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Aim: The Kono‐S anastomosis was introduced as a possible solution to the high surgical recurrence rates in Crohn's disease. However, this technique is known to be challenging, which is why it was originally performed in an extracorporeal setting. The aim of this case series was to assess safety, in terms of intra‐/postoperative complications, and feasibility, in terms of successful performance of anastomosis, of a robot‐assisted intracorporeal Kono‐S anastomosis. Method: This is a prospective single‐centre consecutive case series. Patients were considered eligible if they were diagnosed with refractory Crohn's disease with significant bowel stenosis of the terminal ileum. All patients underwent robot‐assisted intracorporeal Kono‐S anastomosis. Perioperative care was provided according to the Enhanced Recovery After Surgery® protocol. Follow‐up for postoperative complications was 30 days. Results: Twenty patients were included, of whom 11 (55%) were men. The median age was 30 years [interquartile range (IQR) 22–51 years] and the median BMI was 25 kg/m2 (IQR 19–28 kg/m2). Intracorporeal Kono‐S anastomosis was successfully performed in all cases. The median operating time was 155 min (IQR 144–176 min) and the median length of stay was 3 days (IQR 1–5 days). No conversions or 30‐day mortality were observed. One patient experienced anastomotic leakage, which was treated with radiologically guided drainage. A total of three patients experienced postoperative complications in the first 30 days. Conclusion: Performance of intracorporeal robot‐assisted Kono‐S anastomosis seems safe and feasible in this case series for Crohn's disease. Since this is a first case series, further research is required to confirm results in a larger population‐based cohort. [ABSTRACT FROM AUTHOR]

Introduction: Intestinal blood flow is often named as a key factor in the pathophysiology of anastomotic leakage. The distribution between mucosal and serosal microperfusion during surgery remains to be elucidated. Objective: The aim of this study was to assess if the mucosal microcirculation of the intestine is more vulnerable to a surgical hit than the serosal microcirculation during surgery. Methods: In an observational cohort study (n = 9 patients), the microcirculation of the bowel serosa and mucosa was visualized with incident dark-field imaging during surgery. At the planned anastomosis, the following microcirculatory parameters were determined: microvascular flow index (MFI), percentage of perfused vessels (PPV), perfused vessel density (PVD), and total vessel density (TVD). Data are presented as median (interquartile range [IQR]). Results: Perfusion parameters and vessel density were significantly higher for the mucosa than the serosal microcirculation at the planned site for anastomosis or stoma. Mucosal MFI was 3.00 (IQR 3.00–3.00) compared to a serosal MFI of 2.75 (IQR 2.21–2.94), p = 0.03. The PPV was 99% (IQR 98–100) versus 92% (IQR 66–94), p = 0.01. The TVD was 16.77 mm/mm2 (IQR 13.04–18.01) versus 10.42 mm/mm2 (IQR 9.36–11.81), p = 0.01, and the PVD was 15.44 mm/mm2 (IQR 13.04–17.78) versus 9.02 mm/mm2 (IQR 6.43–9.43), p = 0.01. Conclusions: The mucosal microcirculation was preserved, while lower perfusion of the serosa was found at the planned anastomosis or stoma during surgery. Further research is needed to link our observations to the clinically relevant endpoint of anastomotic leakage. [ABSTRACT FROM AUTHOR]

Background: Receiving a stoma significantly impacts patients' quality of life. Coping with this new situation can be difficult, which may result in a variety of physical and psychosocial problems. It is essential to provide adequate guidance to help patients cope with their stoma, as this positively influences self-efficacy in return. Higher self-efficacy reduces psychosocial problems increasing patient's quality of life. This study investigates whether a new mobile application, the Stoma App, improves quality of life. And if personalized guidance, timed support, and peer contact offered as an in-app surplus makes a difference. Methods: A double-blind, randomized controlled trial was conducted between March 2021 and April 2023. Patients aged > 18 years undergoing ileostomy or colostomy surgery, in possession of a compatible smartphone were included. The intervention group received the full version of the app containing personalized and time guidance, peer support, and generic (non-personalized) stoma-related information. The control group received a restricted version with only generic information. Primary outcome was stoma quality of life. Secondary outcomes included psychological adaption, complications, re-admittance, reoperations, and length of hospital stay. Results: The intervention version of the app was used by 96 patients and the control version by 112 patients. After correction for confounding, the intervention group reported a significant 3.1-point improvement in stoma-related quality of life one month postoperatively (p = 0.038). On secondary outcomes, no significant improvements could be retrieved of the intervention group. Conclusion: The Stoma App improves the quality of life of stoma patients. Peer support and personalized guidance are of significant importance in building self-efficacy. It is to be recommended to implement Stoma app—freely available software qualifying as a medical device—in standard stoma care pathways for the benefits of both patients and healthcare providers. [ABSTRACT FROM AUTHOR]

Background: Substantial variation exists when performing a minimally invasive right hemicolectomy (MIRH) due to disparities in training, expertise and differences in implementation of innovations. This study aimed to achieve national consensus on an optimal and standardized MIRH technique for colon cancer and to develop and validate a video-based competency assessment tool (CAT) for MIRH. Method: Statements covering all elements of MIRH were formulated. Subsequently, the Delphi technique was used to reach consensus on a standardized MIRH among 76 colorectal surgeons from 43 different centres. A CAT was developed based on the Delphi results. Nine surgeons assessed the same 12 unedited full-length videos using the CAT, allowing evaluation of the intraclass correlation coefficient (ICC). Results: After three Delphi rounds, consensus (≥80% agreement) was achieved on 23 of the 24 statements. Consensus statements included the use of low intra-abdominal pressure, detailed anatomical outline how to perform complete mesocolic excision with central vascular ligation, the creation of an intracorporeal anastomosis, and specimen extraction through a Pfannenstiel incision using a wound protector. The CAT included seven consecutive steps to measure competency of the MIRH and showed high consistency among surgeons with an overall ICC of 0.923. Conclusion: Nationwide consensus on a standardized and optimized technique of MIRH was reached. The CAT developed showed excellent interrater reliability. These achievements are crucial steps to an ongoing nationwide quality improvement project (the Right study). The Delphi technique was employed to achieve a broad national consensus on 23 statements among 76 colorectal surgeons, defining a standardized MIRH. This standard includes complete mesocolic excision, intracorporeal anastomosis and Pfannenstiel incision using a wound protector. Building upon this consensus, a video-based competency assessment tool was developed, exhibiting excellent reliability. [ABSTRACT FROM AUTHOR]

Introduction: Intestinal blood flow is often named as a key factor in the pathophysiology of anastomotic leakage. The distribution between mucosal and serosal microperfusion during surgery remains to be elucidated. Objective: The aim of this study was to assess if the mucosal microcirculation of the intestine is more vulnerable to a surgical hit than the serosal microcirculation during surgery. Methods: In an observational cohort study (n = 9 patients), the microcirculation of the bowel serosa and mucosa was visualized with incident dark-field imaging during surgery. At the planned anastomosis, the following microcirculatory parameters were determined: microvascular flow index (MFI), percentage of perfused vessels (PPV), perfused vessel density (PVD), and total vessel density (TVD). Data are presented as median (interquartile range [IQR]). Results: Perfusion parameters and vessel density were significantly higher for the mucosa than the serosal microcirculation at the planned site for anastomosis or stoma. Mucosal MFI was 3.00 (IQR 3.00–3.00) compared to a serosal MFI of 2.75 (IQR 2.21–2.94), p = 0.03. The PPV was 99% (IQR 98–100) versus 92% (IQR 66–94), p = 0.01. The TVD was 16.77 mm/mm2 (IQR 13.04–18.01) versus 10.42 mm/mm2 (IQR 9.36–11.81), p = 0.01, and the PVD was 15.44 mm/mm2 (IQR 13.04–17.78) versus 9.02 mm/mm2 (IQR 6.43–9.43), p = 0.01. Conclusions: The mucosal microcirculation was preserved, while lower perfusion of the serosa was found at the planned anastomosis or stoma during surgery. Further research is needed to link our observations to the clinically relevant endpoint of anastomotic leakage. [ABSTRACT FROM AUTHOR]

Background: Improving physical activity, especially in combination with optimizing protein intake, after surgery has a potential positive effect on recovery of physical functioning in patients after gastrointestinal and lung cancer surgery. The aim of this randomized controlled trial is to evaluate the efficacy of a blended intervention to improve physical activity and protein intake after hospital discharge on recovery of physical functioning in these patients. Methods: In this multicenter single-blinded randomized controlled trial, 161 adult patients scheduled for elective gastrointestinal or lung cancer surgery will be randomly assigned to the intervention or control group. The purpose of the Optimal Physical Recovery After Hospitalization (OPRAH) intervention is to encourage self-management of patients in their functional recovery, by using a smartphone application and corresponding accelerometer in combination with coaching by a physiotherapist and dietician during three months after hospital discharge. Study outcomes will be measured prior to surgery (baseline) and one, four, eight, and twelve weeks and six months after hospital discharge. The primary outcome is recovery in physical functioning six months after surgery, and the most important secondary outcome is physical activity. Other outcomes include lean body mass, muscle mass, protein intake, symptoms, physical performance, self-reported limitations in activities and participation, self-efficacy, hospital readmissions and adverse events. Discussion: The results of this study will demonstrate whether a blended intervention to support patients increasing their level of physical activity and protein intake after hospital discharge improves recovery in physical functioning in patients after gastrointestinal and lung cancer surgery. Trial registration: The trial has been registered at the International Clinical Trials Registry Platform at 14–10-2021 with registration number NL9793. Trial registration data are presented in Table 1. [ABSTRACT FROM AUTHOR]

Purpose: Minimally invasive right hemicolectomy (MIRH) is the cornerstone of treatment for patients with right-sided colon cancer. This operation has evolved during recent decades, with many innovations and improvements but this has also resulted in high variability of uptake with subsequent substantial variableness. The aim of this ongoing study is to identify current surgical variations, determine the most optimal and standardised MIRH and nationally train and implement that technique to improve short-term clinical and long-term oncological outcomes. Methods: The Right study is a national multicentre prospective interventional sequential cohort study. Firstly, current local practice was evaluated. Subsequently, a standardised surgical technique for right-sided colon cancer was determined using the Delphi consensus method, and this procedure was trained during hands-on courses. The standardised MIRH will be implemented with proctoring (implementation cohort), after which the performance will be monitored (consolidation cohort). Patients who will receive a minimally invasive (extended) right hemicolectomy for cT1-3N0-2M0 colon cancer will be included. The primary outcome is patient safety reflected in the 90-day overall complication rate according to the Clavien–Dindo classification. Secondary outcomes will include intraoperative complications, 90-day mortality rate, number of resected tumour-positive lymph nodes, completeness of mesocolic excision, surgical quality score, locoregional and distant recurrence and 5-year overall survival. A total number of 1095 patients (365 per cohort) will be included. Discussion: The Right study is designed to safely implement the best surgical practice concerning patients with right-sided colon cancer aiming to standardise and improve the surgical quality of MIRH at a national level. Trial registration: ClinicalTrials.gov: NCT04889456, May 2021. [ABSTRACT FROM AUTHOR]

Aim: Proper education, guidance and support is crucial before and following creation of a stoma. Patients with a stoma and their close relatives need to adapt to and cope with this new – and sometimes unforeseen – situation, which may result in insecurities and a variety of psychosocial problems. Self‐efficacy is associated both with a reduction in psychosocial problems and with improved quality of life. The main objective of this study was to investigate whether self‐reported quality of life of patients with a stoma can be enhanced by offering personalized and timed guidance, as well as peer contact, in a patient‐centred mobile application. Method: A multicentre, double‐blind, randomized controlled trial will be conducted. Consented adults >18 years of age who will receive an ileostomy or colostomy and possess an eligible smartphone will be included. The intervention group will be given the full version of the application (containing personalized and timed guidance, such as operation‐specific information and information on the associated care pathway) to install on their smartphone. In addition, the intervention group has access to a protected peer‐support platform within the app. The control group will receive a restricted version of the application that contains only generic (non‐personalized) stoma‐related information. The primary outcome is quality of life, 3 months postoperatively. Secondary outcomes are Patient Reported Outcome Measures (PROMs), such as psychological adaption, as well as number of complications, re‐admission and re‐operation rates and the length of hospital stay. Results: Patient enrolment began in March 2021. Data collection was not complete when this protocol was submitted. Conclusion: We hypothesize that patients with a stoma who are supported by the intervention version of the app will report a significantly higher quality of life than patients with a stoma who are supported by the control version of the app (ie, are not offered personalized and timed guidance and information and do not have access to peer support in the app). [ABSTRACT FROM AUTHOR]

Background In the I CARE study, colon cancer patients were randomly assigned to receive follow-up care from either a general practitioner (GP) or a surgeon. Here, we address a secondary outcome, namely, detection of recurrences and effect on time to detection of transferring care from surgeon to GP. Methods Pattern, stage, and treatment of recurrences were described after 3 years. Time to event was defined as date of surgery, until date of recurrence or last follow-up, with death as competing event. Effects on time to recurrence and death were estimated as hazard ratios (HRs) using Cox regression. Restricted mean survival times were estimated. Results Of 303 patients, 141 were randomly assigned to the GP and 162 to the surgeon. Patients were male (67%) with a mean age of 68.0 (8.4) years. During follow-up, 46 recurrences were detected; 18 (13%) in the GP vs 28 (17%) in the surgeon group. Most recurrences were detected via abnormal follow-up tests (74%) and treated with curative intent (59%). Hazard ratio for recurrence was 0.75 (95% confidence interval [CI] = 0.41 to 1.36) in GP vs surgeon group. Patients in the GP group remained in the disease-free state slightly longer (2.76 vs 2.71 years). Of the patients, 38 died during follow-up; 15 (11%) in the GP vs 23 (14%) in the surgeon group. Of these, 21 (55%) deaths were related to colon cancer. There were no differences in overall deaths between the groups (HR = 0.76, 95% CI = 0.39 to 1.46). Conclusion Follow-up provided by GPs vs surgeons leads to similar detection of recurrences. Also, no differences in mortality were found. [ABSTRACT FROM AUTHOR]

Background: The role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity. Methods: Patients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity. Results: In 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424–4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%. Conclusions: The stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial. [ABSTRACT FROM AUTHOR]

Aim: A prolonged interval (>4 weeks) between short‐course radiotherapy (25 Gy in five fractions) (SCRT‐delay) and total mesorectal excision for rectal cancer has been associated with a decreased postoperative complication rate and offers the possibility of organ preservation in the case of a complete tumour response. This prospective cohort study systematically evaluated patient‐reported bowel dysfunction and physician‐reported radiation‐induced toxicity for 8 weeks following SCRT‐delay. Method: Patients who were referred for SCRT‐delay for intermediate risk, oligometastatic or locally advanced rectal cancer were included. Repeated measurements were done for patient‐reported bowel dysfunction (measured by the low anterior resection syndrome [LARS] questionnaire and categorized as no, minor or major LARS) and physician‐reported radiation‐induced toxicity (according to Common Terminology Criteria for Adverse Events version 4.0) before start of treatment (baseline), at completion of SCRT and 1, 2, 3, 4, 6 and 8 weeks thereafter. Results: Fifty‐one patients were included; 31 (61%) were men and the median age was 67 years (range 44–91). Patient‐reported bowel dysfunction and physician‐reported radiation‐induced toxicity peaked at weeks 1–2 after completion of SCRT and gradually declined thereafter. Major LARS was reported by 44 patients (92%) at some time during SCRT‐delay. Grade 3 radiation‐induced toxicity was reported in 17 patients (33%) and concerned predominantly diarrhoea. No Grade 4–5 radiation‐induced toxicity occurred. Conclusion: During SCRT‐delay, almost every patient experiences temporary mild–moderate radiation‐induced toxicity and major LARS, but life‐threatening toxicity is rare. SCRT‐delay is a safe alternative to SCRT‐direct surgery that should be proposed when counselling rectal cancer patients on neoadjuvant strategies. [ABSTRACT FROM AUTHOR]

Background: To achieve an adequate visual working field during laparoscopic colorectal surgery without disturbance of the small intestine, patients are positioned in the Trendelenburg position. This position results in hemodynamic changes that may increase the risk of cardiopulmonary complications and prolonged hospital stay. Recently, an intraoperative retractor sponge was introduced as an alternative to the Trendelenburg position during laparoscopic surgery. The objective of this trial is to study the impact of the use of an intraoperative retractor sponge on the duration of the hospital stay and risk of perioperative complications in patients undergoing laparoscopic surgery for colorectal cancer.Methods/design: The SPONGE trial is a monocenter study and follows the cohort multiple randomized controlled trial (cmRCT) design. It will be conducted within a multicenter prospective observational cohort of colorectal cancer patients of all stages, for whom longitudinal clinical data and patient-reported outcomes are collected. Patients within the cohort, who will undergo laparoscopic surgery for distal colon or rectal cancer, are eligible for inclusion and form a subcohort. From this subcohort, a 1:1 random sample will be offered to undergo surgery with the use of the retractor sponge. Patients from the subcohort who are not selected will undergo standard treatment, that is, surgery in the Trendelenburg position. The primary endpoint is the duration of the postoperative hospital stay. Secondary outcomes are duration of surgery; intraoperative blood loss and fluid balance; and postoperative body temperature, oxygenation and complications. Both arms require 94 patients.Discussion: This study is the first randomized controlled trial to evaluate the effect of sponge-assisted laparoscopic colorectal surgery in comparison with standard Trendelenburg position on hospital stay and peri- and postoperative complications. Results of this study will also be relevant for other surgical procedures in the pelvic region. The present study is the second randomized controlled trial according to the cmRCT design, which is embedded within our colorectal cancer cohort.Trial Registration Number: ClinicalTrials.gov NCT02574013 . Registered 27 September 2015. [ABSTRACT FROM AUTHOR]

Background: In minimally invasive surgery of the sigmoid colon and rectum a retractor sponge has been introduced as an alternative to the Trendelenburg position. This randomized clinical trial (RCT) compared postoperative duration of hospital stay and perioperative outcomes in patients with sigmoid or rectal cancer undergoing sponge-assisted versus Trendelenburg position surgery. Methods: The SPONGE trial is a single-centre RCT nested within the Dutch nationwide prospective observational cohort of patients with colorectal cancer, and follows the Trials within Cohorts (TwiCs) design. Patients with sigmoid or rectal cancer undergoing elective laparoscopic or robotic surgery were randomized to either sponge-assisted or Trendelenburg surgery on a 1:1 basis using block randomization. Duration of postoperative hospital stay was the primary outcome and was compared using the Mann-Whitney U test. Secondary endpoints included the proportion of complications, readmissions, or mortality versus the X2 test in intention-to-treat and per-protocol analyses. This trial was not blinded for patients in the intervention arm or physicians. Results: Between November 2015 and June 2021, 82 patients were randomized to sponge-assisted surgery and 81 to Trendelenburg surgery. After post-randomization exclusion, 150 patients remained for analyses (75 patients per arm). There was no statistically significant difference in median duration of hospital stay (5 days versus 4 days, respectively; P=0.06), 30-day postoperative complications (30 per cent versus 31 per cent; P=1.00), readmission rate (8 per cent versus 15 per cent; P= 0.30), or mortality (0 per cent versus 1 per cent, P=1.00). The per-protocol analysis showed similar results. No adverse device events were seen. Conclusion: Sponge-assisted laparoscopic/robotic surgery does not reduce the duration of hospital stay, or perioperative morbidity or mortality. [ABSTRACT FROM AUTHOR]

Purpose: Dose-escalated chemoradiation (CRT) for locally advanced rectal cancer did not result in higher complete response rates but initiated more tumor regression in the randomized RECTAL-BOOST trial (Clinicaltrials.gov NCT01951521). This study compared patient reported outcomes between patients who received dose-escalated CRT (5 × 3 gray boost + CRT) or standard CRT for 2 years after randomization.Methods and Materials: Patients with locally advanced rectal cancer who were participating in the RECTAL-BOOST trial filled out European Organisation for Research and Treatment of Cancer QLQ-C30 and CR29 questionnaires on quality of life (QoL) and symptoms at baseline, 3, 6, 12, 18, and 24 months after start of treatment. Between-group differences in functional QoL domains were estimated using a linear mixed-effects model and expressed as effect size (ES). Symptom scores were compared using Mann-Whitney U test.Results: Patients treated with dose-escalated CRT (boost group, n = 51) experienced a significantly stronger decline in global health at 3 and 6 months (ES -0.4 and ES -0.4), physical functioning at 6 months (ES -1.1), role functioning at 3 and 6 months (ES -0.8 and ES -0.6), and social functioning at 6 months (ES -0.6), compared with patients treated with standard CRT (control group, n = 64). The boost group reported significantly more fatigue at 3 and 6 months (83% vs 66% respectively 89% vs 76%), pain at 3 and 6 months (67% vs 36% respectively 80% vs 44%), and diarrhea at 3 months (45% vs 29%) compared with the control group. From 12 months onwards, QoL and symptoms were similar between groups, apart from more blood/mucus in stool in the boost group.Conclusions: In patients with locally advanced rectal cancer, dose-escalated CRT resulted in a transient deterioration in global health, physical, role, and social functioning and more pain, fatigue and diarrhea at 3 and 6 months after start of treatment compared with standard CRT. From 12 months onwards, the effect of dose-escalated CRT on QoL largely resolved. [ABSTRACT FROM AUTHOR]

Background: Current guidelines recommend maintaining intra-operative normothermia to avoid surgical site infections (SSI) after colorectal cancer surgery. The aim of this study was to assess whether compliance with normothermia as part of temperature management measures is an effective strategy to reduce post-operative SSI and complications. Patients and Methods: This was a cohort study of patients undergoing surgery for primary colorectal cancer in 2011-2017 in a large teaching hospital in which temperature management using the Bair Hugger™ system (3M™ Center, St. Paul, MN) was standard care. Data from the prospective Dutch Surgical Audit (DCRA) database were complemented by highly granular intra-operative central body temperature data. A multivariable logistic regression model was used. Results: A total of 1,015 patients undergoing surgery for primary colorectal cancer were included. Temperature outcomes for the entire study cohort were as follows: mean temperature was 36.3°C (standard deviation [SD] ±0.5°C), median temperature nadir was 35.8°C (interquartile range [IQR] 35.6°C-36.1°C), median percentage of time at nadir was 2.0% (IQR 0.8%-10.7%), and median percentage of time less than 36.0°C was 1.0% (IQR 0.0%-33.3%). Thirty-day SSI rate was 10% (n = 101). Logistic regression models adjusting for gender, diabetes mellitus, body mass index (BMI), rectal cancer, duration of surgery, open surgery, emergency surgery, and period of surgery showed no association between any of the four temperature outcomes and SSI. Multivariable analysis also failed to show an association between intra-operative hypothermia and 30-day complications, mortality, or re-admission. Conclusions: In a hospital in which temperature management is standard care, intra-operative hypothermia and SSI rates in patients undergoing colorectal cancer surgery were low. Compliance with normothermia appears to be an effective strategy to reduce SSI. [ABSTRACT FROM AUTHOR]

Aim: Unlike meta‐analyses of randomized controlled trials, population‐based studies in colorectal cancer (CRC) patients have shown a significant association between open surgery and increased 30‐ and 90‐day mortality compared with laparoscopic surgery. Long‐term mortality, however, is scarcely reported. This retrospective population‐based study aimed to compare long‐term mortality after open and laparoscopic surgery for CRC. Method: The Dutch Colorectal Audit and the Dutch Cancer Centre registry were used to identify patients from three large nonacademic teaching hospitals who underwent curative resection for CRC between 2009 and 2018. Patients with relative contraindications for laparoscopic surgery (cT4 or pT4 tumours, distant metastasis requiring additional resection and emergency surgery) were excluded. Multivariable regression was used to assess the effect of laparoscopic surgery on long‐term mortality with adjustment for gender, age, American Society of Anesthesiologists score, TNM stage, chemoradiation therapy and other confounders. Results: We included 4531 patients, of whom 1298 (29%) underwent open surgery. The median follow‐up was 43 months (interquartile range 23–71 months). Open surgery was associated with an increased risk of long‐term mortality (adjusted hazard ratio 1.26, 95% confidence interval 1.10–1.45, p = 0.001). Mixed‐effects Cox regression with year of surgery as a random effect also showed an increased risk after open surgery (adjusted hazard ratio 1.33, 95% confidence interval 1.11–1.52, p = 0.004). Conclusion: Open surgery seems to be associated with increased long‐term mortality in the elective setting for CRC patients. A minimally invasive approach might improve long‐term outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Pathologic complete tumor response after chemoradiation in patients with locally advanced rectal cancer (LARC) is associated with a favorable prognosis and allows organ-sparing treatment strategies. In the RECTAL-BOOST trial, we aimed to investigate the effect of an external radiation boost to the tumor before chemoradiation on pathologic or sustained clinical complete tumor response in LARC.Methods and Materials: This multicenter, nonblinded, phase 2 randomized controlled trial followed the trials-within-cohorts design, which is a pragmatic trial design allowing cohort participants to be randomized for an experimental intervention. Patients in the intervention group are offered the intervention (and can either accept or refuse this), whereas patients in the control group are not notified about the randomization. Participants of a colorectal cancer cohort referred for chemoradiation of LARC to either of 2 radiation therapy centers were eligible. Patients were randomized to no boost or an external radiation boost (5 × 3 Gy) without concurrent chemotherapy, directly followed by standard pelvic chemoradiation (25 × 2 Gy with concurrent capecitabine). The primary outcome was pathologic complete response (ie, ypT0N0) in patients with planned surgery at 12 weeks, or, as surrogate for pathologic complete response, a 2-year sustained clinical complete response for patients treated with an organ preservation strategy. Analyses were intention to treat. The study was registered with ClinicalTrials.gov, number NCT01951521.Results: Between September 2014 and July 2018, 128 patients were randomized. Fifty-one of the 64 (79.7%) patients in the intervention group accepted and received a boost. Compared with the control group, fewer patients in the intervention group had a cT4 stage and a low rectal tumor (31.3% vs 17.2% and 56.3% vs 45.3%, respectively), and more patients had a cN2 stage (59.4% vs 70.3%, respectively). Rate of pathologic or sustained clinical complete tumor response was similar between the groups: 23 of 64 (35.9%; 95% confidence interval [CI], 24.3-48.9) in the intervention group versus 24 of 64 (37.5%; 95% CI, 25.7-50.5) in the control group (odds ratio [OR] = 0.94; 95% CI, 0.46-1.92). Near-complete or complete tumor regression was more common in the intervention group (34 of 49; 69.4%) than in the control group (24 of 53; 45.3%; (OR = 2.74, 95% CI 1.21-6.18). Grade ≥3 acute toxicity was comparable: 6 of 64 (9.4%) in the intervention group versus 5 of 64 (7.8%) in the control group (OR = 1.22; 95% CI, 0.35-4.22).Conclusions: Dose escalation with an external radiation therapy boost to the tumor before neoadjuvant chemoradiation did not increase the pathologic or sustained clinical complete tumor response rate in LARC. [ABSTRACT FROM AUTHOR]

Background: Neoadjuvant chemoradiation with delayed surgery (CRT-DS) and short-course radiotherapy with immediate surgery (SCRT-IS) are two commonly used treatment strategies for rectal cancer. However, the optimal treatment strategy for patients with intermediate-risk rectal cancer remains a discussion. This study compares quality of life (QOL) between SCRT-IS and CRT-DS from diagnosis until 24 months after treatment. Methods: In a prospective colorectal cancer cohort, rectal cancer patients with clinical stage T2-3N0-2M0 undergoing SCRT-IS or CRT-DS between 2013 and 2017 were identified. QOL was assessed using EORTC-C30 and EORTC-CR29 questionnaires before the start of neoadjuvant treatment (baseline) and at 3, 6, 12, 18 and 24 months after. Patients were 1:1 matched using propensity sore matching. Between- and within-group differences in QOL domains were analyzed with linear mixed-effects models. Symptoms and sexual interest at 12 and 24 months were compared using logistic regression models. Results: 156 of 225 patients (69%) remained after matching. The CRT-DS group reported poorer emotional functioning at 3, 6, 12, 18 and 24 months (mean difference with SCRT-IS: −9.4, −12.1, −7.3, −8.0 and −7.9 respectively), and poorer global health, physical-, role-, social- and cognitive functioning at 6 months (mean difference with SCRT-IS: −9.1, −9.8, −14.0, −9.2 and −12.6, respectively). Besides emotional functioning, all QOL domains were comparable at 12, 18 and 24 months. Within-group changes showed a significant improvement of emotional functioning after baseline in the SCRT-IS group, whereas only a minor improvement was observed in the CRT-DS group. Symptoms and sexual interest in male patients at 12 and 24 months were comparable between the groups. Conclusions: In rectal cancer patients, CRT-DS may induce a stronger decline in short-term QOL than SCRT-IS. From 12 months onwards, QOL domains, symptoms and sexual interest in male patients were comparable between the groups. However, emotional functioning remained higher after SCRT-IS than after CRT-DS. [ABSTRACT FROM AUTHOR]

Background/Aims: Several initiatives have started to transfer colorectal cancer follow-up (FU) from secondary to primary care. For this purpose, it is important to assess when and how recurrences of rectal carcinoma are detected after treatment with curative intent. Methods: Retrospective multicentre cohort study. Patients participating in an FU programme after curative intended treatment for rectal cancer stages I-III between 2007 and 2014. Results: Of the 378 patients, 64 (17%) developed recurrent disease (RD). Most were detected during scheduled FU consultations (n = 55) by (a combination of) radiological examinations and carcinoembryonic antigen levels, and were asymptomatic (n = 53); outside scheduled FU consultations, RD was detected during the treatment of postoperative complications or ostomy reversal (n = 5), or due to symptoms (n = 4). Most frequent sites of recurrence were liver (50%), lung (44%), multiple (22%) or locoregional (16%). Treatment of RD with curative intent was performed more frequently when detected during scheduled FU (60 vs. 22%). The only predictive factor for developing RD was stage III disease on initial presentation. Conclusions: The majority of rectal cancer patients are diagnosed with RD at an asymptomatic stage during scheduled FU consultations. Only a few patients presented with RD outside the FU programme. Arguably, general practitioners could order these same diagnostic tests during FU. [ABSTRACT FROM AUTHOR]

Purpose: Follow-up after colorectal cancer treatment with curative intent aims to detect recurrences and metachronous tumors in a timely manner. The objective of this study is to assess how recurrent disease presents and is diagnosed within scheduled follow-up according to the national guideline for the Netherlands.Methods: In a retrospective study of consecutive patients with colorectal cancer who were treated in 2 hospitals in the Netherlands, we identified patients with colon cancer who underwent surgery with curative intent between January 2007 and December 2012. Patients who developed recurrent disease were included for further analyses.Results: From a total of 446 patients who were been treated for colon carcinoma with curative intent, 74 developed recurrent disease (17%). In 43 of those patients (58%), recurrent disease was detected during a scheduled follow-up visit, with 41 (95%) being asymptomatic. Tumor marker testing, imaging, and colonoscopy identified all of these recurrences. In the remaining 31 patients with recurrent disease (42%), recurrence was found during non-scheduled interval visits; 26 (84%) of these patients were symptomatic. The most prevalent symptoms were abdominal pain, altered defecation, and weight loss. Patients with asymptomatic recurrences had a significantly higher overall survival compared with patients with symptomatic recurrences.Conclusions: In this cohort, 42% of the recurrences after initial curative treatment for colon cancer were found during non-scheduled interval visits, mainly based on symptoms. Primary care physicians who take care of patients whose colon cancer might recur should be aware of the relatively high rate of symptomatic recurrences and of typical presenting symptoms. [ABSTRACT FROM AUTHOR]

Mroczkowski & Zajdel [7] question the plausibility of the presented data; however, the authors misinterpreted the Kaplan-Meier graph. Mroczkowski et al. question whether our claim of increased mortality after open surgery can be made based on the presented data. We agree that the competency in open surgery should be preserved as conversion to open surgery or primary open surgery is necessary under certain circumstances, but it should not come at the cost of increased mortality and morbidity and a middle ground should be found. [Extracted from the article]

Background: It is expected that in 2020 more than 17,000 cases of colorectal cancer will be diagnosed in The Netherlands. To date, patients are included in a surgeon-led follow-up programme whose main focus is recurrence detection. However, patients often experience multiple physical and psychosocial problems. Currently, these problems are not always encountered. More care by a generalist is suggested as a solution. Furthermore, patients prefer to undergo rehabilitation in their own environment and to be more involved in their own health care. eHealth applications might enhance this. Oncokompas(2.0) is an online self-management application which facilitates access to supportive care. This study aims to evaluate primary care follow-up and aftercare in comparison with secondary care follow-up and aftercare for patients with colon cancer. Second, the added value of Oncokompas(2.0) to care will be assessed.Methods/design: This is a multi-centre 2 × 2 factorial randomised controlled trial with a calculated sample size of 300 patients. Patients with stage I, II, or III colon carcinoma are eligible. Patients will be randomly assigned in four groups: (1) usual follow-up visits and aftercare provided in secondary care, (2) usual follow-up visits and aftercare provided in secondary care with additional use of Oncokompas(2.0), (3) follow-up and aftercare in primary care, and (4) follow-up and aftercare in primary care with additional use of Oncokompas(2.0). The primary outcome is quality of life. Secondary outcomes include physical outcomes, psychosocial outcomes, number of investigations, referrals and related communication between secondary and primary care, (time of) recurrence detection and protocol adherence, attention to preventive care, self-management of patients, patient satisfaction, and preference of care at the end of the trial. Data collection will be done by questionnaires and extractions from electronic medical records.Discussion: The results of this study will provide evidence, which has been scarce to date, on prominent general practitioner involvement in care for colon cancer patients after initial treatment. Also, it evaluates the efficacy of an eHealth application to enhance patient empowerment.Dutch Trial Register: NTR4860 (registered on 2 October 2014). [ABSTRACT FROM AUTHOR]

Background: It is expected that in 2020 more than 17,000 cases of colorectal cancer will be diagnosed in The Netherlands. To date, patients are included in a surgeon-led follow-up programme whose main focus is recurrence detection. However, patients often experience multiple physical and psychosocial problems. Currently, these problems are not always encountered. More care by a generalist is suggested as a solution. Furthermore, patients prefer to undergo rehabilitation in their own environment and to be more involved in their own health care. eHealth applications might enhance this. Oncokompas2.0 is an online self-management application which facilitates access to supportive care. This study aims to evaluate primary care follow-up and aftercare in comparison with secondary care follow-up and aftercare for patients with colon cancer. Second, the added value of Oncokompas2.0 to care will be assessed. Methods/Design: This is a multi-centre 2 × 2 factorial randomised controlled trial with a calculated sample size of 300 patients. Patients with stage I, II, or III colon carcinoma are eligible. Patients will be randomly assigned in four groups: (1) usual follow-up visits and aftercare provided in secondary care, (2) usual follow-up visits and aftercare provided in secondary care with additional use of Oncokompas2.0, (3) follow-up and aftercare in primary care, and (4) follow-up and aftercare in primary care with additional use of Oncokompas2.0. The primary outcome is quality of life. Secondary outcomes include physical outcomes, psychosocial outcomes, number of investigations, referrals and related communication between secondary and primary care, (time of) recurrence detection and protocol adherence, attention to preventive care, self-management of patients, patient satisfaction, and preference of care at the end of the trial. Data collection will be done by questionnaires and extractions from electronic medical records. Discussion: The results of this study will provide evidence, which has been scarce to date, on prominent general practitioner involvement in care for colon cancer patients after initial treatment. Also, it evaluates the efficacy of an eHealth application to enhance patient empowerment. [ABSTRACT FROM AUTHOR]