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Aim To summarise our centre’s experience managing patients with neuroendocrine tumours (NETs) in the first 5 years after the introduction of peptide receptor radionuclide therapy (PRRT) with [ 177 Lu]Lu-DOTA-octreotate (LUTATE). The report emphasises aspects of the patient management related to functional imaging and use of radionuclide therapy. Methods We describe the criteria for treatment with LUTATE at our centre, the methodology for patient selection, and the results of an audit of clinical measures, imaging results and patient-reported outcomes. Subjects are treated initially with four cycles of ~ 8 GBq of LUTATE administered as an outpatient every 8 weeks. Results In the first 5 years offering LUTATE, we treated 143 individuals with a variety of NETs of which approx. 70% were gastroentero-pancreatic in origin (small bowel: 42%, pancreas: 28%). Males and females were equally represented. Mean age at first treatment with LUTATE was 61 ± 13 years with range 28–87 years. The radiation dose to the organs considered most at risk, the kidneys, averaged 10.6 ± 4.0 Gy in total. Median overall survival (OS) from first receiving LUTATE was 72.5 months with a median progression-free survival (PFS) of 32.3 months. No evidence of renal toxicity was seen. The major long-term complication seen was myelodysplastic syndrome (MDS) with a 5% incidence. Conclusions LUTATE treatment for NETs is a safe and effective treatment. Our approach relies heavily on functional and morphological imaging informing the multidisciplinary team of NET specialists to guide appropriate therapy, which we suggest has contributed to the favourable outcomes seen.

Although it is now considered a standard treatment to irradiate an advanced mid or low rectal tumor before surgical total mesorectal excision (TME), the optimal time interval between radiation therapy and surgery remains controversial. Between 1995 and 2005, patients undergoing preoperative radiation therapy and TME for locally advanced mid and low rectal tumors treated in the VU Medical Center or the Zaans Medical Center were entered into this study. All patients received identical radiation treatment in the VU Medical Center and were subsequently operated on within 2 weeks in the Zaans Medical Center (SI group) and after 6-8 weeks in the VU Medical Center (LI group). Preoperative tumor staging, operative data, postoperative complications, pathology results, and follow-up were compared. The SI group (N=57) underwent surgery after a median delay of 4 days and the LI group (N=51) after 45 days. Operative data and short-term morbidity were comparable for both groups. However, significantly higher numbers of complete remissions (12 vs 0%), tumor downstaging (55 vs 26%), and less lymph-node metastases (22 vs 44%) were found in the LI group. No significant differences were found regarding local control or long-term survival after a median follow-up of 34 months. Several advantages, such as complete remissions and downstaging in the LI group, do not appear to have expression in a better survival or less local recurrences after a median follow-up of 34 months. Although larger (randomized) studies will be needed for definite conclusions, this may indicate that patients can be operated on within 2 weeks after radiation therapy.

Background The objective of this study was to assess the effect of two different time intervals between radiation therapy and surgery for rectal cancer on the histological tumor regression grade (TRG) in the resected specimen. Methods Between 1995 and 2000, patients undergoing preoperative radiation therapy and TME for locally advanced (T3N0 and T3N1) mid and low rectal tumors treated in the VU University Medical Center or the Zaans Medical Center were entered into this study. All patients received identical radiation treatment (5 x 5 Gy) in the VU University medical center and were subsequently operated on within 2 weeks in the Zaans Medical Center (SI group) and after 6-8 weeks in the VU University Medical Center (LI group). All available histological material was reevaluated for TRG and correlated to survival. Results Sixty-seven patients were included in the present study, 28 in the LI group and 39 in the SI group. Patient gender was comparable for both groups with 21 (75%) male patients in the LI group versus 26 (67%) male patients in the SI group (p = 0.46). A T3N0 preoperative tumor stage was found in 21 (75%) patients in the LI group and in 33 (85%) patients in the SI group (p = 0.36). All tumors were histologically proven adenocarcinoma. Patients in the SI group were significantly older (67 vs. 58 years). In the LI group, a significantly more pronounced histological tumor regression was found. A complete response (TRG1), combined with a near complete histological response (TRG 2), were present in 12 patients in the LI group and in four patients in the SI group (p = 0.002). Radicality of resection was comparable for both groups. With a follow-up of over 60 months, there were no statistically significant differences between the SI and LI groups regarding local control, overall, or disease-free survival. Conclusion Although histological tumor regression is significantly more pronounced following a long interval between radiation therapy and surgery, in the present study, this is not reflected in a better radical resection rate, local control or better overall and disease-free survival.

Purpose Pelvic-floor rehabilitation does not provide the same degree of relief in all fecal incontinent patients. We aimed at studying prospectively the ability of tests to predict the outcome of pelvic-floor rehabilitation in patients with fecal incontinence. Materials and methods Two hundred fifty consecutive patients (228 women) underwent medical history and a standardized series of tests, including physical examination, anal manometry, pudendal nerve latency testing, anal sensitivity testing, rectal capacity measurement, defecography, endoanal sonography, and endoanal magnetic resonance imaging. Subsequently, patients were referred for pelvic-floor rehabilitation. Outcome of pelvic-floor rehabilitation was quantified by the Vaizey incontinence score. Linear regression analyses were used to identify candidate predictors and to construct a multivariable prediction model for the posttreatment Vaizey score. Results After pelvic-floor rehabilitation, the mean baseline Vaizey score (18, SD ± 3) was reduced with 3.2 points ( p  < 0.001). In addition to the baseline Vaizey score, three elements from medical history were significantly associated with the posttreatment Vaizey score (presence of passive incontinence, thin stool consistency, primary repair of a rupture after vaginal delivery at childbed) ( R 2 , 0.18). The predictive value was significantly but marginally improved by adding the following test results: perineal and/or perianal scar tissue (physical examination), and maximal squeeze pressure (anal manometry; R 2 , 0.20; p  = 0.05). Conclusion Additional tests have a limited role in predicting success of pelvic-floor rehabilitation in patients with fecal incontinence.

Background: Although evidence is growing that most patients who need an operation for diverticular disease of the sigmoid colon can be treated by a single-stage procedure, a two-stage procedure will still be necessary in some patients because of significant sepsis or technical difficulties. The outcomes of 65 patients who underwent secondary restoration after a Hartmann procedure for complicated diverticulitis were studied and the factors leading to complications and mortality were identified. Patients and Methods: Of 91 patients, in a consecutive 12-year period, whose primary operation was a Hartmann procedure, 72 survived longer than 3 months after discharge. Sixty-five underwent an attempted reversal of the Hartmann procedure. The POSSUM scores were calculated in all patients as well as the morbidity and mortality rates. Results: In 63 (96.9%) patients the bowel continuity could be restored with a morbidity of 38.5% and a mortality of 3.1%. The POSSUM and p-POSSUM scores adequately predicted the mortality in this series. Conclusion: This series shows that when surgical treatment for complicated diverticular disease of the sigmoid colon is necessary, the Hartmann procedure is still a valid indication. In a high percentage of patients the Hartmann procedure could be restored with a low mortality.

Two female patients aged 62 and 44 years with progressive systemic sclerosis and passive faecal incontinence are described. Both had the typical gut motility disorders of dysphagia, heartburn, and constipation. Anorectal physiology tests showed a low resting pressure in both and an absent rectoanal inhibitory reflex in one. In both patients anal endosonography showed a thin internal anal sphincter with changed reflectivity suggestive of fibrosis. In both patients anorectal sensation and pudendal nerve function were normal. Histological examination of the rectum in one patient showed collagenous replacement of the rectal muscularis propria with prominent atrophy of the musculature. This study suggests that the internal sphincter may be selectively affected by progressive systemic sclerosis, which may lead to passive faecal incontinence.

Introduction We aimed to categorize laparoscopic rectal resections according to technical difficulty to standardize learning purposes and stratify results, making future studies more comparable. Materials and methods Fifty patients undergoing a laparoscopic total mesorectal excision were prospectively followed. Four preoperatively known facts (gender, body mass index (BMI), tumor localization, and preoperative radiation therapy) were compared to four operative outcomes (operation time, blood loss, a visual analogue score (VAS) for difficulty rewarded by the surgeon, and oncological radicality of the procedure). Results Operating time for male and female patients was 257 vs. 245 min ( P  = 0.229), blood loss was 300 vs. 300 ml ( P  = 0.309), the VAS was 8 vs. 6 ( P  < 0.001), and radicality was 93% vs. 91% ( P  = 0.806). Operating time was 215, 250, and 305 min for high, mid, and low tumors (Spearman −0.44; P  = 0.02), respectively. Blood loss was 105, 300, and 600 ml (Spearman −0.38; P  = 0.01). Lower tumors were rewarded a higher VAS (Spearman −0.57; P  < 0.001) and were less often radically resected (Spearman 0.32; P  = 0.026). Operating time for irradiated and nonirradiated patients was 277 vs. 225 min ( P  = 0.008), blood loss was 500 vs. 150 ml ( P  = 0.006), the VAS was 7 vs. 5 ( P  < 0.001), and radicality was 79% vs. 100% ( P  = 0.046). Operating time was 240 min for BMI 25–30 and 253 min for BMI > 30 (Spearman 0.13; P  = 0.391). Blood loss was 150 ml for BMI 25–30 and 500 ml for BMI > 30 (Spearman 0.38; P  = 0.01). Higher BMIs were rewarded a higher VAS (Spearman 0.06; P  = 0.704). BMI had no correlation to radicality of the procedure (Spearman −0.12; P  = 0.402). There was an association between technical difficulty score and operation time ( P  = 0.007), blood loss ( P  < 0.001), VAS ( P  < 0.001), and radicality of surgery ( P  = 0.043). Conclusion Laparoscopic surgery in male, irradiated, and obese patients with lower tumors seemed more difficult. A categorization according to technical difficulty, to preoperatively predict difficulty of the procedure, was found feasible.

BACKGROUND--The aetiology and pathology of rectal prolapse and solitary rectal ulcer are poorly understood. AIMS--To examine the full thickness rectal wall in these two conditions. METHODS--The pathological abnormalities in the surgically resected rectal wall were studied from nine patients with solitary rectal ulcer syndrome, 11 complete rectal prolapse, and nine cancer controls. Routine haematoxylin and eosin and Van Gieson staining for collagen were performed. RESULTS--The rectal wall from solitary rectal ulcer syndrome specimens was thickened compared with complete rectal prolapse and controls. The major difference was in the muscularis propria (2.2 v 1.1 v 1.2 mm, medians, p < 0.005) and particularly the inner circular muscular layer, and to a lesser extent the submucosal and outer longitudinal muscular layers. Some solitary rectal ulcer syndrome specimens showed unique features such as decussation of the two muscular layers (four of nine), nodular induration of inner circular layer (four of nine) and grouping of outer longitudinal layer into bundles (three of nine); these were not seen in complete rectal prolapse or control specimens. CONCLUSIONS--These features, which resemble the features of high pressure sphincter tissue, may be of aetiological importance, and suggest a different pathogenesis for these two disorders. Excess collagen was seen in both disorders, was more severe in solitary rectal ulcer syndrome specimens, and probably reflects a response to repeated trauma.

Laparoscopic total mesorectal excision (TME) is being used in rectal cancer more frequently. The aim of this study was to analyze the differences in short-term outcomes between open and laparoscopic TME. In this nonrandomized consecutive study, the short-term outcomes of 100 patients undergoing TME for proven rectal cancer were analyzed. Two groups of 50 patients underwent an open or laparoscopic TME for rectal cancer. Both groups were comparable. Laparoscopic surgery took longer to perform (250 vs. 197.5 min, p < 0.01), but was accompanied by less blood loss (350 vs. 800 ml, p < 0.01). Enteric function recovered sooner after laparoscopy. The numbers of major and minor complications were comparable between both groups, although fewer patients had major complications in the laparoscopic group (6 vs. 15 patients, p = 0.03). Hospital stay was shorter for patients who underwent a laparoscopic abdominoperineal resection (10 vs. 12 days, p = 0.04). Median follow-up was 17 months for the laparoscopic group and 22 months for the open group. Survival analyses between the groups showed no statistical difference in disease-free and overall survival. This study shows that laparoscopic TME for rectal cancer is a safe and feasible technique with some short-term benefits over open TME.