Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): VIDI grant from Netherlands Organization of Scientific Research (NWO). Rosalind Franklin Fellowship from the University Medical Center Groningen. Both to Marit Westerterp, PhD Smooth muscle cells (SMCs) regulate blood flow distribution and blood pressure via vasoconstriction mediated by α-adrenergic receptors (α-ARs). Plasma membrane cholesterol may affect α1-AR signaling, but consequences for SMC-mediated vasoconstriction are unclear. Cholesterol loading promotes SMC-to-macrophage transition in vitro, which may enhance atherosclerotic plaque vulnerability. The cholesterol transporters ATP Binding Cassette A1 and G1 (ABCA1/ABCG1) are highly expressed by SMCs and mediate cholesterol efflux to apolipoprotein A1 and high-density lipoprotein (HDL), respectively. The role of ABCA1/ABCG1-mediated cholesterol efflux pathways in SMC-mediated vasoconstriction and atherogenesis remains poorly understood. We generated mice with SMC-specific Abca1/Abcg1 deficiency on the low-density lipoprotein receptor deficient (Ldlr-/-) background by crossbreeding Abca1fl/flAbcg1fl/flLdlr-/- mice with Myh11-CreERT2 transgenic mice and feeding them tamoxifen-diet. To induce SMC cholesterol accumulation and atherogenesis, we fed Myh11-CreERT2Abca1fl/flAbcg1fl/flLdlr-/- and Myh11-CreERT2Ldlr-/- mice Western-type diet (WTD) for 16 weeks. Combined SMC-Abca1/Abcg1 deficiency increased vasoconstriction in aortic rings induced by the α1-AR agonist phenylephrine, with reversal by methyl-β-cyclodextrin, substantiating its cholesterol-dependency. Unexpectedly, SMC-Abca1/Abcg1 deficiency induced urinary bladder enlargement by >20-fold, resembling bladder outlet obstruction (BOO). This was reversed by the α1-AR antagonist tamsulosin, indicating its dependence on bladder neck SMC constriction. Moreover, SMC-Abca1/Abcg1 deficiency decreased SMC markers and increased macrophage- and fibroblast-markers in the bladder wall, enhancing collagen deposition, consistent with SMC transdifferentiation. However, after 16 weeks WTD, SMC-Abca1/Abcg1 deficiency did not affect atherosclerotic lesion size, fibrous cap thickness, necrotic core, collagen, or macrophage content, suggesting that SMCs in atherosclerotic plaques were not affected. This may be due to low Abca1/Abcg1 expression in intimal compared to medial SMCs. We uncover a new role of SMC cholesterol efflux pathways in suppressing α1-AR mediated vasoconstriction and bladder SMC transdifferentiation, decreasing BOO. Our data may provide a mechanistic link for the association between BOO and diabetes in humans, particularly because diabetes is associated with decreased cholesterol efflux. SMC-Abca1/Abcg1 deficiency did not affect atherosclerotic lesion size or plaque composition, presumably due to low Abca1/Abcg1 expression in intimal SMCs of atherosclerotic lesions, as shown in mice and humans.

Background The timing and degree of implementation of minimally invasive surgery (MIS) for colorectal cancer vary among countries. Insights in national differences regarding implementation of new surgical techniques and the effect on postoperative outcomes are important for quality assurance, can show potential areas for country-specific improvement, and might be illustrative and supportive for similar implementation programs in other countries. Therefore, this study aimed to evaluate differences in patient selection, applied techniques, and results of minimal invasive surgery for colorectal cancer between the Netherlands and Sweden. Methods Patients who underwent elective minimally invasive surgery for T1-3 colon or rectal cancer (2012–2018) registered in the Dutch ColoRectal Audit or Swedish ColoRectal Cancer Registry were included. Time trends in the application of MIS were determined. Outcomes were compared for time periods with a similar level of MIS implementation (Netherlands 2012–2013 versus Sweden 2017–2018). Multilevel analyses were performed to identify factors associated with adverse short-term outcomes. Results A total of 46,095 Dutch and 8,819 Swedish patients undergoing MIS for colorectal cancer were included. In Sweden, MIS implementation was approximately 5 years later than in the Netherlands, with more robotic surgery and lower volumes per hospital. Although conversion rates were higher in Sweden, oncological and surgical outcomes were comparable. MIS in the Netherlands for the years 2012–2013 resulted in a higher reoperation rate for colon cancer and a higher readmission rate but lower non-surgical complication rates for rectal cancer if compared with MIS in Sweden during 2017–2018. Conclusion This study showed that the implementation of MIS for colorectal cancer occurred later in Sweden than the Netherlands, with comparable outcomes despite lower volumes. Our study demonstrates that new surgical techniques can be implemented at a national level in a controlled and safe way, with thorough quality assurance.

Purpose Pulmonary arterial hypertension (PAH) is a fatal disease with characteristic vascular remodeling, including fibrosis, within an inflammatory milieu in the distal pulmonary vascular bed. Interleukin (IL)-1β and IL-18 levels, two potent proinflammatory cytokines, are elevated in patient serum and animal models of PAH. The release of these cytokines is regulated by the activation of the NLRP3 inlfammasome, hallmarked by caspase-1 cleavage. We hypothesized that pirfenidone (PFD) an antifibrotic and antinflammatory agent delays the progression of PAH by suppressing NLRP3 inflammasome activation. Methods We investigated the effect of preventive PFD treatment in the rat model for neointimal PAH induced by monocrotaline and aortocaval shunt. The disease severity was assessed by pulmonary hemodynamics and histology. The NLRP3 inflammasome activation was assessed by immunohistochemisry and immunoblotting on lung homogenate. For proof of concept, the effect of PFD on NLRP3 inflammasome was additionally tested, by qPCR and ELISA, on bone marrow derived macrophages (BMDMs) after LPS/nigericin stimulation. Results Inflammasome activation was increased in the model compared to control as assessed by cleavage the ratio of caspase-1 (145%, p=0.023), IL-1β (142%, p=0.002) and IL-18 (210%, p=0.006). PFD treatment led to reduction of mPAP and occlusion (mPAP:28 ±8 mmHg vs 36 ±4mmHg, p=0.004; occlusion 28 ±4% vs 18 ±10%, p=0.008). So did the level of IL-1β and IL-18 activation when compared to the PAH untreated group (35%, p=0.027; 68%, p=0.005). The perivascular collagen content correlated with mPAP (p=0.025) and occlusion (p<0.001) regarding fibrosis. On BMDMs, both the inflammasome related gene expression relative to control and the IL-1β excretion were reduced by PFD (NLRP3: 40% p<0.001; IL-1β: 61% p<0.001; IL-18: 50% p<0.001 & IL-1β in medium: 44% p<0.001). Conclusion Inflammasome is activated in experimental flow-associated PAH, based on the cleavage of caspase-1 and its products IL-1β and IL-18. Its activation correlates with pulmonary hemodynamics and vascular remodeling. PFD suppresses NLRP3 inflammasome activation and ameliorates PAH, assessed by pulmonary hemodynamics and vascular remodeling. Pulmonary arterial hypertension (PAH) is a fatal disease with characteristic vascular remodeling, including fibrosis, within an inflammatory milieu in the distal pulmonary vascular bed. Interleukin (IL)-1β and IL-18 levels, two potent proinflammatory cytokines, are elevated in patient serum and animal models of PAH. The release of these cytokines is regulated by the activation of the NLRP3 inlfammasome, hallmarked by caspase-1 cleavage. We hypothesized that pirfenidone (PFD) an antifibrotic and antinflammatory agent delays the progression of PAH by suppressing NLRP3 inflammasome activation. We investigated the effect of preventive PFD treatment in the rat model for neointimal PAH induced by monocrotaline and aortocaval shunt. The disease severity was assessed by pulmonary hemodynamics and histology. The NLRP3 inflammasome activation was assessed by immunohistochemisry and immunoblotting on lung homogenate. For proof of concept, the effect of PFD on NLRP3 inflammasome was additionally tested, by qPCR and ELISA, on bone marrow derived macrophages (BMDMs) after LPS/nigericin stimulation. Inflammasome activation was increased in the model compared to control as assessed by cleavage the ratio of caspase-1 (145%, p=0.023), IL-1β (142%, p=0.002) and IL-18 (210%, p=0.006). PFD treatment led to reduction of mPAP and occlusion (mPAP:28 ±8 mmHg vs 36 ±4mmHg, p=0.004; occlusion 28 ±4% vs 18 ±10%, p=0.008). So did the level of IL-1β and IL-18 activation when compared to the PAH untreated group (35%, p=0.027; 68%, p=0.005). The perivascular collagen content correlated with mPAP (p=0.025) and occlusion (p<0.001) regarding fibrosis. On BMDMs, both the inflammasome related gene expression relative to control and the IL-1β excretion were reduced by PFD (NLRP3: 40% p<0.001; IL-1β: 61% p<0.001; IL-18: 50% p<0.001 & IL-1β in medium: 44% p<0.001). Inflammasome is activated in experimental flow-associated PAH, based on the cleavage of caspase-1 and its products IL-1β and IL-18. Its activation correlates with pulmonary hemodynamics and vascular remodeling. PFD suppresses NLRP3 inflammasome activation and ameliorates PAH, assessed by pulmonary hemodynamics and vascular remodeling.

Despite the increased awareness of differences in the inflammatory response between men and women, only limited research has focused on the biological factors underlying these sex differences. The cholesterol derivative 27-hydroxycholesterol (27HC) has been shown to have opposite inflammatory effects in independent experiments using mouse models of atherosclerosis and non-alcoholic steatohepatitis (NASH), pathologies characterized by cholesterol-induced inflammation. As the sex of mice in thesein vivomodels differed, we hypothesized that 27HC exerts opposite inflammatory effects in males compared to females. To explore whether the sex-opposed inflammatory effects of 27HC translated to humans, plasma 27HC levels were measured and correlated with hepatic inflammatory parameters in obese individuals. To investigate whether 27HC exerts sex-opposed effects on inflammation, we injected 27HC into female and male Niemann-Pick disease type C1 mice (Npc1(nih)) that were used as an extreme model of cholesterol-induced inflammation. Finally, the involvement of estrogen signaling in this mechanism was studied in bone marrow-derived macrophages (BMDMs) that were treated with 27HC and 17 beta-estradiol (E2). Plasma 27HC levels showed opposite correlations with hepatic inflammatory indicators between female and male obese individuals. Likewise, hepatic 27HC levels oppositely correlated between female and maleNpc1(nih)mice. Twenty-seven hydroxycholesterol injections reduced hepatic inflammation in femaleNpc1(nih)mice in contrast to maleNpc1(nih)mice, which showed increased hepatic inflammation after 27HC injections. Furthermore, 27HC administration also oppositely affected inflammation in female and male BMDMs cultured in E2-enriched medium. Remarkably, female BMDMs showed higher ER alpha expression compared to male BMDMs. Our findings identify that the sex-opposed inflammatory effects of 27HC are E2-dependent and are potentially related to differences in ER alpha expression between females and males. Hence, the individual's sex needs to be taken into account when 27HC is employed as a therapeutic tool as well as in macrophage estrogen research in general. (c) 2020 The Authors.The Journal of Pathologypublished by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.

This study aimed to determine predictive factors for the circumferential resection margin (CRM) within two northern European countries with supposed similarity in providing rectal cancer care.

Aim: The aim of the study was to assess the correlation between diagnostic tests and symptoms in patients with various types of fecal incontinence (FI) referred to a tertiary pelvic floor centre over a period of four years. Method: Patients’ type and severity of FI were evaluated through St Mark’s and ICIQ-BS questionnaires and underwent endoanal ultrasound (EAUS), anorectal manometry (AM) and evacuation proctography to correlate underlying anatomical and physiological characteristics and four different types of FI (urge FI, passive FI, urgency and soiling). Results: 474 patients have been included. Those with urge FI and urgency, only hypersensitivity on AM reached statistical significance. Patients with passive FI, only hyposensitivity on AM was statistical significant. Patients with soiling had significantly more passive leakage of contrast during evacuation proctography. Internal and external anal sphincter defects on EAUS, high grade of intussusception or incomplete emptying on evacuation proctography were not correlated with the type of fecal incontinence. Conclusion: Although pelvic floor tests are commonly used in the initial evaluation of FI, none of them seems to accurately correlate with symptoms. Continence is multifactorial and cannot be explained by anatomical or physiological abnormalities in isolation. Clinical evaluation should drive treatment modalities rather than investigations.

BACKGROUND:Previous analysis of Dutch practice in treatment of left-sided obstructive colon cancer (LSOCC) until 2012 showed that emergency resection (ER) was preferred, with high mortality in patients aged ≥70 years. Consequently, Dutch and European guidelines in 2014 recommended a bridge to surgery (BTS) with either self-expandable metal stent (SEMS) or decompressing stoma (DS) in high-risk patients. The implementation and effects of these guidelines have not yet been evaluated. Therefore, our aim was to perform an in-depth update of national practice concerning curative treatment of LSOCC, including an evaluation of guideline implementation.PATIENTS AND METHODS:This multicenter cohort study was conducted in 75 of 77 hospitals in the Netherlands. We included data on patients who underwent curative resection of LSOCC in 2009 through 2016 obtained from the Dutch ColoRectal Audit. Additional data were retrospectively collected.RESULTS:A total of 2,587 patients were included (2,013 ER, 345 DS, and 229 SEMS). A trend was observed in reversal of ER (decrease from 86.2% to 69.6%) and SEMS (increase from 1.3% to 7.8%) after 2014, with an ongoing increase in DS (from 5.2% in 2009 to 22.7% in 2016). DS after 2014 was associated with more laparoscopic resections (66.0% vs 35.5%; P<.001) and more 2-stage procedures (41.5% vs 28.6%; P=.01) with fewer permanent stomas (14.7% vs 29.5%; P=.005). Overall, more laparoscopic resections (25.4% vs 13.2%; P<.001) and shorter total hospital stays (14 vs 15 days; P<.001) were observed after 2014. However, similar rates of primary anastomosis (48.7% vs 48.6%; P=.961), 90-day complications (40.4% vs 37.9%; P=.254), and 90-day mortality (6.5% vs 7.0%; P=.635) were observed.CONCLUSIONS:Guideline revision resulted in a notable change from ER to BTS for LSOCC. This was accompanied by an increased rate of laparoscopic resections, more 2-stage procedures with a decreased permanent stoma rate in patients receiving DS as BTS, and a shorter total hospital stay. However, overall 90-day complication and mortality rates remained relatively high.

Aim: The CANTOS trial indicated that pathways required for IL-1β secretion increase cardiovascular risk in humans. IL-1β and IL-18 are produced via the NLRP3 inflammasome in myeloid cells in response to excessive cholesterol accumulation, but mechanisms linking NLRP3 inflammasome activation to atherosclerosis are unclear. ATP Binding Cassette A1 and G1 (ABCA1/G1) mediate cholesterol efflux to HDL and Abca1/g1 deficiency in myeloid cells leads to excessive cholesterol accumulation. We aimed to obtain new insights into mechanisms linking NLRP3 inflammasome activation to atherogenesis.

Introduction: Despite the increasing number of publications concerning 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) for staging of esophageal cancer and the increasing availability of this novel diagnostic modality, its exact role in preoperative staging of these tumors is still unknown. The aim of this study was to systematically review the literature regarding the diagnostic performance of FDG-PET in preoperative staging of patients with esophageal cancer and to calculate summary estimates of its sensitivity and specificity. Materials and Methods: The databases of PubMed, Embase and Cochrane were searched for relevant studies. Two reviewers independently assessed the methodological quality of each study. A meta-analysis of the reported sensitivity and specificity of each study was performed. Results: Twelve studies met the inclusion criteria. The studies had several design deficiencies. Pooled sensitivity and specificity for the detection of locoregional metastases were 0.51 (95% CI, 0.34-0.69) and 0.84 (95% CI, 0.76-0.91) respectively. For distant metastases, pooled sensitivity and specificity were 0.67 (95% CI, 0.58-0.76) and 0.97 (95% CI, 0.90-1.0), respectively. Conclusion: FDG-PET showed moderate sensitivity and specificity for the detection of locoregional metastases, and reasonable sensitivity and specificity in detection of distant lymphatic and hematogenous metastases.

Introduction: Because of improvements in diagnostic technology, the incidental detection of synchronous primary tumors during the preoperative work-up of patients with esophageal cancer has increased. The aim of this study was to determine the rate and clinical relevance of synchronous neoplasms seen on FDG-PET in staging of esophageal cancer. Methods: From January 1996 to July 2004, 366 patients with biopsy-proven malignancy of the esophagus underwent FDG-PET for initial staging. This series of patients was retrospectively reviewed for the detection of synchronous primary neoplasms. Results: Twenty synchronous primary neoplasms were identified in 366 patients (5.5%). Eleven neoplasms were localized in the colorectum, 5 in the kidney, and 2 in the thyroid gland, 1 in the lung, and 1 in the gingiva. One of the thyroid lesions and the lung lesion were erroneously interpreted as metastases, leading to incorrect upstaging of the esophageal tumor. Conclusions: FDG-PET detected unexpected synchronous primary neoplasms in 5.5% of patients with esophageal cancer. Sites of pathologic FDG uptake should be confirmed by dedicated additional investigations before treatment, because synchronous neoplasms may mimic metastases.

A Snapshot study design eliminates changes in treatment and outcome over time. This population based Snapshot study aimed to determine current practice and outcome of rectal cancer treatment with published landmark randomized controlled trials as a benchmark.

AimThe construction of a new coloanal anastomosis (CAA) following anastomotic leakage after low anterior resection (LAR) is challenging. The available literature on this topic is scarce. The aim of this two-centre study was to determine the clinical success and morbidity after redo CAA. MethodThis retrospective cohort study included all patients with anastomotic leakage after LAR for rectal cancer who underwent a redo CAA between 2010 and 2014 in two tertiary referral centres. Short- and long-term morbidity were analysed, including both anastomotic leakage and permanent stoma rates on completion of follow-up. ResultsA total of 59 patients were included, of whom 45 (76%) were men, with a mean age of 59years (SD9.4). The median interval between index and redo surgery was 14months [interquartile range (IQR) 8-27]. The median duration of follow-up was 27months (IQR 17-36). The most frequent complication was anastomotic leakage of the redo CAA occurring in 24 patients (41%), resulting in a median of three reinterventions (IQR 2-4) per patient. At the end of follow-up, bowel continuity was restored in 39/59 (66%) patients. Fourteen (24%) patients received a definitive colostomy and six (10%) still had a diverting ileostomy. In a multivariable model, leakage of the redo CAA was the only risk factor for permanent stoma (OR 0.022; 95% CI 0.004-0.122). ConclusionRedo CAA is a viable option in selected patients with persisting leakage after LAR for rectal cancer who want their bowel continuity restored. However, patients should be fully informed about the relatively high morbidity and reintervention rates.

Rectal cancer surgery is accompanied with high morbidity and poor long term functional outcome. Screening programs have shown a shift towards more early staged cancers. Patients with early rectal cancer can potentially benefit significantly from rectal preserving therapy. For the earliest stage cancers, local excision is sufficient when the risk of lymph node disease and subsequent recurrence is below 5 %. However, the majority of early cancers are associated with an intermediate risk of lymph node involvement (5–20 %) suggesting that local excision alone is not sufficient, while completion radical surgery, which is currently standard of care, could be a substantial overtreatment for this group of patients.

Objective—The ATP-binding cassette (ABC) transporter B6 (ABCB6) is highly expressed in megakaryocyte progenitors, but its role in platelet production and disease has not been elucidated. Approach and Results—Among various ABC transporters, ABCB6 was highly expressed in megakaryocyte progenitors, exhibiting the same pattern of expression of genes involved in heme synthesis pathway. Transplantation of Abcb6 deficient (Abcb6−/−) bone marrow into low density lipoprotein receptor deficient recipient mice resulted in expansion and proliferation of megakaryocyte progenitors, attributable to increased reactive oxygen species production in response to porphyrin loading. The enhanced megakaryopoiesis in Abcb6−/− bone marrow–transplanted mice was further illustrated by increased platelet counts, mean platelet volume, and platelet activity. Platelets from Abcb6−/− bone marrow–transplanted mice had higher levels of chemokine (C-C motif) ligand 5, which was associated with increased plasma chemokine (C-C motif) ligand 5 levels. There were also increased platelet–leukocyte aggregates, which resulted in leukocyte activation. Abcb6−/− bone marrow–transplanted mice had accelerated atherosclerosis which was associated with deposition of the chemotactic agent, chemokine (C-C motif) ligand 5 in atherosclerotic plaques, resulting in increased macrophage accumulation. Conclusions—Our findings identify a new role of ABCB6 in preventing atherosclerosis development by dampening platelet production, reactivity, and chemokine (C-C motif) ligand 5 deposition in atherosclerotic lesions.

Annually approximately 18,044 patients are admitted to Dutch hospitals with hip fractures. This is an increasing demand for medical care due to the increasing amount of elderly people. Although previous studies showed that routine check of X-rays following hip fracture surgery is unnecessary, it remains routine in most clinics in the Netherlands. In addition to the radiation exposure to the patient, it is painful and leads to unnecessary costs. This study aims to establish if routine check X-rays 1 day after internal fixation for hip fracture with adequate image intensifier guidance influence postoperative management.

One of the most important ways to reduce biliary duct injury in laparoscopic cholecystectomy is to achieve the critical view of safety (CVS) before transection of the cystic artery and duct. Documenting CVS is possible with photo prints, video imaging, or both. These documentations can be used as a proof of the right procedure in case of biliary duct injury, but only if the documentation is good enough to be judged independently by others.

This report describes a set of scientific procedures used to assess the impact of foods and food ingredients on the expression of appetite (psychological and behavioural). An overarching priority has been to enable potential evaluators of health claims about foods to identify justified claims and to exclude claims that are not supported by scientific evidence for the effect cited. This priority follows precisely from the principles set down in the PASSCLAIM report. The report allows the evaluation of the strength of health claims, about the effects of foods on appetite, which can be sustained on the basis of the commonly used scientific designs and experimental procedures. The report includes different designs for assessing effects on satiation as opposed to satiety, detailed coverage of the extent to which a change in hunger can stand alone as a measure of appetite control and an extensive discussion of the statistical procedures appropriate for handling data in this field of research. Because research in this area is continually evolving, new improved methodologies may emerge over time and will need to be incorporated into the framework. One main objective of the report has been to produce guidance on good practice in carrying out appetite research, and not to set down a series of commandments that must be followed.

Omloo, Jikke M.T.1; Westerterp, Marinke1; Boellaard, Ronald3; Hoekstra, Otto S.3; Sloof, Gerrit W.2; Jan B van Lanschot, J.1 Author Information

Background: The detection of distant metastases in patients with oesophageal cancer may be improved with [F-18]fluorodeoxyglucose positron emission tomography (FDG-PET), preventing unnecessary surgical explorations. The aim of this study was to assess the additional value of FDG-PET after a state-of-the-art preoperative staging protocol.Methods: All patients in this prospective cohort study were staged with multidetector computed tomography, endoscopic ultrasonography and external ultrasonography of the neck, both combined with selective fine-needle aspiration cytology. Patients considered eligible for curative surgery after these investigations underwent FDG-PET.Results: FDG-PET revealed suspicious hot spots in 30 (15.1 per cent) of 199 patients. Metastases were confirmed in eight (4.0 per cent). In six of these, distant metastases were confirmed before surgery, but exploratory surgery was necessary for histological confirmation in the other two. All eight upstaged patients had clinical stage III-IV disease before FDG-PET (6.6 per cent of 122 with stage III-IV disease). In seven patients (3.5 per cent) hot spots appeared to be synchronous neoplasms, mainly colonic polyps. However, those in the remaining 15 (7.5 per cent) were false positive, leading to unnecessary additional investigations.Conclusion: FDG-PET improves the selection of patients with oesophageal cancer for potentially curative surgery, especially in stages III-IV. However, the diagnostic benefit is limited after state-of-the-art staging, and so broad implementation in daily clinical practice is questionable.