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Introduction: To improve care for patients with colorectal peritoneal metastases (CRC-PM) or pseudomyxoma peritonei (PMP), the Dutch CRS-HIPEC quality registry was initiated in 2019. The aims are to describe the development and content of this registry and to give insight into the data collected during the first years., Materials and Methods: The registry is an observational cohort in the Netherlands. All patients with CRC-PM or PMP who intend to undergo cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) from 6 hospitals are included. Clinical data and outcomes (including hospital variation) were analyzed., Results: In 2019-2022, 889 patients were included in the CRS-HIPEC quality registry: 749 (84 %) with CRC-PM and 140 (16 %) with PMP. Peritoneal metastases were diagnosed synchronously in 51 % of CRC-PM patients and in 94 % of PMP patients. In patients undergoing complete CRS, the median peritoneal cancer index was 8 (IQR 4-13) for CRC-PM and 15 (IQR 6-26) for PMP. Complete cytoreduction was achieved in 639 CRC-PM patients (97 %) and 108 PMP patients (82 %). HIPEC was mainly performed with mitomycin C (CRC-PM: 94 %, PMP: 92 %). Major postoperative complications (Clavien-Dindo grade ≥3) occurred in 148 CRC-PM patients (22 %) and 30 PMP patients (23 %) with 90-day mortality rates of 2 %. In CRC-PM, differences between hospitals were observed regarding proportions of diagnostic laparoscopies/laparotomies, (neo)adjuvant treatment, ostomy formations and re-admissions., Conclusion: The CRS-HIPEC quality registry provides insight into the outcomes of CRS-HIPEC and enables clinical auditing and observational cohort studies aiming to improve treatment outcomes for patients with CRC-PM and PMP., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Purpose: It is assumed that case-based questions require higher order cognitive processing, whereas questions that are not case-based require lower order cognitive processing. In this study, we investigated to what extent case-based questions and questions that are not case-based, relate to Bloom's taxonomy., Methods: In this article, 4800 questions of the Progress Test were classified whether it was a case-based question and the level of Bloom's taxonomy. Lower-order questions require students to remember or/and basically understand the knowledge. Higher-order questions require students to apply, analyze, or/and evaluate. A phi-coefficient was calculated to investigate the relations between the presence of case-based questions and the required level of cognitive processing., Results: Our results demonstrated that case-based questions were measuring higher levels of cognitive processing in 98.1% of the questions. Of the non-case-based questions, 33.7% required a higher level of cognitive processing. The phi-coefficient demonstrated a significant moderate correlation between the presence of a patient case in a question and its required level of cognitive processing (phi-coefficient = 0.55, p<0.001)., Conclusion: Medical teachers should be aware of the association between item formats (case-based versus non-case-based) and the cognitive processes they elicit in order to meet a certain balance in a test, taking the learning objectives as well as the test difficulty into account.

Background: In the Netherlands, surgery for peritoneal metastases of colorectal cancer (PMCRC) is centralised, whereas PMCRC is diagnosed in all hospitals. This study assessed whether hospital of diagnosis affects treatment selection and overall survival (OS)., Methods: Between 2005 and 2015, all patients with synchronous PMCRC without systemic metastases were selected from the Netherlands Cancer Registry. Treatment was classified as cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), systemic therapy or other/no treatment. Hospitals of diagnosis were classified as: (1) non-teaching or academic/teaching hospital and (2) HIPEC centre or referring hospital. Referring hospitals were further classified based on the frequency of CRS/HIPEC as high-, medium- or low-frequency hospital. Multivariable regression analyses were used to assess the independent influence of hospital categories on the likelihood of CRS/HIPEC and OS., Results: A total of 2661 patients, diagnosed in 89 hospitals, were included. At individual hospital level, CRS/HIPEC and systemic therapy ranged from 0% to 50% and 6% to 67%, respectively. Hospital of diagnosis influenced the likelihood of CRS/HIPEC: 33% versus 13% for HIPEC centres versus referring hospitals (odds ratio (OR) 3.66 [2.40-5.58]) and 11% versus 17% for non-teaching hospitals versus academic/teaching hospitals (OR 0.60 [0.47-0.77]). Hospital of diagnosis affected median OS: 14.1 versus 9.6 months for HIPEC centres versus referring hospitals (hazard ratio (HR) 0.82 [0.67-0.99]) and 8.7 versus 11.5 months for non-teaching hospitals versus academic/teaching hospitals (HR 1.15 [1.06-1.26]). Compared with diagnosis in medium-frequency referring hospitals, median OS was increased in high-frequency referring hospitals (12.6 months, HR 0.82 [0.73-0.91]) and reduced in low-frequency referring hospitals (8.1 months, HR 1.12 [1.01-1.24])., Conclusion: Treatment disparities among hospitals of diagnosis and their impact on survival indicate suboptimal treatment selection for PMCRC., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Local recurrence after rectal cancer treatment occurs in ≈5% to 10% of patients. Neoadjuvant (chemo)radiotherapy for primary rectal cancer renders treatment of recurrent disease more difficult., Objective: The purpose of this study was to review contemporary multimodality therapies, including their outcome, for locally recurrent rectal carcinoma after (chemo)radiotherapy and complete surgical resection of primary rectal cancer., Data Sources: A comprehensive literature search of PubMed and EMBASE was performed., Study Selection: All English language articles presenting original patient data regarding treatment and the respective outcome of previously irradiated locally recurrent rectal cancer were included., Interventions: All of the treatment modalities for locally recurrent rectal cancer were reviewed., Main Outcome Measures: Primary outcome parameters were local control, metastasis-free survival, and overall survival. Secondary outcome parameters were perioperative morbidity and mortality, and prognostic factors for treatment outcome., Results: Of 854 studies, 9 studies and 474 patients with locally recurrent rectal carcinoma were included. Various treatment regimens were used, most with curative intent. Reirradiation was composed of (neo-)adjuvant external beam radiotherapy (with or without concurrent chemotherapy), additional intraoperative radiotherapy, or intraoperative radiotherapy only. Surgical technique highly varied, depending on the extent of the lesion. Radiation toxicity, perioperative morbidity, and mortality were generally acceptable. Outcome was better after curative intent treatment, any surgical resection, and R0 resections in particular. Moreover, reirradiation is associated with increased complete resection rates, which in turn positively affected local control and overall survival., Limitations: Most studies were retrospectively designed, with highly variable therapies, patient populations, and duration of follow-up., Conclusions: A complete resection is the most important prognostic factor and should be the goal of treatment in locally recurrent rectal carcinoma. Reirradiation seems safe and of additional value in reaching a complete resection. Considering the available evidence, at present reirradiation should be given on a case-specific basis, with all of the patients entering an international prospective database.

Progress testing in the Netherlands has a long history. It was first introduced at one medical school which had a problem-based learning (PBL) curriculum from the start. Later, other schools with and without PBL curricula joined. At present, approximately 10,000 students sit a test every three months. The annual progress exam is not a single test. It consists of a series of 4 tests per annum which are summative in the end. The current situation with emphasis on the formative and summative aspects will be discussed. The reader will get insight into the way progress testing can be used as feedback for students and schools.

Background: The peritoneum is the second most common site of recurrence in colorectal cancer. Early detection of peritoneal carcinomatosis (PC) by imaging is difficult. Patients eventually presenting with clinically apparent PC have a poor prognosis. Median survival is only about five months if untreated and the benefit of palliative systemic chemotherapy is limited. Only a quarter of patients are eligible for curative treatment, consisting of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CR/HIPEC). However, the effectiveness depends highly on the extent of disease and the treatment is associated with a considerable complication rate. These clinical problems underline the need for effective adjuvant therapy in high-risk patients to minimize the risk of outgrowth of peritoneal micro metastases. Adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) seems to be suitable for this purpose. Without the need for cytoreductive surgery, adjuvant HIPEC can be performed with a low complication rate and short hospital stay., Methods/design: The aim of this study is to determine the effectiveness of adjuvant HIPEC in preventing the development of PC in patients with colon cancer at high risk of peritoneal recurrence. This study will be performed in the nine Dutch HIPEC centres, starting in April 2015. Eligible for inclusion are patients who underwent curative resection for T4 or intra-abdominally perforated cM0 stage colon cancer. After resection of the primary tumour, 176 patients will be randomized to adjuvant HIPEC followed by routine adjuvant systemic chemotherapy in the experimental arm, or to systemic chemotherapy only in the control arm. Adjuvant HIPEC will be performed simultaneously or shortly after the primary resection. Oxaliplatin will be used as chemotherapeutic agent, for 30 min at 42-43 °C. Just before HIPEC, 5-fluorouracil and leucovorin will be administered intravenously. Primary endpoint is peritoneal disease-free survival at 18 months. Diagnostic laparoscopy will be performed routinely after 18 months postoperatively in both arms of the study in patients without evidence of disease based on routine follow-up using CT imaging and CEA., Discussion: Adjuvant HIPEC is assumed to reduce the expected 25 % absolute risk of PC in patients with T4 or perforated colon cancer to a risk of 10 %. This reduction is likely to translate into a prolonged overall survival., Trial Registration Number: NCT02231086 (Clinicaltrials.gov).

Background: Gastrointestinal stromal tumors (GIST) of the rectum are a challenge for the colorectal surgeon. In case of a locally advanced rectal GIST, an extended or multivisceral resection with significant morbidity and -mortality is often necessary. Literature is lacking on the combined modality of transanal endoscopisc microsurgery (TEM) following imatinib for these patients., Methods: We describe a combined approach for a locally advanced GIST of the rectum with preoperative imatinib -treatment and subsequent local excision using the TEM procedure., Results: After six months of treatment with imatinib the TEM procedure was successfully performed with a radical -resection of the remnant tumor. Twenty-four months after surgery this patient has no evidence of disease., Conclusions: A TEM procedure following treatment with imatinib may safely be performed in selected patients with a locally advanced GIST., (Copyright© Acta Chirurgica Belgica.)

Introduction: New diagnostics, the emergence of total mesorectal excision and neoadjuvant treatments have improved outcome for patients with rectal cancer. Patients with distal rectal cancer undergoing an abdominoperineal excision seem to do worse compared to those treated with sphinctersparing techniques. The aim of this study was to evaluate the quality of care for patients undergoing an abdominoperineal excision for distal rectal cancer during the last 15 years., Materials and Methods: All patients with rectal cancer, who underwent an abdominoperineal excision between December 1996 and December 2010 in 5 Dutch hospitals were analysed. Patients were divided into three cohorts; 1996-2001, 2001-2005 and 2006-2010. All data was extracted from medical records., Results: 477 patients were identified. There was no significant difference in sex, age, BMI, prior pelvic surgery and ASA stages between the cohorts. MRI became a standard tool in the work-up, the use increased from 4.5% in the first, to 95.1% in the last cohort (p < 0.0001). Neoadjuvant treatment shifted from predominantly none (64.9% in cohort 1) to short course radiotherapy (66.7% in cohort 2) and chemoradiation therapy (55.7% in cohort 3). There was a trend towards a decreased circumferential resection margin involvement in the cohorts (18.8%, 16.7% and 11.4%; p = 0.142). Accidental bowel perforations have significantly decreased from 28.6%, and 21.7% to 9.2% in cohort 3 (p < 0.0001)., Conclusion: Significant improvements in work-up, neoadjuvant and surgical treatment have been made for patients with low rectal cancer, undergoing an abdominoperineal excision. These improvements result in improved short term outcome., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Purpose: This nationwide study evaluated results of cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal metastasis of colorectal origin in the Netherlands following a national protocol., Methods: In a multi-institutional study prospective databases of patients with peritoneal carcinomatosis (PC) from colorectal cancer and pseudomyxoma peritonei (PMP) treated according to the Dutch HIPEC protocol, a uniform approach for the CRS and HIPEC treatment, were reviewed. Primary end point was overall survival and secondary end points were surgical outcome and progression-free survival., Results: Nine-hundred sixty patients were included; 660 patients (69 %) were affected by PC of colorectal carcinoma and the remaining suffered from PMP (31 %). In 767 procedures (80 %), macroscopic complete cytoreduction was achieved. Three-hundred and thirty one patients had grade III-V complications (34 %). Thirty-two patients died perioperatively (3 %). Median length of hospital stay was 16 days (range 0-166 days). Median follow-up period was 41 months (95 % confidence interval (CI), 36-46 months). Median progression-free survival was 15 months (95 % CI 13-17 months) for CRC patients and 53 months (95 % CI 40-66 months) for PMP patients. Overall median survival was 33 (95 % CI 28-38 months) months for CRC patients and 130 months (95 % CI 98-162 months) for PMP patients. Three- and five-year survival rates were 46 and 31 % respectively in case of CRC patients and 77 and 65 % respectively in case of PMP patients., Conclusions: The results underline the safety and efficacy of cytoreduction and HIPEC for PC from CRC and PMP. It is assumed the uniform Dutch HIPEC protocol was beneficial.

Background: Transperitoneal rectal stump resection is a complicated procedure with risk of inadvertent bowel, vascular and nerve injury. This study analysed the feasibility and safety of the use of transanal endoscopic microsurgery (TEM) to excise rectal stumps that would otherwise require a combined transabdominal and perineal approach., Methods: Rectal stump resection was performed by a transanal approach using TEM. Stumps were removed by complete rectal wall resection and intersphincteric resection of the anus, leaving the mesorectum in place., Results: The study included nine patients with a rectal stump ranging in length from 8 to 20 cm after previous surgery for inflammatory bowel disease (6), Lynch syndrome (1), collagenous colitis (1) or anastomotic leakage (1). The median duration of operation was 161 (range 107-239) min. The median postoperative length of hospital stay was 5 (range 2-71) days. One patient required an additional small-incision laparotomy to remove a stump extending up to the promontory and another developed a postoperative abscess. There were no perioperative complications., Conclusion: TEM appeared to be a useful and safe approach for close rectal dissection and removal of a rectal stump while avoiding an abdominal approach for pelvic dissection., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Unlabelled: 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a known method to diagnose inflammatory processes and thus may be a promising imaging technique to detect anastomotic bowel leak. The aim of this study was to assess postoperative FDG uptake in colorectal anastomosis in patients without suspicion of active infection or anastomotic leakage., Patients, Methods: Design of a prospective observational pilot study in order to assess normal FDG uptake in the patient anastomosis after colorectal surgery. Patients that underwent colorectal surgery with primary anastomosis received FDG-PET of the abdomen, 2-6 days postoperatively., Results: 35 patients met the inclusion criteria. Three patients were not scanned for various reasons. Of the remaining 32 patients, one demonstrated an increased uptake of FDG at the site of the anastomosis. In the other 31 patients FDG uptake was negligible (n = 17) or scored as physiological (n = 14). None of the scanned patients developed a clinical relevant anastomotic leakage within the first 30 days after surgery., Conclusion: The present study shows that FDG uptake in colorectal anastomosis remains low within the first six days after surgery in patients without anastomotic leakage. Therefore, FDG-PET might be useful to investigate further as a tool to detect anastomotic leakage in an the early postoperative phase.

Background: The CARTS study is a multicenter feasibility study, investigating the role of rectum saving surgery for distal rectal cancer., Methods/design: Patients with a clinical T1-3 N0 M0 rectal adenocarcinoma below 10 cm from the anal verge will receive neoadjuvant chemoradiation therapy (25 fractions of 2 Gy with concurrent capecitabine). Transanal Endoscopic Microsurgery (TEM) will be performed 8 - 10 weeks after the end of the preoperative treatment depending on the clinical response.Primary objective is to determine the number of patients with a (near) complete pathological response after chemoradiation therapy and TEM. Secondary objectives are the local recurrence rate and quality of life after this combined therapeutic modality. A three-step analysis will be performed after 20, 33 and 55 patients to ensure the feasibility of this treatment protocol., Discussion: The CARTS-study is one of the first prospective multicentre trials to investigate the role of a rectum saving treatment modality using chemoradiation therapy and local excision. The CARTS study is registered at clinicaltrials.gov (NCT01273051).

Background: Enhanced recovery after surgery programs have been developed to improve recovery, shorten hospital stays, and reduce morbidity., Objective: The aim of the current study was to examine the effects of the enhanced recovery program on the outcome of rectal surgery., Design: A cohort of patients who underwent open rectal surgery after an enhanced recovery program was compared with a historic case-matched control group receiving conventional perioperative care. Patients were matched for type of surgery, disease, comorbidity, and demographic characteristics. Data regarding fast-track targets, length of hospital stay, mortality, complications, relaparotomies, and readmissions were collected., Results: Forty-one patients in the enhanced recovery group were compared with 82 case-matched patients receiving conventional care. The length of hospital stay (median: 8 days vs 12 days, P < .005) was reduced in the enhanced recovery after surgery group. There were no significant differences in epidural use, mortality, morbidity, and readmission rates between groups., Limitations: This study performed an intention-to-treat analysis for the multimodal enhanced recovery program in rectal surgery. Specific elements of the program were not analyzed separately. The study used nonrandomly assigned historic controls for comparison., Conclusion: Enhanced recovery after surgery programs help to reduce the length of hospital stay after rectal surgery.

Background: Preoperative risk prediction to assess mortality and morbidity may be helpful to surgical decision making. The aim of this study was to compare mortality and morbidity of colorectal resections performed in a tertiary referral center with mortality and morbidity as predicted with physiological and operative score for enumeration of mortality and morbidity (POSSUM), Portsmouth POSSUM (P-POSSUM), and colorectal POSSUM (CR-POSSUM). The second aim of this study was to analyze the accuracy of different POSSUM scores in surgery performed for malignancy, inflammatory bowel diseases, and diverticulitis. POSSUM scoring was also evaluated in colorectal resection in acute vs. elective setting. In procedures performed for malignancy, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) score was assessed in the same way for comparison., Methods: POSSUM, P-POSSUM, and CR-POSSUM predictor equations for mortality were applied in a retrospective case-control study to 734 patients who had undergone colorectal resection. The total group was assessed first. Second, the predictive value of outcome after surgery was assessed for malignancy (n = 386), inflammatory bowel diseases (n = 113), diverticulitis (n = 91), and other indications, e.g., trauma, endometriosis, volvulus, or ischemia (n = 144). Third, all subgroups were assessed in relation to the setting in which surgery was performed: acute or elective. In patients with malignancy, the ACPGBI score was calculated as well. In all groups, receiver operating characteristic (ROC) curves were constructed., Results: POSSUM, P-POSSUM, and CR-POSSUM have a significant predictive value for outcome after colorectal surgery. Within the total population as well as in all four subgroups, there is no difference in the area under the curve between the POSSUM, P-POSSUM, and CR-POSSUM scores. In the subgroup analysis, smallest areas under the ROC curve are seen in operations performed for malignancy, which is significantly worse than for diverticulitis and in operations performed for other indications. For elective procedures, P-POSSUM and CR-POSSUM predict outcome significantly worse in patients operated for carcinoma than in patients with diverticulitis. In acute surgical interventions, CR-POSSUM predicts mortality better in diverticulitis than in patients operated for other indications. The ACPGBI score has a larger area under the curve than any of the POSSUM scores. Morbidity as predicted by POSSUM is most accurate in procedures for diverticulitis and worst when the indication is malignancy., Conclusion: The POSSUM scores predict outcome significantly better than can be expected by chance alone. Regarding the indication for surgery, each POSSUM score predicts outcome in patients operated for diverticulitis or other indications more accurately than for malignancy. The ACPGBI score is found to be superior to the various POSSUM scores in patients who have (elective) resection of colorectal malignancy.

Background: Enhanced Recovery After Surgery (ERAS) programs are associated with reduced hospital morbidity and mortality. The aim of the present study was to evaluate whether the introduction of ERAS care improved the adverse events in colorectal surgery. In a cohort study, mortality, morbidity, and length of stay were compared between ERAS patients and carefully matched historical controls., Methods: Patients were matched for their type of disease, the type of surgery, P-Possum (Portsmouth-Possum), CR-Possum (Colorectal-Possum) Physiological and Operative Score for Enumeration of Mortality and Morbidity (POSSUM), gender, and American Society of Anesthesiologists (ASA) grade. The primary outcome measures of this study were mortality and morbidity. Secondary outcome measures were fluid intake, length of hospital stay, the number of relaparotomies, and the number of readmissions within 30 days. Data on the ERAS patients were collected prospectively., Results: Sixty-one patients treated according to the ERAS program were compared with 122 patients who received conventional postoperative care. The two groups were comparable with respect to age, ASA grade, P-Possum (Portsmouth-Possum), CR-Possum (Colorectal-Possum) score, type of surgery, stoma formation, type of disease, and gender. Morbidity was lower in the ERAS group compared to the control group (14.8% versus 33.6% respectively; P = <0.01). Patients in the ERAS group received significantly less fluid and spent fewer days in the hospital (median 6 days, range 3-50 vs. median 9 days, range 3-138; P = 0.032). There was no difference between the ERAS and the control group for mortality (0% vs. 1.6%; P = 0.55) and readmission rate (3.3% vs. 1.6%; P = 0.60)., Conclusion: Enhanced Recovery After Surgery program reduces morbidity and the length of hospital stay for patients undergoing elective colonic or rectal surgery.

Background: For patients with acute colitis, the decision when and how to operate is difficult in most cases. It was the aim of this systematic review to analyze early mortality and morbidity of colectomy for severe acute colitis in order to identify opportunities to improve perioperative treatment and outcome., Methods: A systematic review of the available literature in the Medline and PubMed databases from 1975 to 2007 was performed. All articles were assessed methodologically; the articles of poor methodological quality were excluded. Articles on laparoscopic colectomy for acute colitis were analyzed separately., Results: In total, 29 studies met the criteria for the systematic review, describing a total of 2,714 patients, 1,257 of whom were operated on in an acute setting, i.e., urgent or emergency colectomy. Reported in-hospital mortality was 8.0%; the 30-day mortality was 5.2%. Morbidity was 50.8%. The majority of complications were of infectious and thromboembolic nature. Over the last three decades, there was a shift in indications from toxic megacolon, from 71.1% in 1975-1984 to 21.6% in 1995-2005, to severe acute colitis not responding to conservative treatment, from 16.5% in 1975-1984 to 58.1% in 1995-2007. Mortality decreased from 10.0% to 1.8%. Morbidity remained high, exceeding 40% in the last decade. Mortality after laparoscopic surgery was 0.6%. Complication rate varies from 16-37%., Conclusion: Colectomy for acute colitis is complicated by considerable morbidity. The incidence of adverse outcome has substantially decreased over the last three decades, but further improvements are still required. The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions about both conventional and laparoscopic surgery.

Background & Aims: It was shown that patients in the Netherlands remain exposed to unnecessarily prolonged starvation after abdominal surgery. The present study examined whether a structured collaborative effort would help to implement the early start of oral nutrition after colorectal surgery., Methods: In 2006, twenty-six Dutch hospitals signed up to a "breakthrough project" concerning the implementation of the enhanced recovery after surgery (ERAS) programme with early oral feeding as one of the key elements. Each hospital determined the usual start of food intake by analyzing 50 patients who underwent a colorectal resection in 2004 (n=1126). Subsequently, over the course of one year 861 colorectal surgery patients were treated according to the ERAS programme. The first day that patients were eating before and after the breakthrough project was compared using Kaplan-Meier analyses and Cox regression models., Results: Patients treated according to the ERAS programme were eating 3 days earlier than the patients traditionally treated (p<0.000). Two days after surgery 65% of the ERAS patients were eating normal food versus 7% of the pre-ERAS patients., Conclusions: The present nationwide collaborative effort was successful in implementing a change towards an early start of oral nutrition after abdominal surgery.

Radiofrequency ablation (RFA) for liver metastasis of colorectal (H-CRC) origin is a well-documented technique in surgically unresectable disease. Overall recurrence figures appear inferior to resection but are based on a selection of patients with unresectable disease, often due to multiple localisations of extensive disease. Lesion based recurrence is probably more appropriate to predict results of RFA in surgically resectable H-CRC and figures may be good enough to consider RFA an alternative treatment in high risk patients.

Background: Loop ileostomy is an established technique for temporary deviation of bowel contents to avoid clinical anastomotic leakage, fistulas, or use of an inflamed colon. Anesthetic risks and postoperative complications of the closure operation result in a significant proportion of ileostomies that are never closed, factors that should be borne in mind when fashioning temporary stomas. We investigated loop ileostomy closure under local anesthesia as a way to avoid these problems., Methods: As a feasibility study, 15 successive patients underwent closure of a loop ileostomy under local anesthesia. The patients' experience of the procedure, postoperative pain, analgesia requirements, and oral intake were prospectively evaluated., Results: Procedures could be comfortably completed under safe doses of local anesthesia. Use of standard nasogastric tubes was avoided and immediately postoperatively patients were able to resume a full oral diet. Discharge was on the second postoperative day (median). Complications were paralytic ileus for two days (1 patient), anastomotic leakage (1 patient), and superficial wound infection (1 patient)., Conclusion: Reversal of loop ileostomy can be performed safely and comfortably under local anesthesia. Postoperative results compare favorably with those of routine procedures.

Background: The wire-guided excision of nonpalpable breast cancer often results in tumor resections with inadequate margins. This prospective, randomized trial was undertaken to investigate whether intraoperative ultrasound (US) guidance enables a better margin clearance than the wire-guided technique in the breast-conserving treatment of nonpalpable breast cancers., Methods: Patients with a preoperative histological diagnosis of nonpalpable breast cancer that could be visualized both with US and mammography were included. Patients were randomized to undergo either a wire-guided or a US-guided excision. Adequate margins were defined as >or=1 mm., Results: Of 49 included patients, 23 were assigned to undergo wire-guided excision and 26 to undergo US-guided excision. One patient crossed over to US-guided excision after inadvertent wire displacement. Mean tumor diameter, specimen weight, and operating time were similar in both groups. The excision was adequate in 24 (89%) of 27 US-guided excisions and 12 (55%) of 22 wire-guide excisions (P =.007)., Conclusions: US-guided excision seems to be superior to wire-guided excision with respect to margin clearance of mammographically detected and US-visible nonpalpable breast cancers. Patients do not have to undergo the unpleasant wire placement before surgery.

Few cases of anti-colon cancer specific T lymphocytes have been described so far. Moreover, the majority of these effectors were generated in vitro by stimulating PBMC from patients or healthy donors with peptides that were derived from proteins expressed and/or secreted by colon cancer tissue such as CEA, Mucin or Her-2/neu. The aim of our study was to evaluate the immunogenicity of colorectal carcinomas in an autologous setting. We exploited the antigen processing and presentation capacity of dendritic cells (DC) to establish an in vitro autologous system that can bypass the need of obtaining cultured tumor cells. DC were generated from the adherent monocyte fraction of PBMC taken from stage II/III colorectal cancer patients. A single cell suspension was prepared by mechanical and enzymatic disruption of the surgical specimens immediately after resection. DC were loaded with autologous tumor lysate, obtained by repeated freezing and thawing, before being used as stimulators for autologous PBL. HLA-class II restricted T cells that recognize the autologous tumor could be generated in a proportion of patients. The fine specificity of the anti-tumor T cells indicates that differentiation as well as tumor restricted antigens are expressed in colon cancer and that these antigens can evoke a class II HLA-restricted response in an autologous setting. Altogether these findings may open a new perspective for a DC based vaccination of colon cancer patients., (Copyright 2000 Wiley-Liss, Inc.)

Background and Purpose: Postoperative adhesions frequently occur and can account for various symptoms, including chronic abdominal pain. Conventional adhesiolysis by laparotomy results in an unacceptably high rate of recurrence. A minimally invasive procedure (laparoscopic adhesiolysis) might improve the outcome by inflicting less surgical trauma, but well-documented reports focused on laparoscopic adhesiolysis for chronic abdominal pain are lacking., Patients and Methods: Twelve consecutive patients with chronic abdominal pain caused by adhesions who were treated by laparoscopic adhesiolysis were assessed preoperatively and during a 1-year follow-up period applying validated scoring systems: McGill and SLC-90 tests to evaluate personalities and MOS SF-36 and GIQLI questionnaires for the quality of life assessments., Results: No psychological influences were identified. Only two patients experienced a lasting improvement in quality of life, and five patients had more or less stable complaints. Five patients required laparotomy within a year after laparoscopic adhesiolysis., Conclusions: Laparoscopic adhesiolysis has yet not passed the stage of clinical trial and requires objective evaluation, including detailed information on recurrence and de novo adhesions in correlation with clinical outcome.

In the course of a century, tumour immunology has revealed a picture of a very complex immune system involving the recognition and eradication of malignancies. Many tumours evade the immune system, and understanding of tumour escape mechanisms is the key to a successful immunotherapy for cancer. A wide array of tumour immunotherapy modalities have been developed, many of which have reached the phase of clinical trials, with some satisfactory results. Based on the available clinical, data and the techniques available for further improvement, we analyse the prospects for the different treatment modalities, and predict an important role for tumour immunotherapy in the near future., (Copyright 2000 Harcourt Publishers Ltd.)

Immunotherapy of cancer is entering into a new phase of active investigation both at the pre-clinical and clinical level. This is due to the exciting developments in basic immunology and tumour biology that have allowed a tremendous increase in our understanding of mechanisms of interactions between the immune system and tumour cells. This review briefly summarizes the state of the art in basic tumour immunology before discussing the clinical applications of the new concepts in the clinical setting. Clinical approaches are diverse but can now be based on strong scientific rationales. The analysis of the available clinical results suggests that, despite some disappointments, there is room for optimism that both active immunotherapy (vaccination) and adoptive immunotherapy may soon become part of the therapeutic arsenal to combat cancer in a more efficient way.

Surgery is, and always has been, the main treatment modality of solid tumours. For a long period, it consisted of a number of surgical procedures dictated by basic oncologic principles, most of which are still adhered to. Over the last few decades, increased understanding of the disease, new or improved diagnostic facilities, novel and perfected adjuvant treatments, improved surgical techniques and daring challenges to established dogmas have all contributed to the development of surgical oncology. The heritage from the past came under close scrutiny, and the fruits of basic and clinical science were added to an ever expanding body of knowledge. It is impossible to review all developments in surgical oncology of the last 25 years in one comprehensive paper. Therefore we have restricted ourselves to those items that appear most representative for the changes that have taken place, and those diseases that have the greatest numerical impact., (Copyright 1999 Harcourt Publishers Ltd.)

A peptide-binding assay employing the HLA class I molecules on intact human B cells is described. The peptide antigens are stripped from the HLA class I molecules by mild acid treatment, after which the cells are incubated with a FL-labeled reference peptide together with different concentrations of the peptide of interest. The effectiveness by which the latter peptide competes for binding to the HLA class I molecules is assayed by measuring the amount of HLA-bound FL-labeled reference peptide with FACscan analysis. The assay is easy to perform because there is no need to purify HLA class I molecules, or to transfect cells with HLA class I molecules, and no radioactive label is used. Moreover, large panels of HLA-typed human B-cell lines are available as tools for peptide binding to a vast array of HLA molecules. The binding assay was optimized and validated with peptides of known binding capacity to either HLA-A*0201 or HLA-A*0301. The kinetics of peptide binding in this assay were shown to be comparable to that in assays employing soluble HLA class I molecules. Application of the assay in the search for potential HLA-A*0301 restricted CTL epitopes, derived from HIV-1 polymerase, resulted in the identification of five high-affinity binding peptides.

In the development of cytotoxic T lymphocyte (CTL)-mediated immunotherapy, the identification of CTL epitopes is of crucial importance. Binding of a peptide to major histocompatibility complex (MHC) class I molecules is one of the prerequisites for its function as a CTL epitope. We describe the technique, validation, and application of a simple cellular assay, intended for the screening of peptides for binding, that can be applied to any human leukocyte antigen (HLA) allele. Reconstitution of peptides in MHC class I molecules after elution by acid treatment was previously shown to be possible in specially engineered cell lines expressing only one type of MHC class I, and was applied for the HLA-A*0201 allele. We now report the optimal conditions for application of this type of binding assay to the HLA-A*0301 allele. The adaptations that were necessary to make the technique operational for HLA-A*0301 are shown in detail. These consisted of lowering the pH during acid treatment to 2.9 and lengthening the duration of elution to 90 s. Furthermore, immediate aspiration of eluted peptides appeared to be essential for this allele. We found also that the use of Epstein-Barr virus (EBV)-transformed B cell lines (B-LCL) yields results similar to those of the use of cell lines expressing only one specific MHC class I allele. Homozygosity for the desired HLA allele improves the sensitivity of the assay, but heterozygous cells can also be employed. Finally, we applied this technique to a search for HLA-A*0301 binding peptides derived from carcinoembryonic antigen (CEA). Of a set of 34 CEA-specific peptides that fit with a specified HLA-A*0301-binding motif, we identified a set of six peptides with high binding affinity to this allele. These peptides can be regarded as potential CTL epitopes.