[One hundred years of the Association of Surgeons in the Netherlands. VIII. Surgical oncology].
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Humans↗
Biomedical subjects
T Wiggers
Publications and source records attributed to T Wiggers.
Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial.
PURPOSE: Total mesorectal excision (TME) surgery in the treatment of rectal cancer has been shown to result in a reduction in the number of local recurrences in retrospective studies. Reports on improved local control after preoperative, hypofractionated radiotherapy (RT) have led to the introduction of a prospective randomized multicenter trial, in which the effect of TME surgery with or without preoperative RT were evaluated. Any benefit in regard to a reduced local recurrence rate and possible improved survival must be weighed against potential adverse effects in both the short-term and the long-term. The present study was undertaken to assess the acute side effects of short-term, preoperative RT in rectal cancer patients and to study the influence of five doses of 5 Gy on surgical parameters, postoperative morbidity and mortality in patients randomized in the Dutch TME trial. PATIENTS AND METHODS: We analyzed 1,530 Dutch patients entered onto a prospective randomized trial, comparing preoperative RT with five doses of 5 Gy followed by TME surgery with TME surgery alone, of which 1,414 patients were assessable. Toxicity from RT, surgery characteristics, and postoperative complications and mortality were compared. RESULTS: Toxicity during RT hardly occurred. Irradiated patients had 100 mL more blood loss during the operation (P <.001) and showed more perineal complications (P =.008) in cases of abdominoperineal resection. The total number of complications was slightly increased in the irradiated group (P =.008). No difference was observed in postoperative mortality (4.0% v 3.3%) or in the number of reinterventions. CONCLUSION: Preoperative hypofractionated RT is a safe procedure in patients treated with TME surgery, despite a slight increase in complications when compared with TME surgery only.
Adult↗
The circumferential margin in rectal cancer. Recommendations based on the Dutch Total Mesorectal Excision Study.
A very low local recurrence rate in rectal cancer is possible with optimal staging, preoperative radiotherapy and the use of total mesorectal excision (TME). Data from a study where patients were randomised for preoperative radiotherapy (or not) and complete removal of the tumour and mesorectum were examined. A consensus meeting was held to discuss the data in which the following guidelines for implementation were made. Adequate imaging is necessary to increase the likelihood of a R0 resection. Advances cases (possible margin to the endopelvicfascie less than 2 mm) need a long course of preoperative radiotherapy. Primary resectable cases benefit from a short course of radiation directly followed by surgery. A continuous quality control of surgery is mandatory in order to maintain the skill for a TME. A complete pathology report is important for the quality control of the surgical treatment and to predict the outcome of treatment. All of the involved disciplines in the diagnosis and treatment of rectal cancer should focus on the circumferential margin to guide for optimal treatment. Multidisciplinary teams are important for the achievement of optimal treatment planning of rectal cancer patients and maintenance of the highest level of quality control.
Colorectal Surgery↗
Hospital volume and post-operative mortality after resection for gastric cancer.
AIMS: In low-volume hospitals, expertise in gastric surgery is difficult to maintain because of the decreasing incidence of gastric cancer and the fall of surgery for ulcer disease. We evaluated the prognostic impact of hospital volume on post-operative mortality (POM) in a consecutive series of 1978 patients. METHODS: Information on patients undergoing resection for gastric cancer in the period 1987-97 was retrieved from the Rotterdam Cancer Registry. The relationship between hospital volume and POM was analysed by logistic regression, adjusting for other prognostic factors. RESULTS: POM was 7.9% on average but varied between the 22 hospitals from 3.1% to 15.1% (P=0.15). Hospital volume had no prognostic influence (P=0.74). Prognostic factors were age (70-79 years odds ratio (OR)=3.8, 80+ years OR=6.0), sex (male OR=1.7), stage (IV OR=1.8) and (partial) gastrectomy for cardia cancers (OR=2.0). CONCLUSION: Variation in POM between hospitals was large but not related to hospital volume. For cardia cancer, POM rates were lower after oesophagogastrectomy.
Adult↗
[Follow-up after oncological surgery].
After an operative and adjuvant treatment of solid tumours there are a number of reasons for follow-up: treatment of the functional and psychological results of the therapy, quality control with respect to the treatment, screening for metachronous tumours, reassuring the patient, and the detection of asymptomatic recurrences. Most follow-up schedules are based on the probability of a recurrence and not on the effectiveness of possible interventions. Negative effects are false positive test results, morbidity and even mortality due to a new intervention, and the knowledge that there is a recurrence for which in the absence of complaints no effective treatment is possible. In the ideal situation every patient should have a personal monitoring schedule based on the aforementioned considerations whilst taking into account comorbidity and the patient's wishes. This documented agreement should state the frequency of the follow-up visits, the type of examination and the person responsible for carrying out the monitoring.
Continuity of Patient Care↗
Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer.
BACKGROUND: Short-term preoperative radiotherapy and total mesorectal excision have each been shown to improve local control of disease in patients with resectable rectal cancer. We conducted a multicenter, randomized trial to determine whether the addition of preoperative radiotherapy increases the benefit of total mesorectal excision. METHODS: We randomly assigned 1861 patients with resectable rectal cancer either to preoperative radiotherapy (5 Gy on each of five days) followed by total mesorectal excision (924 patients) or to total mesorectal excision alone (937 patients). The trial was conducted with the use of standardization and quality-control measures to ensure the consistency of the radiotherapy, surgery, and pathological techniques. RESULTS: Of the 1861 patients randomly assigned to one of the two treatment groups, 1805 were eligible to participate. The overall rate of survival at two years among the eligible patients was 82.0 percent in the group assigned to both radiotherapy and surgery and 81.8 percent in the group assigned to surgery alone (P=0.84). Among the 1748 patients who underwent a macroscopically complete local resection, the rate of local recurrence at two years was 5.3 percent. The rate of local recurrence at two years was 2.4 percent in the radiotherapy-plus-surgery group and 8.2 percent in the surgery-only group (P<0.001). CONCLUSIONS: Short-term preoperative radiotherapy reduces the risk of local recurrence in patients with rectal cancer who undergo a standardized total mesorectal excision.
Adenocarcinoma↗
[Local tumor control and (disease-free) survival after surgery with pre- and intraoperative radiotherapy for primary non-resectable rectal carcinoma and local recurrence].
OBJECTIVE: Survey of the results of multimodality treatment for primary irresectable rectum carcinoma and local recurrence of rectal cancer. DESIGN: Retrospective. METHODS: During the period 1 February 1994 to 31 August 1999, 43 patients with locally advanced primary rectal cancer (25 men and 18 women; mean age: 64 years (range: 36-86)) and 53 patients with a local recurrence (33 men and 20 women; mean age: 61 years (39-82)) were treated with a multimodality treatment: i.e. preoperative radiotherapy (doses 50.4 Gy, or 30.0 Gy in the case of reirradiation), extensive surgery and intraoperative radiotherapy (doses 10-17.5 Gy). This treatment took place at two hospitals in the Netherlands, the Catharina Hospital in Eindhoven and, since 1997, the Daniel den Hoed Cancer Centre in Rotterdam. In 2000 data were collected for the local control and (disease-free) survival; these were analysed using the Kaplan-Meier method. Patients also completed a questionnaire about the quality of life at a median period of 14 months (range: 4-60) after the operation; the response level was 96% (76/79). RESULTS: After 3 years, the local control, disease-free survival and survival rates for the locally advanced primary rectal cancer group were 74%, 60% and 55% respectively, and for the locally recurrent rectal cancer group 64%, 34% and 50% respectively. Tumour resection with microscopically negative margins had a statistically significant positive effect on the local control and disease-free survival in both groups as well as on the survival in the locally advanced primary patient group. Seven of the 96 patients (7%) died as a result of complications. Of the patients with a primary irresectable carcinoma or a local recurrent tumour who completed the questionnaire the results were as follows: 56% and 63% respectively had been able to resume employment, 53% and 59% respectively had been able to resume their previous lifestyle, 15% and 27% respectively indicated radicular pain as a new symptom, 26% and 46% respectively stated problems with walking, 42% and 44% respectively stated problems with urinating and 59% and 52% respectively a reduction in sexual activity.
Adult↗
Comparison of intraoperative radiation therapy-containing multimodality treatment with historical treatment modalities for locally recurrent rectal cancer.
PURPOSE: Treatment protocols for patients with locally recurrent rectal cancer have changed in the last two decades. Subsequently, treatment goals shifted from palliation to possible cure. In this retrospective study, we explored the treatment variables that may have contributed to the improvement in outcome by comparing three treatment modalities from two collaborating institutions in patients with similar tumor characteristics. METHODS: Ninety-four patients were treated with electron-beam radiation therapy only (1975-1990), 19 with combined preoperative electron-beam radiation therapy and surgery (1989-1996), and 33 with intraoperative radiation therapy-multimodality treatment (1994-1999). Intraoperative radiation therapy was delivered either as intraoperative electron-beam radiotherapy (10-17.5 Gy) in 20 patients or as intraoperative high-dose-rate brachytherapy (10 Gy) in 13 patients. No patient had received prior electron-beam radiation therapy. RESULTS: The three-year survival, disease-free survival, and local control rates were 14, 8, and 10 percent, respectively, in the electron-beam radiation therapy-only group and 11, 0, and 14 percent, respectively, in the combined electron-beam radiation therapy-surgery group. The overall intraoperative radiation therapy-multimodality treatment group showed significantly better three-year survival, disease-free survival, and local control rates of 60, 43, and 73 percent, respectively, compared with the historical control groups (P < 0.001). CONCLUSION: The outcome of patients with locally recurrent rectal cancer was improved after the introduction of intraoperative radiation therapy-multimodality treatment.
Aged↗
Abdominosacral resection for primary irresectable and locally recurrent rectal cancer.
PURPOSE: The purpose of this study was to present a technique of abdominosacral resection and its results in patients with locally advanced primary or locally recurrent rectal cancer with dorsolateral fixation. METHODS: Between 1994 and 1999, 13 patients with locally advanced primary rectal cancer and 37 patients with locally recurrent rectal cancer underwent abdominosacral resection as part of a multimodality treatment, i.e., preoperative irradiation, surgery, and intraoperative irradiation. After the abdominal phase, the patient was turned from supine to prone position to perform the transsacral phase of the resection. RESULTS: Margins were microscopically negative in 26 patients (52 percent), microscopically positive in 18 (36 percent), and positive with gross residual disease in 6 patients. Operation time ranged from 210 to 590 (median, 390) minutes, and blood loss ranged from 400 to 10,000 (median, 3,500) ml. No operative or hospital deaths occurred. Postoperative complications occurred in 41 patients (82 percent); most notable were perineal wound infections or dehiscence (n = 24, 48 percent). Other complications were postoperative urinary retention or incontinence (n = 9, 18 percent), peritonitis (n = 4), grade II neuropathy (n = 1), and fistula formation (n = 3). Kaplan-Meier 3-year overall survival, disease-free survival, and local control rates were, respectively, 41 percent, 31 percent, and 61 percent. Completeness of the resection (negative vs. positive margins) was a significant factor influencing survival (P = 0.04), disease-free survival (P = 0.0006), and local control (P = 0.0002). CONCLUSION: The abdominosacral resection provides wide access and may be the therapeutic solution for the accomplishment of a radical resection for distally situated, dorsally or dorsolaterally fixed primary or locally recurrent rectal cancers.
Abdomen↗
Major liver resection results in a changed plasma amino acid pattern as reflected by a decreased Fischer ratio which improves by bactericidal/permeability increasing protein.
BACKGROUND/AIMS: Major liver resection results in a high morbidity and mortality, and endotoxin plays a role in post-resection hepatic failure. Severe hepatic failure as seen in hepatitis and cirrhosis may be accompanied by hepatic encephalopathy and is characterized by a typical plasma amino acid pattern reflected by a decreased Fischer ratio. This study was performed to evaluate the plasma amino acid pattern in patients undergoing major liver surgery receiving placebo or the endotoxin-neutralizing agent bactericidal/permeability-increasing protein (rBPI21). PATIENTS AND METHODS: Forty-eight patients were randomized in this phase II, dose escalation, multicenter trial. Plasma amino acid profiles were determined preoperatively, and on the first (day 1) and third (day 3) postoperative day. RESULTS: In the placebo group the Fischer ratio decreased significantly on both postoperative days. Administration of rBPI21 also resulted in a decreased Fischer ratio on day 1, but not on day 3. Highly elevated alanine plasma levels were observed on day 1 in placebo-treated patients, whereas rBPI21 prevented this elevation. Plasma alanine levels on day 1 correlated with the duration of post-resection hepatic failure. CONCLUSIONS: Major liver resection results in a decreased Fischer ratio and a rise in plasma alanine levels. Plasma levels of alanine on the first postoperative day correlated with the duration of the post-resection hepatic failure. rBPI21 improved the Fischer ratio and prevented the rise of plasma alanine levels.
Adult↗
Urologic and sexual morbidity following multimodality treatment for locally advanced primary and locally recurrent rectal cancer.
AIMS: In the treatment of patients with locally advanced primary or locally recurrent rectal cancer much attention is given to the oncological aspects. In long-term survivors, urogenital morbidity can have a large effect on the quality of life. This study evaluates the functional outcome after multimodality treatment in these patient groups. PATIENTS AND METHODS: Between 1994 and August 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with multimodality treatment: i.e. high-dose preoperative external beam radiation therapy, followed by extended surgery and intraoperative radiotherapy. The medical records of the 121 patients were reviewed. To assess long-term urogenital morbidity, all patients still alive, with a minimum follow-up of 4 months, were asked to fill out a questionnaire about their voiding and sexual function. Seventy-six of the 79 currently living patients (96%) returned the questionnaire (median FU 14 months, range 4-60). RESULTS: The questionnaire revealed identifiable voiding dysfunction as a new problem in 31% of the male and 58% of the female patients. In 42% of patients after locally advanced primary and 48% after locally recurrent rectal cancer treatment bladder dysfunction occurred. The preoperative ability to have an orgasm had disappeared in 50% of the male and 50% of the female patients, and in 45% of patients after locally advanced primary and in 57% after locally recurrent rectal cancer treatment. CONCLUSION: Multimodality treatment for locally advanced primary and recurrent rectal cancer results in acceptable urogenital dysfunction if weighed by the risk of uncontrolled tumour progression. Long-term voiding and sexual function is decreased in half of the patients. Preoperative counselling of these patients on treatment-related urogenital morbidity is important.
Adult↗
Coagulopathy following major liver resection: the effect of rBPI21 and the role of decreased synthesis of regulating proteins by the liver.
This prospective study investigated the role of reduced hepatic synthesis of regulating proteins in coagulopathy after partial hepatectomy (PH) compared with major abdominal surgery (MAS) without involvement of the liver. Furthermore, we studied the effect of rBPI21, an endotoxin-neutralizing agent, on coagulopathy after PH was studied. Compared with MAS, PH resulted in significantly elevated levels of thrombin-antithrombin-III and plasmin-alpha2-antiplasmin complexes. Levels of antithrombin-3, alpha2-antiplasmin, fibrinogen, plasminogen, alpha2-macroglobulin (alpha2-M), and C1-inhibitor remained lower following PH. Treatment with rBPI21 led to significantly lower levels of tissue-type plasminogen activator (t-PA). Post-operative disseminated intravascular coagulation (DIC) was associated with significantly higher bilirubin and t-PA plasma levels and significantly lower levels of alpha2-M. This study indicates that PH induced hepatic failure results in decreased synthesis of hepatic regulating plasma proteins and subsequent activation of coagulation and fibrinolysis. Prevention of t-PA release by rBPI21 may have important clinical implications. Decreased availability of alpha2-M may be a factor in post-operative DIC.
Abdomen↗
The European Society of Surgical Oncology.
Surgery is the key to local tumor control and survival in the vast majority of cancer patients. Optimally performed oncological operations, based both on a profound knowledge of the disease and on organ-based technical expertise are therefore essential. In this field the multinational European Society of Surgical Oncology (ESSO) wants to play a pivotal role, improving surgical treatment and encouraging and promoting education and training in surgical oncology at all levels. To achieve this goal the ESSO is of the opinion that recognition of surgical oncology as a separate subspecialty has to pursued.
Accreditation↗
[Gastrointestinal metastases of lobular mammary carcinoma].
Three women, two aged 63 and one aged 47 years, developed serious abdominal pains and nausea during and/or years after treatment for metastasized lobular mammary carcinoma. These symptoms were due to jejunal tumour with perforation, sigmoid and hepatic metastases and perforated gastric metastases, respectively. After surgical treatment of the affected part of the gastrointestinal tract, the patients survived for a number of months without abdominal symptoms. Infiltrating lobular mammary carcinoma is more often associated with gastrointestinal metastases than infiltrating ductal mammary carcinoma. Progressive abdominal symptoms attributable to such metastases constitute an indication for a change of the systemic treatment. In case of insufficient effect of this treatment, and in acute situations, surgical treatment may result in protracted palliation.
Abdominal Pain↗
First evaluation study of the Dutch Working Party on silicone breast implants (SBI) and the silicone-related symptom complex (SRSC).
This cohort study evaluates the postoperative prevalence of antinuclear antibodies (ANA) in relation to symptoms related to the so-called silicone-related symptom complex (SRSC). A total of 63 women who underwent mastectomy followed by immediate breast reconstruction with a silicone implant (SBI) between Septembber 1990 and May 1995 at the University Hospital Rotterdam/Daniel den Hoed Cancer Center, participated voluntarily in the study. Their sera were tested for the presence of antinuclear antibodies (ANA) and at the same time they were screened for the prevalence of SRSC-related symptoms by questionnaire. All patients were also examined physically. Sixteen per cent of the women were ANA positive. There was no difference in SRSC expression between ANA-positive and ANA-negative women. The lack of difference in symptom expression between the ANA-positive and ANA-negative women and the rather low complaint percentage proves that if ANA positivity is related to the SRSC, we found no evidence that patients with a SBI with a positive ANA differed from the ANA-negative patients.
Adult↗
Motivations, satisfaction, and information of immediate breast reconstruction following mastectomy.
This study evaluated patients' motivations for, and satisfaction with, the treatment and information of immediate breast reconstruction (IBR) with a silicone prosthesis. It studied satisfaction more deeply by relating it to the quality of life, body-image and sexual functioning. Seventy-three patients who received mastectomy, followed by IBR with a subpectoral silicone prosthesis, completed a self-report questionnaire concerning their motivations for, perceived advantages of and satisfaction with IBR, the information received, quality of life, body image, and sexual functioning. Despite the fact that 50% of the reconstructions resulted in complications or complaints, 70% of the women were satisfied with the reconstruction and only 12% would never choose IBR again. Satisfaction was strongly correlated with the need for information. The higher the patient's expectations, the higher their need for information. The most common perceived advantage of IBR was the avoidance of an external prosthesis. A majority of patients were satisfied with the breast reconstruction. However, a sizeable proportion needed more information about breast reconstruction and the use of the silicone prosthesis. To avoid too high expectations more attention should be given to possible complications and the moderate cosmetic results.
Adult↗
Morbidity of immediate breast reconstruction (IBR) after mastectomy by a subpectorally placed silicone prosthesis: the adverse effect of radiotherapy.
AIMS: This study evaluates the incidence of local complications after immediate breast reconstruction (IBR) following mastectomy with a subpectorally placed silicone prosthesis, with emphasis on the effect of radiation treatment on IBR. METHODS: The medical records of 100 women, who underwent a mastectomy followed by IBR with a subpectorally placed silicone prosthesis at the University Hospital Rotterdam/Daniel den Hoed Cancer Center, between March 1990 and March 1995, were reviewed. Thirteen prostheses were implanted prior to radiation treatment, and 15 prostheses were implanted after irradiation of the chest wall. RESULTS: Early complications were seen in 15% of the IBR and were more often in irradiated women. At long-term follow-up, the most common complication was capsular contracture (21%). This occurred significantly more around prostheses placed in a previously irradiated area (P<0.0005), or which were irradiated after IBR (P=0.001). Loss of prosthesis was seen in 11 cases, and was significantly (P<0.005) more in irradiated women (n=5; 18%) compared to women who were not irradiated (n=6; 7%). CONCLUSIONS: Complications after IBR with a silicone prosthesis were more common in women who were treated with radiotherapy prior to or after IBR following mastectomy than in women who were not irradiated. In particular, capsular contracture around a prosthesis placed in a previously irradiated area was significantly increased. The use of musculocutaneous flaps, such as the transverse rectus abdominis muscle or latissimus dorsi flap, is preferable for reconstruction of previously irradiated breasts. There is no indication to remove the prosthesis before radiation therapy of the chest wall.
Adult↗
Controlled introduction of the sentinel node biopsy in breast cancer in a multi-centre setting: the role of a coordinator for quality control.
AIMS: It is proposed that sentinel node biopsy should replace axillary lymph-node dissection. We analysed the role of a coordinator in the introduction of the sentinel node biopsy in breast cancer in a multi-centre setting to assure standardization and quality control. METHODS: We included 232 operable breast cancer patients. Part of the procedure was an ultrasound examination of the axilla with fine needle aspiration cytology. The sentinel node was identified with 99m-Technetium and Patent Blue. RESULTS: The results of the procedure, sensitivity and false negativity, were the same for the three participating hospitals. We think this is mostly due to the coordinator who supplied information about the technique, pitfalls and results to all teams. CONCLUSIONS: Our experience regarding the organization aspects of introducing the sentinel node procedure in a multi-centre setting now serves as a model in organizing its application in a much wider number of hospitals.
Axilla↗