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Copyright of BJS Open is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of BJS Open is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of British Journal of Surgery is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Pseudomyxoma peritonei (PMP) is a rare disease, most commonly of appendiceal origin. Treatment consists of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS–HIPEC). The aim of this study was to identify prognostic factors for recurrence and survival. Methods: This was an observational study using a prospectively designed database containing consecutive patients with PMP originating from the appendix, undergoing CRS–HIPEC at a tertiary referral centre between 1996 and 2015. Histopathological slides were reassessed. Cox regression was used for multivariable analyses. Results: Of 225 patients identified, 36 (16·0 per cent) were diagnosed with acellular mucin, 149 (66·2 per cent) had disseminated peritoneal adenomucinosis (DPAM) and 40 (17·8 per cent) had peritoneal mucinous carcinomatosis (PMCA). The 5‐year overall survival (OS) rates were 93, 69·8 and 55 per cent respectively. Recurrence was observed in 120 patients (53·3 per cent), 39 of whom (17·3 per cent) were treated with a second CRS–HIPEC procedure. Factors independently associated with poor disease‐free survival were six or seven affected regions (hazard ratio (HR) 6·01, 95 per cent c.i. 2·04 to 17·73), incomplete cytoreduction (R2a resection: HR 1·67, 1·05 to 2·65; R2b resection: HR 2·00, 1·07 to 3·73), and more than threefold raised carcinoembryonic antigen (CEA) and/or carbohydrate antigen (CA) 19‐9 level (HR 2·31, 1·30 to 4·11). Factors independently associated with poorer OS were male sex (HR 1·74, 1·09 to 2·77), incomplete cytoreduction (R2a resection: HR 1·87, 1·14 to 3·08; R2b resection: HR 2·28, 1·19 to 4·34), and more than threefold raised CEA and/or CA19‐9 level (HR 2·89, 1·36 to 6·16). Conclusion: CEA and CA19‐9 levels raised more than threefold above the upper limit identify patients with PMP of appendiceal origin and poorer survival. [ABSTRACT FROM AUTHOR]

Background: Nationwide audits facilitate quality and outcome assessment of pancreatoduodenectomy. Differences may exist between countries but studies comparing nationwide outcomes of pancreatoduodenectomy based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation. Methods: Anonymized data from patients undergoing pancreatoduodenectomy between 2014 and 2016 were extracted from the German Society for General and Visceral Surgery StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit, and compared using descriptive statistics. Univariable and multivariable risk analyses were undertaken. Results: Overall, 4495 patients were included, 2489 in Germany and 2006 in the Netherlands. Adenocarcinoma was a more frequent indication for pancreatoduodenectomy in the Netherlands. German patients had worse ASA fitness grades, but Dutch patients had more pulmonary co‐morbidity. Dutch patients underwent more minimally invasive surgery and venous resections, but fewer multivisceral resections. No difference was found in rates of grade B/C postoperative pancreatic fistula, grade C postpancreatectomy haemorrhage and in‐hospital mortality. There was more centralization in the Netherlands (1·3 versus 13·3 per cent of pancreatoduodenectomies in very low‐volume centres; P < 0·001). In multivariable analysis, both hospital stay (difference 2·49 (95 per cent c.i. 1·18 to 3·80) days) and risk of reoperation (odds ratio (OR) 1·55, 95 per cent c.i. 1·22 to 1·97) were higher in the German audit, whereas risk of postoperative pneumonia (OR 0·57, 0·37 to 0·88) and readmission (OR 0·38, 0·30 to 0·49) were lower. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality. Conclusion: This comparison of the German and Dutch audits showed variation in case mix, surgical technique and centralization for pancreatoduodenectomy, but no difference in mortality and pancreas‐specific complications. This comparison of the German and Dutch audits of 4495 patients undergoing pancreatoduodenectomy revealed good overall surgical outcome but noteworthy differences in patient characteristics, indication, surgical technique, centralization and outcome between the two countries. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality. Variation in practice between two countries [ABSTRACT FROM AUTHOR]

Background: Patients with limited peritoneal metastases from colorectal cancer may be candidates for an aggressive surgical approach including cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS–HIPEC). Selection is based on surgical inspection during laparoscopy or laparotomy. The aim of this study was to investigate whether diffusion‐weighted MRI (DW‐MRI) can be used to select patients for CRS–HIPEC. Methods: This was a prospective study at a tertiary referral centre. Patients with confirmed or suspected colorectal peritoneal metastases scheduled for exploratory laparotomy or laparoscopy were eligible. Two radiologists assessed the peritoneal cancer index (PCI) on CT (CT‐PCI) and DW‐MRI (MRI‐PCI). The reference standard was PCI at surgery. Radiologists were blinded to the surgical PCI and to each other's findings. The main outcome was the accuracy of DW‐MRI in predicting whether patients had resectable disease (PCI less than 21) or not. Results: Fifty‐six patients were included in the study, of whom 49 could be evaluated. The mean(s.d.) PCI at surgery was 11·27(7·53). The mean MRI‐PCI was 10·18(7·07) for reader 1 and 8·59(7·08) for reader 2. Readers 1 and 2 correctly staged 47 of 49 and 44 of 49 patients respectively (accuracy 96 and 90 per cent). Both readers detected all patients with resectable disease with a PCI below 21 at surgery (sensitivity 100 per cent). No patient was overstaged. The intraclass correlation (ICC) between readers was excellent (ICC 0·91, 95 per cent c.i. 0·77 to 0·96). MRI‐PCI had a stronger correlation with surgical PCI (ICC 0·83–0·88) than did CT‐PCI (ICC 0·39–0·44). Conclusion: DW‐MRI is a promising non‐invasive tool to guide treatment selection in patients with peritoneal metastases from colorectal cancer. Promising staging tool [ABSTRACT FROM AUTHOR]

Background: Patients with colorectal peritoneal carcinomatosis have a very poor prognosis. The recently developed consensus molecular subtype (CMS) classification of primary colorectal cancer categorizes tumours into four robust subtypes, which could guide subtype‐targeted therapy. CMS4, also known as the mesenchymal subtype, has the greatest propensity to form distant metastases. CMS4 status and histopathological features of colorectal peritoneal carcinomatosis were investigated in this study. Methods: Fresh‐frozen tissue samples from primary colorectal cancer and paired peritoneal metastases from patients who underwent cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy were collected. Histopathological features were analysed, and a reverse transcriptase–quantitative PCR test was used to assess CMS4 status of all collected lesions. Results: Colorectal peritoneal carcinomatosis was associated with adverse histopathological characteristics, including a high percentage of stroma in both primary tumours and metastases, and poor differentiation grade and high‐grade tumour budding in primary tumours. Furthermore, CMS4 was significantly enriched in primary tumours with peritoneal metastases, compared with unselected stage I–IV tumours (60 per cent (12 of 20) versus 23 per cent; P = 0.002). The majority of peritoneal metastases (75 per cent, 21 of 28) were also classified as CMS4. Considerable intrapatient subtype heterogeneity was observed. Notably, 15 of 16 patients with paired tumours had at least one CMS4‐positive tumour location. Conclusion: Significant enrichment for CMS4 was observed in colorectal peritoneal carcinomatosis. Surgical relevance Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS‐HIPEC) improves survival of selected patients with colorectal peritoneal carcinomatosis, but recurrence is common. Histopathological and molecular analysis of colorectal peritoneal carcinomatosis could provide clues for development of novel therapies. In this study, colorectal peritoneal carcinomatosis was found to be enriched for tumours with high stromal content and CMS4‐positive status. To further improve prognosis for patients with colorectal peritoneal carcinomatosis, therapies that target tumour–stroma interaction could be added to CRS‐HIPEC. [ABSTRACT FROM AUTHOR]

Weak evidence base for clinical trials [ABSTRACT FROM AUTHOR]

Background: Postoperative convalescence is mainly determined by the extent and duration of postoperative ileus. This randomized clinical trial evaluated the effects of early oral feeding on functional gastrointestinal recovery and quality of life. Methods: One hundred and twenty-eight patients undergoing elective open colorectal or abdominal vascular surgery participated in the trial. Of these, 67 were randomized to a conventional return to diet, and 61 to a regimen allowing resumption of an oral diet as soon as tolerated (free diet group). Results: Reinsertion of a nasogastric tube was necessary in 20 per cent of the free diet group and 10 per cent of the conventional group (P = 0.213). The complication rate was similar for both groups, as was return of gastrointestinal function. A normal diet was tolerated after a median of 2 days in the free diet group compared with 5 days in the conventional group (P < 0.001). Quality of life scores were similar in both groups. Conclusion: Early resumption of oral intake does not diminish the duration of postoperative ileus or lead to a significantly increased rate of nasogastric tube reinsertion. Tolerance of oral diet is not influenced by gastrointestinal functional recovery. As there is no reason to withhold oral intake following open colorectal or abdominal vascular surgery, postoperative management should include early resumption of diet. [ABSTRACT FROM AUTHOR]

Background: Treatment of suspected hepatocellular adenoma (HA) remains controversial. The aim of this study was to evaluate the management of HA at a time when magnetic resonance imaging (MRI) and computed tomography (CT) are highly sensitive methods for diagnosing HA. Methods: Between January 2000 and January 2005, data from 48 consecutive women with HA (median age 36 years) were prospectively collected. The protocol for diagnostic work-up consisted of multiphasic MRI or CT. Management was observation if the tumour was smaller than 5 cm and surgical intervention if it was 5 cm or larger. Results: The median follow-up was 24 (range 3-73) months. Sixteen (33 per cent) patients had invasive procedures because of tumour size 5 cm or larger, malignant characteristics or haemorrhage. The remaining 32 patients (67 per cent) were observed; haemorrhage and malignant degeneration did not occur and none of the lesions showed enlargement after withdrawal of oral contraceptives. Multiple HAs were found in 32 (67 per cent) patients; liver steatosis was significantly more common in these patients than in those with a solitary lesion (59 versus 19 per cent; P = 0·008). Conclusion: Observation of adenomas smaller than 5 cm is justified because of improved radiological reliability. Resection should be reserved for patients with malignant tumour characteristics or with single lesions 5 cm or larger. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]