LVEF categorized by 5-percentiles and mortality (p for trend = 0.24) (Table 1). In contrast, CAD was more strongly associated with increased 10-year mortality (55.0% vs. 31.5%, HR 1.43; 95% CI 1.25–1.64) irrespective of LVEF (Figure 1B).

Conclusion

Among newly diagnosed patients with HF and LVEF 10–49%, presence of CAD impacts mortality substantially more than LVEF per se. These results emphasize that assessment of CAD is pivotal for prognostication of newly diagnosed patients with HF and LVEF 10–49%.

Funding Acknowledgement

Type of funding sources: None.

Marital status, cardiovascular events, and intensive blood pressure lowering among men and women in the Systolic Blood Pressure Intervention Trial

Background

Married persons may have lower rates of mortality and cardiovascular disease (CV) than unmarried persons although data regarding potential differences between men and women are conflicting. The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced CV morbidity and mortality in high-risk patients. We hypothesized that marital status would influence CV event risk and the impact of intensive BP control, and that these effects would vary according to sex.

Purpose

To assess the risks of CV events and mortality according to marital status in a high-risk population, and to assess if marital status modified the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled, open-label trial of 9361 individuals at high CV risk, at least 50 years of age, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to either intensive or standard BP control and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. Secondary efficacy endpoints included the individual components of the primary endpoint and all-cause death. Event risk according to marital status, including variation of the effects of intensive BP control, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. The group of subjects who were married or living in a marriage-like relationship served as baseline.

Results

Information on marital status was available for 8762 (93.6%) individuals. A total of 4863 (55.5%) were married or in a marriage-like relationship, 3149 (35.9%) were widowed, divorced, or separated, and 750 (8.6%) were never married. Marital status did not differ between patients randomized to intensive versus standard BP control (P=0.51). The risk of the primary endpoint was not significantly affected by marital status (P>0.05), in neither men nor women (P-interaction>0.05). The same was true for its individual components except the risk of CV death which was higher among never married men (adjusted hazard ratio [aHR], 3.29, 95% confidence interval [CI]: 1.34–8.09; P=0.009; P-sex-interaction=0.99). The risk of all-cause death was higher among widowed, divorced, or separated men (aHR, 1.90, 95% CI: 1.35–2.67; P<0.001) and among never married men (aHR, 2.53, 95% CI: 1.51–4.26; P<0.001), but not women belong to these groups (P>0.05; P-sex-interaction=0.24) (Figure). Associations were not modified by age (P-interaction>0.05). Marital status did not modify the effect of intensive BP control for any of the endpoints (P-interaction>0.05).

Conclusions

In SPRINT, never married men had higher risks of both CV death and all-cause death while widowed, divorced, or separated men had a higher risk of all-cause death. The risks and benefits of intensive BP control were not affected by marital status.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Greater event rates in high-risk patients with a history of heart disease: from the Systolic Blood Pressure Intervention Trial (SPRINT)

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in patients at high CV risk. Effects were consistent among patients with and without prevalent CV disease. However, it is unknown whether the benefits and risks of intensive BP control are affected by the specific type of heart disease.

Purpose

To assess the risks of incident CV events and safety events in patients with individual types of heart disease, and to assess if the presence of heart disease modified the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled trial comprising 9,361 individuals ≥50 years of age at high CV risk, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to intensive or standard BP control. The primary efficacy endpoint was the composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events. We assessed event risk in patients with self-reported heart disease versus those without and further assessed the safety and efficacy of intensive BP control, including relevant interactions, in these individuals, using multivariable Cox proportional-hazards regression.

Results

Of 9361 participants, 326 (3.5%) reported a history of congestive heart failure, 760 (8.1%) of myocardial infarction, 1206 (12.9%) of angina, and 1830 (19.6%) of atrial fibrillation, atrial flutter, or irregular heartbeat. The prevalence of these conditions did not significantly differ between patients randomized to intensive versus standard BP control (P>0.05 for all). At median 3.2 years (range 0–4.8 years), congestive heart failure (adjusted hazard ratio [aHR], 1.94, 95% confidence interval [CI], 1.45–2.61; P<0.001), myocardial infarction (aHR, 1.73, 95% CI, 1.33–2.25; P<0.001), angina (aHR, 1.41, 95% CI, 1.09–1.84; P=0.01), and atrial fibrillation, atrial flutter, or irregular heartbeat (aHR, 1.36, 95% CI, 1.12–1.64; P=0.002) were all independently associated with the primary endpoint (Figure). All conditions except prior myocardial infarction were also associated with composite serious adverse events (P=0.24 for myocardial infarction, P<0.05 for all others). A history of angina modified the efficacy of intensive versus standard BP control, i.e., patients without angina appeared to benefit from intensive BP control (aHR, 0.66, 95% CI, 0.54–0.80; P<0.001) while those with angina did not (aHR, 1.04, 95% CI, 0.76–1.44; P=0.80) (P=0.02 for interaction). No significant interactions were detected for the primary safety endpoint.

Conclusions

In SPRINT, a history of any type of heart disease was associated with a greater risk for both efficacy and safety events. Patients with angina did not appear to derive benefit from intensive BP control.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Primary health insurance and cardiovascular outcomes in the systolic blood pressure intervention trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in high-risk patients. Although antihypertensive therapies were provided at no cost to trial participants, patients were covered by various entities. Insurance coverage provides a unique dimension of risk assessment and may provide additional prognostic information in this setting.

Purpose

To assess the risks of incident CV events and safety events in a high CV risk population according to type of health insurance, and to assess if insurance type interacted with the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled trial conducted across 102 US sites of 9,361 high-risk adults ≥50 years, without diabetes, and with a systolic BP 130–180 mmHg at screening. Study participants were randomized to intensive (target systolic BP <120mmHg) or standard BP control (target systolic BP <140mmHg) and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. The primary safety endpoint was the composite of serious adverse events. The risk of efficacy and safety events according to type of health insurance, including the effect of intensive BP control in each subgroup, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. Private/other insurance type served as the reference group.

Results

Of 9361 participants, 3980 (42.5%) were covered by private/other insurance, 1483 (15.8%) by a Veterans Affairs (VA) health plan, 2691 (28.8%) by Medicare, 207 (2.2%) by Medicaid, and 1000 (10.7%) were uninsured. Insurance coverage distribution was well-balanced between the two study arms (P>0.05). Compared with patients who had private/other insurance, the risk of the primary endpoint was significantly higher among Medicaid beneficiaries (adj. hazard ratio [HR], 1.81, 95% confidence interval [CI], 1.09–3.00; P=0.02). The risk of death was similarly highest among Medicaid patients (adj. HR, 2.08, 95% CI, 1.08–4.02; P=0.03) and was also significantly higher among VA patients (adj. HR, 1.49, 95% CI, 1.11–2.99; P=0.008) (Figure). Serious adverse events were more common in the VA population (HR, 1.12, 95% CI, 1.01–1.23; P=0.03). Insurance type did not modify the efficacy and safety of intensive BP control (P>0.05 for all interactions).

Conclusions

In SPRINT, Medicaid beneficiaries were at significantly greater risk for experiencing a primary CV event. Medicaid patients and VA patients both had higher mortality than those covered by private/other insurance. The risks and benefits of intensive BP control were not affected by insurance type.

Funding Acknowledgement

Type of funding sources: None. Risk of death and health insurace type

Local peritoneal toxicity from adjuvant pressurized intraperitoneal aerosol chemotherapy with oxaliplatin in high-risk patients with colonic cancer

This research letter describes unexpected and unacceptable local toxicity manifesting as abdominal pain after adjuvant pressurized intraperitoneal aerosol chemotherapy with 92 mg/m2 oxaliplatin in the PIPAC-OPC3 study. It is not clear whether the toxicity is dose- or drug-dependent (or both), but the preliminary data suggest that tolerability is improved by dose reduction to 46 mg/m2.

Value of regular endosonography and [18F]fluorodeoxyglucose PET-CT after surgery for gastro-oesophageal junction, stomach or pancreatic cancer

BACKGROUND

Most patients undergo follow-up after surgery for cancers of the gastro-oesophageal junction, stomach or pancreas, but data to support which modalities to use and the frequency of investigation are limited.

METHODS

Patients in the EUFURO study were randomized to either visits to the outpatient clinic at 3, 6, 9, 12, 18, and 24 months after surgery (standard), or to the addition of [18F]fluorodeoxyglucose (FDG) PET-CT and endoscopic ultrasonography (EUS) with guided fine-needle aspiration biopsy to clinical assessments (intervention). Data from the intervention arm were used to analyse the diagnostic performance of endosonography or [18F]FDG PET-CT in detecting recurrences.

RESULTS

During the scheduled follow-up, 42 of 89 patients developed recurrence; PET-CT and EUS in combination detected 38 of these recurrences. EUS detected 23 of the 42 patients with recurrent disease during follow-up and correctly diagnosed 17 of 19 locoregional recurrences. EUS was able to detect isolated locoregional recurrence in 11 of 13 patients. In five patients, EUS was false-positive for isolated locoregional recurrence owing to missed distant metastases. PET-CT detected locoregional recurrence in only 12 of 19 patients, and isolated locoregional recurrence in only 7 of 13. False-positive PET-CT results in 23 patients led to a total of 44 futile procedures.

CONCLUSION

Accuracy in detecting recurrences by concomitant use of PET-CT and EUS was high (90 per cent). PET-CT had moderate to high sensitivity for overall recurrence detection, but low specificity. EUS was superior to PET-CT in the detection of locoregional and isolated locoregional recurrences.

Intraoperative ultrasound imaging in the surgical treatment of congenital hyperinsulinism: prospective, blinded study

Background

In congenital hyperinsulinism (CHI), preoperative prediction of the histological subtype (focal, diffuse, or atypical) relies on genetics and 6-[¹⁸F]fluoro-l-3,4-dihydroxyphenylalanine (¹⁸F-DOPA) PET–CT. The scan also guides the localization of a potential focal lesion along with perioperative frozen sections. Intraoperative decision-making is still challenging. This study aimed to describe the characteristics and potential clinical impact of intraoperative ultrasound imaging (IOUS) during CHI surgery.

Methods

This was a prospective, observational study undertaken at an expert centre over a 2-year interval. IOUS was performed blinded to preoperative diagnostic test results (genetics and ¹⁸F-DOPA PET–CT), followed by unblinding and continued IOUS during pancreatic resection. Characteristics and clinical impact were assessed using predefined criteria.

Results

Eighteen consecutive, surgically treated patients with CHI, with a median age of 5.5 months, were included (focal 12, diffuse 3, atypical 3). Focal lesions presented as predominantly hypoechoic, oval lesions with demarcated or blurred margins. Patients with diffuse and atypical disease had varying echogenicity featuring stranding and non-shadowing hyperechoic foci in three of six, whereas these characteristics were absent from those with focal lesions. The blinded IOUS-based subclassification was correct in 17 of 18 patients; one diffuse lesion was misclassified as focal. IOUS had an impact on the surgical approach in most patients with focal lesions (9 of 12), and in those with diffuse (2 of 3) and atypical (2 of 3) disease when the resection site was close to the bile or pancreatic duct.

Conclusion

Uniform IOUS characteristics made all focal lesions identifiable. IOUS had a clinical impact in 13 of 18 patients by being a useful real-time supplementary modality in terms of localizing focal lesions, reducing the need for frozen sections, and preserving healthy tissue and delicate structures.

The role of home visits by a nurse to improve palliation in patients treated with self-expandable metallic stents due to incurable esophageal cancer

Self-expandable metallic stent (SEMS) is a preferred option to relieve dysphagia and to palliate patients with incurable esophageal or gastro-esophageal junction (GEJ) cancer. Health Related Quality of Life (QoL) represents a clinically relevant outcome measure in research focused on palliation of patients with advanced GI cancer. In this context, home visits by a nurse carry the potential to offer important advantages. Eighty patients with incurable esophageal or GEJ cancer were randomized to either standard follow up or to an intervention containing regular home visits by a nurse. The primary outcome variable QoL was assessed by EORTC QLQ-C30 and OES-18 before insertion of SEMS, and at 2, 7 and 12 weeks thereafter. Secondary outcomes were; need for re-interventions, number of patients receiving palliative oncological therapy and overall survival. Sixty-six males and 13 females, with a median age of 71, were included. Self-reported overall QoL was significantly higher in the intervention group (P = 0.03). The organ specific module OES-18 revealed a significant reduction in dysphagia by the intervention (P = 0.03) as well as fewer eating disabilities (P = 0.04). No differences were observed in secondary outcomes except for overall survival, where the median survival was increased from 114 to 183 days by the active intervention (P = 0.02). Home visits by a nurse seem to play an important palliative role after placement of SEMS in patients with incurable esophageal or GEJ cancer by improving QoL and may carry the potential to increase overall survival.

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) of peritoneal metastasis from gastric cancer: a descriptive cohort study

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) represents a novel approach to deliver intraperitoneal chemotherapy. We report our experience with PIPAC in patients with peritoneal metastasis (PM) from gastric cancer (GC). Data from GC patients (n = 20) included in the prospective PIPAC-OPC1 and PIPAC-OPC2 studies are reported. All patients had received prior systemic chemotherapy. The mean peritoneal cancer index (PCI) was 10.5 (range 0-39) and nine patients had diffuse GC. PIPAC with cisplatin 7.5 mg/m² and doxorubicin 1.5 mg/m² were administered at 4-6-week intervals. Outcome criteria were objective tumour response, survival and adverse events. Twenty patients had 52 PIPAC procedures with a median follow-up of 10.4 months (3.3-26.5). Median survival from the time of PM diagnosis and after the first PIPAC procedure was 11.5 months and 4.7 months, respectively. Fourteen patients had repeated PIPAC (> 2), and the objective tumour response according to the histological peritoneal regression grading score (PRGS) was observed in 36%, whereas 36% had stable disease. Ten patients completed the three prescheduled sessions (per protocol group) and 40% of those displayed an objective tumour response, while 20% had stable disease. Only minor postoperative complications were noted, and none were considered causally related to the PIPAC treatment. PIPAC with low-dose cisplatin and doxorubicin can induce a quantifiable objective tumour response in selected patients with PM from GC. Survival data are encouraging and warrant further clinical studies.

Phase II randomized clinical trial of endosonography and PET/CT versus clinical assessment only for follow-up after surgery for upper gastrointestinal cancer (EUFURO study)

Background

Upper gastrointestinal malignancies have a poor prognosis. There is no consensus on how patients should be followed after surgery. The authors hypothesized that a structured follow-up programme including endoscopic ultrasonography (EUS) and [18F]fluorodeoxyglucose (FDG) PET/CT would detect cancer recurrences, leading to more patients being eligible for therapy.

Methods

After surgery with curative intent for adenocarcinomas in the gastro-oesophageal junction, stomach or pancreas, patients were randomized 1 : 1 to standard clinical assessment in the outpatient clinic at 3, 6, 9, 12, 18 and 24 months after operation, or clinical assessment plus imaging including [18F]FDG PET/CT and EUS. The primary endpoint was number of patients receiving oncological treatment for recurrence. Secondary endpoints were overall and progression-free survival, survival after recurrence detection of isolated locoregional recurrences and risk factors affecting survival.

Results

In total, 183 patients were enrolled, including 93 who underwent standard follow-up and 90 who had follow-up plus imaging. A recurrence was detected in 84 patients within 2 years after surgery (42 in each group), including 33 of 42 patients in the imaging group who were asymptomatic. Some 25 of 42 patients in the imaging group and 14 of 42 in the standard group received chemotherapy (P = 0·028). Although survival after detection of recurrence in asymptomatic patients was significantly longer than that for symptomatic patients (P < 0·001), overall survival from date of surgery in the two treatment groups was comparable.

Conclusion

Follow-up after surgery for upper gastrointestinal cancer with EUS and PET/CT leads to detection of more asymptomatic cancer recurrences and patients referred for treatment without prolonging overall survival. Registration number: NCT02209415 (http://www.clinicaltrials.gov).

Multicentre study of multidisciplinary team assessment of pancreatic cancer resectability and treatment allocation

BACKGROUND

Multidisciplinary team (MDT) meetings have been adopted widely to ensure optimal treatment for patients with cancer. Agreements in tumour staging, resectability assessments and treatment allocation between different MDTs were assessed.

METHODS

Of all patients referred to one hospital, 19 patients considered to have non-metastatic pancreatic cancer for evaluation were selected randomly for a multicentre study of MDT decisions in seven units across Northern Europe. Anonymized clinical information and radiological images were disseminated to the MDTs. All patients were reviewed by the MDTs for radiological T, N and M category, resectability assessment and treatment allocation. Each MDT was blinded to the decisions of other teams. Agreements were expressed as raw percentages and Krippendorff's α values, both with 95 per cent confidence intervals.

RESULTS

A total of 132 evaluations in 19 patients were carried out by the seven MDTs (1 evaluation was excluded owing to technical problems). The level of agreement for T, N and M categories ranged from moderate to near perfect (46·8, 61·1 and 82·8 per cent respectively), but there was substantial variation in assessment of resectability; seven patients were considered to be resectable by one MDT but unresectable by another. The MDTs all agreed on either a curative or palliative strategy in less than half of the patients (9 of 19). Only fair agreement in treatment allocation was observed (Krippendorff's α 0·31, 95 per cent c.i. 0·16 to 0·45). There was a high level of agreement in treatment allocation where resectability assessments were concordant.

CONCLUSION

Considerable disparities in MDT evaluations of patients with pancreatic cancer exist, including substantial variation in resectability assessments.

Severe peritoneal sclerosis after repeated pressurized intraperitoneal aerosol chemotherapy with oxaliplatin (PIPAC OX): report of two cases and literature survey

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new laparoscopic administration of chemotherapy for peritoneal metastasis (PM). PIPAC is repeated every 5th week, and seems to stabilize or improve quality of life, and might improve survival. So far, PIPAC has been well tolerated. With this paper, we aim to highlight a potential severe adverse reaction, as we describe the first cases of severe peritoneal sclerosis (SPS) caused by PIPAC. Patients with isolated PM were included in a prospective PIPAC protocol. Following insufflation of normothermic CO₂, laparoscopy was performed at an intraabdominal pressure of 12 mmHg. After peritoneal lavage and quadrant biopsies of the PM, the patients were treated with oxaliplatin 92 mg/m² (flowrate 0.5 ml/s, maximum pressure of 200 per square inch). Treatment related toxicity was evaluated after 2 weeks. Response was evaluated histologically by the Peritoneal Regression Grading Score (PRGS) and cytologically by analysis of the lavage fluid. In a series of 24 PIPAC patients treated with oxaliplatin, two patients developed SPS. Patient one had a mucinous adenocarcinoma of the appendix with PM, the mean PRGS was reduced from 2.75 to 1.75 during the course of therapy. Patient two had an appendiceal goblet cell carcinoid with a dominating mucinous adenocarcinoma component with PM, the mean PRGS was reduced from 2.00 to 1.67. Repeated applications of PIPAC with oxaliplatin can lead to SPS.

Randomized clinical trial of laparoscopic ultrasonography before laparoscopic colorectal cancer resection

BACKGROUND

Intraoperative ultrasonography during open surgery for colorectal cancer may be useful for the detection of unrecognized liver metastases. Laparoscopic ultrasonography (LUS) for the detection of unrecognized liver metastasis has not been studied in a randomized trial. This RCT tested the hypothesis that LUS would change the TNM stage and treatment strategy.

METHODS

Patients with colorectal cancer and no known metastases were randomized (1 : 1) to laparoscopic examination (control or laparoscopy plus LUS) in three Danish centres. Neither participants nor staff were blinded to the group assignment.

RESULTS

Three hundred patients were randomized, 150 in each group. After randomization, 43 patients were excluded, leaving 128 in the control group and 129 in the LUS group. Intraoperative T and N categories were not altered by LUS, but laparoscopy alone identified previously undetected M1 disease in one patient (0·8 per cent) in the control group and three (2·3 per cent) in the LUS group. In the latter group, LUS suggested that an additional six patients (4·7 per cent) had M1 disease with liver (4) or para-aortal lymph node (2) metastases. The change in treatment strategy was greater in the LUS than in the control group (7·8 (95 per cent c.i. 3·8 to 13·8) and 0·8 (0 to 4·2) per cent respectively; P = 0·010), but the suspected M1 disease was benign in half of the patients.

CONCLUSION

Routine LUS during resection of colorectal cancer is not recommended. Registration number: NCT02079389 (http://www.clinicaltrials.gov).

Abstract P2-12-06: Prevention of seroma formation after mastectomy by local methylprednisolone injection - A randomized controlled clinical trial

Objective: To investigate the effect of local steroid administration on seroma formation until 14 days of dryness.

Background: Seroma formation, the most prevalent postoperative complication after mastectomy, is an inflammatory process that is potentially preventable via local steroid administration.

Methods: This double-blind, randomized, placebo-controlled intervention study included 212 women who were scheduled for mastectomy for primary breast cancer. The patients were classified according to the surgical axillary procedure: mastectomy with sentinel lymph node biopsy (M+SLNB) or mastectomy with level I-II axillary lymph node dissection (M+ALND). The participants received either 80 mg of methylprednisolone or saline intracavitary via the drain orifice upon drain removal.

Results: After M+SLNB, 46% (32 of 69) of the patients developed seromas in the steroid group vs. 78% (52 of 67) in the saline group (p<0.0001). The mean cumulative seroma volume in the intention-to-treat material for the first 10 and 30 days was significantly lower in the steroid group than in the saline group (24 vs.127 mL and 177 vs. 328 mL, respectively) (p<0.0001). After M+ALND, 94% of the patients developed seromas in both the steroid (35 of 37) and saline (34 of 36) groups, and steroid administration displayed no significant effect on seroma formation. Additionally, no difference in the infection rate was observed.

Conclusion: Methylprednisolone administered intracavitary on the first postoperative day after M+SLNB exerted a highly significant preventive effect against seroma formation during the first 30 days. Future studies may clarify whether higher or repeated steroid doses enhance these effects.

Citation Format: Qvamme G, Axelsson CK, Lanng C, Wegeberg B, Mortensen MB, Okholm M, Arpi MR, Szecsi PB. Prevention of seroma formation after mastectomy by local methylprednisolone injection - A randomized controlled clinical trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-06.

The incidence and prognosis of true duodenal carcinomas

INTRODUCTION

Primary duodenal carcinoma (PDC) is a rare gastrointestinal tumor. The difficult distinction between PDC and other types of carcinoma (e.g. within the periampullary region) is reflected in the scarce literature on true duodenal carcinomas. However, this distinction may be important in relation to the overall prognosis as well as in the choice of adjuvant or palliative treatment strategies. The aim of this study was to evaluate the incidence, management and prognosis of patients with true PDC within a well-defined geographical area.

METHODS

Retrospective analysis of all patients diagnosed with true PDC from 1997 to 2012 within the Region of Southern Denmark. Only patients where the surgeon and the pathologist agreed on the tumor being classified as originating from the duodenum were included.

RESULTS

Seventy-one patients (43 M, 28 F) with a mean age of 67 years (range 35-87) met the criteria for true PDC. The incidence was 5.4 per 1,000,000, and the pathological classification was: Adenocarcinoma 87%, mucinous adenocarcinoma 7%, carcinoma 4% and signet ring cell carcinoma 1%. Intended curative resection was performed in 28 patients (39%) (22 Whipple procedures and 6 local resections), and all but one patient had negative resection margins. Thirteen patients (46%) had lymph node metastasis. Twenty-nine (67%) of the palliative treated patients had a single (n = 24) or double by-pass procedure (n = 5). The median and 5-year survival for the resected patients were 23 months (CI 7-44) and 27% (CI 10-44). The median survival in the palliative group was 5 months (CI 2-11), and none of the patients were alive after three years.

CONCLUSION

The incidence of true PDC within a geographical and histopathologically completely monitored area was 5.4 per 1,000,000. Less than 40% of the patients could be resected and they had a median survival of 23 month and an estimated 5-year survival of 27%. The prognosis of true PDC seemed lower than expected according to previously published data.

A randomised crossover comparison of mouth-to-face-shield ventilation and mouth-to-pocket-mask ventilation by surf lifeguards in a manikin

Thirty surf lifeguards (mean (SD) age: 25.1 (4.8) years; 21 male, 9 female) were randomly assigned to perform 2 × 3 min of cardiopulmonary resuscitation on a manikin using mouth-to-face-shield ventilation (AMBU LifeKey) and mouth-to-pocket-mask ventilation (Laerdal Pocket Mask). Interruptions in chest compressions, effective ventilation (visible chest rise) ratio, tidal volume and inspiratory time were recorded. Interruptions in chest compressions per cycle were increased with mouth-to-face-shield ventilation (mean (SD) 8.6 (1.7) s) compared with mouth-to-pocket-mask ventilation (6.9 (1.2) s, p < 0.0001). The proportion of effective ventilations was less using mouth-to-face-shield ventilation (199/242 (82%)) compared with mouth-to-pocket-mask ventilation (239/240 (100%), p = 0.0002). Tidal volume was lower using mouth-to-face-shield ventilation (mean (SD) 0.36 (0.20) l) compared with mouth-to-pocket-mask ventilation (0.45 (0.20) l, p = 0.006). No differences in inspiratory times were observed between mouth-to-face-shield ventilation and mouth-to-pocket-mask ventilation. In conclusion, mouth-to-face-shield ventilation increases interruptions in chest compressions, reduces the proportion of effective ventilations and decreases delivered tidal volumes compared with mouth-to-pocket-mask ventilation.

A randomised crossover comparison of manikin ventilation through Soft Seal®, i-gel™ and AuraOnce™ supraglottic airway devices by surf lifeguards

Forty surf lifeguards attempted to ventilate a manikin through one out of three supraglottic airways inserted in random order: the Portex® Soft Seal®; the Intersurgical® i-gel™; and the Ambu® AuraOnce™. We recorded the time to ventilate and the proportion of inflations that were successful, without and then with concurrent chest compressions. The mean (SD) time to ventilate with the Soft Seal, i-gel and AuraOnce was 35.2 (7.2)s, 15.6 (3.3)s and 35.1 (8.5) s, respectively, p < 0.0001. Concurrent chest compression prolonged the time to ventilate by 5.0 (1.3-8.1)%, p = 0.0072. The rate of successful ventilations through the Soft Seal (100%) was more than through the AuraOnce (92%), p < 0.0001, neither of which was different from the i-gel (97%). The mean (SD) tidal volumes through the Soft Seal, i-gel and AuraOnce were 0.65 (0.14) l, 0.50 (0.16) l and 0.39 (0.19) l, respectively. Most lifeguards (85%) preferred the i-gel. Ventilation through supraglottic airway devices may be considered for resuscitation by surf lifeguards.

Characteristics, therapy and outcome in an unselected and prospectively registered cohort of pancreatic cancer patients

PURPOSE

Pancreatic cancer (PC) is associated with a dismal prognosis. Few studies have examined characteristics and outcome in an unselected population-based cohort of PC patients. Therefore, we investigated patient baseline characteristics, therapy choices and survival in a complete cohort of patients with PC.

METHODS

All cases diagnosed with PC between 2007 and 2009 in the Region of Southern Denmark (pop: 1,200,000) were prospectively registered. Patient characteristics including performance status, information about haematology, liver function and therapy were retrieved from patient charts, and used to compare differently treated and untreated groups.

RESULTS

Six-hundred-eighteen cases were registered as PC; 25 of which did not have adenocarcinomas. Patients were divided in 3 clinical groups based on initial therapy; group 1: resection (n=64), group 2: chemotherapy or chemo-radiotherapy (n=191), group 3: no tumour directed therapy (n=324). Median survival (mOS) (95% confidence interval (CI)) in the three groups was 25.7 months (18-30), 8.1 months (7.0-9.5) and 1.1 months (1.0-1.3) respectively. Three percent of patients participated in clinical trials. An evaluation of baseline factors prognostic value suggested that treated patients differed significantly from non-treated patients.

CONCLUSION

This study reports survival in treated groups comparable to results obtained from clinical trials with highly selected patients. However the majority of patients with PC do not receive cancer directed therapy. This group was significantly different in several baseline factors, which could suggest a different biology. Improving the outcome of PC patients calls for research into the large group of untreated patients, as only a minority of patients receive cancer directed therapy.

Endoscopic ultrasound, endoscopic sonoelastography, and strain ratio evaluation of lymph nodes with histology as gold standard

BACKGROUND AND STUDY AIMS

Accurate lymph node staging is essential for the selection of an optimal treatment in patients with upper gastrointestinal cancer. Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are considered to be the most accurate method for locoregional staging. Endoscopic sonoelastography (ESE) assesses the elasticity of lymph nodes and has been used to differentiate lymph nodes with promising results. The aim of this study was to evaluate the use of EUS, EUS - FNA, ESE, and ESE-strain ratio using histology as the gold standard.

PATIENTS AND METHODS

Patients with upper gastrointestinal cancer who were referred for EUS examination were enrolled if surgical treatment was planned and the patient had a lymph node that was accessible for EUS - FNA and EUS-guided fine-needle marking (FNM). The lymph node was classified using EUS, ESE, and ESE-strain ratio. Finally, EUS - FNA and EUS - FNM were performed. The marked lymph node was isolated during surgery for histological examination.

RESULTS

The marked lymph node was isolated for separate histological examination in 56 patients, of whom 22 (39 %) had malignant lymph nodes and 34 (61 %) had benign lymph nodes. There were no complications of EUS - FNM. The sensitivity of EUS for differentiation between malignant and benign lymph nodes was 86 % compared with 55 % - 59 % for the different ESE modalities. The specificity of EUS was 71 % compared with 82 % - 85 % using ESE modalities.

CONCLUSION

The use of the EUS - FNM technique enabled the identification of a specific lymph node and thereby the use of histology as gold standard. ESE and ESE-strain ratio were no better than standard EUS in differentiating between malignant and benign lymph nodes in patients with resectable upper gastrointestinal cancer.

Intra- and interobserver agreement of endoscopic sonoelastography in the evaluation of lymph nodes

PURPOSE

There is a lack of studies on the intra- and interobserver variability of endoscopic ultrasonography (EUS) and especially endoscopic sonoelastography (ES). The aim of this study was to evaluate the intra- and interobserver agreement of EUS and ES during the evaluation of a specific lymph node in patients with upper gastrointestinal malignancies (UGIM). The ES strain ratio was used to differentiate between benign and malignant lymph nodes and the interobserver agreement was evaluated.

MATERIALS AND METHODS

This study prospectively enrolled 62 patients with UGIM. EUS and ES were performed by two observers in randomized order of a specific lymph node using a linear Pentax echoendoscope and the Hitachi EUB-8500 US unit. The lymph node was classified as malignant or benign on the basis of EUS, ES, an ES scoring system, and 5 repeated strain ratio measurements. The intraobserver variation was evaluated by each observer performing 20 strain ratio measurements of the same lymph node. Finally, EUS fine needle aspiration was performed. The kappa statistic was used to test for interobserver variability.

RESULTS

One patient was excluded due to inadequate ES imaging. Thus, 61 patients were included in the analysis of the interobserver agreement. Using EUS, ES, and an ES scoring system, the kappa values were 0.80, 0.58, and 0.35, respectively. An ES strain ratio of 3.81 was defined as the cut-off value between benign and malignant lymph nodes using cytology as the gold standard (n = 55). Using this modality, a kappa value of 0.59 was obtained. A t-test comparison of the measured strain ratios for the two observers found no significant differences.

CONCLUSION

ES and ES strain ratio evaluation of lymph nodes were feasible and may be reproduced with good interobserver agreement in a blinded clinical setup. The predefined ES scoring system provided only poor interobserver agreement. Image selection should be part of the intra- and interobserver evaluation. ES strain ratio seemed promising but larger studies are needed to evaluate this new feature.

Endoscopic ultrasound-guided fine-needle marking of lymph nodes

BACKGROUND AND STUDY AIMS

No previous studies have evaluated the ability of endoscopic ultrasonography to describe the anatomic location of lymph nodes on the basis of a node-to-node comparison. The aim of this study was to assess the feasibility and safety of a new endoscopic ultrasound (EUS)-guided fine-needle technique for marking lymph nodes.

PATIENTS AND METHODS

Twenty-five patients with suspected or confirmed malignancies of the upper gastrointestinal tract were prospectively included. EUS-guided fine-needle marking (EUS-FNM) was performed with a silver pin with a diameter that allowed it to fit into a 19-gauge needle. The position of the pin was verified by EUS. End points were the ability to identify and isolate the marked lymph node during surgery and a comparison between the location of the pin as suggested by EUS and the actual location found in the resected specimen.

RESULTS

Twenty-three lymph nodes were marked. Nineteen intended surgical isolations were performed. The lymph nodes were isolated in the resection specimens in 18 patients (95 %). In 2 out of 20 cases the pin was not localized by laparoscopic ultrasonography. In 89 % of the cases the marked lymph node was in the same location as described by EUS. One pin (5 %) was not retrieved. In three cases, a small hematoma was observed. There was no sign of long-term complications.

CONCLUSION

EUS-FNM with a silver pin in lymph nodes is feasible and safe. EUS-FNM seems to be a suitable tool for evaluating lymph nodes on the basis of a node-to-node comparison.

Impact of upper gastrointestinal endoscopic ultrasound in children

The impact and feasibility of upper gastrointestinal endoscopic ultrasound (EUS) in younger children are unknown. We retrospectively reviewed the EUS procedures we had performed in children younger than 16 years with regard to feasibility, safety, and impact on further treatment. In all, 18 patients (12 boys, 6 girls; median age 12 years, range 0.5-15) underwent EUS. The indications were as follows: tumor (9), epigastric pain (3), recurrent pancreatitis (2), unexplained jaundice (2), hypoglycemia (1), and von Hippel-Lindau disease (1). We concluded that EUS had a significant impact in 78% of the cases. EUS seems to be a safe, feasible, and valuable diagnostic tool.

Esophageal cancer: biology, natural history, staging and therapeutic options

The distribution of adenocarcinomas and squamous cell carcinomas in esophageal cancer (EC) has changed, and focus directed towards tumors of the distal esophagus and the esophagogastric junction. The genetic events leading to EC are not fully clarified, but important risk factors have been identified. Accurate pretherapeutic tumor evaluation should be provided for a multi-disciplinary and individually tailored patient management programme. Endoscopic ultrasonography (EUS) and PET-CT play an important role in the assessment of disease, evaluation of treatment response and during follow-up.

Impact of endoscopic ultrasonography (EUS) on surgical decision-making in upper gastrointestinal tract cancer: an international multicenter study

BACKGROUND

Endoscopic ultrasonography (EUS) is an integrated part of the pretherapeutic evaluation program for patients with upper gastrointestinal (GI) tract cancer. Whether the clinical impact of EUS differs between surgeons from different countries is unknown. The same applies to the potential clinical influence of EUS misinterpretations. The aim of this study was to evaluate the interobserver agreement on predefined treatment strategies between surgeons from four different countries, with and without EUS, and to evaluate the clinical consequences of EUS misinterpretations.

METHODS

One hundred patients with upper GI tract cancer were randomly selected from all upper GI tract cancer patients treated at Odense University Hospital between 1997 and 2000. Based on patient records and EUS database results, a case story was created with and without the EUS result for each patient. Four surgeons were asked to select the relevant treatment strategy in each case, at first without knowledge of the EUS and thereafter with the EUS result available. Interobserver agreement and impact of EUS misinterpretations were evaluated using the actual final treatment of each patient as reference.

RESULTS

Three of four or all four surgeons agreed on the same treatment strategy for nearly 60% of the patients with and without the EUS results. Treatment decisions were changed in 34% based on the EUS results, and the majority of these changes were toward nonsurgical and palliative treatments (85%). Interobserver agreement was relatively low, but overall EUS increased kappa values from 0.16 ("poor") to 0.33 ("fair"), thus indicating increased overall agreement after the EUS results were available. EUS conclusion regarding stage or resectability was wrong in 17% of the cases, but only one serious event would have been the clinical result of EUS misinterpretations.

CONCLUSION

Despite being used in different ways by different surgeons, EUS did change patient management in one third of the cases. The impact of EUS misinterpretations seemed very low, and this study confirmed one of the strongest clinical possibilities of EUS, i.e., the ability to detect nonresectable cases. EUS is an important imaging modality for oncosurgeons from different countries.

Combined preoperative endoscopic and laparoscopic ultrasonography for prediction of R0 resection in upper gastrointestinal tract cancer

BACKGROUND

This study evaluated the ability of combined endoscopic and laparoscopic ultrasonography to predict R0 resection and avoid unnecessary surgery in patients with upper gastrointestinal tract cancer (UGIC).

METHODS

A total of 411 consecutive patients with UGIC (182 pancreatic cancers, 134 gastric cancers and 95 oesophageal cancers) treated between January 2002 and May 2004 were analysed prospectively. The allocation of patients into resectability groups by endoscopic ultrasonography (EUS) and laparoscopic ultrasonography (LUS) was compared with the treatment actually undertaken.

RESULTS

The combination of EUS and LUS correctly predicted R0 resection in 90.6 per cent, R1-R2 in 91 per cent and irresectability in 91.4 per cent of patients. Ten patients (2.4 per cent) had explorative laparotomy only. There were no complications associated with the EUS and LUS procedures.

CONCLUSION

The routine use of EUS and LUS before surgery predicted R0 resection in nine of ten patients and reduced the number of unnecessary laparotomies to less than 3 per cent.

Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial

OBJECTIVES

To evaluate the long term effects of perioperative beta blockade on mortality and cardiac morbidity in patients with diabetes undergoing major non-cardiac surgery.

DESIGN

Randomised placebo controlled and blinded multicentre trial. Analyses were by intention to treat.

SETTING

University anaesthesia and surgical centres and one coordinating centre.

PARTICIPANTS

921 patients aged > 39 scheduled for major non-cardiac surgery.

INTERVENTIONS

100 mg metoprolol controlled and extended release or placebo administered from the day before surgery to a maximum of eight perioperative days.

MAIN OUTCOME MEASURES

The composite primary outcome measure was time to all cause mortality, acute myocardial infarction, unstable angina, or congestive heart failure. Secondary outcome measures were time to all cause mortality, cardiac mortality, and non-fatal cardiac morbidity.

RESULTS

Mean duration of intervention was 4.6 days in the metoprolol group and 4.9 days in the placebo group. Metoprolol significantly reduced the mean heart rate by 11% (95% confidence interval 9% to 13%) and mean blood pressure by 3% (1% to 5%). The primary outcome occurred in 99 of 462 patients in the metoprolol group (21%) and 93 of 459 patients in the placebo group (20%) (hazard ratio 1.06, 0.80 to 1.41) during a median follow-up of 18 months (range 6-30). All cause mortality was 16% (74/462) in the metoprolol group and 16% (72/459) in the placebo group (1.03, 0.74 to 1.42). The difference in risk for the proportion of patients with serious adverse events was 2.4% (- 0.8% to 5.6%).

CONCLUSIONS

Perioperative metoprolol did not significantly affect mortality and cardiac morbidity in these patients with diabetes. Confidence intervals, however, were wide, and the issue needs reassessment.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN58485613.

Prospective evaluation of patient tolerability, satisfaction with patient information, and complications in endoscopic ultrasonography

BACKGROUND AND STUDY AIMS

Prospective data are lacking on the safety of endoscopic ultrasonography (EUS) and on patient satisfaction with the procedure. We prospectively recorded complications related to EUS in order to establish morbidity and mortality. In addition the levels of patient satisfaction were evaluated, with regard to the tolerability of the procedure (pain, discomfort, and anxiety levels) and the provision of information.

PATIENTS AND METHODS

3324 consecutive patients who underwent EUS were studied with regard to complications. During the study period 300 patients were interviewed and followed up in detail as part of the evaluation of patient satisfaction.

RESULTS

Ten patients (0.3 %) suffered from a complication related to the EUS procedure, and two patients died (0.06 %). There were no significant differences between the complication rates for EUS-guided fine-needle aspiration (EUS-FNA) and for EUS, but both fatal cases related to EUS-FNA/EUS-guided intervention. Nine of the ten patients with complications (90 %) had a diagnosis of malignancy, and esophageal perforation accounted for half of all complications. Although the majority of patients with nonlethal complications were managed well on conservative regimens, only one case, of self-limiting acute pancreatitis, could be classified as a mild complication. With regard to patient tolerability, only minor incidents occurred during the EUS procedure (tracheal suction 5 %, vomiting 0.3 %, aspiration 0.3 %) and no intervention was necessary. During the procedure, 80 % of the patients had no or only slight pain and more than 95 % experienced only slight or no anxiety, whereas more than half of the patients experienced moderate to severe discomfort. More than 90 % of the patients were satisfied or very satisfied with the information provided to them before and after the EUS, and the same number of patients were ready without hesitation to undergo an additional EUS examination if necessary.

CONCLUSIONS

EUS, EUS-FNA and EUS-guided intervention are safe techniques, but severe and lethal complications do occur. The EUS procedures can be performed with a high level of patient satisfaction and with low levels of pain, discomfort and anxiety.

A new method for three-dimensional laparoscopic ultrasound model reconstruction

BACKGROUND

Laparoscopic ultrasound is an important modality in the staging of gastrointestinal tumors. Correct staging depends on good spatial understanding of the regional tumor infiltration. Three-dimensional (3D) models may facilitate the evaluation of tumor infiltration. The aim of the study was to perform a volumetric test and a clinical feasibility test of a new 3D method using standard laparoscopic ultrasound equipment.

METHODS

Three-dimensional models were reconstructed from a series of two-dimensional ultrasound images using either electromagnetic tracking or a new 3D method. The volumetric accuracy of the new method was tested ex vivo, and the clinical feasibility was tested on a small series of patients.

RESULTS

Both electromagnetic tracked reconstructions and the new 3D method gave good volumetric information with no significant difference. Clinical use of the new 3D method showed accurate models comparable to findings at surgery and pathology.

CONCLUSIONS

The use of the new 3D method is technically feasible, and its volumetrically, accurate compared to 3D with electromagnetic tracking.

Cost-effectiveness of endoscopic ultrasonography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography in patients suspected of pancreaticobiliary disease

BACKGROUND

It is not known whether initial endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) is more cost effective than endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A cost-effectiveness analysis of EUS, MRCP and ERCP was performed on 163 patients. The effectiveness of an investigation was defined as the percentage of patients with no need for further evaluation after the investigation in question had been performed. Costs were assumed from the budget-holder's point of view.

RESULTS

MRCP, EUS and ERCP had a total accuracy of 0.91, 0.93 and 0.92, respectively. Eighty-four (52%) patients needed endoscopic therapy in combination with ERCP, giving an effectiveness of MRCP, EUS, and ERCP of 0.44, 0.45 and 0.92, respectively. The cost-effectiveness of MRCP, EUS, and ERCP was 6622, 7353 and 4246 Danish Kroner (DKK) per fully investigated and treated patient (1 DKK=0.14 EUR).

CONCLUSION

Within a patient population with a probability of therapeutic ERCP in 50% of the patients, ERCP was the most cost-effective strategy.

Is there a difference in diagnostic accuracy and clinical impact between endoscopic ultrasonography and magnetic resonance cholangiopancreatography?

BACKGROUND AND STUDY AIMS

It is still unknown whether there is a difference in diagnostic accuracy and clinical impact between endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP).

PATIENTS AND METHODS

The test performance and potential clinical impact of EUS and MRCP, had each investigation been performed as the first examination method, were compared prospectively in 163 patients admitted for and examined by endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

The accuracies of EUS and MRCP were 0.93 and 0.91, respectively (no significant difference, P > 0.05). Had EUS or MRCP been performed as the first investigation in the 75 patients who had a presumed high probability for needing therapeutic ERCP, only 15 and nine patients, respectively, would have avoided ERCP. In this group of patients, one patient needed other diagnostic investigations following EUS compared with 11 patients following MRCP ( P = 0.004). For the 57 patients with an intermediate probability of needing endoscopic therapy, EUS and MRCP would have spared 37 and 38 patients, respectively, from the need to have an ERCP. In 31 patients with a presumed low risk of needing endoscopic therapy, 30 and 29 patients would have been spared from ERCP had EUS and MRCP, respectively, been performed initially.

CONCLUSIONS

There was no difference in the diagnostic accuracy and clinical impact between EUS and MRCP in the majority of the patients. The impact of EUS or MRCP on the ERCP workload was highly dependent on the presumed probability of needing endoscopic therapy.

Is the 'Trondsen Discriminant Function' useful in patients referred for endoscopic retrograde cholangiopancreatography?

BACKGROUND

Ideally, patients should only be referred to endoscopic retrograde cholangiopancreatography (ERCP) if therapy is indicated. The aim of this study was to evaluate whether or not the 'Trondsen Discriminant Function' (DF) could be used for selecting patients directly for ERCP.

METHODS

The DF was calculated in 163 patients referred for ERCP with the DF value being unknown to the endoscopist. Compared to the final diagnoses of the patients, the sensitivity and specificity of a positive DF value for predicting biliary obstruction and need of endoscopic therapy were calculated.

RESULTS

Ninety-three (57%) patients had obstruction of the bile duct and 84 (52%) needed endoscopic therapy. A positive DF value had a sensitivity, specificity, positive predictive value and negative predictive value for predicting biliary obstruction of 81%, 72%, 79% and 73%, respectively. If only patients with a positive DF value had been examined by ERCP, 50 (31%) patients would have been saved from this investigation. Had a negative DF value stopped the patients from further diagnostic evaluation, 18 (11%) would have had undiagnosed pathological conditions.

CONCLUSION

A positive DF value is useful for selecting which patients should be referred directly for ERCP because of a high probability that they will need endoscopic therapy. A negative DF value cannot be used to stop the patient from further diagnostic evaluation.

Clinical impact of endoscopic ultrasonography at a county hospital

BACKGROUND AND STUDY AIMS

Although endoscopic ultrasonography (EUS) is a well-described examination method, there have been few reports concerning its clinical impact. The aim of this study was to describe EUS as it is performed at a county hospital, with an emphasis on the indications and clinical outcome.

PATIENTS AND METHODS

Patients examined using EUS between December 1997 and November 2000 were recorded prospectively. Follow-up was conducted by examining each patient's medical records at least 3 months after the investigation. The EUS findings were compared with the patient's final diagnosis, and the decisions made by the referring department on the basis of each investigation were recorded.

RESULTS

A total of 344 EUS procedures were performed. In the third year, the distribution of patients relative to the various referral diagnoses was: 78 with suspected benign pancreaticobiliary disease, 33 for staging of known upper gastrointestinal tract malignancy, 15 with suspected mediastinal disease or for staging of lung cancer, 13 with suspected submucosal lesions, and five with unclassified disease. Follow-up was possible in 340 patients (99 %). Compared to the final diagnosis in each patient, the sensitivity, specificity, and accuracy rates of EUS were 86 %, 90 %, and 88 %, respectively. The EUS findings made more invasive procedures unnecessary in 199 patients (58 %). EUS led to a switch to less invasive procedures in 61 patients (18 %), and it had no influence on the further management strategy in 80 patients (24 %).

CONCLUSIONS

EUS has a high level of accuracy and a substantial clinical impact when performed in an unselected population. The estimated numbers of investigations needed appear to justify setting up an EUS center at institutions with a catchment population of 350 000 inhabitants.

Initial experience with new dedicated needles for laparoscopic ultrasound-guided fine-needle aspiration and histological biopsies

BACKGROUND AND STUDY AIMS

Laparoscopic ultrasonography (LUS) is an important imaging modality during laparoscopic staging of intra-abdominal malignancies, but LUS-assisted biopsy is often difficult or impossible. We report a newly developed inbuilt biopsy system for direct LUS-guided fine-needle aspiration (FNA) and Tru-cut biopsies.

PATIENTS AND METHODS

LUS-guided biopsy was performed in 20 patients with upper gastrointestinal tract tumors. The biopsied lesions had either not been previously detected by other imaging modalities or had been inaccessible, or the biopsy sample had been inadequate. Primary diagnosis, duration of biopsy procedure, needle monitoring (visibility, penetration, and deviation), complications, technical failures, and pathological findings were prospectively recorded.

RESULTS

44 biopsies were performed with 25 needles (19, 20, and 22-G). Needle monitoring and penetration were good or acceptable in 18 patients (90%). Slight needle deviation (<10 mm) was seen in eight patients (40%). The LUS-guided biopsy specimen was sufficient for analysis in 13 patients (65%). In two additional patients, adequate material was obtained, but pathological examination was impossible owing to incorrect handling of the specimen. The biopsy procedures lasted 16.3 minutes (range 10-20 minutes) and no complications were seen.

CONCLUSIONS

LUS-guided fine-needle aspiration or Trucut biopsy is possible using this newly developed biopsy system. These preliminary data suggest that LUS-guided biopsy may further improve the diagnostic possibilities of LUS.

Clinical impact of endoscopic ultrasound-guided fine needle aspiration biopsy in patients with upper gastrointestinal tract malignancies. A prospective study

BACKGROUND AND STUDY AIMS

Several studies have evaluated the accuracy of endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) in the upper gastrointestinal tract, but so far no studies have specifically evaluated the clinical impact of EUS-FNAB in upper gastrointestinal tract cancer patients. In this consecutive and prospective study, EUS-FNAB was only performed if a positive malignant finding would change the therapeutic strategy.

PATIENTS AND METHODS

Between 1997 and 1999, 307 consecutive patients were referred for EUS with a diagnosis or strong suspicion of esophageal, gastric or pancreatic cancer; 274 patients were potential candidates for surgical treatment and had EUS. According to predefined impact criteria, 27% (75/274) of the patients had EUS-FNAB for staging or diagnostic reasons.

RESULTS

The overall clinical impact of EUS-FNAB was 13%, 14%, and 30% in esophageal, gastric, and pancreatic cancer, respectively. The staging-related clinical impact was similar for all three types of cancer (11-12.5%), whereas the diagnosis-related impact was highest in pancreatic cancer patients (86%). EUS-FNAB was inadequate in 13% and gave false-negative results in 5%. The overall sensitivity, specificity and accuracy for EUS-FNAB were 80%, 78% and 80%, respectively. No complications related to the biopsy procedure were seen.

CONCLUSIONS

If EUS-FNAB was performed only in cases where a positive malignant result would change patient management, then approximately one out of four patients with upper gastrointestinal tract cancer would require a biopsy. With this approach the actual clinical impact of EUS-FNAB ranged from 13% in esophageal cancer to 30% in pancreatic cancer. EUS-FNAB plays a limited, but very important clinical role in the assessment of upper gastrointestinal tract cancer.

Laparoscopic four-way ultrasound probe with histologic biopsy facility using a flexible tru-cut needle

Laparoscopic ultrasound (LUS) is widely used in the staging of upper gastrointestinal malignancies. However, accurate N-staging and pathological confirmation of metastases have proved difficult. A new four-way laparoscopic ultrasound probe has been developed. The probe has a biopsy attachment with a needle guide for a flexible tru-cut needle or an aspiration needle. It is now possible to take real-time laparoscopic ultrasound guided biopsies. Furthermore, there is a possibility for interventionel LUS with tumor destruction, celiac plexus neurolysis, and cyst aspiration. In this short technical note, the equipment and the technique are described.

Cost-effectiveness of different diagnostic strategies in patients with nonresectable upper gastrointestinal tract malignancies

BACKGROUND AND METHODS

Using a simple model, this retrospective study evaluated the cost-effectiveness of different diagnostic strategies used for pretherapeutic detection of patients with disseminated or locally nonresectable upper gastrointestinal tract malignancies (UGIM). Of 162 consecutive UGIM patients referred for treatment, 73 (45%) had disseminated or locally nonresectable disease, and these patients were eligible for evaluation.

RESULTS

The noninvasive diagnostic strategies (computed tomography [CT] with ultrasonography [US] and endoscopic ultrasonography [EUS]) had a low procedure cost, but a diagnostic strategy based on CT with US or CT with US and laparoscopy was not cost-effective. The inclusion of endoscopic or laparoscopic ultrasonography seemed necessary to the provision of a cost-effective strategy because both techniques had a high diagnostic accuracy combined with a low cost. A change in diagnostic strategy from CT with US to CT with US and EUS resulted in a net saving regarding the cost of each additional nonresectable patient detected, but this strategy still required up to 20% futile explorative laparotomies.

CONCLUSIONS

The combination of endoscopic and laparoscopic ultrasonography was cost-effective and had no complications in this study. We use this strategy as our standard in the pretherapeutic evaluation of UGIM patients.

The role of gastrointestinal endosonography in diagnostic and therapeutic interventional procedures

Over the past 15 years endoscopic ultrasonography (EUS) has become an integrated part of gastrointestinal imaging. The more recent development of echoendoscopes and needles for EUS guided fine needle aspiration has stimulated the interest in interventional EUS procedures, both for diagnostic and therapeutic purposes. This paper describes the technique and experience with some of the interventional EUS procedures based on the present literature. Many of the techniques must still be considered experimental and will need substantial clinical testing in larger series before any final conclusions can be made. However, the present level of interventional EUS seems to indicate, that some of these techniques could be cost-effective alternatives in specific clinical situations, and in some cases even the only possible theraputic action. Future research in interventional EUS should be concentrated in experienced endosonography centers under careful monitoring of complications and clinical outcome.

TNM staging and assessment of resectability of pancreatic cancer by laparoscopic ultrasonography

BACKGROUND

Laparoscopic ultrasonography (LUS) is an imaging modality that combines laparoscopy and ultrasonography. The purpose of this prospective blinded study was to evaluate the TNM stage and assessment of resectability by LUS in patients with pancreatic cancer.

METHODS

Of the 71 consecutive patients admitted to our department, 36 were excluded from the study, mainly due to evident signs of metastatic disease or another condition that would preclude surgery. Thus, a total of 35 patients were enrolled in the study. All patients underwent abdominal CT scan, ultrasonography, endoscopic ultrasonography (EUS), diagnostic laparoscopy, and LUS. Histopathologic examination was considered to be the final evaluation for LUS in all but three patients, where EUS was used as the reference.

RESULTS

The accuracy of LUS in T staging was 29/33 (80%); in N staging it was 22/34 (76%); in M staging, it was 23/34 (68%); and in overall TNM staging, it was 23/34 (68%). In assessment of nonresectability, distant metastases, and lymph node metastases, the sensitivity was 0.86, 0.43 and 0.67, respectively, for LUS alone. Combining the information gleaned from laparoscopy and LUS, the accuracy in finding nonresectable tumors was 89%.

CONCLUSIONS

Diagnostic laparoscopy with LUS is highly accurate in TNM staging and assessment of resectability of pancreatic cancer and should be considered an important modality in the assessment algorithm.

Laparoscopic ultrasonography--a method for staging of upper gastrointestinal cancer

Laparoscopic ultrasonography (LUS) is a method that can be useful in the staging of upper gastrointestinal cancer. Dedicated transducers are available, and preliminary studies have proposed indications for the use of LUS staging of hepatic, esophageal, gastric, and pancreatic cancer disease. In the staging and resectability assessment of upper gastrointestinal cancer LUS seems to provide important additional information thus avoiding futile laparotomies in non-resectable patients. This short review summarizes some of the most relevant references concerning the use of LUS in upper gastrointestinal tract cancer.

The variability of the incremental postprandial portal vein flow response is partly caused by a relationship between fasting flow rate and phase activity of the migrating motor complex

OBJECTIVE

Results from studies on portal flow rate (PFR) have demonstrated a considerable intra- as well as interindividual variability of the incremental integrated response (IIR). We hypothesized that part of the variation of the IIR might be related to variability of the fasting PFR caused by a relationship between PFR and characteristics of the migrating motor complex (MMC).

DESIGN

We examined 12 healthy men and PFR was recorded by using the percutaneous colour Doppler technique. Gastric emptying (GE) was determined by scintigraphy and the meal consisted of an omelette of 100 g (1400 kJ; 60% fat, 20% protein, 20% carbohydrates) tagged with 99mTc sulphur colloids followed by 150 ml water mixed with 111In DTPA. The design included recording of PFR in phase II as well as in phase III of the MMC. Meal ingestion took place in the following duodenal phase I. Postprandial recordings of GE and PFR were performed at 10 min intervals for the following 2 h.

RESULTS

Median (95% confidence limits) amount of solid emptied at 120 min was 68% (59-81%). PFR in phase III was significantly higher than in phase II (1.56 l/min (1.35-1.93 l/min) vs 0.96 l/min (0.84-1.12 l/min), P< 0.001). PFR increased after the meal and a peak flow of 2.19 l/min (1.58-2.46 I/min) was recorded 10 min after ingestion (P< 0.01 vs phase III). Based on these characteristics a difference in IIR is to be expected, and the calculations revealed that IIR is considerably higher in the phase II series than in the phase III series (50 l/min x 120 min (8-90 l/min) vs -26 l/min x 120 min (-55 to 1 l/min), P< 0.001). In both series a weak but significant inverse relationship was demonstrated between amounts emptied during a 20-min period and the corresponding IIR (n = 72; r = -0.27, P< 0.05 (III); r = -0.29; P< 0.05 (II)).

CONCLUSION

We conclude that fasting PFR is related to phase activity of the MMC and characteristics of the postprandial IIR depend upon MMC activity at the time of recording of the fasting value. Future studies on PFR need to be performed with phase related recording of fasting flow and meal ingestion in relation to preselected characteristics of the MMC.