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Contains fulltext : 190038.pdf (Publisher’s version ) (Open Access) Background: The increasing sub-classification of cancer patients due to more detailed molecular classification of tumors, and limitations of current trial designs, require innovative research designs. We present the design, governance and current standing of three comprehensive nationwide cohorts including pancreatic, esophageal/gastric, and colorectal cancer patients (NCT02070146). Multidisciplinary collection of clinical data, tumor tissue, blood samples, and patient-reported outcome (PRO) measures with a nationwide coverage, provides the infrastructure for future and novel trial designs and facilitates research to improve outcomes of gastrointestinal cancer patients.Material and methods: All patients aged ≥18 years with pancreatic, esophageal/gastric or colorectal cancer are eligible. Patients provide informed consent for: (1) reuse of clinical data; (2) biobanking of primary tumor tissue; (3) collection of blood samples; (4) to be informed about relevant newly identified genomic aberrations; (5) collection of longitudinal PROs; and (6) to receive information on new interventional studies and possible participation in cohort multiple randomized controlled trials (cmRCT) in the future.Results: In 2015, clinical data of 21,758 newly diagnosed patients were collected in the Netherlands Cancer Registry. Additional clinical data on the surgical procedures were registered in surgical audits for 13,845 patients. Within the first two years, tumor tissue and blood samples were obtained from 1507 patients; during this period, 1180 patients were included in the PRO registry. Response rate for PROs was 90%. The consent rate to receive information on new interventional studies and possible participation in cmRCTs in the future was >85%. The number of hospitals participating in the cohorts is steadily increasing.Conclusion: A comprehensive nationwide multidisciplinary gastrointestinal cancer cohort is feasible and surpasses the limitations of classical study designs. With this initiative, novel and innovative studies can be performed in an efficient, safe, and comprehensive setting. 8 p.

The incidence of colorectal cancer has risen in recent years and currently over 50% of patients are over 70 years of age. Many questions regarding the optimal management of the growing group of elderly colorectal cancer patients are still unanswered. The research presented in this thesis focuses on several components of the treatment of colorectal cancer in an ageing world and comprises three parts. Part 1 describes technological developments in the treatment of colorectal cancer. A major advancement in recent years has been the introduction of laparoscopic colorectal surgery. Our research showed that for low rectal cancer, the advantages of laparoscopic surgery are reduced blood loss, faster recovery and shorter hospitalization. A study on the functional outcome after transanal resection of rectal tumours, using flexible portals, showed excellent functional results and an significant improvement of continence for patients with reduced preoperative function. A systematic literature review showed that laparoscopic resection leads to reduced cardiac complications compared to conventional resection for colorectal cancer. There was insufficient data on the outcome for elderly patients. Part 2 focusses on treatment decisions for elderly colorectal cancer patients. A retrospective study of patients diagnosed with low rectal cancer demonstrated that oncologic decision-making is still largely based on age and that guideline adherence is significantly reduced with increasing age. Population-based data showed improved survival after surgery for colorectal cancer between 2008 and 2011, concurrent with a rise in the use of laparoscopic techniques. The elderly seem to profit most of this improved postoperative survival. Participation of elderly in clinical trials on laparoscopic surgery for colorectal cancer was investigated and it was shown that 44% of trial protocols exclude elderly from participation and their inclusion has lagged behind. Part 3 investigates the role of a geriatrician in the multidisciplinary care of elderly cancer patients. A systematic review studied the effect of a geriatric evaluation on treatment decision-making for elderly cancer patients. A geriatric evaluation has significant impact on oncologic and non-oncologic treatment decisions in older cancer patients and deserves consideration in the work-up for these patients. Through a national survey of cancer specialists and geriatricians it was shown that a geriatric oncology program has been initiated by half of respondents, while others are interested in doing so. However, many obstacles still remain. Finally, an observational study demonstrated the value of a geriatric consultation in oncologic treatment decision-making and in optimizing elderly prior or during oncologic therapy.

Background: According to the literature, the conversion rate for laparoscopic cholecystectomy (LC) after endoscopic sphincterotomy (ES) for cholecystodocholithiasis reaches 20%, at least when LC is performed 6 to 8 weeks afterward. It is hypothesized that early planned LC after ES prevents recurrent biliary complications and reduces operative morbidity and hospital stay. Methods: All consecutive patients who underwent LC after ES between 2001 and 2004 were retrospectively evaluated. Recurrent biliary complications during the waiting time for LC, conversion rate, postoperative complications, and hospital stay were documented. Results: This study analyzed 167 consecutive patients (59 men) with a median age of 54 years. The median interval between ES and LC was 7 weeks (range, 1–49 weeks). During the waiting time for LC, 33 patients (20%) had recurrent biliary complications including cholecystitis (n = 18, 11%), recurrent choledocholithiasis (n = 9, 5%), cholangitis (n = 4, 2%), and biliary pancreatitis (n = 2, 1%). Of these 33 patients, 15 underwent a second endoscopic retrograde cholangiography (ERC). The median time between ES and the development of recurrent complications was 22 days (range, 3–225 days). Most of the biliary complications (76%) occurred more than 1 week after ES. Conversion to open cholecystectomy occurred for 7 of 33 patients with recurrent complications during the waiting period, compared with 13 of 134 patients with an uncomplicated waiting period (p = 0.14). This concurred with doubled postoperative morbidity (24% vs 11%; p = 0.09) and a longer hospital stay (median, 4 vs 2 days; p < 0.001). Conclusion: In this retrospective analysis, 20% of all patients had recurrent biliary complications during the waiting period for cholecystectomy after ES. These recurrent complications were associated with a significantly longer hospital stay. Cholecystectomy within 1 week after ES may prevent recurrent biliary complications in the majority of cases and reduce the postoperative hospital stay.

The incidence of elderly patients with colorectal cancer (CRC) has risen significantly over the past decades and is expected to rise even further in upcoming years. Currently, more than 30% of the newly diagnosed CRC patients is 75 years or older. The ageing process makes these older heterogeneous group of cancer patients unique. Therefore, age itself is not a useful selection tool for oncologic treatment. Treatment decision making in the elderly is challenging and optimizing this decision making is very important for this heterogeneous group of patients. The aim of this thesis was to obtain more knowledge on the surgical treatment of elderly CRC patients. Furthermore, the impact of ostomies was studied as well as the usefulness of frailty instruments for risk stratification of older patients and the relevance of geriatric consultations.