Abstract Background Prophylactic mesh reinforcement (PMA) has proven to reduce the incidence of incisional hernia, especially in high-risk patients, but the morbidity of long-term mesh-related complications are largely unknown. This study aims to evaluate all reoperations after mesh-reinforcement 14 years since the initiation of the PRIMA-trial. Study design Patients receiving prophylactic onlay or sublay-mesh in the PRIMA-trial between 2009 and 2012 were included on an as-treated basis from participating centers that made reoperation notes available. Main outcomes were the incidences of abdominal wall complications requiring mesh-explantation, mesh-related ileus, and mesh-related problems during laparotomy for other diagnoses. Results Out of 373 patients randomized to PMA, 242 could be included: 127 with onlay and 115 with sublay mesh. Median follow-up was 69 months (IQR 30–199). Thirty-four patients underwent re-operation for any reason during entire follow-up, 22 after onlay (17.3%) and 12 after sublay mesh (10.4%). Reoperation rate for abdominal wall complications that required mesh explantation was 4/127 (3.1%) after onlay and 0% after sublay mesh. Mesh-related ileus occurred in none of the onlay group, and 3/115 (2.6%) in the sublay group. During subsequent laparotomies for other primary diagnoses, adhesions to the meshes were noted in 3/10 (33%) patients in the onlay-group and 1/5 (20%) in the sublay-group, and the mesh was removed in 10/127 (7.9%) and 7/115 (6.1%) patients, respectively. Conclusions In high-risk patients receiving a prophylactic mesh during midline laparotomy closure, low incidences of mesh complications requiring re-operation and mesh-related problems during unrelated subsequent laparotomies were found, both for the onlay and sublay techniques.

Abstract Purpose Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) is characterized by neuropathic pain in a predictable, circumscript abdominal area. The diagnostic delay is long, with half of ACNES-affected individuals reporting next to pain, also nausea, bloating, or loss of appetite mimicking some kind of visceral disease. The aim of this study was to describe these phenomena and to determine whether treatment could successfully reverse the visceral symptoms. Methods This was a prospective observational study. Adult patients who fulfilled published criteria for ACNES and reported at least one visceral symptom at intake were eligible for the study. A self-developed Visceral Complaints ACNES Score (VICAS) questionnaire that scores several visceral symptoms (minimum 1 point, maximum 9 points) was completed before and after therapy. The success of treatment was defined as at least 50% reduction in pain. Results Data from 100 selected (at least one visceral symptom) patients (86 females) aged 39 ± 5 years were available for analysis. Frequently reported symptoms were abdominal bloating (78%), nausea (66%) and altered defecation (50%). Successful pain treatment significantly reduced the number of visceral symptoms, with a VICAS before of 3 (range 1–8) and after of 1 (range: 0–6) (p < 0.001). A low baseline VICAS was associated with successful treatment outcome (OR: 0.738, 95% CI: 0.546–0.999). Conclusion Patients with ACNES may report a variety of visceral symptoms. Successful treatment substantially reduces these visceral symptoms in selected patients, indicating a segmental relation between the abdominal wall and the viscera.

Background: Achieving R0 margin status in liver surgery for cancer remains challenging. This study aimed to compare the recurrence rates after surgical treatment for liver metastases in patients with margin status R0 and R1. Special focus of our study was if the coagulating-water-dropper device (CWDD), locally used, influences our Results. The CWDD is a combined coagulation and water dropping device used to seal the liver parenchyma after dissection. Material and Methods: A total of 339 patients treated for liver metastases with the CWDD between January 2010 and August 2018 were identified from a single-institutional retrospective database. Clinicopathologic factors were analysed. Recurrence patterns and survival rates in R1 (margin < 1 mm) were compared with R0. Preliminary Results: An R0 resection was performed in 217 patients (64%) and R1 in 122 (36%) patients. In 98.2% the liver metastases were of colorectal origin. No independent variables were predictive of recurrence in R1. Presentation of intrahepatic recurrence (n=173) was not significantly different between R0 and R1 (50% vs 53%, p=0.24). In patients with a surgical margin recurrence (n=40) there was also no significant difference found between R0 and R1 resection (59% vs 41%, p=0.66). The median overall survival of R0 and R1 was 49 and 46 months. R1 showed decreased long-term survival compared with R0, but not significant. Five-year survival was 45% in R0 and 38% in R1. Difference in survival was mainly found after 50 months follow-up. Conclusion: R1 resection margin has no significant consequence for intrahepatic or surgical margin recurrence in patients undergoing liver surgery using the CWDD. Our study showed a trend towards a similar recurrence rate in R1 compared to R0.

Background: Máxima Medical Center (MMC) is one of two regional centres for liver surgery in the south east of the Netherlands. Since the introduction of liver surgery almost 20 years ago, many improvements in technology and equipment were made. The purpose of this study is to present an overview of the perioperative and long term results of liver surgery in MMC between 1999 and 2017.

Background: Concerns have been raised concerning tumour progression after PVE. This study aimed to compare the survival outcomes of patient subjected to major liver resection for colorectal liver metastases with or without PVE. To reduce selection bias, PVE patients were matched to non-PVE patients using propensity score matching with as primary endpoints overall and disease-free survival. Methods: All consecutive patients who underwent major liver resection for colorectal liver metastases at three academic medical centers between January 2000 and December 2015 were included. For a propensity matched comparison, all patients who underwent PVE before major liver resection were selected. Patients were matched to patients who had undergone major liver resection without PVE. Results: Of 745 patients undergoing major liver resection for CRLM, a total of 46 patients who underwent PVE had sufficient data and were matched. Both disease-free and overall survival were comparable between the two groups after matching. Conclusion: Comparable disease free survival and overall survival were found in patients who underwent portal vein embolization before major liver resection compared to matched controls treated with major surgery alone. PVE is a valuable tool to improve resectability rate of patients with colorectal liver metastases and does not affect long term oncological outcomes in patients proceeding with liver resection.

Background: Ongoing entrapment of end twigs of intercostal nerves in the rectus abdominis muscle may lead to spontaneous neuropathic discharges and severe pain in what is known as the anterior cutaneous nerve entrapment syndrome (ACNES). Persistent pain relief is reported with sequential trigger point infiltrations using local anesthetic agents. However, adding corticosteroids as a means to improve anesthetic efficacy is controversial. Aim of the present study was to evaluate the effects of trigger point injections using local anesthetics combined with corticosteroids in ACNES patients. Methods: Patients >18 years with suspected ACNES received 1-3 injections of 10 cc of 1% lidocaine combined with 40 mg of methylprednisolone into the point of maximal abdominal wall pain. Pain was recorded during physical examination just prior to and 15-20 minutes after injection and during follow up using a visual analogue scale and a verbal rating scale. A reduction of >50% on a Visual Analogue Scale (VAS: 1-100 mm) or a minimal 2 of points on a Verbal Rating Scale (VRS: 0-4) was considered a ‘successful response’. Results: Between August 2008 and December 2010, 50 consecutive patients were studied. Immediately following infiltration, 72% (36/50) demonstrated a successful response. One thirds of the injected patients (17/50) reported a lasting pain reduction. Five of these 17 patients needed multiple injections. Conclusions: Trigger point infiltration(s) using a local anesthetic agent combined with methylprednisolone offers long-term pain relief in one third of patients with ACNES. It is unclear whether the anesthetic effect is due to methylprednisolone or to lidocaine. 2 Erasmus Medical Center Rotterdam

Background: Efforts to improve the outcome of liver surgery by combining curative resection with chemotherapy have failed to demonstrate definite overall survival benefit. This may partly be due to the fact that these studies often involve strict inclusion criteria. Consequently, patients with a high risk profile as characterized by Fong’s Clinical Risk Score (CRS) are often underrepresented in these studies. Conceptually, this group of patients might benefit the most from chemotherapy. The present study evaluates the impact of neo-adjuvant chemotherapy in high-risk patients with primary resectable colorectal liver metastases, without extrahepatic disease. Our hypothesis is that adding neo-adjuvant chemotherapy to surgery will provide an improvement in overall survival (OS) in patients with a high-risk profile. Methods/Design: CHARISMA is a multicenter, randomized, phase III clinical trial. Patients will be randomized to either surgery alone (standard treatment, arm A) or to 6 cycles of neo-adjuvant oxaliplatin-based chemotherapy, followed by surgery (arm B). Patients must be ≥ 18 years of age with liver metastases of histologically confirmed primary colorectal carcinoma. Patients with extrahepatic metastases are excluded. Liver metastases must be deemed primarily resectable. Only patients with a CRS of 3–5 are eligible. The primary study endpoint is OS. Secondary endpoints are progression free survival (PFS), quality of life, morbidity of resection, treatment response on neo-adjuvant chemotherapy, and whether CEA levels can predict treatment response. Discussion: CHARISMA is a multicenter, randomized, phase III clinical trial that will provide an answer to the question if adding neo-adjuvant chemotherapy to surgery will improve OS in a well-defined high-risk patient group with colorectal liver metastases. Trial registration: The CHARISMA is registered at European Union Clinical Trials Register (EudraCT), number: 2013-004952-39, and in the “Netherlands national Trial Register (NTR), number: 4893.

On the basis of the lack of response of invasive lobular breast cancer to neoadjuvant chemotherapy, we questioned the effectiveness of adjuvant chemotherapy in relation to histology.Women with primary nonmetastatic invasive ductal or (mixed type) lobular breast cancer, aged 50-70 years, diagnosed between 1995 and 2008, were selected from the Netherlands Cancer Registry and followed until January 1, 2010. The patients were divided in two groups: one group receiving adjuvant hormonal therapy only and the other receiving adjuvant hormonal therapy in combination with adjuvant chemotherapy.In total, 19 609 patients had ductal cancer and 3685 had lobular cancer. The 10-year overall survival rate in ductal cancer when treated with hormonal therapy alone was 69%, compared with 74% with the combination therapy (P < 0.0001). In lobular cancer, 10-year survival rates were 68% after hormonal treatment alone and 66% after the combination therapy (P = 0.45). The hazard ratio (HR) for mortality in ductal cancer after combination therapy was 0.70 [95% confidence interval (CI) 0.64-0.76; P < 0.0001], compared with hormonal treatment alone. The HR in lobular cancer was 1.00 (95% CI 0.82-1.21; P = 0.97).Adjuvant chemotherapy seems to confer no additional beneficial effects in postmenopausal patients with pure or mixed type lobular breast cancer receiving hormonal therapy.

With the increasing possibilities for surgical treatment of colorectal liver metastases, careful selection of patients who may benefit from surgical treatment becomes critical. The addition of PET to F-18-FDG may significantly improve conventional staging by CT. Up to now, definitive evidence that the addition of F-18-FDG PET to conventional staging leads to superior clinical results and improved clinical management in these patients has been lacking. In this randomized controlled trial in patients with colorectal liver metastases, we investigated whether the addition of F-18-FDG PET is beneficial and reduces the number of futile laparotomies. Methods: A total of 150 patients with colorectal liver metastases selected for surgical treatment by imaging with CT were randomly assigned to CT only (n = 75) or CT plus F-18-FDG PET (n = 75). Patients were followed up for at least 3 y. The primary outcome measure was futile laparotomy, defined as any laparotomy that did not result in complete tumor treatment, that revealed benign disease, or that did not result in a disease-free survival period longer than 6 mo. Results: Patient and tumor characteristics were similar for both groups. The number of futile laparotomies was 34 (45%) in the control arm without F-18-FDG PET and 21 (28%) in the experimental arm with F-18-FDG PET; the relative risk reduction was 38% (95% confidence interval, 4%-60%, P 5 0.042). Conclusion: The number of futile laparotomies was reduced from 45% to 28%; thus, the addition of F-18-FDG PET to the work-up for surgical resection of colorectal liver metastases prevents unnecessary surgery in 1 of 6 patients.

In Thailand, axillary lymph node dissection (ALND) is the dominant form of treatment for breast cancer, even though the treatment often leaves patients with some degree of arm morbidity. Sentinel lymph node biopsy (SNB) is widely accepted globally as a preferable alternative procedure because of its lower rates of associated morbidity. This study compared the cost-utility of SNB and ALND in patients with early stage breast cancer in Thailand.A decision tree with a 5-year time horizon was developed. Outcomes that were relevant to SNB and ALND were included, along with locoregional recurrence of cancer and lymphedema scenarios. The model parameters were derived from a meta-analysis of international clinical trials and other relevant literature. The resources and cost data were derived from the medical records of tertiary hospitals. Health utilities were measured by using the standard gamble technique. A sensitivity analysis was performed using a set of plausible parameters.The incremental cost-effectiveness ratio (ICER) in the base-case analysis showed that SNB was more cost-effective than ALND. ICERs were −275,140 and −470,600 Thailand baht/quality-adjusted life-year gained from the provider perspective and the societal perspective, respectively. The most sensitive parameter was the utility score of patients with early stage breast cancer who had received breast-conserving therapy with lymphedema; the sensitivity and specificity of SNB had no impact on the ICER.The study confirmed that SNB was an economically viable alternative treatment to ALND. In developing countries, where resources are limited, nationwide implementation of SNB warrants widespread support from relevant stakeholders, including medical personnel and policymakers.

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A case of an entirely intramuscular mixed tumour occurred in an 82-year-old man, who presented with a large mass in the region of the right triceps muscle. A lobulated tumour was seen, with plump, round epithelioid cells embedded in a chondromyxoid stroma. Immunohistochemical examination showed strong S100 protein and pancytokeratin positivity in most of the tumour cells. Cytogenetic analysis revealed complex clonal chromosomal changes: 47, XY, +i (2) (q10), –15, der (17)t(15;17) (q11; p12), +r. Differential diagnosis against extraskeletal myxoid chondrosarcoma (EMC) may be problematic, particularly in an incisional biopsy. Chromosomal analysis can be very helpful in solving this problem, since EMC shows a specific reciprocal chromosome translocation characterised as t (9;22) (q22–31) (q11–12).