Publications by authors named "Donald L van der Peet"

104 Publications

Health related quality of life following open versus minimally invasive total gastrectomy for cancer: Results from a randomized clinical trial.

Eur J Surg Oncol 2021 Aug 30. Epub 2021 Aug 30.

Department of Gastrointestinal Surgery, Amsterdam University Medical Center Location VU University Medical Center, Amsterdam, the Netherlands; Department of Clinical Epidemiology, Amsterdam University Medical Center, Amsterdam, the Netherlands.

Introduction: Minimally invasive techniques show improved short-term and comparable long-term outcomes compared to open techniques in the treatment of gastric cancer and improved survival has been seen with the implementation of multimodality treatment. Therefore, focus of research has shifted towards optimizing treatment regimens and improving quality of life.

Materials And Methods: A randomized trial was performed in thirteen hospitals in Europe. Patients were randomized between open total gastrectomy (OTG) or minimally invasive total gastrectomy (MITG) after neoadjuvant chemotherapy. This study investigated patient reported outcome measures (PROMs) on health-related quality of life (HRQoL) following OTG or MITG, using the Euro-Qol-5D (EQ-5D) and the European Organization for Research and Treatment of Cancer (EORTC) questionnaires, modules C30 and STO22. Due to multiple testing a p-value < 0.001 was deemed statistically significant.

Results: Between January 2015 and June 2018, 96 patients were included in this trial. Forty-nine patients were randomized to OTG and 47 to MITG. A response compliance of 80% was achieved for all PROMs. The EQ5D overall health score one year after surgery was 85 (60-90) in the open group and 68 (50-83.8) in the minimally invasive group (P = 0.049). The median EORTC-QLQ-C30 overall health score one year postoperatively was 83,3 (66,7-83,3) in the open group and 58,3 (35,4-66,7) in the minimally invasive group (P = 0.002). This was not statistically significant.

Conclusion: No differences were observed between open total gastrectomy and minimally invasive total gastrectomy regarding HRQoL data, collected using the EQ-5D, EORTC QLQ-C30 and EORTC-QLQ-STO22 questionnaires.
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http://dx.doi.org/10.1016/j.ejso.2021.08.031DOI Listing
August 2021

C-reactive protein after major abdominal surgery in daily practice.

Surgery 2021 May 21. Epub 2021 May 21.

Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands.

Background: Infectious complications are frequently encountered after abdominal surgery. Early recognition, diagnosis, and subsequent timely treatment is the single most important denominator of postoperative outcome. This study prospectively addressed the predictive value of routine assessment of C-reactive protein levels as an early marker for infectious complications after major abdominal surgery.

Methods: Consecutive patients undergoing major abdominal surgery between November 2015 and November 2019 were prospectively enrolled. Routine C-reactive protein measurements were implemented on postoperative days 3, 4, and 5, and additional computed tomography examinations were performed on demand. The primary endpoint was the occurrence of Clavien-Dindo grade III or higher infectious complications.

Results: Of 350 patients, 71 (20.3%) experienced a major infectious complication, and median time to diagnosis was 7 days. C-reactive protein levels were significantly higher in patients with major infectious complications compared to minor or no infectious complications. The optimal cut-off was calculated for each postoperative day, being 175 mg/L on day 3, 130 mg/L on day 4, and 144 mg/L on day 5, and corresponding sensitivities, specificities, and positive and negative predictive values were over 80%, 65%, 40%, and 92% respectively. Alternative safe discharge cut-offs were calculated at 105 mg/L, 71 mg/L and 63 mg/L on days 3, 4, and 5, respectively, each having a negative predictive value of over 97%.

Conclusion: The C-reactive protein cut-offs provided in this study can be used as a discharge criterion or to select patients that might require an invasive intervention due to infectious complications. These diagnostic criteria can easily be implemented in daily surgical practice.
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http://dx.doi.org/10.1016/j.surg.2021.04.025DOI Listing
May 2021

What Is Weight Loss After Bariatric Surgery Expressed in Percentage Total Weight Loss (%TWL)? A Systematic Review.

Obes Surg 2021 08 17;31(8):3833-3847. Epub 2021 May 17.

Department of Surgery, Spaarne Gasthuis, Spaarnepoort 1, Hoofddorp, 2134 TM, the Netherlands.

Percentage total weight loss (%TWL) might be better than percentage excess weight loss to express weight loss in bariatric surgery. In this systematic review, performed according to the PRISMA statement, results of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB) are assessed in %TWL. A total of 13,426 studies were screened and 49 included, reporting data of 24,760 patients. The results show that, despite limiting data, LRYGB is favorable over LSG in terms of weight loss in short-term follow-up. Although recent guidelines recommend to use %TWL when reporting outcome in bariatric surgery, this study shows that there is still insufficient quality data in %TWL, especially on LSG. The use of %TWL as the primary outcome measure in bariatric surgery should be encouraged.
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http://dx.doi.org/10.1007/s11695-021-05394-xDOI Listing
August 2021

Intrathoracic vs Cervical Anastomosis After Totally or Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer: A Randomized Clinical Trial.

JAMA Surg 2021 Jul;156(7):601-610

Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.

Background: Transthoracic minimally invasive esophagectomy (MIE) is increasingly performed as part of curative multimodality treatment. There appears to be no robust evidence on the preferred location of the anastomosis after transthoracic MIE.

Objective: To compare an intrathoracic with a cervical anastomosis in a randomized clinical trial.

Design, Setting, And Participants: This open, multicenter randomized clinical superiority trial was performed at 9 Dutch high-volume hospitals. Patients with midesophageal to distal esophageal or gastroesophageal junction cancer planned for curative resection were included. Data collection occurred from April 2016 through February 2020.

Intervention: Patients were randomly assigned (1:1) to transthoracic MIE with intrathoracic or cervical anastomosis.

Main Outcomes And Measures: The primary end point was anastomotic leakage requiring endoscopic, radiologic, or surgical intervention. Secondary outcomes were overall anastomotic leak rate, other postoperative complications, length of stay, mortality, and quality of life.

Results: Two hundred sixty-two patients were randomized, and 245 were eligible for analysis. Anastomotic leakage necessitating reintervention occurred in 15 of 122 patients with intrathoracic anastomosis (12.3%) and in 39 of 123 patients with cervical anastomosis (31.7%; risk difference, -19.4% [95% CI, -29.5% to -9.3%]). Overall anastomotic leak rate was 12.3% in the intrathoracic anastomosis group and 34.1% in the cervical anastomosis group (risk difference, -21.9% [95% CI, -32.1% to -11.6%]). Intensive care unit length of stay, mortality rates, and overall quality of life were comparable between groups, but intrathoracic anastomosis was associated with fewer severe complications (risk difference, -11.3% [-20.4% to -2.2%]), lower incidence of recurrent laryngeal nerve palsy (risk difference, -7.3% [95% CI, -12.1% to -2.5%]), and better quality of life in 3 subdomains (mean differences: dysphagia, -12.2 [95% CI, -19.6 to -4.7]; problems of choking when swallowing, -10.3 [95% CI, -16.4 to 4.2]; trouble with talking, -15.3 [95% CI, -22.9 to -7.7]).

Conclusions And Relevance: In this randomized clinical trial, intrathoracic anastomosis resulted in better outcome for patients treated with transthoracic MIE for midesophageal to distal esophageal or gastroesophageal junction cancer.

Trial Registration: Trialregister.nl Identifier: NL4183 (NTR4333).
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http://dx.doi.org/10.1001/jamasurg.2021.1555DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117060PMC
July 2021

Conflicting Guidelines: A Systematic Review on the Proper Interval for Colorectal Cancer Treatment.

World J Surg 2021 07 3;45(7):2235-2250. Epub 2021 Apr 3.

Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands.

Background: Timely treatment for colorectal cancer (CRC) is a quality indicator in oncological care. However, patients with CRC might benefit more from preoperative optimization rather than rapid treatment initiation. The objectives of this study are (1) to determine the definition of the CRC treatment interval, (2) to study international recommendations regarding this interval and (3) to study whether length of the interval is associated with outcome.

Methods: We performed a systematic search of the literature in June 2020 through MEDLINE, EMBASE and Cochrane databases, complemented with a web search and a survey among colorectal surgeons worldwide. Full-text papers including subjects with CRC and a description of the treatment interval were included.

Results: Definition of the treatment interval varies widely in published studies, especially due to different starting points of the interval. Date of diagnosis is often used as start of the interval, determined with date of pathological confirmation. The end of the interval is rather consistently determined with date of initiation of any primary treatment. Recommendations on the timeline of the treatment interval range between and within countries from two weeks between decision to treat and surgery, to treatment within seven weeks after pathological diagnosis. Finally, there is no decisive evidence that a longer treatment interval is associated with worse outcome.

Conclusions: The interval from diagnosis to treatment for CRC treatment could be used for prehabilitation to benefit patient recovery. It may be that this strategy is more beneficial than urgently proceeding with treatment.
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http://dx.doi.org/10.1007/s00268-021-06075-7DOI Listing
July 2021

Learning Curves of Ivor Lewis Totally Minimally Invasive Esophagectomy by Hospital and Surgeon Characteristics: A Retrospective Multi-National Cohort Study.

Ann Surg 2021 Feb 10. Epub 2021 Feb 10.

Department of Surgery, Radboudumc, Nijmegen, The Netherlands Department of Operating Rooms, Radboudumc, Nijmegen, the Netherlands Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands Amsterdam UMC, location AMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands Department of Surgery, Gelre Ziekenhuizen, Apeldoorn, The Netherlands Division of Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital and Helsinki University Department of Surgery, medical Centre Leeuwarden, Leeuwarden, The Netherlands Department of UGI Surgery, Norfolk and Norwich University Hospital Foundation Trust, Norwich, UK Department of Surgery, Odense University Hospital, Denmark Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands Department of Surgery, Hospital Group Twente, Almelo, The Netherlands Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands Department of Surgery and Cancer, Imperial College London, London, United Kingdom.

Objective: To describe the pooled learning curves of Ivor Lewis TMIE in hospitals stratified by predefined hospital and surgeon related factors.

Summary Background Data: Ivor Lewis totally minimally invasive esophagectomy (TMIE) is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning.

Methods: A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and two-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, (TMIE) experience, clinic visits, courses and fellowships followed, and proctor supervision.

Results: This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume ≥50 compared to centers with an annual volume < 50. Analysis with an annual volume cut-off of 30 cases showed similar but less pronounced results. No outcomes suggesting more efficient learning were found for longer experience as consultant, visiting an expert clinic, completing a MIE fellowship or implementation under proctor supervision.

Conclusions: More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.
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http://dx.doi.org/10.1097/SLA.0000000000004801DOI Listing
February 2021

Molecular profiles of response to neoadjuvant chemoradiotherapy in oesophageal cancers to develop personalized treatment strategies.

Mol Oncol 2021 04 23;15(4):901-914. Epub 2021 Feb 23.

Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, location VUmc, The Netherlands.

Identification of molecular predictive markers of response to neoadjuvant chemoradiation could aid clinical decision-making in patients with localized oesophageal cancer. Therefore, we subjected pretreatment biopsies of 75 adenocarcinoma (OAC) and 16 squamous cell carcinoma (OSCC) patients to targeted next-generation DNA sequencing, as well as biopsies of 85 OAC and 20 OSCC patients to promoter methylation analysis of eight GI-specific genes, and subsequently searched for associations with histopathological response and disease-free (DFS) and overall survival (OS). Thereby, we found that in OAC, CSMD1 deletion (8%) and ETV4 amplification (5%) were associated with a favourable histopathological response, whereas SMURF1 amplification (5%) and SMARCA4 mutation (7%) were associated with an unfavourable histopathological response. KRAS (15%) and GATA4 (7%) amplification were associated with shorter OS. In OSCC, TP63 amplification (25%) and TFPI2 (10%) gene promoter methylation were associated with an unfavourable histopathological response and shorter DFS (TP63) and OS (TFPI2), whereas CDKN2A deletion (38%) was associated with prolonged OS. In conclusion, this study identified candidate genetic biomarkers associated with response to neoadjuvant chemoradiotherapy in patients with localized oesophageal cancer.
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http://dx.doi.org/10.1002/1878-0261.12907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8024738PMC
April 2021

The clinical suspicion of a leaking intrathoracic esophagogastric anastomosis: the role of CT imaging.

J Thorac Dis 2020 Dec;12(12):7182-7192

Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands.

Background: CT imaging is the primary diagnostic approach to assess the integrity of the intrathoracic anastomosis following Ivor Lewis esophagectomy. In the postoperative setting interpretation of CT findings, such as air and fluid collections, may be challenging. Establishment of a scoring system that incorporates CT findings to diagnose anastomotic leakage could assist radiologists and surgeons in the postoperative phase.

Methods: Consecutive patients who underwent a CT scan for a clinical suspicion of postoperative anastomotic leakage following Ivor Lewis esophagectomy between 2010 and 2016 in two medical centers were retrospectively included. Scans were excluded when oral contrast was not (correctly) administered. Acquired images were randomized and independently assessed by two experienced gastrointestinal radiologists, blinded for clinical information. For this study anastomotic leakage was defined as a visible defect during endoscopy or thoracotomy.

Results: A total of 80 patients had 101 CT scans, resulting in 32 scans with a confirmed anastomotic leak (25 patients). After multivariable backward stepwise logistic regression, a practical 5-point scoring system was developed, which included the following CT findings: presence of extraluminal oral contrast, air collection at the anastomotic site, fluid collection at the anastomotic site, pneumothorax and loculated pleural effusion. Patients with a score of ≥3 were considered at high risk for anastomotic leakage (positive predictive value: 83.3%), patients with scores <3 were considered at low risk for anastomotic leakage (negative predictive value: 84.4%). The scoring system showed a superior diagnostic performance compared to the original CT report and blinded interpretation of two radiologists.

Conclusions: Our CT-based practical scoring system enables a standardized approach in CT assessment and could facilitate early recognition of anastomotic leakage in patients after Ivor Lewis esophagectomy.
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http://dx.doi.org/10.21037/jtd-20-954DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797855PMC
December 2020

Usability and Preliminary Effectiveness of a Preoperative mHealth App for People Undergoing Major Surgery: Pilot Randomized Controlled Trial.

JMIR Mhealth Uhealth 2021 01 7;9(1):e23402. Epub 2021 Jan 7.

Department of Rehabilitation Medicine, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.

Background: Major surgery is associated with negative postoperative outcomes such as complications and delayed or poor recovery. Multimodal prehabilitation can help to reduce the negative effects of major surgery. Offering prehabilitation by means of mobile health (mHealth) could be an effective new approach.

Objective: The objectives of this pilot study were to (1) evaluate the usability of the Be Prepared mHealth app prototype for people undergoing major surgery, (2) explore whether the app was capable of bringing about a change in risk behaviors, and (3) estimate a preliminary effect of the app on functional recovery after major surgery.

Methods: A mixed-methods pilot randomized controlled trial was conducted in two Dutch academic hospitals. In total, 86 people undergoing major surgery participated. Participants in the intervention group received access to the Be Prepared app, a smartphone app using behavior change techniques to address risk behavior prior to surgery. Both groups received care as usual. Usability (System Usability Scale), change in risk behaviors 3 days prior to surgery, and functional recovery 30 days after discharge from hospital (Patient-Reported Outcomes Measurement Information System physical functioning 8-item short form) were assessed using online questionnaires. Quantitative data were analyzed using descriptive statistics, chi-square tests, and multivariable linear regression. Semistructured interviews about the usability of the app were conducted with 12 participants in the intervention group. Thematic analysis was used to analyze qualitative data.

Results: Seventy-nine people-40 in the intervention group and 39 in the control group-were available for further analysis. Participants had a median age of 61 (interquartile range 51.0-68.0) years. The System Usability Scale showed that patients considered the Be Prepared app to have acceptable usability (mean 68.2 [SD 18.4]). Interviews supported the usability of the app. The major point of improvement identified was further personalization of the app. Compared with the control group, the intervention group showed an increase in self-reported physical activity and muscle strengthening activities prior to surgery. Also, 2 of 2 frequent alcohol users in the intervention group versus 1 of 9 in the control group drank less alcohol in the run-up to surgery. No difference was found in change of smoking cessation. Between-group analysis showed no meaningful differences in functional recovery after correction for baseline values (β=-2.4 [95% CI -5.9 to 1.1]).

Conclusions: The Be Prepared app prototype shows potential in terms of usability and changing risk behavior prior to major surgery. No preliminary effect of the app on functional recovery was found. Points of improvement have been identified with which the app and future research can be optimized.

Trial Registration: Netherlands Trial Registry NL8623; https://www.trialregister.nl/trial/8623.
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http://dx.doi.org/10.2196/23402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7819776PMC
January 2021

The Association of Textbook Outcome and Long-Term Survival After Esophagectomy for Esophageal Cancer.

Ann Thorac Surg 2021 10 19;112(4):1134-1141. Epub 2020 Nov 19.

Department of Surgery, Amsterdam University Medical Centers, location AMC, Cancer Center Amsterdam, Amsterdam, the Netherlands. Electronic address:

Background: Esophagectomy is the key component of curative esophageal cancer treatment. Textbook outcome is a composite measure describing an optimal perioperative course, including variables related to radical resection, including at least 15 lymph nodes, and an uncomplicated postoperative course without hospital readmission. This study assessed clinicopathologic predictors of textbook outcome and the association of textbook outcome with survival in 2 tertiary referral centers.

Methods: All patients with esophageal cancer who underwent esophagectomy with gastric tube reconstruction and curative intent between 2007 and 2016 were included. Patients with carcinoma in situ and patients undergoing a salvage or nonelective procedure were excluded. The primary end point was the association of textbook outcome of esophageal cancer surgery with long-term survival. Secondary end points were clinicopathologic predictors of textbook outcome.

Results: In total, 1065 patients were included, of whom 327 achieved textbook outcome (30.7%). Squamous cell carcinoma (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.39 to 0.80), hybrid approach (OR, 0.30; 95% CI, 0.10 to 0.89), and American Society of Anesthesiologists (ASA) class II or higher predicted worse textbook rates (ASA class II: OR, 0.33, 95% CI, 0.22 to 0.49; ASA class III or IV: OR, 0.68; 95% CI, 0.48 to 0.96), whereas neoadjuvant therapy predicted a better textbook rate (OR, 1.58; 95% CI, 1.08 to 2.31). Superior overall (hazard ratio, 0.77; 95% CI, 0.64 to 0.93) and disease-free survival (hazard ratio, 0.80; 95% CI, 0.67 to 0.96) were observed in the textbook outcome group.

Conclusions: Achieved textbook outcome was associated with better overall and disease-free survival, thus illustrating the association of improved short-term outcomes and long-term survival and the importance of pursuing textbook outcome.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.035DOI Listing
October 2021

Outcome expectation and risk tolerance in patients seeking bariatric surgery.

Surg Obes Relat Dis 2021 Jan 25;17(1):139-146. Epub 2020 Aug 25.

Department of Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands.

Background: Average long-term outcome after laparoscopic Roux-en-Y gastric bypass is 25% total weight loss. The risk of short-term complications (leakage and bleeding), acute internal herniation, and mortality are 4.0%, 2.5%, and .2%, respectively. There is a paucity of evidence on what patients expect in terms of weight loss and to what extent surgical risks are tolerated.

Objective: To examine the patient's weight loss expectations and acceptance of the morbidity and mortality risk after primary laparoscopic Roux-en-Y gastric bypass.

Setting: Teaching hospital, Amsterdam, the Netherlands.

Methods: Two-hundred patients participated in a standardized survey after completion of an extensive multidisciplinary screening, before surgery. Weight loss expectations, naive assessment, and acceptation of risks of morbidity and mortality were addressed with standard gamble methods.

Results: The 200 participants (156 female, 78%) had a mean age of 45.1 years and a mean body mass index of 42.3 kg/m. Weight loss was overestimated by 151 patients (75.5%), and 79 participants (39.5%) were disappointed with the predicted weight loss. Median accepted risks on short-term complications, acute internal herniation, and mortality were 35.8% (interquartile range, 21.0%-58.0%), 25.1% (interquartile range, 15.9%-50.8%), and 4.5% (interquartile range, 1.0%-10.0%), respectively.

Conclusion: Patients seeking bariatric surgery seem to have unrealistic weight loss objectives and are willing to accept substantial risks to achieve these goals.
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http://dx.doi.org/10.1016/j.soard.2020.08.020DOI Listing
January 2021

Open versus minimally invasive total gastrectomy after neoadjuvant chemotherapy: results of a European randomized trial.

Gastric Cancer 2021 Jan 31;24(1):258-271. Epub 2020 Jul 31.

Department of Gastro-Intestinal Surgery, Amsterdam University Medical Center, Location VU University, De Boelelaan 1117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands.

Background: Surgical resection with adequate lymphadenectomy is regarded the only curative option for gastric cancer. Regarding minimally invasive techniques, mainly Asian studies showed comparable oncological and short-term postoperative outcomes. The incidence of gastric cancer is lower in the Western population and patients often present with more advanced stages of disease. Therefore, the reproducibility of these Asian results in the Western population remains to be investigated.

Methods: A randomized trial was performed in thirteen hospitals in Europe. Patients with an indication for total gastrectomy who received neoadjuvant chemotherapy were eligible for inclusion and randomized between open total gastrectomy (OTG) or minimally invasive total gastrectomy (MITG). Primary outcome was oncological safety, measured as the number of resected lymph nodes and radicality. Secondary outcomes were postoperative complications, recovery and 1-year survival.

Results: Between January 2015 and June 2018, 96 patients were included in this trial. Forty-nine patients were randomized to OTG and 47 to MITG. The mean number of resected lymph nodes was 43.4 ± 17.3 in OTG and 41.7 ± 16.1 in MITG (p = 0.612). Forty-eight patients in the OTG group had a R0 resection and 44 patients in the MITG group (p = 0.617). One-year survival was 90.4% in OTG and 85.5% in MITG (p = 0.701). No significant differences were found regarding postoperative complications and recovery.

Conclusion: These findings provide evidence that MITG after neoadjuvant therapy is not inferior regarding oncological quality of resection in comparison to OTG in Western patients with resectable gastric cancer. In addition, no differences in postoperative complications and recovery were seen.
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http://dx.doi.org/10.1007/s10120-020-01109-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790799PMC
January 2021

Kinase Inhibitor Treatment of Patients with Advanced Cancer Results in High Tumor Drug Concentrations and in Specific Alterations of the Tumor Phosphoproteome.

Cancers (Basel) 2020 Feb 1;12(2). Epub 2020 Feb 1.

Department of Medical Oncology, RadboudUMC, Radboud University, Geert Grooteplein Zuid 8, 6525 GA Nijmegen, The Netherlands.

Identification of predictive biomarkers for targeted therapies requires information on drug exposure at the target site as well as its effect on the signaling context of a tumor. To obtain more insight in the clinical mechanism of action of protein kinase inhibitors (PKIs), we studied tumor drug concentrations of protein kinase inhibitors (PKIs) and their effect on the tyrosine-(pTyr)-phosphoproteome in patients with advanced cancer. Tumor biopsies were obtained from 31 patients with advanced cancer before and after 2 weeks of treatment with sorafenib (SOR), erlotinib (ERL), dasatinib (DAS), vemurafenib (VEM), sunitinib (SUN) or everolimus (EVE). Tumor concentrations were determined by LC-MS/MS. pTyr-phosphoproteomics was performed by pTyr-immunoprecipitation followed by LC-MS/MS. Median tumor concentrations were 2-10 µM for SOR, ERL, DAS, SUN, EVE and >1 mM for VEM. These were 2-178 × higher than median plasma concentrations. Unsupervised hierarchical clustering of pTyr-phosphopeptide intensities revealed patient-specific clustering of pre- and on-treatment profiles. Drug-specific alterations of peptide phosphorylation was demonstrated by marginal overlap of robustly up- and downregulated phosphopeptides. These findings demonstrate that tumor drug concentrations are higher than anticipated and result in drug specific alterations of the phosphoproteome. Further development of phosphoproteomics-based personalized medicine is warranted.
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http://dx.doi.org/10.3390/cancers12020330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7072422PMC
February 2020

White blood cell and cell-free DNA analyses for detection of residual disease in gastric cancer.

Nat Commun 2020 Jan 27;11(1):525. Epub 2020 Jan 27.

Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands.

Liquid biopsies are providing new opportunities for detection of residual disease in cell-free DNA (cfDNA) after surgery but may be confounded through identification of alterations arising from clonal hematopoiesis. Here, we identify circulating tumor-derived DNA (ctDNA) alterations through ultrasensitive targeted sequencing analyses of matched cfDNA and white blood cells from the same patient. We apply this approach to analyze samples from patients in the CRITICS trial, a phase III randomized controlled study of perioperative treatment in patients with operable gastric cancer. After filtering alterations from matched white blood cells, the presence of ctDNA predicts recurrence when analyzed within nine weeks after preoperative treatment and after surgery in patients eligible for multimodal treatment. These analyses provide a facile method for distinguishing ctDNA from other cfDNA alterations and highlight the utility of ctDNA as a predictive biomarker of patient outcome to perioperative cancer therapy and surgical resection in patients with gastric cancer.
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http://dx.doi.org/10.1038/s41467-020-14310-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6985115PMC
January 2020

Implementation of robot-assisted Ivor Lewis procedure: Robotic hand-sewn, linear or circular technique?

Am J Surg 2020 07 26;220(1):62-68. Epub 2019 Nov 26.

Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands.

Background: Robot-assisted surgery for esophageal cancer is increasingly applied. Despite this upsurge, the preferential technique to create a robot-assisted intrathoracic anastomosis has not been established.

Data Sources: Bibliographic databases were searched to identify studies that performed a robot-assisted Ivor Lewis esophagectomy and described the technical details of the anastomotic technique. Out of 1701 articles, 16 studies were included for systematic review.

Conclusions: This review shows that all technique used to create a thoracoscopic anastomosis can be adopted to robotic surgery. Techniques can be divided into three categories: robotic hand-sewn, circular stapling or linear stapling and robotic hand-sewn closure of the stapler defect. With limited robotic experience, circular stapling might be the preferred technique, however requires a well-trained bedside assistant. The linear stapling technique or hand-sewn technique are more challenging but enable experienced robotic surgeons to perform a controlled anastomosis without bedside support.
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http://dx.doi.org/10.1016/j.amjsurg.2019.11.031DOI Listing
July 2020

Letter to the Editor: Comparison of Outcomes with Semi-mechanical and Circular Stapled Intrathoracic Esophagogastric Anastomosis Following Esophagectomy.

World J Surg 2020 01;44(1):320

Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands.

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http://dx.doi.org/10.1007/s00268-019-05244-zDOI Listing
January 2020

[Non-metastatic oesophageal cancer: diagnosis and treatment].

Ned Tijdschr Geneeskd 2019 09 13;163. Epub 2019 Sep 13.

Amsterdam UMC, afd. Heelkunde, Amsterdam.

The incidence of oesophageal cancer is on the rise, particularly due to an increase in the number of adenocarcinomas of the distal oesophagus. Adenomas and squamous cell carcinomas are the most common histological subtypes; each should be considered as a different entity. The diagnosis 'oesophageal cancer' is confirmed on the basis of histopathological investigation of biopsies, whereas tumour staging is conducted through transoesophageal endoscopic ultrasound and FDG-PET/CT diagnostics. There are various options to treat patients with oesophageal cancer, such as endoscopic resection, multimodal therapy or definitive chemoradiotherapy. Since 2012, neoadjuvant chemoradiotherapy followed by surgery is the standard treatment for oesophageal cancer, except with regard to patients with a T1 or M1 tumour. In the Netherlands, most surgical procedures are now minimally invasive procedures. Despite improved treatment options, mortality rates associated with oesophageal cancer remain high.
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September 2019

Distribution of lymph node metastases in esophageal carcinoma [TIGER study]: study protocol of a multinational observational study.

BMC Cancer 2019 Jul 4;19(1):662. Epub 2019 Jul 4.

The Royal Marsden, London, UK.

Background: An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients.

Methods: The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival.

Discussion: The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics.

Trial Registration: NCT03222895 , date of registration: July 19th, 2017.
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http://dx.doi.org/10.1186/s12885-019-5761-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610993PMC
July 2019

Letter to the Editor: Outcome of Self-Expanding Metal Stents in the Treatment of Anastomotic Leaks After Ivor Lewis Esophagectomy.

World J Surg 2019 09;43(9):2348

Department of Gastrointestinal Surgery, VU University Medical Center, Amsterdam UMC, Amsterdam, The Netherlands.

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http://dx.doi.org/10.1007/s00268-019-05033-8DOI Listing
September 2019

Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial.

Trials 2019 Apr 25;20(1):239. Epub 2019 Apr 25.

Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital Dordrecht, Dordrecht, Netherlands.

Background: Infected necrosis complicates 10% of all acute pancreatitis episodes and is associated with 15-20% mortality. The current standard treatment for infected necrotizing pancreatitis is the step-up approach (catheter drainage, followed, if necessary, by minimally invasive necrosectomy). Catheter drainage is preferably postponed until the stage of walled-off necrosis, which usually takes 4 weeks. This delay stems from the time when open necrosectomy was the standard. It is unclear whether such delay is needed for catheter drainage or whether earlier intervention could actually be beneficial in the current step-up approach. The POINTER trial investigates if immediate catheter drainage in patients with infected necrotizing pancreatitis is superior to the current practice of postponed intervention.

Methods: POINTER is a randomized controlled multicenter superiority trial. All patients with necrotizing pancreatitis are screened for eligibility. In total, 104 adult patients with (suspected) infected necrotizing pancreatitis will be randomized to immediate (within 24 h) catheter drainage or current standard care involving postponed catheter drainage. Necrosectomy, if necessary, is preferably postponed until the stage of walled-off necrosis, in both treatment arms. The primary outcome is the Comprehensive Complication Index (CCI), which covers all complications between randomization and 6-month follow up. Secondary outcomes include mortality, complications, number of (repeat) interventions, hospital and intensive care unit (ICU) lengths of stay, quality-adjusted life years (QALYs) and direct and indirect costs. Standard follow-up is at 3 and 6 months after randomization.

Discussion: The POINTER trial investigates if immediate catheter drainage in infected necrotizing pancreatitis reduces the composite endpoint of complications, as compared with the current standard treatment strategy involving delay of intervention until the stage of walled-off necrosis.

Trial Registration: ISRCTN, 33682933 . Registered on 6 August 2015. Retrospectively registered.
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http://dx.doi.org/10.1186/s13063-019-3315-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482524PMC
April 2019

Definitive Chemoradiotherapy Versus Trimodality Therapy for Resectable Oesophageal Carcinoma: Meta-analyses and Systematic Review of Literature.

World J Surg 2019 May;43(5):1271-1285

Department of Gastrointestinal Surgery, VU University Medical Center, De Boelelaan 1117, 7F020, 1081 HV, Amsterdam, The Netherlands.

Background: Standard therapy for loco-regionally advanced, resectable oesophageal carcinoma is trimodality therapy (TMT) consisting of neoadjuvant chemoradiotherapy and oesophagectomy. Evidence of survival advantage of TMT over organ-preserving definitive chemoradiotherapy (dCRT) is inconclusive. The aim of this study is to compare survival between TMT and dCRT.

Methods: A systematic review and meta-analyses were conducted. Randomised controlled trials and observational studies on resectable, curatively treated, oesophageal carcinoma patients above 18 years were included. Three online databases were searched for studies comparing TMT with dCRT. Primary outcomes were 1-, 2-, 3- and 5-year overall survival rates. Risk of bias was assessed using the Cochrane risk of bias tools for RCTs and cohort studies. Quality of evidence was evaluated according to Grading of Recommendation Assessment, Development and Evaluation.

Results: Thirty-two studies described in 35 articles were included in this systematic review, and 33 were included in the meta-analyses. Two-, three- and five-year overall survival was significantly lower in dCRT compared to TMT, with relative risks (RRs) of 0.69 (95% CI 0.57-0.83), 0.76 (95% CI 0.63-0.92) and 0.57 (95% CI 0.47-0.71), respectively. When only analysing studies with equal patient groups at baseline, no significant differences for 2-, 3- and 5-year overall survival were found with RRs of 0.83 (95% CI 0.62-1.10), 0.81 (95% CI 0.57-1.14) and 0.63 (95% CI 0.36-1.12).

Conclusion: These meta-analyses do not show clear survival advantage for TMT over dCRT. Only a non-significant trend towards better survival was seen, assuming comparable patient groups at baseline. Non-operative management of oesophageal carcinoma patients might be part of a personalised and tailored treatment approach in future. However, to date hard evidence proving its non-inferiority compared to operative management is lacking.
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http://dx.doi.org/10.1007/s00268-018-04901-zDOI Listing
May 2019

Autologous Activated Fibrin Sealant for the Esophageal Anastomosis: A Feasibility Study.

J Surg Res 2019 02 27;234:49-53. Epub 2018 Sep 27.

Department of Gastrointestinal Surgery, VU University Medical Center, Amsterdam, the Netherlands.

Background: Esophageal cancer is surgically treated by means of an esophagectomy. However, esophagectomies are associated with high morbidity rates with dehiscence of the anastomosis occurring in 19% of these procedures in the Netherlands. Application of a fibrin sealant may improve mechanical strength of the anastomosis. The aim of this study was to determine the technical feasibility of the application of an autologous fibrin sealant by aerosolized spraying on esophageal anastomoses.

Methods: This study was designed as a single-center feasibility study. Patients undergoing elective minimal invasive esophageal surgery with the creation of a thoracic or a cervical anastomosis were eligible. Fibrin sealant (Vivostat) was applied to the anastomosis intraoperatively. Feasibility was measured using a nine-item checklist, designed for intraoperative application.

Results: In total, fifteen patients, between the ages of 43-79 y, were included in this study. One procedure scored eight out of nine points on the feasibility checklist, so application was considered as unsuccessful. The other fourteen procedures obtained a 100% score and were documented as successful procedures. Together, this led to a success rate of 93%. Grade III anastomotic leakage occurred in one of the fifteen patients (6.7%).

Conclusions: This study showed that application of fibrin sealant on esophageal anastomoses is technically feasible and safe. Future studies may investigate the possible protective effects of fibrin sealant application on the development of anastomotic leakage. NCT03251040.
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http://dx.doi.org/10.1016/j.jss.2018.08.049DOI Listing
February 2019

Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.

BMJ 2018 Oct 8;363:k3965. Epub 2018 Oct 8.

Department of Surgery, St Antonius Hospital, 3435CM, PO box 2500, Nieuwegein, Netherlands

Objective: To assess whether laparoscopic cholecystectomy is superior to percutaneous catheter drainage in high risk patients with acute calculous cholecystitis.

Design: Multicentre, randomised controlled, superiority trial.

Setting: 11 hospitals in the Netherlands, February 2011 to January 2016.

Participants: 142 high risk patients with acute calculous cholecystitis were randomly allocated to laparoscopic cholecystectomy (n=66) or to percutaneous catheter drainage (n=68). High risk was defined as an acute physiological assessment and chronic health evaluation II (APACHE II) score of 7 or more.

Main Outcome Measures: The primary endpoints were death within one year and the occurrence of major complications, defined as infectious and cardiopulmonary complications within one month, need for reintervention (surgical, radiological, or endoscopic that had to be related to acute cholecystitis) within one year, or recurrent biliary disease within one year.

Results: The trial was concluded early after a planned interim analysis. The rate of death did not differ between the laparoscopic cholecystectomy and percutaneous catheter drainage group (3% 9%, P=0.27), but major complications occurred in eight of 66 patients (12%) assigned to cholecystectomy and in 44 of 68 patients (65%) assigned to percutaneous drainage (risk ratio 0.19, 95% confidence interval 0.10 to 0.37; P<0.001). In the drainage group 45 patients (66%) required a reintervention compared with eight patients (12%) in the cholecystectomy group (P<0.001). Recurrent biliary disease occurred more often in the percutaneous drainage group (53% 5%, P<0.001), and the median length of hospital stay was longer (9 days 5 days, P<0.001).

Conclusion: Laparoscopic cholecystectomy compared with percutaneous catheter drainage reduced the rate of major complications in high risk patients with acute cholecystitis.

Trial Registration: Dutch Trial Register NTR2666.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174331PMC
http://dx.doi.org/10.1136/bmj.k3965DOI Listing
October 2018

CRITICS-II: a multicentre randomised phase II trial of neo-adjuvant chemotherapy followed by surgery versus neo-adjuvant chemotherapy and subsequent chemoradiotherapy followed by surgery versus neo-adjuvant chemoradiotherapy followed by surgery in resectable gastric cancer.

BMC Cancer 2018 Sep 10;18(1):877. Epub 2018 Sep 10.

Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.

Background: Although radical surgery remains the cornerstone of cure in resectable gastric cancer, survival remains poor. Current evidence-based (neo)adjuvant strategies have shown to improve outcome, including perioperative chemotherapy, postoperative chemoradiotherapy and postoperative chemotherapy. However, these regimens suffer from poor patient compliance, particularly in the postoperative phase of treatment. The CRITICS-II trial aims to optimize preoperative treatment by comparing three treatment regimens: (1) chemotherapy, (2) chemotherapy followed by chemoradiotherapy and (3) chemoradiotherapy.

Methods: In this multicentre phase II non-comparative study, patients with clinical stage IB-IIIC (TNM 8th edition) resectable gastric adenocarcinoma are randomised between: (1) 4 cycles of docetaxel+oxaliplatin+capecitabine (DOC), (2) 2 cycles of DOC followed by chemoradiotherapy (45Gy in combination with weekly paclitaxel and carboplatin) or (3) chemoradiotherapy. Primary endpoint is event-free survival, 1 year after randomisation (events are local and/or regional recurrence or progression, distant recurrence, or death from any cause). Secondary endpoints include: toxicity, surgical outcomes, percentage radical (R0) resections, pathological tumour response, disease recurrence, overall survival, and health related quality of life. Exploratory endpoints include translational studies on predictive and prognostic biomarkers.

Discussion: The aim of this study is to select the most promising among three preoperative treatment arms in patients with resectable gastric adenocarcinoma. This treatment regimen will subsequently be compared with the standard therapy in a phase III trial.

Trial Registration: clinicaltrials.gov NCT02931890 ; registered 13 October 2016. Date of first enrolment: 21 December 2017.
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http://dx.doi.org/10.1186/s12885-018-4770-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6131797PMC
September 2018

Non-Invasive Detection of Anastomotic Leakage Following Esophageal and Pancreatic Surgery by Urinary Analysis.

Dig Surg 2019 15;36(2):173-180. Epub 2018 Jun 15.

Department of Gastrointestinal surgery, VU University Medical Center, Amsterdam, The Netherlands.

Background: Esophagectomy or pancreaticoduodenectomy is the standard surgical approach for patients with tumors of the esophagus or pancreatic head. Postoperative mortality is strongly correlated with the occurrence of anastomotic leakage (AL). Delay in diagnosis leads to delay in treatment, which ratifies the need for development of novel and accurate non-invasive diagnostic tests for detection of AL. Urinary volatile organic compounds (VOCs) reflect the metabolic status of an individual, which is associated with a systemic immunological response. The aim of this study was to determine the diagnostic accuracy of urinary VOCs to detect AL after esophagectomy or pancreaticoduodenectomy.

Methods: In the present study, urinary VOCs of 63 patients after esophagectomy (n = 31) or pancreaticoduodenectomy (n = 32) were analyzed by means of field asymmetric ion mobility spectrometry. AL was defined according to international study groups.

Results: AL was observed in 15 patients (24%). Urinary VOCs of patients with AL after pancreaticoduodenectomy could be distinguished from uncomplicated controls, area under the curve 0.85 (95% CI 0.76-0.93), sensitivity 76%, and specificity 77%. However, this was not observed following esophagectomy, area under the curve 0.51 (95% CI 0.37-0.65).

Conclusion: In our study population AL following pancreaticoduodenectomy could be discriminated from uncomplicated controls by means of urinary VOC analysis, NTC03203434.
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http://dx.doi.org/10.1159/000488007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482982PMC
June 2019

Mediastinal lymphadenectomy for esophageal cancer: Differences between two countries, Japan and the Netherlands.

Ann Gastroenterol Surg 2018 May 1;2(3):176-181. Epub 2018 May 1.

VUmc Amsterdam The Netherlands.

Extent of mediastinal lymphadenectomy during esophagectomy is clearly different between two representative countries of the Eastern and Western world, such as Japan and the Netherlands. In Japan, a clear policy is the standard complete two- or three-field type of lymphadenectomy whereas, in the Netherlands, a limited form is usually carried out. Reasons for these differences can be found in the different types of tumor, 80% of adenocarcinomas in the West and almost 95% of squamous cell cancer in Japan. Moreover, location of the tumors, distally located in the Netherlands whereas, in Japan, the majority are located in the middle and proximal thoracic esophagus. Also, type of neoadjuvant therapy, namely chemoradiotherapy in the Netherlands, and chemotherapy in Japan, are different. Arguments for more extended mediastinal lymphadenectomy are currently challenged in the West, first by the systematic use of chemoradiotherapy as neoadjuvant therapy and, second, the retrospective analysis of large data. According to two studies, the importance of extended lymphadenectomy is shown to be relative and less clear, especially in esophageal adenocarcinomas after neoadjuvant therapy. International efforts such as the TIGER study will help to standardize and find a relationship between the type and location of esophageal cancer, use of neoadjuvant therapy, extent of lymphadenectomy and survival.
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http://dx.doi.org/10.1002/ags3.12172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5980465PMC
May 2018

Different Perspectives on Predictability and Preventability of Surgical Readmissions.

J Surg Res 2019 05 8;237:95-105. Epub 2018 Mar 8.

Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands. Electronic address:

Background: Although unscheduled readmissions are increasingly being used as a quality indicator, only few readmission studies have focused on surgical patient populations.

Methods: An observational study "[email protected]" was performed at three centers in the Netherlands. Readmitted patients and treating doctors were surveyed to assess the discharge process during index admission and their opinion on predictability and preventability of the readmission. Risk factors associated with predictability and preventability as judged by patients and their doctor were identified. Cohen's kappa was calculated to measure pairwise agreement of considering readmission as predictable/preventable. PRISMA root cause categories were used to qualify the reasons for readmission.

Results: In 237 unscheduled surgical readmissions, more patients assessed their readmissions to be likely preventable compared with their treating doctors (28.7% versus 6.8%; kappa, 0.071). This was also reflected in poor consensus about risk factors and root causes of these readmissions. When patients reported that they did not feel ready for discharge or requested their doctor to allow them to stay longer at discharge during index admission, they deemed their readmission more likely predictable and preventable. Doctors focused on measurable factors such as the clinical frailty scale and biomarkers during discharge process. Health-care worker failures were strongly associated with preventable readmissions.

Conclusions: There is no consensus between readmitted patients and treating doctors about predictability and preventability of readmissions, nor about associated risk factors and root causes. Patients should be more effectively involved in their discharge process, and the relevance of optimal communication between them should be emphasized to create a safe and efficient discharge process.
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http://dx.doi.org/10.1016/j.jss.2018.02.009DOI Listing
May 2019

Post-treatment/Pre-operative PET Response Is Not an Independent Predictor of Outcomes for Patients With Gastric and GEJ Adenocarcinoma.

Ann Surg 2018 12;268(6):e78-e79

Department of Surgery, VU University medical center, Amsterdam, The Netherlands.

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http://dx.doi.org/10.1097/SLA.0000000000002669DOI Listing
December 2018

Comment on: A Propensity Score Matched Analysis of Open Versus Minimally Invasive Transthoracic Esophagectomy in the Netherlands.

Ann Surg 2018 12;268(6):e74-e75

Department of Surgery, VU University Medical Center, Amsterdam, the Netherlands.

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http://dx.doi.org/10.1097/SLA.0000000000002642DOI Listing
December 2018
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