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Objectives Body composition assessment using CT images at the L3-level is increasingly applied in cancer research and has been shown to be strongly associated with long-term survival. Robust high-throughput automated segmentation is key to assess large patient cohorts and to support implementation of body composition analysis into routine clinical practice. We trained and externally validated a deep learning neural network (DLNN) to automatically segment L3-CT images. Methods Expert-drawn segmentations of visceral and subcutaneous adipose tissue (VAT/SAT) and skeletal muscle (SM) of L3-CT-images of 3187 patients undergoing abdominal surgery were used to train a DLNN. The external validation cohort was comprised of 2535 patients with abdominal cancer. DLNN performance was evaluated with (geometric) dice similarity (DS) and Lin's concordance correlation coefficient. Results There was a strong concordance between automatic and manual segmentations with median DS for SM, VAT, and SAT of 0.97 (IQR: 0.95-0.98), 0.98 (IQR: 0.95-0.98), and 0.95 (IQR: 0.92-0.97), respectively. Concordance correlations were excellent: SM 0.964 (0.959-0.968), VAT 0.998 (0.998-0.998), and SAT 0.992 (0.991-0.993). Bland-Altman metrics indicated only small and clinically insignificant systematic offsets; SM radiodensity: 0.23 Hounsfield units (0.5%), SM: 1.26 cm2.m−2 (2.8%), VAT: −1.02 cm2.m−2 (1.7%), and SAT: 3.24 cm2.m−2 (4.6%). Conclusion A robustly-performing and independently externally validated DLNN for automated body composition analysis was developed. Advances in knowledge This DLNN was successfully trained and externally validated on several large patient cohorts. The trained algorithm could facilitate large-scale population studies and implementation of body composition analysis into clinical practice. [ABSTRACT FROM AUTHOR]

Background: Unnecessary D2-gastrectomy and associated costs can be prevented after detecting non-curable gastric cancer, but impact of staging on treatment costs is unclear. This study determined the cost impact of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18FFDG-PET/CT) and staging laparoscopy (SL) in gastric cancer staging. Materials and Methods: In this cost analysis, four staging strategies were modeled in a decision tree: (1) 18FFDG-PET/CT first, then SL, (2) SL only, (3) 18FFDG-PET/CT only, and (4) neither SL nor 18FFDG-PET/CT. Costs were assessed on the basis of the prospective PLASTIC-study, which evaluated adding 18FFDG-PET/CT and SL to staging advanced gastric cancer (cT3–4 and/or cN+) in 18 Dutch hospitals. The Dutch Healthcare Authority provided 18FFDG-PET/CT unit costs. SL unit costs were calculated bottom-up. Gastrectomy-associated costs were collected with hospital claim data until 30 days postoperatively. Uncertainty was assessed in a probabilistic sensitivity analysis (1000 iterations). Results: 18FFDG-PET/CT costs were €1104 including biopsy/cytology. Bottom-up calculations totaled €1537 per SL. D2-gastrectomy costs were €19,308. Total costs per patient were €18,137 for strategy 1, €17,079 for strategy 2, and €19,805 for strategy 3. If all patients undergo gastrectomy, total costs were €18,959 per patient (strategy 4). Performing SL only reduced costs by €1880 per patient. Adding 18FFDG-PET/CT to SL increased costs by €1058 per patient; IQR €870–1253 in the sensitivity analysis. Conclusions: For advanced gastric cancer, performing SL resulted in substantial cost savings by reducing unnecessary gastrectomies. In contrast, routine 18FFDG-PET/CT increased costs without substantially reducing unnecessary gastrectomies, and is not recommended due to limited impact with major costs. Trial registration: NCT03208621. This trial was registered prospectively on 30-06-2017. [ABSTRACT FROM AUTHOR]

Objective: To examine the influence of the LOGICA RCT (randomized controlled trial) upon the practice and outcomes of laparoscopic gastrectomy within the Netherlands. Background: Following RCTs the dissemination of complex interventions has been poorly studied. The LOGICA RCT included 10 Dutch centers and compared laparoscopic to open gastrectomy. Methods: Data were obtained from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) on all gastrectomies performed in the Netherlands (2012-2021), and the LOGICA RCT from 2015 to 2018. Multilevel multivariable logistic regression analyses were performed to assess the effect of laparoscopic versus open gastrectomy upon clinical outcomes before, during, and after the LOGICA RCT. Results: Two hundred eleven patients from the LOGICA RCT (105 open vs 106 laparoscopic) and 4131 patients from the DUCA data set (1884 open vs 2247 laparoscopic) were included. In 2012, laparoscopic gastrectomy was performed in 6% of patients, increasing to 82% in 2021. No significant effect of laparoscopic gastrectomy on postoperative clinical outcomes was observed within the LOGICA RCT. Nationally within DUCA, a shift toward a beneficial effect of laparoscopic gastrectomy upon complications was observed, reaching a significant reduction in overall [adjusted odds ratio (aOR):0.62; 95% CI: 0.46-0.82], severe (aOR: 0.64; 95% CI: 0.46-0.90) and cardiac complications (aOR: 0.51; 95% CI: 0.30-0.89) after the LOGICA trial. Conclusions: The wider benefits of the LOGICA trial included the safe dissemination of laparoscopic gastrectomy across the Netherlands. The robust surgical quality assurance program in the design of the LOGICA RCT was crucial to facilitate the national dissemination of the technique following the trial and reducing potential patient harm during surgeons learning curve. [ABSTRACT FROM AUTHOR]

Background: For gastric cancer patients, surgical resection with en-bloc lymphadenectomy is the cornerstone of curative treatment. Open gastrectomy has long been the preferred surgical approach worldwide. However, this procedure is associated with considerable morbidity. Several meta-analyses have shown an advantage in short-term outcomes of laparoscopic gastrectomy compared to open procedures, with similar oncologic outcomes. However, it remains unclear whether the results of these Asian studies can be extrapolated to the Western population. In this trial from the Netherlands, patients with resectable gastric cancer will be randomized to laparoscopic or open gastrectomy. Methods: The study is a non-blinded, multicenter, prospectively randomized controlled superiority trial. Patients (≥18 years) with histologically proven, surgically resectable (cT1-4a, N0-3b, M0) gastric adenocarcinoma and European Clinical Oncology Group performance status 0, 1 or 2 are eligible to participate in the study after obtaining informed consent. Patients (n = 210) will be included in one of the ten participating Dutch centers and are randomized to either laparoscopic or open gastrectomy. The primary outcome is postoperative hospital stay (days). Secondary outcome parameters include postoperative morbidity and mortality, oncologic outcomes, readmissions, quality of life and cost-effectiveness. Discussion: In this randomized controlled trial laparoscopic and open gastrectomy are compared in patients with resectable gastric cancer. It is expected that laparoscopic gastrectomy will result in a faster recovery of the patient and a shorter hospital stay. Secondly, it is expected that laparoscopic gastrectomy will be associated with a lower postoperative morbidity, less readmissions, higher cost-effectiveness, better postoperative quality of life, but with similar mortality and oncologic outcomes, compared to open gastrectomy. The study started on 1 December 2014. Inclusion and follow-up will take 3 and 5 years respectively. Short-term results will be analyzed and published after discharge of the last randomized patient. [ABSTRACT FROM AUTHOR]

Background: Malignant transformation of hepatocellular adenomas (HCAs) into hepatocellular carcinomas (HCCs) has been reported repeatedly and is considered to be one of the main reasons for surgical treatment. However, its actual risk is currently unknown. Objective: To provide an estimation of the frequency of malignant transformation of HCAs and to discuss its clinical implications. Methods: A systematic literature search was conducted using the following databases: The Cochrane Hepatobiliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE and EMBASE. Results: One hundred and fifty-seven relevant series and 17 case reports (a total of 1635 HCAs) were retrieved, reporting an overall frequency of malignant transformation of 4.2%. Only three cases (4.4%) of malignant alteration were reported in a tumour smaller than 5 cm in diameter. Discussion: Malignant transformation of HCAs into HCCs remains a rare phenomenon with a reported frequency of 4.2%. A better selection of exactly those patients presenting with an HCA with an amplified risk of malignant degeneration is advocated in order to reduce the number of liver resections and thus reducing the operative risk for these predominantly young patients. The Bordeaux adenoma tumour markers are a promising method of identifying these high-risk adenomas. [ABSTRACT FROM AUTHOR]

The article presents a medical case of life-threatening hemorrhage from adenomas in the liver during pregnancy. The findings of an ultrasound examination are revealed which showed a possible liver hematoma and free abdominal fluid. Possible consequences of delay in diagnosing rupture of the liver is highlighted.

Purpose: Interest in prehabilitation, the preoperative enhancement of patients' condition, is rising in the surgical field. Challenging factors appear to be patients' motivation to participate in and their compliance with prehabilitation programs. The aim of this qualitative study was to study the real-life experience of prehabilitation by assessing the lived experience and perceptions of participants in a multimodal prehabilitation program and to explore factors that influence participation and compliance during prehabilitation., Methods: Patients who underwent surgery for colorectal cancer and who had participated in the 4-week multimodal prehabilitation program "BEFORE" feasibility study were recruited. Their lived experiences were collected through semi-structured, individual, in-depth interviews. Interviews were transcribed verbatim and analyzed using a thematical approach. As no new information emerged after the interviews, data were considered saturated., Results: Six patients were interviewed. Seven main themes were discussed during the interviews, including information provision, motivation for participation, and content of the program. The results of this study emphasize the importance of adequate patient education, in-hospital exercise with the supervision of physiotherapists, and a patient-centered program. Logistical problems and the impact of cancer diagnosis were most frequently reported as barriers to participation., Conclusion: Participation could be improved by providing adequate information and solving logistical issues. Patient-centeredness of the program is an important feature in improving adherence., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Sier et al.)

Background: For many colorectal cancer patients, primary surgery is the standard care of treatment. Further insights in perioperative care are crucial. The aim of this study is to assess the prognostic value of body composition for postoperative complications after laparoscopic and open colorectal surgery., Methods: From January 2013 to 2018 all consecutive patients who underwent surgery for colorectal cancer were enrolled in this study. Patients with a preoperative CT-scan <90 days before surgery were included. All CT-scans were obtained retrospectively, and body composition was analysed using a single transverse slice at the level of the third lumbar vertebra (L3) within the Slice-O-Matic-software. The studied outcome measure was the occurrence of major postoperative complications (Clavien-Dindo grade ≥3b)., Results: A total of 1213 patients were included in the final analyses. Multivariable analyses showed that patients with low-skeletal muscle mass Z-score (OR 0.67, 95 % CI 0.45-0.97, p = 0.036) or a high visceral adipose tissue Z-score (OR 1.56, 95 % CI 1.06-2.29, p = 0.023) were significantly associated with an increased risk of developing major postoperative complications after open surgery. In the laparoscopic group, all six body composition parameters were not significantly associated with an increased risk of developing a major postoperative complication., Conclusions: In this study, open colorectal surgery in patients with either low skeletal muscle mass or high visceral adipose tissue mass was associated with increased risk of postoperative complications. Laparoscopic surgery did not show this correlation. This demonstrates the importance of using minimal invasive surgery in colorectal cancer patients and implementing this as standard care., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

After the success of the enhanced recovery after surgery protocol, perioperative care has been further optimized in accelerated enhanced recovery pathways (ERPs), where optimal pain management is crucial. Spinal anesthesia was introduced as adjunct to general anesthesia to reduce postoperative pain and facilitate mobility. This study aimed to determine which spinal anesthetic agent provides best pain relief in accelerated ERP for colon carcinoma. This single center study was a secondary analysis conducted among patients included in the aCcelerated 23-Hour erAS care for colon surgEry study who underwent elective laparoscopic colon surgery. The first 30 patients included received total intravenous anesthesia combined with spinal anesthesia with prilocaine, the 30 patients subsequently included received spinal anesthesia with hyperbaric bupivacaine. Primary endpoint of this study was the total amount of morphine milligram equivalents (MMEs) administered during hospital stay. Secondary outcomes were amounts of MMEs administered in the recovery room and surgical ward, pain score using the numeric rating scale, complication rates and length of hospital stay. Compared to prilocaine, the total amount of MMEs administered was significantly lower in the bupivacaine group (n = 60, 16.3 vs 6.3, P = .049). Also, the amount of MMEs administered and median pain scores were significantly lower after intrathecal bupivacaine in the recovery room (MMEs 11.0 vs 0.0, P = .012 and numeric rating scale 2.0 vs 1.5, P = .004). On the surgical ward, median MMEs administered, and pain scores were comparable. Postoperative outcomes were similar in both groups. Spinal anesthesia with hyperbaric bupivacaine was associated with less opioid use and better pain reduction immediately after surgery compared to prilocaine within an accelerated ERP for elective, oncological colon surgery., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Complications can be classified using the most-severe Clavien-Dindo-Classification (CDC) per patient or the total complication burden per patient expressed in the Comprehensive Complication Index (CCI). This study determined the additional value of CCI to CDC in examining the impact of complications after gastric cancer surgery., Methods: The CCI and CDC were determined in the multicenter randomized LOGICA-trial comparing laparoscopic versus open D2-gastrectomy for cancer (cT1-4aN0-3M0). Differences in median CCI between laparoscopic and open gastrectomy were compared for overall postoperative complications and cardiovascular, gastrointestinal, infectious, pulmonary, and other complications. CCI and CDC were correlated to hospitalization, ICU-stay and reoperations using Spearman's rho-test and compared with standard Fisher's z-transformation., Results: Between 2015 and 2018, 211 patients underwent laparoscopic (n = 106) or open (n = 105) D2-gastrectomy, and 157 (74%) received neoadjuvant chemotherapy. Median CCI was comparable between laparoscopic versus open gastrectomy regarding overall complications (CCI 0 [IQR 0-23.5] versus 0 [IQR 0-22.6]; p = 0.755) and subgroups of complications (p > 0.05). Both CCI and CDC showed moderate positive correlations for hospitalization (r s  = 0.646 versus r s  = 0.628; p = 0.001, difference clinically irrelevant), and reoperations (r s  = 0.590 versus r s  = 0.599; p = 0.070), and weak correlations for ICU-stay (r s  = 0.446 versus r s  = 0.440; p = 0.189)., Conclusions: The CCI is a composite scoring system based on the CDC and reflects a subjective interpretation of complication burden from the perspectives of both physicians and patients, following abdominal surgery other than gastrectomy. Implementing CCI showed no clinically relevant benefit and caused additional workload compared to CDC for assessing complication burden. Therefore, using the CCI alongside the CDC after gastric cancer surgery is not recommended., Competing Interests: Declaration of competing interest Jelle P. Ruurda: Consulting or Advisory Role: Intuitive Surgical, Medtronic. Richard van Hillegersberg: Consulting or Advisory Role: Intuitive Surgical, Medtronic. Lodewijk A.A. Brosens: Advisory Role: Bristol Myers Squibb. Misha D.P. Luyer: Consulting or Advisory Role: Galvani, Medtronic. Research Funding: Dutch Cancer Foundation. Travel, Accommodations, Expenses: Medtronic., (© 2023 Published by Elsevier Ltd.)

Introduction: Clinical benefits of laparoscopic surgery are well established, but evidence for financial benefits is limited. This study aimed to compare the financial impact of the introduction of laparoscopic colorectal surgery., Methods: This study included patients who underwent colorectal surgery between January 2010 and 2015. We collected a range of financial data and divided the patients into 2 groups. Primary outcome was total cost defined by surgical-related costs., Results: A total of 1,246 patients were included, of which 440 surgeries were performed laparoscopically. The total median cost of laparoscopy was higher compared to open surgery (EUR 4,665 vs. EUR 4,268, p = 0.001). Laparoscopy was associated with higher equipment costs (EUR 857 vs. EUR 232, p < 0.001), longer operating time (3.2 vs. 2.5 hours, p < 0.001), and more readmissions (10.9 vs. 8.5%, p < 0.001). However, after adjusting for heterogeneity, no difference was found in total cost. Surgical-related costs were counterbalanced by lower costs associated with shorter median hospital stay (6 vs. 9 days, p < 0.001), less morbidity (37.3 vs. 55.1%, p < 0.001), and less mortality (1.8 vs. 5.6%, p = 0.013) for laparoscopy., Conclusion: During the introduction of laparoscopy for colorectal surgery, no significant differences were found in total cost between laparoscopic and open colorectal surgery. However, favorable postoperative outcomes were achieved with laparoscopic surgery., (© 2020 S. Karger AG, Basel.)

A 32-year-old Caucasian female, who had an abdominoplasty with sublay mesh placement for rectus abdominis diastasis becamepregnant one year later. The gestation was uneventful and the baby was born healthy after 40 weeks of pregnancy. During and after the pregnancy the patient's abdomen had been evaluated intensively and there was no recurrence of rectus abdominis diastasis. In this particular case the tissues of the abdominal wall elongated as the foetus grew larger, except for the site where the rectus diastasis has been corrected. The experience with this particular case does not assure that all patients will have the same uneventful outcomes as described. Nonetheless, it shows that pregnancy after abdominoplasty with mesh placing for rectus abdominis diastasis can be safe for both mother and child. However, each patient must be informed about the risks of pregnancy in this particular situation and professional follow-up is mandatory when pregnancy does occur. This is, as far as we know, the first case report of an uneventful pregnancy after rectus abdominis diastasis repair with the placement of a sublay mesh and abdominoplasty., Competing Interests: All authors declare no conflicts of interest., (© 2020 The Authors. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.)

Background: Little is known about the costs of the current treatment strategy in locally advanced rectal cancer, in which patients with a clinical complete response after chemoradiotherapy are treated in a watch-and-wait policy., Objective: The aim of this study is to present the oncological outcome and hospital costs of patients with a complete response after chemoradiotherapy (watch-and-wait policy) and patients with an incomplete response after chemoradiotherapy (total mesorectal excision)., Design: This was a cohort study., Settings: This study was conducted at an academic and a nonacademic hospital., Patients: Patients with locally advanced rectal cancer received either a watch-and-wait policy or total mesorectal excision depending on their clinical response to chemoradiotherapy., Interventions: Watch-and-wait policy and total mesorectal excision were the treatments applied., Main Outcome Measures: The primary outcomes measured were overall, local recurrence-free, and distant metastasis-free survival and hospital costs over a 2-year follow-up period., Results: A total of 292 patients with locally advanced rectal cancer were included. Mean age was 65.1 years, and 64.7% were men. One hundred five patients were included in the watch-and-wait subgroup, and 187 patients were in the total mesorectal excision subgroup. Both subgroups showed good oncological outcomes. Hospital costs consisted of 5 categories: costs of primary surgery, costs of adjuvant chemotherapy, costs of examinations, costs of additional surgery, and costs of treatment of regrowth/metastasis. The mean costs per patient were &OV0556;6713 (watch-and-wait subgroup) and &OV0556;17,108 (total mesorectal excision subgroup) over the first 2 years., Limitations: This study was limited by the following: costs were only from a hospital perspective, follow-up was 2 years, the study was retrospective in part, and there was no comparative study., Conclusions: Overall survival was good in both subgroups and comparable to literature. The mean costs per patient differ between the watch-and-wait subgroup (&OV0556;6713) and the total mesorectal excision subgroup (&OV0556;17,108). No comparison between the groups could be made. Based on the results of this study, the current strategy, where patients with a clinical complete response are treated in a watch-and-wait policy, and patients with an incomplete response are treated with total mesorectal excision, is likely to be (cost)saving. See Video Abstract at http://links.lww.com/DCR/B177. RESULTADOS ONCOLÓGICOS Y COSTOS HOSPITALARIOS EN EL TRATAMIENTO DE PACIENTES CON CANCER DE RECTO: ACTITUD DE ESPERA-VIGILANCIA Y TRATAMIENTO QUIRÚRGICO ESTANDARD: Se sabe poco sobre el costo del tratamiento actual en casos de cancer de recto localmente avanzado, cuando se aplica una política de vigilancia y espera en aquellos pacientes que presentan una respuesta clínica completa después de radio-quimioterapia.El propósito final del presente estudio es dar a conocer el resultado oncológico y los costos hospitalarios de los pacientes que presentan una respuesta clínica completa después de radio-quimioterapia (actitud de vigilancia-espera) y los pacientes con una respuesta incompleta después luego de radio-quimioterapia (excisión total del mesorrecto-ETM).Estudio de cohortes.Hospitales académicos y no académicos.Todos aquellos pacientes tratados por un cáncer de recto localmente avanzado y que fueron seguidos con una política de vigilancia y espera o la ETM, en función de la respuesta clínica a la radio-quimioterapia.Políticas de vigilancia-espera, excisión total del mesorrecto.Sobrevida global libre de recurrencia local, metástasis a distancia, sobrevida libre de enfermedad y costos hospitalarios durante un período de seguimiento de dos años.Se incluyeron 292 pacientes diagnosticados de cancer de recto localmente avanzado. La edad media fue de 65,1 años, 64,7% eran de sexo masculino. Se incluyeron 105 pacientes en el subgrupo de vigilancia-espera, y 187 en el subgrupo de excisión total del mesorrecto. Ambos subgrupos mostraron optimos resultados oncológicos. Los costos hospitalarios se dividieron en cinco categorías: costos de cirugía primaria; costos de quimioterapia adyuvante; costos de exámenes; costos de cirugía adicional; y costos del tratamiento de rebrote / metástasis. Los costos medios por paciente fueron de &OV0556; 6.713 (subgrupo de espera-vigilancia) y &OV0556; 17.108 (subgrupo de excisión total del mesorrecto) durante los primeros dos años.Analisis de costos desde una perspectiva hospitalaria durante un seguimiento de dos años, estudio parcialmente retrospectivo, no comparativo.La sobrevida general fue optima en ambos subgrupos y comparable con la literatura. El costo promedio por paciente difiere entre el subgrupo de vigilancia y espera (&OV0556; 6.713) con el subgrupo de la ETM(&OV0556; 17.108). No se pudieron comparar definitivamente ambos grupos. Basados en los resultados del presente estudio, es probable que la estrategia actual, en la que los pacientes con respuesta clínica completa sean tratados con una política de vigilancia y espera, presenten muy probablemente un cierto ahorro en el costo con relación a los pacientes con una respuesta incompleta tratados con excisión total del mesorrecto. Consulte Video Resumen en http://links.lww.com/DCR/B177. (Traducción-Dr. Xavier Delgadillo).

Background & Aims: Sarcopenia in gastrointestinal cancer has been associated with poor clinical outcome after surgery. The effect of low muscle mass on the inflammatory response to surgery has not been investigated, however skeletal muscle wasting in the context of cachexia is associated with a hyperinflammatory state at baseline. Knowledge on this matter can provide new insight into the detrimental effects of sarcopenia on postoperative recovery, possibly leading to novel therapeutic strategies. The aim of this study was to evaluate whether low muscle mass is associated with increased inflammation after resection of colorectal malignancies., Methods: Eighty-seven consecutive patients undergoing elective resection of a primary colorectal tumor were enrolled. Muscle mass was assessed on routine preoperative computed tomography (CT) scans using image analysis by Osirix(®) by measuring skeletal muscle at the third lumbar vertebra (L3) level. The effect of muscle mass on pre- and postoperative plasma concentrations of C-reactive protein (CRP), calprotectin and interleukin-6 (IL-6) was analyzed. Clinical outcome was assessed by HARM (HospitAl stay, Readmission, and Mortality) scores., Results: Skeletal muscle mass was not predictive of plasma concentrations of CRP and IL-6. However, low skeletal muscle mass was significantly predictive of high plasma concentrations of calprotectin on postoperative days (POD) 2 through 5, reaching highest significance on POD4 (regression beta, -6.06; 95% confidence interval, -10.45 to -1.68; p = 0.007)., Conclusions: Low muscle mass in patients undergoing surgery for colorectal cancer was associated with an increased postoperative inflammatory response. This may be at least part of the explanation for the high incidence of postoperative complications in sarcopenic patients., (Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)