[Botox preceding ventral hernia repair: it's not about esthetics]

Ventral hernia is a common complication after laparotomy. The aim during ventral hernia repair is to close the abdomen through medialization of the rectus muscles. Particularly in patients with large ventral hernia, chronically retracted lateral muscles may preclude muscle medialization and therewith closure of the abdomen. A recent development in abdominal wall surgery is the injection of botulinum toxin (botox) in the lateral abdominal wall muscles a few weeks prior to surgery. These intramuscular injections cause a temporary partial paralysis resulting in elongation of the lateral muscles, compared to pre-botox contracted and retracted lateral muscles, and therewith facilitate closure of the abdomen. Despite positive first results only little is known about this new application of botox. In this article we discuss both the technical aspects as well as the current state of this new technique.

A Clinical Decision Tool for Selection of Patients With Symptomatic Cholelithiasis for Cholecystectomy Based on Reduction of Pain and a Pain-Free State Following Surgery

Importance

There is currently no consensus on the indication for cholecystectomy in patients with uncomplicated gallstone disease.

Objective

To report on the development and validation of a multivariable prediction model to better select patients for surgery.

Design, Setting, and Participants

This study evaluates data from 2 multicenter prospective trials (the previously published Scrutinizing (In)efficient Use of Cholecystectomy: A Randomized Trial Concerning Variation in Practice [SECURE] and the Standardized Work-up for Symptomatic Cholecystolithiasis [Success] trial) collected from the outpatient clinics of 25 Dutch hospitals between April 2014 and June 2019 and including 1561 patients with symptomatic uncomplicated cholelithiasis, defined as gallstone disease without signs of complicated cholelithiasis (ie, biliary pancreatitis, cholangitis, common bile duct stones or cholecystitis). Data were analyzed from January 2020 to June 2020.

Exposures

Patient characteristics, comorbidity, surgical outcomes, pain, and symptoms measured at baseline and at 6 months' follow-up.

Main Outcomes and Measures

A multivariable regression model to predict a pain-free state or a clinically relevant reduction in pain after surgery. Model performance was evaluated using calibration and discrimination.

Results

A total of 1561 patients were included (494 patients in 7 hospitals in the development cohort and 1067 patients in 24 hospitals in the validation cohort; 6 hospitals included patients in both cohorts). In the development cohort, 395 patients (80.0%) underwent cholecystectomy. After surgery, 225 patients (57.0%) reported that they were pain free and 295 (74.7%) reported a clinically relevant reduction in pain. A multivariable prediction model showed that increased age, no history of abdominal surgery, increased visual analog scale pain score at baseline, pain radiation to the back, pain reduction with simple analgesics, nausea, and no heartburn were independent predictors of clinically relevant pain reduction after cholecystectomy. After internal validation, good discrimination was found (C statistic, 0.80; 95% CI, 0.74-0.84) between patients with and without clinically relevant pain reduction. The model had very good overall calibration and minimal underestimation of the probability. External validation indicated a good discrimination between patients with and without clinically relevant pain reduction (C statistic, 0.74; 95% CI, 0.70-0.78) and fair calibration with some overestimation of probability by the model.

Conclusions and Relevance

The model validated in this study may help predict the probability of pain reduction after cholecystectomy and thus aid surgeons in deciding whether patients with uncomplicated cholelithiasis will benefit from cholecystectomy.

Population preference for treatment of uncomplicated appendicitis

Background

Non-operative treatment of uncomplicated appendicitis is safe and increasing in popularity, but has other risks and benefits compared with appendicectomy. This study aimed to explore the preference of the general population regarding operative or antibiotic treatment of uncomplicated appendicitis.

Methods

In this prospective study, a clinical scenario and questionnaire were submitted to a panel comprising a sample of an average adult population. The survey was distributed by an independent, external research bureau, and included a comprehensive explanation of the risks and benefits of both treatment options. The primary outcome was the proportion of participants who would prefer antibiotics over surgery. Secondary outcomes were reasons for this preference and the accepted recurrence rate within 1 year when treated with antibiotics only. All outcomes were weighted for the average Dutch population.

Results

Of 254 participants, 49.2 per cent preferred antibiotic treatment for uncomplicated appendicitis, 44.5 per cent preferred surgery, and 6.3 per cent could not make a decision. About half of the participants preferring antibiotics would accept a recurrence risk of more than 50 per cent within 1 year. Avoiding surgery was their main reason. In participants preferring surgery, many tolerated a recurrence risk of no more than 10 per cent when treated with antibiotics. Removal of the cause of appendicitis was their main reason.

Conclusion

Around half of the average population sample preferred antibiotics over surgical treatment of uncomplicated appendicitis and were willing to accept a high recurrence risk to avoid surgery initially. Participants who preferred surgery tolerated only a very low recurrence risk with antibiotic treatment.

Budget Impact of Restrictive Strategy Versus Usual Care for Cholecystectomy (SECURE-trial)

OBJECTIVES

A cost-effectiveness analysis of a multicenter randomized-controlled trial comparing restrictive strategy versus usual care in patients with gallstones showed that savings by restrictive strategy could not compensate for the lower proportion of pain-free patients. However, four subgroups based on combined stratification factors resulted in less cholecystectomies and more pain-free patients in restrictive strategy (female-low volume-BMI > 30, female-low volume-BMI25-30, female-high volume-BMI25-30, and male-low volume-BMI < 25). The aim of this study was to explore the budget impact from a hospital healthcare perspective of implementation of restrictive strategy in these subgroups.

METHODS

Data of the SECURE-trial were used to calculate the hospital budget impact with a time horizon of four years. Based on a study into practice variation, about 19% of hospitals treat patients according restrictive strategy. This represents the proportion of patients treated according restrictive strategy at the start of budget period. Three subanalyses were performed: a scenario analysis in which 30% of patients fall under a restrictive strategy in clinical practice, a sensitivity analysis in which we calculated the budget impact with the low and high 95% confidence limits of the expected future number of patients, a subgroup analysis in which restrictive strategy was also implemented in two additional subgroups (male-high volume-BMI < 25 and female-high volume-BMI >30).

RESULTS

Budget impact analysis showed savings of €6.7-€15.6 million (2.2%-5.6%) for the period 2021-2024/2025 by implementing the restrictive strategy in the four subgroups and provision of usual care in other patients. Sensitivity analysis with 30% of patients already in the restrictive strategy at the start of the budget period, resulted in savings between €5.4 million and €14.0 million (1.7%-5.0%).

CONCLUSION

Performing a restrictive strategy for selection of cholecystectomy in subgroups of patients and provision of usual care in other patients will result in a lower overall hospital budget needed to treat patients with abdominal pain and gallstones.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR4022. Registered on June 5, 2013.

Impact of the COVID-19 pandemic on incidence and severity of acute appendicitis: a comparison between 2019 and 2020

Background

During the COVID-19 pandemic, a decrease in the number of patients presenting with acute appendicitis was observed. It is unclear whether this caused a shift towards more complicated cases of acute appendicitis. We compared a cohort of patients diagnosed with acute appendicitis during the 2020 COVID-19 pandemic with a 2019 control cohort.

Methods

We retrospectively included consecutive adult patients in 21 hospitals presenting with acute appendicitis in a COVID-19 pandemic cohort (March 15 – April 30, 2020) and a control cohort (March 15 – April 30, 2019). Primary outcome was the proportion of complicated appendicitis. Secondary outcomes included prehospital delay, appendicitis severity, and postoperative complication rates.

Results

The COVID-19 pandemic cohort comprised 607 patients vs. 642 patients in the control cohort. During the COVID-19 pandemic, a higher proportion of complicated appendicitis was seen (46.9% vs. 38.5%; p = 0.003). More patients had symptoms exceeding 24 h (61.1% vs. 56.2%, respectively, p = 0.048). After correction for prehospital delay, presentation during the first wave of the COVID-19 pandemic was still associated with a higher rate of complicated appendicitis. Patients presenting > 24 h after onset of symptoms during the COVID-19 pandemic were older (median 45 vs. 37 years; p = 0.001) and had more postoperative complications (15.3% vs. 6.7%; p = 0.002).

Conclusions

Although the incidence of acute appendicitis was slightly lower during the first wave of the 2020 COVID-19 pandemic, more patients presented with a delay and with complicated appendicitis than in a corresponding period in 2019. Spontaneous resolution of mild appendicitis may have contributed to the increased proportion of patients with complicated appendicitis. Late presenting patients were older and experienced more postoperative complications compared to the control cohort.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00454-y.

Western-type diet influences mortality from necrotising pancreatitis and demonstrates a central role for butyrate

OBJECTIVE

The gut microbiota are the main source of infections in necrotising pancreatitis. We investigated the effect of disruption of the intestinal microbiota by a Western-type diet on mortality and bacterial dissemination in necrotising pancreatitis and its reversal by butyrate supplementation.

DESIGN

C57BL/6 mice were fed either standard chow or a Western-type diet for 4 weeks and were then subjected to taurocholate-induced necrotising pancreatitis. Blood and pancreas were collected for bacteriology and immune analysis. The cecum microbiota composition of mice was analysed using 16S rRNA gene amplicon sequencing and cecal content metabolites were analysed by targeted (ie, butyrate) and untargeted metabolomics. Prevention of necrotising pancreatitis in this model was compared between faecal microbiota transplantation (FMT) from healthy mice, antibiotic decontamination against Gram-negative bacteria and oral or systemic butyrate administration. Additionally, the faecal microbiota of patients with pancreatitis and healthy subjects were analysed.

RESULTS

Mortality, systemic inflammation and bacterial dissemination were increased in mice fed Western diet and their gut microbiota were characterised by a loss of diversity, a bloom of Escherichia coli and an altered metabolic profile with butyrate depletion. While antibiotic decontamination decreased mortality, Gram-positive dissemination was increased. Both oral and systemic butyrate supplementation decreased mortality, bacterial dissemination, and reversed the microbiota alterations. Paradoxically, mortality and bacterial dissemination were increased with FMT administration. Finally, patients with acute pancreatitis demonstrated an increase in Proteobacteria and a decrease of butyrate producers compared with healthy subjects.

CONCLUSION

Butyrate depletion and its repletion appear to play a central role in disease progression towards necrotising pancreatitis.

Diagnosis of Uncomplicated and Complicated Appendicitis in Adults

Background:

Diagnostic work-up of acute appendicitis remains challenging. While some guidelines advise to use a risk stratification based on clinical parameters, others use standard imaging in all patients. As non-operative management of uncomplicated appendicitis has been identified as feasible and safe, differentiation between uncomplicated and complicated appendicitis is of paramount importance. We reviewed the literature to describe the optimal strategy for diagnosis of acute appendicitis.

Methods:

A narrative review about the diagnosis of acute appendicitis in adult patients was conducted. Both diagnostic strategies and goals were analyzed.

Results:

For diagnosing acute appendicitis, both ruling in and ruling out the disease are important. Clinical and laboratory findings individually do not suffice, but when combined in a diagnostic score, a better risk prediction can be made for having acute appendicitis. However, for accurate diagnosis imaging seems obligatory in patients suspected for acute appendicitis. Scoring systems combining clinical and imaging features may differentiate between uncomplicated and complicated appendicitis and may enable ruling out complicated appendicitis. Within conservatively treated patients with uncomplicated appendicitis, predictive factors for non-responsiveness to antibiotics and recurrence of appendicitis need to be defined in order to optimize treatment outcomes.

Conclusion:

Standard imaging increases the diagnostic power for both ruling in and ruling out acute appendicitis. Incorporating imaging features in clinical scoring models may provide better differentiation between uncomplicated and complicated appendicitis. Optimizing patient selection for antibiotic treatment of appendicitis may minimize recurrence rates, resulting in better treatment outcomes.

Clinical Efficacy of Combined Surgical Patient Safety System and the World Health Organization's Checklists in Surgery: A Nonrandomized Clinical Trial

Question

Does patient safety improve when adding the preoperative and postoperative Surgical Patient Safety System checklists to the World Health Organization’s established surgical safety checklist?

Findings

In this stepped-wedge cluster nonrandomized clinical trial with parallel controls that included 9009 surgical procedures, reductions in complications and emergency reoperations occurred when the preoperative Surgical Patient Safety System was added to the surgical safety checklist. The postoperative Surgical Patient Safety System reduced readmissions, whereas overall increased complications were found in the 9678 parallel controls.

Meaning

These findings suggest that joint use of the preoperative and postoperative Surgical Patient Safety System with the intraoperative surgical safety checklist is beneficial for patients.

Importance

Checklists have been shown to improve patient outcomes in surgery. The intraoperatively used World Health Organization surgical safety checklist (WHO SSC) is now mandatory in many countries. The only evidenced checklist to address preoperative and postoperative care is the Surgical Patient Safety System (SURPASS), which has been found to be effective in improving patient outcomes. To date, the WHO SSC and SURPASS have not been studied jointly within the perioperative pathway.

Objective

To investigate the association of combined use of the preoperative and postoperative SURPASS and the WHO SSC in perioperative care with morbidity, mortality, and length of hospital stay.

Design, Setting, and Participants

In a stepped-wedge cluster nonrandomized clinical trial, the preoperative and postoperative SURPASS checklists were implemented in 3 surgical departments (neurosurgery, orthopedics, and gynecology) in a Norwegian tertiary hospital, serving as their own controls. Three surgical units offered additional parallel controls. Data were collected from November 1, 2012, to March 31, 2015, including surgical procedures without any restrictions to patient age. Data were analyzed from September 25, 2018, to March 29, 2019.

Interventions

Individualized preoperative and postoperative SURPASS checklists were added to the intraoperative WHO SSC.

Main Outcomes and Measures

Primary outcomes were in-hospital complications, emergency reoperations, unplanned 30-day readmissions, and 30-day mortality. The secondary outcome was length of hospital stay (LOS).

Results

In total, 9009 procedures (5601 women [62.2%]; mean [SD] patient age, 51.7 [22.2] years) were included, with 5117 intervention procedures (mean [SD] patient age, 51.8 [22.4] years; 2913 women [56.9%]) compared with 3892 controls (mean [SD] patient age, 51.5 [21.8] years; 2688 women [69.1%]). Parallel control units included 9678 procedures (mean [SD] patient age, 57.4 [22.2] years; 4124 women [42.6%]). In addition to the WHO SSC, adjusted analyses showed that adherence to the preoperative SURPASS checklists was associated with reduced complications (odds ratio [OR], 0.70; 95% CI, 0.50-0.98; P = .04) and reoperations (OR, 0.42; 95% CI, 0.23-0.76; P = .004). Adherence to the postoperative SURPASS checklists was associated with decreased readmissions (OR, 0.32; 95% CI, 0.16-0.64; P = .001). No changes were observed in mortality or LOS. In parallel control units, complications increased (OR, 1.09; 95% CI, 1.01-1.17; P = .04), whereas reoperations, readmissions, and mortality remained unchanged.

Conclusions and Relevance

In this nonrandomized clinical trial, adding preoperative and postoperative SURPASS to the WHO SSC was associated with a reduction in the rate of complications, reoperations, and readmissions.

Trial Registration

ClinicalTrials.gov Identifier: NCT01872195

Patient education materials to implement choosing wisely recommendations for internal medicine at the emergency department

BACKGROUND

Choosing Wisely aims to reduce low-value care to improve quality and lower costs. In the Netherlands, this campaign offers three recommendations for internal medicine applicable in emergency departments (EDs): (1) do not place an indwelling urinary catheter in non-critically ill patients who can void; (2) do not order plain abdominal radiographs in patients with acute abdominal pain; and (3) discuss whether treatment limitations are needed. This quality improvement project aims to increase the implementation of the recommendations by patient information leaflets.

METHODS

In a prospective before-after study, we collected data every other week during baseline and intervention periods (both 7 months) in two university medical centres. The primary outcomes were the adherence rates to the recommendations.

RESULTS

805 patients visited the EDs for internal medicine, of whom 391 (48.6%) were hospitalised. Only 153 (19%) patients received the information leaflet. We found no change in implementation rates of the recommendations after the introduction of the patient information leaflet. In the baseline period, 28 patients received a urinary catheter, of whom 5 (17.9%) had no appropriate indication, compared with 4 (25.0%) of 16 patients in the intervention period (p=0.572). Unnecessary abdominal X-ray occurred once in the baseline period and not in the intervention period. Treatment limitations were not reported in 13 (6.5%) of 200 hospitalised patients in the baseline period, and in 17 (8.9%) of 191 patients in the intervention period (p=0.373).

CONCLUSIONS

Patient information leaflets did not increase the implementation of Choosing Wisely recommendations, which can be due to a high baseline rate and a poor dissemination of leaflets. Our ED seems not to be a practicable setting for dissemination of leaflets, since staff engagement was not possible due to high workload and shortage of qualified nursing staff in the Netherlands.

Normal inflammatory markers and acute appendicitis: a national multicentre prospective cohort analysis

PURPOSE

For the diagnosis of acute appendicitis, the combination of clinical and laboratory variables achieves high diagnostic accuracy. Nevertheless, appendicitis can present with normal laboratory tests of inflammation. The aim of this study was to investigate the incidence of normal inflammatory markers in patients operated for acute appendicitis.

METHODS

This is an analysis of data from a prospective, multicentre SNAPSHOT cohort study of patients with suspected acute appendicitis. Only patients with histopathologically proven acute appendicitis were included. Adult patients with acute appendicitis and normal preoperative inflammatory markers were explored further in terms of abdominal complaints, preoperative imaging results and intraoperative assessment of the degree of inflammation and compared to those with elevated inflammatory markers.

RESULTS

Between June and July 2014, 1303 adult patients with histopathologically proven acute appendicitis were included. In only 23 of 1303 patients (1.8%) with proven appendicitis, both preoperative white blood cell count and C-reactive protein levels were normal. Migration of pain was reported less frequently in patients with normal inflammatory markers compared to those with elevated inflammatory marker levels (17.4% versus 43.0%, p = 0.01). Characteristics like fever, duration of symptoms and localized peritonitis were comparable. Only 4 patients with normal inflammatory markers (0.3% overall) had complicated appendicitis at histopathological evaluation.

CONCLUSION

Combined normal WBC and CRP levels are seen in about 2 per 100 patients with confirmed acute appendicitis and can, although rarely, be found in patients with complicated appendicitis.

Bridging-to-Surgery in Patients with Type 2 Intestinal Failure

AIM

Type 2 intestinal failure (IF) is characterized by the need for longer-term parenteral nutrition (PN). During this so-called bridging-to-surgery period, morbidity and mortality rates are high. This study aimed to evaluate to what extent a multidisciplinary IF team is capable to safely guide patients towards reconstructive surgery.

METHODS

A consecutive series of patients with type 2 IF followed up by a specialized IF team between January 1st, 2011, and March 1st, 2016, was analyzed. Data on their first outpatient clinic visit (T1) and their last visit before reconstructive surgery (T2) was collected. The primary outcome was a combined endpoint of a patient being able to recover at home, have (partial) oral intake, and a normal albumin level (> 35 g/L) before surgery.

RESULTS

Ninety-three patients were included. The median number of previous abdominal procedures was 4. At T2 (last visit prior to reconstructive surgery), significantly more patients met the combined primary endpoint compared with T1 (first IF team consultation) (66.7% vs. 28.0% (p < 0.0001), respectively); 86% had home PN. During "bridging-to-surgery," acute hospitalization rate was 40.9% and acute surgery was 4.3%. Postoperatively, 44.1% experienced a major complication, 5.4% had a fistula, and in-hospital mortality was 6.5%. Of the cohort, 86% regained enteral autonomy, and when excluding in-hospital mortality and incomplete follow-up, this was 94.1%. An albumin level < 35 g/L at T2 and weight loss of > 10% at T2 compared with preadmission weight were significant risk factors for major complications.

CONCLUSION

Bridging-to-surgery of type 2 IF patients under the guidance of an IF team resulted in the majority of patients being managed at home, having oral intake, and restored albumin levels prior to reconstructive surgery compared with their first IF consultation.

Discriminating complicated from uncomplicated appendicitis by ultrasound imaging, computed tomography or magnetic resonance imaging: systematic review and meta-analysis of diagnostic accuracy

Background

Discriminating complicated from uncomplicated appendicitis is crucial. Patients with suspected complicated appendicitis are best treated by emergency surgery, whereas those with uncomplicated appendicitis may be treated with antibiotics alone. This study aimed to obtain summary estimates of the accuracy of ultrasound imaging, CT and MRI in discriminating complicated from uncomplicated appendicitis

Methods

A systematic literature review was conducted by an electronic search in PubMed, Embase and the Cochrane Library for studies describing the diagnostic accuracy of complicated versus uncomplicated appendicitis. Studies were included if the population comprised adults, and surgery or pathology was used as a reference standard. Risk of bias and applicability were assessed with QUADAS-2. Bivariable logitnormal random-effect models were used to estimate mean sensitivity and specificity.

Results

Two studies reporting on ultrasound imaging, 11 studies on CT, one on MRI, and one on ultrasonography with conditional CT were included. Summary estimates for sensitivity and specificity in detecting complicated appendicitis could be calculated only for CT, because of lack of data for the other imaging modalities. For CT, mean sensitivity was 78 (95 per cent c.i. 64 to 88) per cent, and mean specificity was 91 (85 to 99) per cent. At a median prevalence of 25 per cent, the positive predictive value of CT for complicated appendicitis would be 74 per cent and its negative predictive value 93 per cent.

Conclusion

Ultrasound imaging, CT and MRI have limitations in discriminating between complicated and uncomplicated appendicitis. Although CT has far from perfect sensitivity, its negative predictive value for complicated appendicitis is high.

Overtreatment of Nonneoplastic Gallbladder Polyps due to Inadequate Routine Ultrasound Assessment

BACKGROUND

The primary aim was to assess the diagnostic accuracy of routine ultrasound assessment for gallbladder polyps. The secondary aim was to identify the characteristics that differentiate neoplastic polyps from nonneoplastic polyps.

METHODS

A total of 156 patients with histopathologically proven gallbladder polyps in 4 Dutch hospitals between 2003 and 2013 were included. Sensitivity and specificity of ultrasound for polyp size, number of polyps, and polyp type were assessed using histopathological findings as a reference standard. In addition, diagnostic accuracy of sonographic size ≥1 cm for neoplasia was assessed. Subgroup analysis for patients with polyps as primary indication for cholecystectomy was performed. The sonographic polyp characteristics on preoperative routine ultrasound were described.

RESULTS

Fifty-six percent of gallbladder polyps were preoperatively identified on ultrasound, of which 31% were neoplastic. Sensitivity and specificity of ultrasound to estimate polyp size were 93 and 43% (subgroup; 92 and 33%). Sensitivity and specificity of sonographic polyp size ≥1 cm for neoplasia were 86 and 32% (subgroup; 94 and 26%). No specific sonographic characteristics for neoplastic polyps could be established due to lack of reporting.

CONCLUSION

Routine ultrasound assessment of polyps is associated with overestimation of polyp size and low specificity of sonographic size ≥1 cm for neoplasia, which contributes to surgical overtreatment of nonneoplastic polyps.

Yield of Screening for COVID-19 in Asymptomatic Patients Before Elective or Emergency Surgery Using Chest CT and RT-PCR (SCOUT): Multicenter Study

OBJECTIVE

To determine the yield of preoperative screening for COVID-19 with chest CT and RT-PCR in patients without COVID-19 symptoms.

SUMMARY OF BACKGROUND DATA

Many centers are currently screening surgical patients for COVID-19 using either chest CT, RT-PCR or both, due to the risk for worsened surgical outcomes and nosocomial spread. The optimal design and yield of such a strategy are currently unknown.

METHODS

This multicenter study included consecutive adult patients without COVID-19 symptoms who underwent preoperative screening using chest CT and RT-PCR before elective or emergency surgery under general anesthesia.

RESULTS

A total of 2093 patients without COVID-19 symptoms were included in 14 participating centers; 1224 were screened by CT and RT-PCR and 869 by chest CT only. The positive yield of screening using a combination of chest CT and RT-PCR was 1.5% [95% confidence interval (CI): 0.8-2.1]. Individual yields were 0.7% (95% CI: 0.2-1.1) for chest CT and 1.1% (95% CI: 0.6-1.7) for RT-PCR; the incremental yield of chest CT was 0.4%. In relation to COVID-19 community prevalence, up to ∼6% positive RT-PCR was found for a daily hospital admission rate >1.5 per 100,000 inhabitants, and around 1.0% for lower prevalence.

CONCLUSIONS

One in every 100 patients without COVID-19 symptoms tested positive for SARS-CoV-2 with RT-PCR; this yield increased in conjunction with community prevalence. The added value of chest CT was limited. Preoperative screening allowed us to take adequate precautions for SARS-CoV-2 positive patients in a surgical population, whereas negative patients needed only routine procedures.

IMARI: multi-Interventional program for prevention and early Management of Anastomotic leakage after low anterior resection in Rectal cancer patIents: rationale and study protocol

Background

Anastomotic leakage (AL) is still a common and feared complication after low anterior resection (LAR) for rectal cancer. The multifactorial pathophysiology of AL and lack of standardised treatment options requires a multi-modal approach to improve long-term anastomotic integrity. The objective of the IMARI-trial is to determine whether the one-year anastomotic integrity rate in patients undergoing LAR for rectal cancer can be improved using a multi-interventional program.

Methods

IMARI is a multicentre prospective clinical effectiveness trial, whereby current local practice (control cohort) will be evaluated, and subsequently compared to results after implementation of the multi-interventional program (intervention cohort). Patients undergoing LAR for rectal cancer will be included. The multi-interventional program includes three preventive interventions (mechanical bowel preparation with oral antibiotics, tailored full splenic flexure mobilization and intraoperative fluorescence angiography using indocyanine green) combined with a standardised pathway for early detection and active management of AL. The primary outcome is anastomotic integrity, confirmed by CT-scan at one year postoperatively. Secondary outcomes include incidence of AL, protocol compliance and association with AL, temporary and permanent stoma rate, reintervention rate, quality of life and functional outcome. Microbiome analysis will be conducted to investigate the role of the rectal microbiome in AL.

In a Dutch nationwide study, the AL rate was 20%, with anastomotic integrity of 90% after one year. Based on an expected reduction of AL due to the preventive approaches of 50%, and increase of anastomotic integrity by a standardised pathway for early detection and active management of AL, we hypothesised that the anastomotic integrity rate will increase from 90 to 97% at one year. An improvement of 7% in anastomotic integrity at one year was considered clinically relevant. A total number of 488 patients (244 per cohort) are needed to detect this difference, with 80% statistical power.

Discussion

The IMARI-trial is designed to evaluate whether a multi-interventional program can improve long-term anastomotic integrity after rectal cancer surgery. The uniqueness of IMARI lies in the multi-modal design that addresses the multifactorial pathophysiology for prevention, and a standardised pathway for early detection and active treatment of AL.

Trial registration

Trialregister.nl (NL8261), January 2020.

Acute pancreatitis

Acute pancreatitis is an unpredictable and potentially lethal disease. The prognosis mainly depends on the development of organ failure and secondary infection of pancreatic or peripancreatic necrosis. In the past 10 years, treatment of acute pancreatitis has moved towards a multidisciplinary, tailored, and minimally invasive approach. Despite improvements in treatment and critical care, severe acute pancreatitis is still associated with high mortality rates. In this Seminar, we outline the latest evidence on diagnostic and therapeutic strategies for acute pancreatitis.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

AIM

The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons.

METHODS

The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements.

RESULTS

This guideline contains 38 evidence based consensus statements on the management of diverticular disease.

CONCLUSION

This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

A systematic review evaluating the influence of incisional Negative Pressure Wound Therapy on scarring

Pathological scars can result in functional impairment, disfigurement, a psychological burden, itch, and even chronic pain. We conducted a systematic review to investigate the influence of incisional Negative Pressure Wound Therapy (iNPWT) on scarring. PubMed, EMBASE and CINAHL were searched for preclinical and clinical comparative studies that investigated the influence of iNPWT on scarring‐related outcomes. Individual studies were assessed using the OHAT Risk of Bias Rating Tool for Human and Animal studies. The body of evidence was rated using OHAT methodology. Six preclinical studies and nine clinical studies (377 patients) were identified. Preclinical studies suggested that iNPWT reduced lateral tension on incisions, increased wound strength, and reduced scar width upon histological assessment. Two clinical studies reported improved patient‐reported scar satisfaction as measured with the PSAS (1 year after surgery), POSAS, and a VAS (both 42, 90, and 180 days after surgery). Five clinical studies reported improved observer‐reported scar satisfaction as measured with the VSS, SBSES, OSAS, MSS, VAS, and POSAS (7, 15, 30, 42, 90, 180, and 365 days after surgery). Three clinical studies did not detect significant differences at any point in time (POSAS, VAS, and NRS). Because of imprecision concerns, a moderate level of evidence was identified using OHAT methodology. Preclinical as well as clinical evidence indicates a beneficial influence of iNPWT on scarring. Moderate level evidence indicates that iNPWT decreases scar width and improves patient and observer‐reported scar satisfaction.

Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study

INTRODUCTION

Idiopathic acute pancreatitis (IAP) remains a dilemma for physicians as it is uncertain whether patients with IAP may actually have an occult aetiology. It is unclear to what extent additional diagnostic modalities such as endoscopic ultrasonography (EUS) are warranted after a first episode of IAP in order to uncover this aetiology. Failure to timely determine treatable aetiologies delays appropriate treatment and might subsequently cause recurrence of acute pancreatitis. Therefore, the aim of the Pancreatitis of Idiopathic origin: Clinical added value of endoscopic UltraSonography (PICUS) Study is to determine the value of routine EUS in determining the aetiology of pancreatitis in patients with a first episode of IAP.

METHODS AND ANALYSIS

PICUS is designed as a multicentre prospective cohort study of 106 patients with a first episode of IAP after complete standard diagnostic work-up, in whom a diagnostic EUS will be performed. Standard diagnostic work-up will include a complete personal and family history, laboratory tests including serum alanine aminotransferase, calcium and triglyceride levels and imaging by transabdominal ultrasound, magnetic resonance imaging or magnetic resonance cholangiopancreaticography after clinical recovery from the acute pancreatitis episode. The primary outcome measure is detection of aetiology by EUS. Secondary outcome measures include pancreatitis recurrence rate, severity of recurrent pancreatitis, readmission, additional interventions, complications, length of hospital stay, quality of life, mortality and costs, during a follow-up period of 12 months.

ETHICS AND DISSEMINATION

PICUS is conducted according to the Declaration of Helsinki and Guideline for Good Clinical Practice. Five medical ethics review committees assessed PICUS (Medical Ethics Review Committee of Academic Medical Center, University Medical Center Utrecht, Radboud University Medical Center, Erasmus Medical Center and Maastricht University Medical Center). The results will be submitted for publication in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Netherlands Trial Registry (NL7066). Prospectively registered.

Success of extracorporeal shock wave lithotripsy and ERCP in symptomatic pancreatic duct stones: a systematic review and meta-analysis

Background and study aims  Pain is the most frequent and dominant symptom of chronic pancreatitis. Currently, these patients are treated using a step-up approach, including analgesics and lifestyle adjustments, endoscopic, and eventually surgical treatment. Extracorporeal shock wave lithotripsy (ESWL) is indicated after failure of the first step in patients with symptomatic intraductal stones larger than 5 mm in the head or body of the pancreas. To assess the complete ductal clearance rate and pain relief after ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones, a systematic review and meta-analysis was performed. Patients and methods  A systematic literature search from January 2000 to December 2018 was performed in PubMed, the Cochrane Library, and EMBASE for studies on ductal clearance rate of ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones. Results  After screening 486 studies, 22 studies with 3868 patients with chronic pancreatitis undergoing ESWL for pancreatic duct stones were included. The pooled proportion of patients with complete ductal clearance was 69.8 % (95 % CI 63.8-75.5). The pooled proportion of complete absence of pain during follow-up was 64.2 % (95 % CI 57.5-70.6). Complete stone fragmentation was 86.3 % (95 % CI 76.0-94.0). Post-procedural pancreatitis and cholangitis occurred in 4.0 % (95 % CI 2.5-5.8) and 0.5 % (95 % CI 0.2-0.9), respectively. Conclusion  Treatment with ESWL results in complete ductal clearance rate in a majority of patients, resulting in absence of pain during follow up in over half of patients with symptomatic chronic pancreatitis caused by obstructing pancreatic duct stones.

Suboptimal care for chronic pancreatitis patients revealed by moderate to low adherence to the United European Gastroenterology evidence-based guidelines (HaPanEU): A Netherlands nationwide analysis

Background and objective

The 2016, United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU) provided evidence-based recommendations for the management of chronic pancreatitis and allowed for the objective evaluation of the quality of care in several domains of disease management through assessment of guideline adherence. Therefore, the aim of this study is to evaluate the current level and the variety of care for chronic pancreatitis patients in the Netherlands using the HaPanEU guidelines as a reference standard. The majority of these patients were diagnosed before the publication of these guidelines. Therefore, in most patients, the results of the present study with respect to those recommendations regarding the diagnostic process of chronic pancreatitis represent guideline correspondence and not adherence.

Methods

A subgroup of patients from the Dutch nationwide chronic pancreatitis registry (CARE) was included in a retrospective cross-sectional observational cohort study. A total of 39 recommendations concerning the non-invasive management of chronic pancreatitis were appointed as quality indicators (QIs). Per patient, the number of relevant QIs was determined and guideline adherence was assessed. Data were analyzed to identify factors associated with guideline adherence.

Results

Overall, 97 patients with chronic pancreatitis from 11 hospitals were included. Per patient, a mean number of 26 relevant QIs was applicable, with an average adherence rate of 53%. In 45% of the patients, guideline adherence was less than 50%. The majority of suboptimal managed QIs concerned the management of chronic pancreatitis complications. Guideline adherence was not associated with hospital type, sex, age or etiology of pancreatitis.

Conclusion

In the Netherlands, adherence to the HaPanEU recommendations for the management of chronic pancreatitis is moderate to low for all non-invasive domains, which may indicate suboptimal care for these patients. Closer guideline adherence could improve the level of care and the clinical outcomes of these patients. A nationwide approach to increase awareness of the key guideline recommendations among clinicians and patients is needed.

Enhanced PeriOperative Care and Health protection programme for the prevention of surgical site infections after elective abdominal surgery (EPOCH): study protocol of a randomised controlled, multicentre, superiority trial

INTRODUCTION

Surgical site infections (SSI) are a common postoperative complication. During the development of the new WHO guidelines on SSI prevention, also in the Netherlands was concluded that perioperative care could be optimised beyond the current standard practice. We selected a limited set of readily available, cheap and evidence-based interventions from these new guidelines that are not part of standard practice in the Netherlands and formulated an Enhanced PeriOperative Care and Health bundle (EPOCH). Here, we describe the protocol for an open-label, randomised controlled, parallel-group, superiority trial to test the effect of the EPOCH bundle added to (national) standard care in comparison to standard care alone on the incidence of SSI.

METHODS AND ANALYSIS

EPOCH consists of intraoperative high fractional inspired oxygen (0.80); goal-directed fluid therapy; active preoperative, intraoperative and postoperative warming; perioperative glucose control and treatment of severe hyperglycaemia (>10 mmol^l-1) and standardised surgical site handling. Patients scheduled for elective abdominal surgery with an incision larger than 5 cm are eligible for inclusion. Participants are randomised daily, 1:1 according to variable block sizes, and stratified per participating centre to either EPOCH added to standard care or standard care only. The primary endpoint will be SSI incidence according to the Centers for Disease Control and Prevention (CDC) definition within 30 days as part of routine clinical follow-up. Four additional questionnaires will be sent out over the course of 90 days to capture disability and costs. Other secondary endpoints include anastomotic leakage, incidence of incisional hernia, serious adverse events, hospital readmissions, length of stay and cost effectiveness. Analysis of the primary endpoint will be on an intention-to-treat basis.

ETHICS AND DISSEMINATION

Ethics approval is granted by the Amsterdam UMC Medical Ethics Committee (reference 2015_121). Results will be disseminated through peer-reviewed journals and summaries shared with stakeholders. This protocol is published before analysis of the results.

TRIAL REGISTRATION NUMBER

Registered in the Dutch Trial Register: NL5572.

International consensus guidelines for surgery and the timing of intervention in chronic pancreatitis

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is a complex inflammatory disease with pain as the predominant symptom. Pain relief can be achieved using invasive interventions such as endoscopy and surgery. This paper is part of the international consensus guidelines on CP and presents the consensus guideline for surgery and timing of intervention in CP.

METHODS

An international working group with 15 experts on CP surgery from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated 20 statements generated from evidence on 5 questions deemed to be the most clinically relevant in CP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on the 20 statements for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach's alpha reliability coefficient.

RESULTS

Strong consensus was obtained for the following statements: Surgery in CP is indicated as treatment of intractable pain and local complications of adjacent organs, and in case of suspicion of malignant (cystic) lesion; Early surgery is favored over surgery in a more advanced stage of disease to achieve optimal long-term pain relief; In patients with an enlarged pancreatic head, a combined drainage and resection procedure, such as the Frey, Beger, and Berne procedure, may be the treatment of choice; Pancreaticoduodenectomy is the most suitable surgical option for patients with groove pancreatitis; The risk of pancreatic carcinoma in patients with CP is too low (2% in 10 year) to recommend active screening or prophylactic surgery; Patients with hereditary CP have such a high risk of pancreatic cancer that prophylactic resection can be considered (lifetime risk of 40-55%). Weak agreement for procedure choice in patients with dilated duct and normal size pancreatic head: both the extended lateral pancreaticojejunostomy and Frey procedure seems to provide equivalent pain control in patients.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning key aspects in surgery and timing of intervention in CP. It is meant to guide clinical practitioners and surgeons in the treatment of patients with CP.

Immediate Closure of Abdominal Cavity with Biologic Mesh versus Temporary Abdominal Closure of Open Abdomen in Non-Trauma Emergency Patients (CLOSE-UP Study)

Background: In more than 10% of emergency laparotomies in non-trauma patients, primary fascial closure is not achievable because of excessive visceral edema, which leaves the patient with an open abdomen (OA). An OA harbors an inherent high risk of serious complications, and temporary closure devices are used to achieve delayed fascial closure. A potential new strategy in preventing OA is immediate closure during the emergency procedure with a non-crosslinked biologic mesh. Methods: This is a prospective comparative cohort feasibility study in 13 teaching hospitals in the Netherlands. Non-trauma patients who underwent emergency laparotomy in which regular sutured primary fascial closure was not achievable because of excessive intra-abdominal edema were eligible. In one cohort, Biomesh (n = 20), the abdominal cavity was immediately closed at the emergency laparotomy with a non-crosslinked biologic mesh. In a parallel cohort, Control (n = 20), the resulting OA was managed by temporary abdominal closure (TAC; inlay polyglactin [Vicryl™] mesh [n = 7]) or commercial (ABThera^TM) abdominal negative pressure therapy device (n = 13)). The primary end point was the proportion of closed abdominal cavities at 90 days. Results: At 90 days, 65% (13/20) of the abdominal cavities were closed in the Biomesh cohort versus 45% (9/20) in Controls (p = 0.204). In the Biomesh cohort, seven of 20 (35%) patients had at least one major complication versus 15 of 20 (75%) patients in the Control cohort (p = 0.011). Both the median number of intensive care unit (ICU) and mechanical ventilation days were significantly lower in the Biomesh cohort; one versus 10 (p = 0.002) and 0 versus four (p = 0.003) days, respectively. The number of abdominal reoperations was significantly lower in the Biomesh cohort (median 0 vs. two, p < 0.001; total number five vs. 44). Conclusions: If primary fascial closure cannot be achieved at the emergency laparotomy in non-trauma patients, immediate abdominal closure by use of a non-crosslinked biologic mesh prevents OA management. This results in a non-significant higher proportion of closed abdominal cavities at 90 days compared with OA management with TAC techniques, and in a significant reduction of major complications and reoperations, and a shorter ICU stay.

Observational versus antibiotic treatment for uncomplicated diverticulitis: an individual-patient data meta-analysis

BACKGROUND

Two RCTs (AVOD and DIABOLO) demonstrated no difference in recovery or adverse outcomes when antibiotics for acute uncomplicated diverticulitis were omitted. Both trials showed non-significantly higher rates of complicated diverticulitis and surgery in the non-antibiotic groups. This meta-analysis of individual-patient data aimed to explore adverse outcomes and identify patients at risk who may benefit from antibiotic treatment.

METHODS

Individual-patient data from those with uncomplicated diverticulitis from two RCTs were pooled. Risk factors for adverse outcomes and the effect of observational management were assessed using logistic regression analyses. P < 0·025 was considered statistically significant owing to multiple testing adjustment.

RESULTS

In total, 545 patients in the observational group and 564 in the antibiotics group were included. No statistical differences were found in 1-year follow-up rates of ongoing diverticulitis (7·2 versus 5·0 per cent in observation versus antibiotics groups respectively; P = 0·062), recurrent diverticulitis (8·6 versus 9·6 per cent; P = 0·610), complicated diverticulitis (4·0 versus 2·1 per cent; P = 0·079) and sigmoid resection (5·0 versus 2·5 per cent; P = 0·214). An initial pain score greater than 7, white blood cell count exceeding 13·5 × 10⁹ /l and previous diverticulitis at presentation were risk factors for adverse outcomes. Antibiotic treatment did not prevent adverse outcomes in patients at high risk of adverse events.

CONCLUSION

Observational management of acute uncomplicated diverticulitis is safe. Some statistical uncertainty remains, depending on the thresholds of clinical relevance, owing to small differences, but no subgroup that would benefit from antibiotic treatment was apparent.

The development and validation of risk-stratification models for short-term outcomes following contaminated complex abdominal wall reconstruction

BACKGROUND

Short-term outcomes for patients undergoing contaminated complex abdominal wall reconstruction (CCAWR), including risk stratification, have not been studied in sufficiently high numbers. This study aims to develop and validate risk-stratification models for Clavien-Dindo (CD) grade ≥ 3 complications in patients undergoing CCAWR.

METHODS

A consecutive cohort of patients who underwent CCAWR in two European national intestinal failure centers, from January 2004 to December 2015, was identified. Data were collected retrospectively for short-term outcomes and used to develop risk models using logistic regression. A further cohort, from January 2016 to December 2017, was used to validate the models.

RESULTS

The development cohort consisted of 272 procedures performed in 254 patients. The validation cohort consisted of 114 patients. The cohorts were comparable in baseline demographics (mean age 58.0 vs 58.1; sex 58.8% male vs 54.4%, respectively). A multi-variate model including the presence of intestinal failure (p < 0.01) and operative time (p < 0.01) demonstrated good discrimination and calibration on validation. Models for wound and intra-abdominal complications were also developed, including pre-operative immunosuppression (p = 0.05), intestinal failure (p = 0.02), increasing operative time (p = 0.04), increasing number of anastomoses (p = 0.01) and the number of previous abdominal operations (p = 0.02). While these models showed reasonable ability to discriminate patients on internal assessment, they were not found to be accurate on external validation.

CONCLUSION

Acceptable short-term outcomes after CCAWR are demonstrated. A robust model for the prediction of CD ≥ grade 3 complications has been developed and validated. This model is available online at www.smbari.co.uk/smjconv2.

Bile leakage after loop closure vs clip closure of the cystic duct during laparoscopic cholecystectomy: A retrospective analysis of a prospective cohort

BACKGROUND

Laparoscopic cholecystectomy (LC) is one of the most frequently performed surgical procedures. Cystic stump leakage is an underestimated, potentially life threatening complication that occurs in 1%-6% of the patients. With a secure cystic duct occlusion technique during LC, bile leakage becomes a preventable complication.

AIM

To investigate the effect of polydioxanone (PDS) loop closure of the cystic duct on bile leakage rate in LC patients.

METHODS

In this retrospective analysis of a prospective cohort, the effect of PDS loop closure of the cystic duct on bile leakage complication was compared to patients with conventional clip closure. Logistic regression analysis was used to develop a risk score to identify bile leakage risk. Leakage rate was assessed for categories of patients with increasing levels of bile leakage risk.

RESULTS

Of the 4359 patients who underwent LC, 136 (3%) underwent cystic duct closure by a PDS loop. Preoperatively, loop closure patients had significantly more complicated biliary disease compared to the clipped closure patients. In the loop closure cohort, zero (0%) bile leakage occurred compared to 59 of 4223 (1.4%) clip closure patients. For patients at increased bile leakage risk (risk score ≥ 1) rates were 1.6% and up to 13% (4/30) for clip closure patients with a risk score ≥ 4. This risk increase paralleled a stepwise increase of actual bile leakage complication for clip closure patients, which was not observed for loop closure patients.

CONCLUSION

Cystic duct closure with a PDS loop during LC may reduce bile leakage in patients at increased risk for bile leakage.

Effect of Early Surgery vs Endoscopy-First Approach on Pain in Patients With Chronic Pancreatitis: The ESCAPE Randomized Clinical Trial

IMPORTANCE

For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier surgery could mitigate disease progression, providing better pain control and preserving pancreatic function.

OBJECTIVE

To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for ≤2 months or weak opioids for ≤6 months) were included. The 18-month follow-up period ended in March 2018.

INTERVENTIONS

There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed.

MAIN OUTCOMES AND MEASURES

The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 [increasing score indicates more pain severity]). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey [SF-36]); and mortality.

RESULTS

Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, -12 points [95% CI, -22 to -2]; P = .02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P = .10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P < .001). Treatment complications (27% vs 25%), mortality (0% vs 0%), hospital admissions, pancreatic function, and quality of life were not significantly different between early surgery and the endoscopy-first approach.

CONCLUSIONS AND RELEVANCE

Among patients with chronic pancreatitis, early surgery compared with an endoscopy-first approach resulted in lower pain scores when integrated over 18 months. However, further research is needed to assess persistence of differences over time and to replicate the study findings.

TRIAL REGISTRATION

ISRCTN Identifier: ISRCTN45877994.

Effect of Cognitive Aids on Adherence to Best Practice in the Treatment of Deteriorating Surgical Patients: A Randomized Clinical Trial in a Simulation Setting

Importance

Failure to rescue causes significant morbidity and mortality in the surgical population. Human error is often the underlying cause of failure to rescue. Human error can be reduced by the use of cognitive aids.

Objectives

To test the effectiveness of cognitive aids on adherence to best practice in the management of deteriorating postoperative surgical ward patients.

Design, Setting, and Participants

Randomized clinical trial in a simulation setting. Surgical teams consisted of 1 surgeon and 2 nurses from a surgical ward from 4 different hospitals in Amsterdam, the Netherlands. Data were analyzed between February 2, 2017, and December 18, 2018.

Interventions

The teams were randomized to manage 3 simulated deteriorating patient scenarios with or without the use of cognitive aids.

Main Outcomes and Measures

The primary outcome of the study was failure to adhere to best practice, expressed as the percentage of omitted critical management steps. The secondary outcome of the study was the perceived usability of the cognitive aids.

Results

Of the total participants, 93 were women and 51 were men. Twenty-five surgical teams performed 75 patient scenarios with cognitive aids, and 25 teams performed 75 patient scenarios without cognitive aids. Using the cognitive aids resulted in a reduction of omitted critical management steps from 33% to 10%, which is a 70% (P < .001) reduction. This effect remained significant (odds ratio, 0.63; 95% CI, -0.228 to -0.061; P = .001) in a multivariate analysis. Overall usability (scale of 0-10) of the cognitive aids was scored at a median of 8.7 (interquartile range, 8-9).

Conclusions and Relevance

Failure to comply with best practice management of postoperative complications is associated with worse outcomes. In this simulation study, adherence to best practice in the management of postoperative complications improves significantly by the use of cognitive aids. Cognitive aids for deteriorating surgical patients therefore have the potential to reduce failure to rescue and improve patient outcome.

Trial Registration

ClinicalTrials.gov identifier: NCT03812861.

Meta-analysis of the role of colonoscopy after an episode of left-sided acute diverticulitis

Background

Routine colonoscopy was traditionally recommended after acute diverticulitis to exclude coexistent malignancy. Improved CT imaging may make routine colonoscopy less required over time but most guidelines still recommend it. The aim of this review was to assess the role of colonoscopy in patients with CT‐proven acute diverticulitis.

Methods

PubMed and Embase were searched for studies reporting the prevalence of advanced colorectal neoplasia (ACN) or colorectal carcinoma in patients who underwent colonoscopy within 1 year after CT‐proven left‐sided acute diverticulitis. The prevalence was pooled using a random‐effects model and, if possible, compared with that among asymptomatic controls.

Results

Seventeen studies with 3296 patients were included. The pooled prevalence of ACN was 6·9 (95 per cent c.i. 5·0 to 9·4) per cent and that of colorectal carcinoma was 2·1 (1·5 to 3·1) per cent. Only two studies reported a comparison with asymptomatic controls, showing comparable risks (risk ratio 1·80, 95 per cent c.i. 0·66 to 4·96). In subgroup analysis of patients with uncomplicated acute diverticulitis, the prevalence of colorectal carcinoma was only 0·5 (0·2 to 1·2) per cent.

Conclusion

Routine colonoscopy may be omitted in patients with uncomplicated diverticulitis if CT imaging is otherwise clear. Patients with complicated disease or ongoing symptoms should undergo colonoscopy.

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Meta-analysis and field synopsis of genetic variants associated with the risk and severity of acute pancreatitis

Background

Genetic risk factors can provide insight into susceptibility for acute pancreatitis (AP) and disease progression towards (infected) necrotizing pancreatitis and persistent organ failure. The aim of the study was to undertake a systematic review of the genetic evidence for AP.

Methods

Online databases (MEDLINE, Embase, BIOSIS, Web of Science, Cochrane Library) were searched to 8 February 2018. Studies that reported on genetic associations with AP susceptibility, severity and/or complications were eligible for inclusion. Meta‐analyses were performed of variants that were reported by at least two data sources. Venice criteria and Bayesian false‐discovery probability were applied to assess credibility.

Results

Ninety‐six studies reporting on 181 variants in 79 genes were identified. In agreement with previous meta‐analyses, credible associations were established for SPINK1 (odds ratio (OR) 2·87, 95 per cent c.i. 1·89 to 4·34), IL1B (OR 1·23, 1·06 to 1·42) and IL6 (OR 1·64, 1·15 to 2·32) and disease risk. In addition, two novel credible single‐nucleotide polymorphisms were identified in Asian populations: ALDH2 (OR 0·48, 0·36 to 0·64) and IL18 (OR 1·47, 1·18 to 1·82). Associations of variants in TNF, GSTP1 and CXCL8 genes with disease severity were identified, but were of low credibility.

Conclusion

Genetic risk factors in genes related to trypsin activation and innate immunity appear to be associated with susceptibility to and severity of AP.

A Systematic Review and Meta-Analysis of the Pressure-Induced Vasodilation Phenomenon and Its Role in the Pathophysiology of Ulcers

BACKGROUND

Physiologic studies show that tissue perfusion increases during moderate amounts of tissue compression. This is attributed to sensory nerves initiating a vasodilatory cascade referred to as pressure-induced vasodilation.

METHODS

PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies investigating perfusion during pressure exposure longer than 10 minutes. Retrieved studies were assessed using the Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies. Results were pooled with random effects models. The body of evidence was rated using the Office of Health Assessment and Translation approach.

RESULTS

Twenty-nine articles were included, of which 19 articles were included in meta-analyses. The evidence indicates that moderate amounts of tissue compression have the capacity to increase perfusion in healthy humans by 46 percent (95 percent CI, 30 to 62 percent). Using the Office of Health Assessment and Translation approach, the authors found a high level of confidence in the body of evidence. Pressure-induced vasodilation blockade was associated with increased pressure ulcer formation. Pressure-induced vasodilation was impaired by neuropathy and by the drugs diclofenac and amiloride.

CONCLUSIONS

This systematic review and meta-analysis indicates that healthy humans have the capacity to increase local perfusion in response to mechanical stress resulting from tissue compression. Because pressure-induced vasodilation is mediated by sensory nerves, pressure-induced vasodilation emphasizes the importance of sensory innervation for durable tissue integrity. Pressure-induced vasodilation impairment seems to provide a complementary explanation for the susceptibility of neuropathic tissues to pressure-induced lesions.

Surgery in Chronic Pancreatitis: Indication, Timing and Procedures

Chronic pancreatitis is a chronic inflammation of the pancreas with pain as its severest symptom and often an impaired quality of life. Surgical intervention plays an important role in the management of pain but is generally kept as a last resort when conservative measures and endoscopy have failed. However, in the last few years multiple studies suggested the superiority of (early) surgical treatment in chronic pancreatitis for multiple end points, including pain relief. In this paper we highlight the most recent high-quality evidence on surgical therapy in chronic pancreatitis and the rationale for early (surgical) intervention.

Restrictive strategy versus usual care for cholecystectomy in patients with gallstones and abdominal pain (SECURE): a multicentre, randomised, parallel-arm, non-inferiority trial

BACKGROUND

International guidelines advise laparoscopic cholecystectomy to treat symptomatic, uncomplicated gallstones. Usual care regarding cholecystectomy is associated with practice variation and persistent post-cholecystectomy pain in 10-41% of patients. We aimed to compare the non-inferiority of a restrictive strategy with stepwise selection with usual care to assess (in)efficient use of cholecystectomy.

METHODS

We did a multicentre, randomised, parallel-arm, non-inferiority study in 24 academic and non-academic hospitals in the Netherlands. We enrolled patients aged 18-95 years with abdominal pain and ultrasound-proven gallstones or sludge. Patients were randomly assigned (1:1) to either usual care in which selection for cholecystectomy was left to the discretion of the surgeon, or a restrictive strategy with stepwise selection for cholecystectomy. For the restrictive strategy, cholecystectomy was advised for patients who fulfilled all five pre-specified criteria of the triage instrument: 1) severe pain attacks, 2) pain lasting 15-30 min or longer, 3) pain located in epigastrium or right upper quadrant, 4) pain radiating to the back, and 5) a positive pain response to simple analgesics. Randomisation was done with an online program, implemented into a web-based application using blocks of variable sizes, and stratified for centre (academic versus non-academic and a high vs low number of patients), sex, and body-mass index. Physicians and patients were masked for study-arm allocation until after completion of the triage instrument. The primary, non-inferiority, patient-reported endpoint was the proportion of patients who were pain-free at 12 months' follow-up, analysed by intention to treat and per protocol. A 5% non-inferiority margin was chosen, based on the estimated clinically relevant difference. Safety analyses were also done in the intention-to treat population. This trial is registered at the Netherlands National Trial Register, number NTR4022.

FINDINGS

Between Feb 5, 2014, and April 25, 2017, we included 1067 patients for analysis: 537 assigned to usual care and 530 to the restrictive strategy. At 12 months' follow-up 298 patients (56%; 95% CI, 52·0-60·4) were pain-free in the restrictive strategy group, compared with 321 patients (60%, 55·6-63·8) in usual care. Non-inferiority was not shown (difference 3·6%; one-sided 95% lower CI -8·6%; p_{non-inferiority}=0·316). According to a secondary endpoint analysis, the restrictive strategy resulted in significantly fewer cholecystectomies than usual care (358 [68%] of 529 vs 404 [75%] of 536; p=0·01). There were no between-group differences in trial-related gallstone complications (40 patients [8%] of 529 in usual care vs 38 [7%] of 536 in restrictive strategy; p=0·16) and surgical complications (74 [21%] of 358 vs 88 [22%] of 404, p=0·77), or in non-trial-related serious adverse events (27 [5%] of 529 vs 29 [5%] of 526).

INTERPRETATION

Suboptimal pain reduction in patients with gallstones and abdominal pain was noted with both usual care and following a restrictive strategy for selection for cholecystectomy. However, the restrictive strategy was associated with fewer cholecystectomies. The findings should encourage physicians involved in the care of patients with gallstones to rethink cholecystectomy, and to be more careful in advising a surgical approach in patients with gallstones and abdominal symptoms.

FUNDING

The Netherlands Organization for Health Research and Development, and CZ healthcare insurance.

[Abdominal pain]

Abdominal pain Abdominal pain can be part of a variety of abdominal and non-abdominal conditions. Individual symptoms and signs from history taking and physical examination have limited discriminatory value for a clear diagnosis. Additional laboratory testing strategies and imaging techniques can provide more guidance in this respect. In this article, we will answer specific practical questions with respect to abdominal pain. Topics discussed include various abdominal conditions, diagnostic markers, the diagnostic value of imaging techniques and new treatments for irritable bowel syndrome.

Prevalence of alpha-1-antitrypsin deficiency carriers in a population with and without colonic diverticula. A multicentre prospective case-control study: the ALADDIN study

PURPOSE

The underling pathophysiological mechanisms that cause the formation of colonic diverticula (diverticulosis) remain unclear. Connective tissue changes due to ageing that cause changes in collagen structure of the colonic wall is one theory. Alpha-1-antitrypsin (A1AT) is a protease inhibitor known to protect connective tissue in other organs. Associations between (carriers of) A1AT deficiency and the development of colonic diverticula will be the main focus of this study.

METHODS

A multicentre prospective case-controlled study. In total, 230 patients ≥ 60 years with acute abdominal pain undergoing an abdominal computed tomography (CT) will be included. The research group consists of patients with diverticulosis and/or diverticulitis; controls are patients without diverticula (0 to ≤ 5 diverticula). Genotype analysis for A1AT deficiency will be performed.

RATIONALE

Hypothetically, connective tissue changes, in particular related to (carriers of) A1AT deficiency, can contribute to the development of diverticula and diverticulitis. We expect to find a higher prevalence of A1AT carriers in patients with diverticulosis compared to patients without diverticulosis. Having diverticulosis does not affect the general health of these individuals per se, when asymptomatic. Once an association is found, present findings can be the basis for a second study to assess the risk of developing acute diverticulitis and its disease course in carriers of A1AT deficiency. Because a large cohort is needed in the latter, we shall first perform a pilot study to investigate the likelihood of the primary hypothesis.

TRIAL REGISTRATION

Netherlands Trial register, NTR6251, NL55016.094.15.

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

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.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3315-6) contains supplementary material, which is available to authorized users.

Complicated Disease Course in Initially Computed Tomography-Proven Uncomplicated Acute Diverticulitis

Background: Although uncomplicated acute diverticulitis has a benign disease course, some patients are at increased risk for complications. Identification of these patients may aid the selection of treatment strategies such as outpatient treatment. This study aimed to assess the rate and timing of a complicated disease course in initially computed tomography (CT)-proven uncomplicated diverticulitis, and to identify risk factors for the development of these diverticular complications. Patients and Methods: Computed tomography-proven, left-sided uncomplicated diverticulitis patients from two cohorts were included. Main outcome measure was complicated diverticulitis (perforation, abscess, obstruction, or fistula) within three months after presentation. Risk factors for diverticular complications were identified using multivariable logistic regression. Results: Of the 1,087 patients with initially CT-proven uncomplicated diverticulitis, 4.9% (53/1,087) developed complicated diverticulitis. Most perforations and abscesses (16/21) occurred during the first 10 days, whereas colonic obstruction and fistula occurred during three months of follow-up. Independent risk factors for the transition from uncomplicated to complicated diverticulitis were American Society of Anesthesiologists (ASA) classification 3/4 (odds ratio [OR] 4.43, 95% confidence interval [CI] 1.57-12.48), duration of symptoms before presentation longer than five days (OR 3.25, 95% CI 1.72-6.13), vomiting (OR 3.94, 95% CI 1.96-7.92), and C-reactive protein (CRP) above 140 mg/L (OR 2.86, 95% CI 1.51-5.43). Conclusion: Approximately one in 20 patients with CT-proven uncomplicated diverticulitis develops a complicated disease course within three months; perforation and abscess occur predominantly within 10 days after presentation. Patients with systemic comorbidity, symptoms for more than five days, those who vomit, or have high CRP levels at presentation are at risk for diverticular complications after an uncomplicated initial presentation and may warrant closer observation.

[Treatment of appendicitis with antibiotics only; still a bridge too far]

Antibiotic treatment instead of surgery for uncomplicated appendicitis seems attractive since it may lead to fewer complications. Moreover, patients who have surgery after failed initial antibiotic treatment have comparable complication rates to those undergoing immediate appendectomy. There are caveats, since patients treated with only antibiotics have a 40% chance of recurrent appendicitis within the following years. Furthermore, about 20% of appendectomy patients who had suspected uncomplicated appendicitis, appeared to have complicated appendicitis instead. This illustrates that differentiation between uncomplicated and complicated appendicitis is far from perfect, which is potentially dangerous as surgery is needed in case of perforated appendicitis. It is unknown whether Dutch patients are willing to receive antibiotic treatment instead of surgery. Is follow-up needed after antibiotic treatment of appendicitis and if so, for how long? What about the 2% of patients with a differential diagnosis of appendicitis in whom a neoplasm is diagnosed? All in all, it may be premature to implement primary antibiotic treatment for suspected uncomplicated appendicitis as first-line treatment.

Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of Patients With Necrotizing Pancreatitis

BACKGROUND & AIMS

In a 2010 randomized trial (the PANTER trial), a surgical step-up approach for infected necrotizing pancreatitis was found to reduce the composite endpoint of death or major complications compared with open necrosectomy; 35% of patients were successfully treated with simple catheter drainage only. There is concern, however, that minimally invasive treatment increases the need for reinterventions for residual peripancreatic necrotic collections and other complications during the long term. We therefore performed a long-term follow-up study.

METHODS

We reevaluated all the 73 patients (of the 88 patients randomly assigned to groups) who were still alive after the index admission, at a mean 86 months (±11 months) of follow-up. We collected data on all clinical and health care resource utilization endpoints through this follow-up period. The primary endpoint was death or major complications (the same as for the PANTER trial). We also measured exocrine insufficiency, quality of life (using the Short Form-36 and EuroQol 5 dimensions forms), and Izbicki pain scores.

RESULTS

From index admission to long-term follow-up, 19 patients (44%) died or had major complications in the step-up group compared with 33 patients (73%) in the open-necrosectomy group (P = .005). Significantly lower proportions of patients in the step-up group had incisional hernias (23% vs 53%; P = .004), pancreatic exocrine insufficiency (29% vs 56%; P = .03), or endocrine insufficiency (40% vs 64%; P = .05). There were no significant differences between groups in proportions of patients requiring additional drainage procedures (11% vs 13%; P = .99) or pancreatic surgery (11% vs 5%; P = .43), or in recurrent acute pancreatitis, chronic pancreatitis, Izbicki pain scores, or medical costs. Quality of life increased during follow-up without a significant difference between groups.

CONCLUSIONS

In an analysis of long-term outcomes of trial participants, we found the step-up approach for necrotizing pancreatitis to be superior to open necrosectomy, without increased risk of reinterventions.

Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis

Background

The traditional fear that every case of acute appendicitis will eventually perforate has led to the generally accepted emergency appendicectomy with minimized delay. However, emergency and thereby sometimes night‐time surgery is associated with several drawbacks, whereas the consequences of surgery after limited delay are unclear. This systematic review aimed to assess in‐hospital delay before surgery as risk factor for complicated appendicitis and postoperative morbidity in patients with acute appendicitis.

Methods

PubMed and EMBASE were searched from 1990 to 2016 for studies including patients who underwent appendicectomy for acute appendicitis, reported in two or more predefined time intervals. The primary outcome measure was complicated appendicitis after surgery (perforated or gangrenous appendicitis); other outcomes were postoperative surgical‐site infection and morbidity. Adjusted odds ratios (ORs) were pooled using forest plots if possible. Unadjusted data were pooled using generalized linear mixed models.

Results

Forty‐five studies with 152 314 patients were included. Pooled adjusted ORs revealed no significantly higher risk for complicated appendicitis when appendicectomy was delayed for 7–12 or 13–24 h (OR 1·07, 95 per cent c.i. 0·98 to 1·17, and OR 1·09, 0·95 to 1·24, respectively). Meta‐analysis of unadjusted data supported these findings by yielding no increased risk for complicated appendicitis or postoperative complications with a delay of 24–48 h.

Conclusion

This meta‐analysis demonstrates that delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical‐site infection or morbidity. Delaying appendicectomy for up to 24 h may be an acceptable alternative for patients with no preoperative signs of complicated appendicitis.

Delay is safe

Validation of a Norwegian version of SURgical PAtient Safety System (SURPASS) in combination with the World Health Organizations' Surgical Safety Checklist (WHO SSC)

Introduction

Surgical safety checklists may contribute to reduction of complications and mortality. The WHO’s Surgical Safety Checklist (WHO SSC) could prevent incidents in operating theatres, but errors also occur before and after surgery. The SURgical PAtient Safety System (SURPASS) is designed to intercept errors with use of checklists throughout the surgical pathway.

Objective

We aimed to validate a Norwegian version of the SURPASS’ preoperative and postoperative checklists for use in combination with the already established Sign In, Time Out and Sign Out parts of the WHO SSC.

Methods and materials

The validation of the SURPASS checklists content followed WHOs recommended guidelines. The process consisted of six steps: forward translation; testing the content; focus groups; expert panels; back translation; and approval of the final version. Qualitative content analysis was used to identify codes and categories for adaption of the SURPASS checklist items throughout Norwegian surgical care. Content validity index (CVI) was used by expert panels to score the relevance of each checklist item. The study was carried out in a neurosurgical ward in a large tertiary teaching hospital in Norway.

Results

Testing the preoperative and postoperative SURPASS checklists was performed in 29 neurosurgical procedures. This involved all professional groups in the entire surgical patient care pathway. Eight clinical focus groups revealed two main categories: ‘Adapt the wording to fit clinical practice’ and ‘The checklist items challenge existing workflow’. Interprofessional scoring of the content validity of the checklists reached >80% for all the SURPASS checklists.

Conclusions

The first version of the SURPASS checklists combined with the WHO SSC was validated for use in Norwegian surgical care with face validity confirmed and CVI >0.80%.

Trial registration number

NCT01872195.