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Huisman JF, Dang H, Moons LMG, Backes Y, Dik VK, Groen JN, Ter Borg F, van Bergeijk JD, Geesing JMJ, Spanier BWM, Terhaar Sive Droste JS, Overwater A, van Lelyveld N, Kessels K, Lacle MM, Offerhaus GJA, Brohet RM, Knijn N, Vleggaar FP, van Westreenen HL, de Vos Tot Nederveen Cappel WH, Boonstra JJ. Diagnostic value of radiological staging and surveillance for T1 colorectal carcinomas: A multicenter cohort study. United European Gastroenterol J 2023. [PMID: 37300377 DOI: 10.1002/ueg2.12403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/19/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND The role of radiological staging and surveillance imaging is under debate for T1 colorectal cancer (CRC) as the risk of distant metastases is low and imaging may lead to the detection of incidental findings. OBJECTIVE The aim of this study was to evaluate the yield of radiological staging and surveillance imaging for T1 CRC. METHODS In this retrospective multicenter cohort study, all patients of 10 Dutch hospitals with histologically proven T1 CRC who underwent radiological staging in the period 2000-2014 were included. Clinical characteristics, pathological, endoscopic, surgical and imaging reports at baseline and during follow-up were recorded and analyzed. Patients were classified as high-risk T1 CRC if at least one of the histological risk factors (lymphovascular invasion, poor tumor differentiation, deep submucosal invasion or positive resection margins) was present and as low-risk when all risk factors were absent. RESULTS Of the 628 included patients, 3 (0.5%) had synchronous distant metastases, 13 (2.1%) malignant incidental findings and 129 (20.5%) benign incidental findings at baseline staging. Radiological surveillance was performed among 336 (53.5%) patients. The 5-year cumulative incidence of distant recurrence, malignant and benign incidental findings were 2.4% (95% confidence interval (CI): 1.1%-5.4%), 2.5% (95% CI: 0.6%-10.4%) and 18.3% (95% CI: 13.4%-24.7%), respectively. No distant metastatic events occurred among low-risk T1 CRC patients. CONCLUSION The risk of synchronous distant metastases and distant recurrence in T1 CRC is low, while there is a substantial risk of detecting incidental findings. Radiological staging seems unnecessary prior to local excision of suspected T1 CRC and after local excision of low-risk T1 CRC. Radiological surveillance should not be performed in patients with low-risk T1 CRC.
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Affiliation(s)
- Jelle F Huisman
- Department of Gastroenterology and Hepatology, Isala, Zwolle, the Netherlands
| | - Hao Dang
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Leon M G Moons
- Department. of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Yara Backes
- Department. of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Vincent K Dik
- Department of Gastroenterology and Hepatology, Medisch Centrum Leeuwarden, Leeuwarden, the Netherlands
| | - John N Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal, Harderwijk, the Netherlands
| | - Frank Ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, the Netherlands
| | - Jeroen D van Bergeijk
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, the Netherlands
| | - Joost M J Geesing
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, the Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | | | - Anouk Overwater
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Niels van Lelyveld
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Koen Kessels
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - G Johan A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard M Brohet
- Departmentof Epidemiology and Statistics, Isala, Zwolle, the Netherlands
| | - Nikki Knijn
- Department of Pathology-DNA, Rijnstate Hospital, Arnhem, the Netherlands
| | - Frank P Vleggaar
- Department. of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
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2
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Spanier BWM. [Health Council advice on the Dutch national colorectal cancer screening program]. Ned Tijdschr Geneeskd 2023; 167. [PMID: 37052395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
In this commentary the recently published Health Council evaluation and optimization report on the Dutch national colorectal cancer screening program is discussed. Besides several recommendations, the Health Council is reluctant to recommend changes to the current screening program. This because the screening program just has been fully implemented since 2019. Definitive conclusions about mortality reduction due to colorectal cancer cannot yet be made. However, there is a clear downward trend in the screening population. Recommended is to initiate a regional pilot study with a lower starting age of 50 years, instead of the currently 55 years. Unfortunately, in accordance with several international guidelines, the starting age is not already being lowered. Furthermore, the current screening program offers the ideal opportunity to analyze more systematically familial colorectal cancer risk in persons with a positive FIT. Also, more attention is needed on how to better reach men between 55-59 years.
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Affiliation(s)
- B W Marcel Spanier
- Rijnstate, afd. Maag-, Darm- en Leverziekten, Arnhem
- Contact: B.W. Marcel Spanier
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3
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Hallensleben ND, Stassen PMC, Schepers NJ, Besselink MG, Anten MPGF, Bakker OJ, Bollen TL, da Costa DW, van Dijk SM, van Dullemen HM, Dijkgraaf MGW, van Eijck B, van Eijck CHJ, Erkelens W, Erler NS, Fockens P, van Geenen EJM, van Grinsven J, Hazen WL, Hollemans RA, van Hooft JE, Jansen JM, Kubben FJGM, Kuiken SD, Poen AC, Quispel R, de Ridder RJ, Römkens TEH, Schoon EJ, Schwartz MP, Seerden TCJ, Smeets XJNM, Spanier BWM, Tan ACITL, Thijs WJ, Timmer R, Umans DS, Venneman NG, Verdonk RC, Vleggaar FP, van de Vrie W, van Wanrooij RLJ, Witteman BJ, van Santvoort HC, Bouwense SAW, Bruno MJ. Patient selection for urgent endoscopic retrograde cholangio-pancreatography by endoscopic ultrasound in predicted severe acute biliary pancreatitis (APEC-2): a multicentre prospective study. Gut 2023:gutjnl-2022-328258. [PMID: 36849226 DOI: 10.1136/gutjnl-2022-328258] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 02/13/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVE Routine urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic biliary sphincterotomy (ES) does not improve outcome in patients with predicted severe acute biliary pancreatitis. Improved patient selection for ERCP by means of endoscopic ultrasonography (EUS) for stone/sludge detection may challenge these findings. DESIGN A multicentre, prospective cohort study included patients with predicted severe acute biliary pancreatitis without cholangitis. Patients underwent urgent EUS, followed by ERCP with ES in case of common bile duct stones/sludge, within 24 hours after hospital presentation and within 72 hours after symptom onset. The primary endpoint was a composite of major complications or mortality within 6 months after inclusion. The historical control group was the conservative treatment arm (n=113) of the randomised APEC trial (Acute biliary Pancreatitis: urgent ERCP with sphincterotomy versus conservative treatment, patient inclusion 2013-2017) applying the same study design. RESULTS Overall, 83 patients underwent urgent EUS at a median of 21 hours (IQR 17-23) after hospital presentation and at a median of 29 hours (IQR 23-41) after start of symptoms. Gallstones/sludge in the bile ducts were detected by EUS in 48/83 patients (58%), all of whom underwent immediate ERCP with ES. The primary endpoint occurred in 34/83 patients (41%) in the urgent EUS-guided ERCP group. This was not different from the 44% rate (50/113 patients) in the historical conservative treatment group (risk ratio (RR) 0.93, 95% CI 0.67 to 1.29; p=0.65). Sensitivity analysis to correct for baseline differences using a logistic regression model also showed no significant beneficial effect of the intervention on the primary outcome (adjusted OR 1.03, 95% CI 0.56 to 1.90, p=0.92). CONCLUSION In patients with predicted severe acute biliary pancreatitis without cholangitis, urgent EUS-guided ERCP with ES did not reduce the composite endpoint of major complications or mortality, as compared with conservative treatment in a historical control group. TRIAL REGISTRATION NUMBER ISRCTN15545919.
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Affiliation(s)
- Nora D Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Pauline M C Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Noord-Holland, The Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Vlietland Groep, Rotterdam, Zuid-Holland, The Netherlands
| | - Olaf J Bakker
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Thomas L Bollen
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - David W da Costa
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Sven M van Dijk
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology, Universtiy of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Methodology department, Amsterdam Public Health Research Institute, Amsterdam, North Holland, The Netherlands
| | - Brechje van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospitals, Apeldoorn, Gelderland, The Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | | | | | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Noord-Brabant, The Netherlands
| | - Robbert A Hollemans
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Frank J G M Kubben
- Department of Gastroenterology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, Overijssel, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, Zuid-Holland, The Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, Den Bosch, Noord-Brabant, The Netherlands
| | - Erik J Schoon
- Gastroenterology, Catharina Hospital, Eindhoven, The Netherlands
| | - Matthijs P Schwartz
- Department of Internal Medicine and Gastroenterology, Meander Medical Center, Amersfoort, The Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Xavier J N M Smeets
- Gastroenterology and Hepatology, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, Groningen, The Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Devica S Umans
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Heptatology, Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, The Netherlands
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Dutch Acute Pancreatitis Study Group, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht Universitair Medisch Centrum+, Maastricht, Limburg, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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4
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Mol B, van Munster KN, Bogaards JA, Weersma RK, Inderson A, de Groof EJ, Rossen NGM, Ponsioen W, Turkenburg M, van Erpecum KJ, Poen AC, Spanier BWM, Beuers UHW, Ponsioen CY. Health-related quality of life in patients with primary sclerosing cholangitis: A longitudinal population-based cohort study. Liver Int 2023; 43:1056-1067. [PMID: 36779848 DOI: 10.1111/liv.15542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND & AIMS Data regarding health-related quality of life (HRQoL) in primary sclerosing cholangitis (PSC) are sparse and have only been studied cross-sectionally in a disease which runs a fluctuating and unpredictable course. We aim to describe HRQoL longitudinally by using repeated measurements in a population-based cohort. METHODS Every 3 months from May 2017 up to August 2020, patients received digital questionnaires at home. These included the EQ-5D, 5-D Itch, patient-based SCCAI and patient-based HBI. The SF-36, measuring HRQoL over eight dimensions as well as a physical component summary (PCS) and mental component summary (MCS) score, was sent annually. Data were compared with Dutch reference data and a matched IBD disease control from the population-based POBASIC cohort. Mixed-effects modelling was performed to identify factors associated with HRQoL. RESULTS Three hundred twenty-eight patients completed 2576 questionnaires. A significant reduction of small clinical relevance in several mean HRQoL scores was found compared with the Dutch reference population: 46.4 versus 48.0, p = .018 for PCS and 47.5 versus 50.5, p = .004 for MCS scores. HRQoL outcomes were significantly negatively associated with coexisting active IBD (PCS -12.2, p < .001 and MCS -12.0, p < .001), which was not the case in case of quiescent IBD. Decreasing HRQoL scores were also negatively associated with increasing age (PCS -0.1 per 10 years, p = .002), female sex (PCS -2.8, p < .001), diagnosis of AIH overlap (PCS -3.7, p = .059), end-stage liver disease (PCS -3.7, p = .015) and presence of itch (PCS -9.2, p < .001 and MCS -3.1, p = .078). The odds of reporting a clinically relevant reduction in EQ-5D scores showed seasonal variation, being lowest in summer (OR = 0.48 relative to spring, p = .037). In patients with liver transplant, HRQoL outcomes were comparable to the Dutch general population. CONCLUSIONS PSC patients report impaired HRQoL of small clinical relevance compared with the general population. After liver transplantation, HRQoL scores are at comparable levels to the general population. HRQoL scores are associated with potentially modifiable factors such as itch and IBD activity.
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Affiliation(s)
- Bregje Mol
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Kim N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Johannes A Bogaards
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, location AMC, Amsterdam, the Netherlands
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - E Joline de Groof
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Noortje G M Rossen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Willemijn Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Maud Turkenburg
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, the Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Ulrich H W Beuers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Location AMC, Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
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5
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Schepers NJ, Hallensleben NDL, Besselink MG, Anten MPGF, Bollen TL, da Costa DW, van Delft F, van Dijk SM, van Dullemen HM, Dijkgraaf MGW, van Eijck CHJ, Erkelens GW, Erler NS, Fockens P, van Geenen EJM, van Grinsven J, Hollemans RA, van Hooft JE, van der Hulst RWM, Jansen JM, Kubben FJGM, Kuiken SD, Laheij RJF, Quispel R, de Ridder RJJ, Rijk MCM, Römkens TEH, Ruigrok CHM, Schoon EJ, Schwartz MP, Smeets XJNM, Spanier BWM, Tan ACITL, Thijs WJ, Timmer R, Venneman NG, Verdonk RC, Vleggaar FP, van de Vrie W, Witteman BJ, van Santvoort HC, Bakker OJ, Bruno MJ. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicentre randomised controlled trial. Lancet 2020; 396:167-176. [PMID: 32682482 DOI: 10.1016/s0140-6736(20)30539-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND It remains unclear whether urgent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy improves the outcome of patients with gallstone pancreatitis without concomitant cholangitis. We did a randomised trial to compare urgent ERCP with sphincterotomy versus conservative treatment in patients with predicted severe acute gallstone pancreatitis. METHODS In this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, patients with predicted severe (Acute Physiology and Chronic Health Evaluation II score ≥8, Imrie score ≥3, or C-reactive protein concentration >150 mg/L) gallstone pancreatitis without cholangitis were assessed for eligibility in 26 hospitals in the Netherlands. Patients were randomly assigned (1:1) by a web-based randomisation module with randomly varying block sizes to urgent ERCP with sphincterotomy (within 24 h after hospital presentation) or conservative treatment. The primary endpoint was a composite of mortality or major complications (new-onset persistent organ failure, cholangitis, bacteraemia, pneumonia, pancreatic necrosis, or pancreatic insufficiency) within 6 months of randomisation. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN97372133. FINDINGS Between Feb 28, 2013, and March 1, 2017, 232 patients were randomly assigned to urgent ERCP with sphincterotomy (n=118) or conservative treatment (n=114). One patient from each group was excluded from the final analysis because of cholangitis (urgent ERCP group) and chronic pancreatitis (conservative treatment group) at admission. The primary endpoint occurred in 45 (38%) of 117 patients in the urgent ERCP group and in 50 (44%) of 113 patients in the conservative treatment group (risk ratio [RR] 0·87, 95% CI 0·64-1·18; p=0·37). No relevant differences in the individual components of the primary endpoint were recorded between groups, apart from the occurrence of cholangitis (two [2%] of 117 in the urgent ERCP group vs 11 [10%] of 113 in the conservative treatment group; RR 0·18, 95% CI 0·04-0·78; p=0·010). Adverse events were reported in 87 (74%) of 118 patients in the urgent ERCP group versus 91 (80%) of 114 patients in the conservative treatment group. INTERPRETATION In patients with predicted severe gallstone pancreatitis but without cholangitis, urgent ERCP with sphincterotomy did not reduce the composite endpoint of major complications or mortality, compared with conservative treatment. Our findings support a conservative strategy in patients with predicted severe acute gallstone pancreatitis with an ERCP indicated only in patients with cholangitis or persistent cholestasis. FUNDING The Netherlands Organization for Health Research and Development, Fonds NutsOhra, and the Dutch Patient Organization for Pancreatic Diseases.
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Affiliation(s)
- Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands.
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Franciscus and Vlietland Hospital, Rotterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - David W da Costa
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Sven M van Dijk
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, Netherlands
| | - Marcel G W Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, Apeldoorn, Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Janneke van Grinsven
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | | | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | | | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Frank J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Robert J F Laheij
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, Netherlands
| | - Carola H M Ruigrok
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - Xavier J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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6
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van Grinsven J, van Dijk SM, Dijkgraaf MG, Boermeester MA, Bollen TL, Bruno MJ, van Brunschot S, Dejong CH, van Eijck CH, van Lienden KP, Boerma D, van Duijvendijk P, Hadithi M, Haveman JW, van der Hulst RW, Jansen JM, Lips DJ, Manusama ER, Molenaar IQ, van der Peet DL, Poen AC, Quispel R, Schaapherder AF, Schoon EJ, Schwartz MP, Seerden TC, Spanier BWM, Straathof JW, Venneman NG, van de Vrie W, Witteman BJ, van Goor H, Fockens P, van Santvoort HC, Besselink MG. Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial. Trials 2019; 20:239. [PMID: 31023380 PMCID: PMC6482524 DOI: 10.1186/s13063-019-3315-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/21/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Janneke van Grinsven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands. .,Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands.
| | - Sven M van Dijk
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands.,Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rottedam, Netherlands
| | - Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands.,NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Djamila Boerma
- Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands
| | | | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital Rotterdam, Rotterdam, Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - René W van der Hulst
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis Haarlem, Haarlem, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, OLVG Amsterdam, Amsterdam, Netherlands
| | - Daan J Lips
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Eric R Manusama
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Donald L van der Peet
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Clinics Zwolle, Zwolle, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis Delft, Delft, Netherlands
| | | | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center Amersfoort, Amersfoort, Netherlands
| | - Tom C Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital Breda, Breda, Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, Arnhem, Netherlands
| | - Jan Willem Straathof
- Department of Gastroenterology and Hepatology, Maxima Medical Center Veldhoven, Veldhoven, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente Enschede, Enschede, Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital Dordrecht, Dordrecht, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei Ede, Ede, Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center Nijmegen, Nijmegen, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, Netherlands.,Department of Surgery, University Medical Center Utrecht, Cancer Center, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, G4.196, PO Box 26000, 1105 AZ, Amsterdam, Netherlands.
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7
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Gevers TJG, Marcel Spanier BW, Veendrick PB, Vrolijk JM. Regression of hepatocellular adenoma after bariatric surgery in severe obese patients. Liver Int 2018; 38:2134-2136. [PMID: 30025198 DOI: 10.1111/liv.13934] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIM Obesity and metabolic syndrome are increasingly recognized as risk factors for hepatocellular adenomas (HCA). There is still sparse evidence whether weight loss or bariatric surgery could induce HCA regression in these patients. In this brief report we describe the effect of weight loss on HCA regression in severe obese patients that had undergone bariatric surgery in our centre. METHODS We performed an Electronic Patient Database search and included all patients who underwent bariatric surgery in our bariatric referral centre and had an ICD-10 code of benign neoplasm of liver in our centre from (2006-2017). All imaging studies of eligible patients were re-evaluated by the study radiologist. Primary outcome was change in maximal diameter of HCA. RESULTS Six of 11 eligible patients were excluded because their lesions were classified as probable focal nodular hyperplasia and two were lost to follow-up. Finally, three women with solitary (n = 1) or multiple HCA (n = 2) and a body mass index (BMI) ranging between 39 and 50 kg/m2 were included. In two patients, HCA completely regressed in 1-2 years following bariatric surgery, after BMI reductions of 36%-48%. The third patient showed a reduction of >50% in diameter of the largest HCA in 2.5 years after bariatric surgery (31% BMI reduction), with complete resolution of smaller HCA. CONCLUSIONS Bariatric induced weight loss results in significant regression of HCA in severe obese women, which emphasizes the role of overweight in HCA pathophysiology.
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Affiliation(s)
- Tom J G Gevers
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Peter B Veendrick
- Department of Radiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
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8
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Overwater A, Kessels K, Elias SG, Backes Y, Spanier BWM, Seerden TCJ, Pullens HJM, de Vos Tot Nederveen Cappel WH, van den Blink A, Offerhaus GJA, van Bergeijk J, Kerkhof M, Geesing JMJ, Groen JN, van Lelyveld N, Ter Borg F, Wolfhagen F, Siersema PD, Lacle MM, Moons LMG. Endoscopic resection of high-risk T1 colorectal carcinoma prior to surgical resection has no adverse effect on long-term outcomes. Gut 2018; 67:284-290. [PMID: 27811313 DOI: 10.1136/gutjnl-2015-310961] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 09/29/2016] [Accepted: 10/09/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE It is difficult to predict the presence of histological risk factors for lymph node metastasis (LNM) before endoscopic treatment of T1 colorectal cancer (CRC). Therefore, endoscopic therapy is propagated to obtain adequate histological staging. We examined whether secondary surgery following endoscopic resection of high-risk T1 CRC does not have a negative effect on patients' outcomes compared with primary surgery. DESIGN Patients with T1 CRC with one or more histological risk factors for LNM (high risk) and treated with primary or secondary surgery between 2000 and 2014 in 13 hospitals were identified in the Netherlands Cancer Registry. Additional data were collected from hospital records, endoscopy, radiology and pathology reports. A propensity score analysis was performed using inverse probability weighting (IPW) to correct for confounding by indication. RESULTS 602 patients were eligible for analysis (263 primary; 339 secondary surgery). Overall, 34 recurrences were observed (5.6%). After adjusting with IPW, no differences were observed between primary and secondary surgery for the presence of LNM (OR 0.97; 95% CI 0.49 to 1.93; p=0.940) and recurrence during follow-up (HR 0.97; 95% CI 0.41 to 2.34; p=0.954). Further adjusting for lymphovascular invasion, depth of invasion and number of retrieved lymph nodes did not alter this outcome. CONCLUSIONS Our data do not support an increased risk of LNM or recurrence after secondary surgery compared with primary surgery. Therefore, an attempt for an en-bloc resection of a possible T1 CRC without evident signs of deep invasion seems justified in order to prevent surgery of low-risk T1 CRC in a significant proportion of patients.
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Affiliation(s)
- A Overwater
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K Kessels
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Gastroenterology & Hepatology, Flevohospital, Almere, The Netherlands
| | - S G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Y Backes
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B W M Spanier
- Department of Gastroenterology & Hepatology, Rijnstate, Arnhem, The Netherlands
| | - T C J Seerden
- Department of Gastroenterology & Hepatology, Amphia Hospital, Breda, The Netherlands
| | - H J M Pullens
- Department of Gastroenterology & Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | | | - A van den Blink
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G J A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J van Bergeijk
- Department of Gastroenterology & Hepatology, Gelderse Vallei, Ede, The Netherlands
| | - M Kerkhof
- Department of Gastroenterology & Hepatology, Groene Hart Hospital, Gouda, The Netherlands
| | - J M J Geesing
- Department of Gastroenterology & Hepatology, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - J N Groen
- Department of Gastroenterology & Hepatology, St. Jansdal Harderwijk, Harderwijk, The Netherlands
| | - N van Lelyveld
- Department of Gastroenterology & Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - F Ter Borg
- Department of Gastroenterology & Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - F Wolfhagen
- Department of Gastroenterology & Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - P D Siersema
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M M Lacle
- Department of Gastroenterology & Hepatology, Isala, Zwolle, The Netherlands
| | - L M G Moons
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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9
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van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, van Eijck CH, Erkelens WG, van Goor H, van Grevenstein WMU, Haveman JW, Hofker SH, Jansen JM, Laméris JS, van Lienden KP, Meijssen MA, Mulder CJ, Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Römkens TE, Scheepers JJ, Schepers NJ, Schwartz MP, Seerden T, Spanier BWM, Straathof JWA, Strijker M, Timmer R, Venneman NG, Vleggaar FP, Voermans RP, Witteman BJ, Gooszen HG, Dijkgraaf MG, Fockens P. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391:51-58. [PMID: 29108721 DOI: 10.1016/s0140-6736(17)32404-2] [Citation(s) in RCA: 395] [Impact Index Per Article: 65.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/19/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes. METHODS In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711. FINDINGS Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio [RR] 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine [18%] patients in the endoscopy group vs six [13%] patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint. INTERPRETATION In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference. FUNDING The Dutch Digestive Disease Foundation, Fonds NutsOhra, and the Netherlands Organization for Health Research and Development.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
| | - Janneke van Grinsven
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands; Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Esther C Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands
| | - Cornelis H Dejong
- Department of Surgery and NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Jan-Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Sijbrand H Hofker
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Johan S Laméris
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Chris J Mulder
- Department of Gastroenterology, VU Medical Centre, Amsterdam, Netherlands
| | | | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Tessa E Römkens
- Department of Gastroenterology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | | | - Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology, Meander Medical Centre, Amersfoort, Netherlands
| | - Tom Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, Netherlands
| | | | | | - Marin Strijker
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Robin Timmer
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hein G Gooszen
- Department of OR/Evidence Based Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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10
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Backes Y, de Vos Tot Nederveen Cappel WH, van Bergeijk J, Ter Borg F, Schwartz MP, Spanier BWM, Geesing JMJ, Kessels K, Kerkhof M, Groen JN, Wolfhagen FHJ, Seerden TCJ, van Lelyveld N, Offerhaus GJA, Siersema PD, Lacle MM, Moons LMG. Risk for Incomplete Resection after Macroscopic Radical Endoscopic Resection of T1 Colorectal Cancer: A Multicenter Cohort Study. Am J Gastroenterol 2017; 112:785-796. [PMID: 28323275 DOI: 10.1038/ajg.2017.58] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 01/02/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The decision to perform secondary surgery after endoscopic resection of T1 colorectal cancer (CRC) depends on the risk of lymph node metastasis and the risk of incomplete resection. We aimed to examine the incidence and risk factors for incomplete endoscopic resection of T1 CRC after a macroscopic radical endoscopic resection. METHODS Data from patients treated between 2000 and 2014 with macroscopic complete endoscopic resection of T1 CRC were collected from 13 hospitals. Incomplete resection was defined as local recurrence at the polypectomy site during follow-up or malignant tissue in the surgically resected specimen in case secondary surgery was performed. Multivariate regression analysis was performed to analyze factors associated with incomplete resection. RESULTS In total, 877 patients with a median follow-up time of 36.5 months (interquartile range 16.0-68.3) were included, in whom secondary surgery was performed in 358 patients (40.8%). Incomplete resection was observed in 30 patients (3.4%; 95% confidence interval (CI) 2.3-4.6%). Incomplete resection rate was 0.7% (95% CI 0-2.1%) in low-risk T1 CRC vs. 4.4% (95% CI 2.7-6.5%) in high-risk T1 CRC (P=0.04). Overall adverse outcome rate (incomplete resection or metastasis) was 2.1% (95% CI 0-5.0%) in low-risk T1 CRC vs. 11.7% (95% CI 8.8-14.6%) in high-risk T1 CRC (P=0.001). Piecemeal resection (adjusted odds ratio 2.60; 95% CI 1.20-5.61, P=0.02) and non-pedunculated morphology (adjusted odds ratio 2.18; 95% CI 1.01-4.70, P=0.05) were independent risk factors for incomplete resection. Among patients in whom no additional surgery was performed, who developed recurrent cancer, 41.7% (95% CI 20.8-62.5%) died as a result of recurrent cancer. CONCLUSIONS In the absence of histological high-risk factors, a 'wait-and-see' policy with limited follow-up is justified. Piecemeal resection and non-pedunculated morphology are independent risk factors for incomplete endoscopic resection of T1 CRC.
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Affiliation(s)
- Y Backes
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - J van Bergeijk
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - F Ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - M P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, The Netherlands
| | - B W M Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - J M J Geesing
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, The Netherlands
| | - K Kessels
- Department of Gastroenterology and Hepatology, Flevo Hospital, Almere, The Netherlands
| | - M Kerkhof
- Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, The Netherlands
| | - J N Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal Hospital, Harderwijk, The Netherlands
| | - F H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - T C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - N van Lelyveld
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - G J A Offerhaus
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands.,Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M M Lacle
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - L M G Moons
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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11
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Coenen S, van Meer S, Vrolijk JM, Richter C, van Erpecum KJ, Mostert MC, Veldhuijzen IK, Reijnders JGP, van Soest H, Dirksen K, Drenth JPH, Koene RPM, Bosschart M, Friederich P, Ter Borg MJ, Daemen RHPJ, Arends JE, Verhagen MAMT, Schout C, Spanier BWM. Clinical impact of five large-scale screening projects for chronic hepatitis B in Chinese migrants in the Netherlands. Liver Int 2016; 36:1425-32. [PMID: 27001619 DOI: 10.1111/liv.13125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/09/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In low-endemic countries it is debated whether first-generation migrants should be screened for chronic hepatitis B infection. We describe the clinical impact of five large-scale Dutch screening projects for hepatitis B in first-generation Chinese migrants. METHODS Between 2009 and 2013 five independent outreach screening projects for hepatitis B targeting first-generation Chinese migrants were conducted in five main Dutch regions. To explore the relevance of our screening we defined clinical impact as the presence of an indication for: (i) antiviral therapy, (ii) strict follow-up because of high hepatitis B DNA levels and/or (iii) surveillance for hepatocellular carcinoma. RESULTS In total, 4423 persons participated in the projects of whom 6.0% (n = 264) were HBsAg positive. One hundred and twenty-nine newly diagnosed HBsAg-positive patients were analysed in specialist care. Among these patients prevalence of cirrhosis was 6.9% and antiviral therapy for hepatitis B was started in 32 patients (25%). In patients without a treatment indication, strict follow-up because of high hepatitis B DNA levels and/or surveillance for hepatocellular carcinoma was considered indicated in 64 patients (50%). CONCLUSIONS In our screening project in first-generation Chinese migrants, antiviral treatment, strict follow-up because of high hepatitis B DNA levels and/or surveillance for hepatocellular carcinoma were considered indicated in three of four analysed HBsAg-positive patients. These data show that detection of hepatitis B in Chinese migrants can have considerable impact on patient care.
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Affiliation(s)
- Sandra Coenen
- Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands.
| | - Suzanne van Meer
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan M Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | - Clemens Richter
- Department of Internal Medicine and Infectious diseases, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marijke C Mostert
- Department of Infectious Disease Control, Municipal Health Services, Rotterdam, the Netherlands
| | - Irene K Veldhuijzen
- Department of Infectious Disease Control, Municipal Health Services, Rotterdam, the Netherlands
| | - Jurriën G P Reijnders
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Hanneke van Soest
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden The Hague, The Hague, the Netherlands
| | - Kees Dirksen
- Department of Infectious Disease Control, Municipal Health Services, The Hague, the Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboudumc Nijmegen, Nijmegen, the Netherlands
| | - René P M Koene
- Department of Infectious Disease Control, Municipal Health Services, Gelderland Zuid, the Netherlands
| | - Maaike Bosschart
- Department of Infectious Disease Control, Municipal Health Services, Gelderland Midden, the Netherlands
| | - Pieter Friederich
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Martijn J Ter Borg
- Department of Gastroenterology and Hepatology, Maxima Medical Center Eindhoven, Eindhoven, the Netherlands
| | - Rick H P J Daemen
- Departments of Infectious Disease Control, Municipal Health Services, Eindhoven, the Netherlands
| | - Joop E Arends
- Department of Internal Medicine and Infectious diseases, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marc A M T Verhagen
- Department of Gastroenterology and Hepatology, Diakonessen Hospital Utrecht, Utrecht, the Netherlands
| | - Christine Schout
- Departments of Infectious Disease Control, Municipal Health Services, Utrecht, the Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
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12
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Backes Y, Moons LMG, van Bergeijk JD, Berk L, Ter Borg F, Ter Borg PCJ, Elias SG, Geesing JMJ, Groen JN, Hadithi M, Hardwick JCH, Kerkhof M, Mangen MJJ, Straathof JWA, Schröder R, Schwartz MP, Spanier BWM, de Vos Tot Nederveen Cappel WH, Wolfhagen FHJ, Koch AD. Endoscopic mucosal resection (EMR) versus endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas (MATILDA-trial): rationale and design of a multicenter randomized clinical trial. BMC Gastroenterol 2016; 16:56. [PMID: 27229709 PMCID: PMC4882830 DOI: 10.1186/s12876-016-0468-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/14/2016] [Indexed: 02/08/2023] Open
Abstract
Background Endoscopic mucosal resection (EMR) is currently the most used technique for resection of large distal colorectal polyps. However, in large lesions EMR can often only be performed in a piecemeal fashion resulting in relatively low radical (R0)-resection rates and high recurrence rates. Endoscopic submucosal dissection (ESD) is a newer procedure that is more difficult resulting in a longer procedural time, but is promising due to the high en-bloc resection rates and the very low recurrence rates. We aim to evaluate the (cost-)effectiveness of ESD against EMR on both short (i.e. 6 months) and long-term (i.e. 36 months). We hypothesize that in the short-run ESD is more time consuming resulting in higher healthcare costs, but is (cost-) effective on the long-term due to lower patients burden, a higher number of R0-resections and lower recurrence rates with less need for repeated procedures. Methods This is a multicenter randomized clinical trial in patients with a non-pedunculated polyp larger than 20 mm in the rectum, sigmoid, or descending colon suspected to be an adenoma by means of endoscopic assessment. Primary endpoint is recurrence rate at follow-up colonoscopy at 6 months. Secondary endpoints are R0-resection rate, perceived burden and quality of life, healthcare resources utilization and costs, surgical referral rate, complication rate and recurrence rate at 36 months. Quality-adjusted-life-year (QALY) will be estimated taking an area under the curve approach and using EQ-5D-indexes. Healthcare costs will be calculated by multiplying used healthcare services with unit prices. The cost-effectiveness of ESD against EMR will be expressed as incremental cost-effectiveness ratios (ICER) showing additional costs per recurrence free patient and as ICER showing additional costs per QALY. Discussion If this trial confirms ESD to be favorable on the long-term, the burden of extra colonoscopies and repeated procedures can be prevented for future patients. Trial registration NCT02657044 (Clinicaltrials.gov), registered January 8, 2016.
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Affiliation(s)
- Y Backes
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3508, GA, Utrecht, Netherlands
| | - L M G Moons
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3508, GA, Utrecht, Netherlands.
| | - J D van Bergeijk
- Department of Gastroenterology & Hepatology, Gelderse Vallei, Ede, Netherlands
| | - L Berk
- Department of Gastroenterology & Hepatology, Sint Franciscus, Rotterdam, Netherlands
| | - F Ter Borg
- Department of Gastroenterology & Hepatology, Deventer Hospital, Deventer, Netherlands
| | - P C J Ter Borg
- Department of Gastroenterology & Hepatology, Ikazia, Rotterdam, Netherlands
| | - S G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - J M J Geesing
- Department of Gastroenterology & Hepatology, Diakonessenhuis, Utrecht, Netherlands
| | - J N Groen
- Department of Gastroenterology & Hepatology, Sint Jansdal, Harderwijk, Netherlands
| | - M Hadithi
- Department of Gastroenterology & Hepatology, Maasstad hospital, Rotterdam, Netherlands
| | - J C H Hardwick
- Department of Gastroenterology & Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - M Kerkhof
- Department of Gastroenterology & Hepatology, Groene Hart Hospital, Gouda, Netherlands
| | - M J J Mangen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - J W A Straathof
- Department of Gastroenterology & Hepatology, Máxima Medical Center, Eindhoven, Netherlands
| | - R Schröder
- Department of Gastroenterology & Hepatology, Gelre Hospital, Apeldoorn, Netherlands
| | - M P Schwartz
- Department of Gastroenterology & Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - B W M Spanier
- Department of Gastroenterology & Hepatology, Rijnstate hospital, Arnhem, Netherlands
| | | | - F H J Wolfhagen
- Department of Gastroenterology & Hepatology, Albert Schweitzer, Dordrecht, Netherlands
| | - A D Koch
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
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13
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Schepers NJ, Bakker OJ, Besselink MGH, Bollen TL, Dijkgraaf MGW, van Eijck CHJ, Fockens P, van Geenen EJM, van Grinsven J, Hallensleben NDL, Hansen BE, van Santvoort HC, Timmer R, Anten MPGF, Bolwerk CJM, van Delft F, van Dullemen HM, Erkelens GW, van Hooft JE, Laheij R, van der Hulst RWM, Jansen JM, Kubben FJGM, Kuiken SD, Perk LE, de Ridder RJJ, Rijk MCM, Römkens TEH, Schoon EJ, Schwartz MP, Spanier BWM, Tan ACITL, Thijs WJ, Venneman NG, Vleggaar FP, van de Vrie W, Witteman BJ, Gooszen HG, Bruno MJ. Early biliary decompression versus conservative treatment in acute biliary pancreatitis (APEC trial): study protocol for a randomized controlled trial. Trials 2016; 17:5. [PMID: 26729193 PMCID: PMC4700728 DOI: 10.1186/s13063-015-1132-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 12/17/2015] [Indexed: 01/25/2023] Open
Abstract
Background Acute pancreatitis is mostly caused by gallstones or sludge. Early decompression of the biliary tree by endoscopic retrograde cholangiography (ERC) with sphincterotomy may improve outcome in these patients. Whereas current guidelines recommend early ERC in patients with concomitant cholangitis, early ERC is not recommended in patients with mild biliary pancreatitis. Evidence on the role of routine early ERC with endoscopic sphincterotomy in patients without cholangitis but with biliary pancreatitis at high risk for complications is lacking. We hypothesize that early ERC with sphincterotomy improves outcome in these patients. Methods/Design The APEC trial is a randomized controlled, parallel group, superiority multicenter trial. Within 24 hours after presentation to the emergency department, patients with biliary pancreatitis without cholangitis and at high risk for complications, based on an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 8 or greater, Modified Glasgow score of 3 or greater, or serum C-reactive protein above 150 mg/L, will be randomized. In 27 hospitals of the Dutch Pancreatitis Study Group, 232 patients will be allocated to early ERC with sphincterotomy or to conservative treatment. The primary endpoint is a composite of major complications (that is, organ failure, pancreatic necrosis, pneumonia, bacteremia, cholangitis, pancreatic endocrine, or exocrine insufficiency) or death within 180 days after randomization. Secondary endpoints include ERC-related complications, infected necrotizing pancreatitis, length of hospital stay and an economical evaluation. Discussion The APEC trial investigates whether an early ERC with sphincterotomy reduces the composite endpoint of major complications or death compared with conservative treatment in patients with biliary pancreatitis at high risk of complications. Trial registration Current Controlled Trials ISRCTN97372133 (date registration: 17-12-2012) Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1132-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands. .,Department of Gastroenterology and Hepatology, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, PO 85500, 3508, GA, Utrecht, The Netherlands.
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Marcel G W Dijkgraaf
- Clinical Research Unit, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, HP 690, PO 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Janneke van Grinsven
- Department of Surgery, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands. .,Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands. .,Department of Surgery, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Gasthuis, PO 10900, 3004, BA, Rotterdam, The Netherlands.
| | - Clemens J M Bolwerk
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Reinier de Graafweg 3-11, 2625, AD, Delft, The Netherlands.
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, VU University Medical Center Amsterdam, PO Box 7057, 1007, MB, Amsterdam, The Netherlands.
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, PO 30001, 9700, RB, Groningen, The Netherlands.
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, PO 9014, 7300, DS, Apeldoorn, The Netherlands.
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Robert Laheij
- Department of Gastroenterology and Hepatology, St. Elisabeth Hospital, PO 90151, 5000, LC, Tilburg, The Netherlands.
| | - René W M van der Hulst
- Department of Gastroenterology and Hepatology, Kennemer Gasthuis, PO 417, 2000, AK, Haarlem, The Netherlands.
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Postbus 95500, 1090, HM, Amsterdam, The Netherlands.
| | - Frank J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Maasstadweg 21, 3079, DZ, Rotterdam, The Netherlands.
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, Sint Lucas Andreas Hospital, PO 9243, 1006, AE, Amsterdam, The Netherlands.
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden, PO 432, 2501, CK Den Haag, The Netherlands.
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, PO 5800, 6202, AZ, Maastricht, The Netherlands.
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, PO 90158, 4800, RK, Breda, The Netherlands.
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, PO 90153, 5200, ME 's-Hertogenbosch, The Netherlands.
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, PO 1350, 5602, ZA, Eindhoven, The Netherlands.
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, PO 1502, 3800, BM, Amersfoort, The Netherlands.
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, PO 9555, 6800, TA, Arnhem, The Netherlands.
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina Hospital, PO 9015, 6500, GS, Nijmegen, The Netherlands.
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, PO 30033, 9700, RM, Groningen, The Netherlands.
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO 50000, 7500, KA, Enschede, The Netherlands.
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, PO 85500, 3508, GA, Utrecht, The Netherlands.
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, PO 444, 3300, AK, Dordrecht, The Netherlands.
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei Ede, PO 9025, 6710, HN, Ede, The Netherlands.
| | - Hein G Gooszen
- Department of Operating Rooms - Evidence Based Surgery, Radboud University Nijmegen Medical Centre, HP 690, PO 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
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14
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da Costa DW, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, van Brunschot S, Bakker OJ, Bollen TL, Dejong CH, van Goor H, Boermeester MA, Bruno MJ, van Eijck CH, Timmer R, Weusten BL, Consten EC, Brink MA, Spanier BWM, Bilgen EJS, Nieuwenhuijs VB, Hofker HS, Rosman C, Voorburg AM, Bosscha K, van Duijvendijk P, Gerritsen JJ, Heisterkamp J, de Hingh IH, Witteman BJ, Kruyt PM, Scheepers JJ, Molenaar IQ, Schaapherder AF, Manusama ER, van der Waaij LA, van Unen J, Dijkgraaf MG, van Ramshorst B, Gooszen HG, Boerma D. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet 2015; 386:1261-1268. [PMID: 26460661 DOI: 10.1016/s0140-6736(15)00274-3] [Citation(s) in RCA: 192] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients with mild gallstone pancreatitis, cholecystectomy during the same hospital admission might reduce the risk of recurrent gallstone-related complications, compared with the more commonly used strategy of interval cholecystectomy. However, evidence to support same-admission cholecystectomy is poor, and concerns exist about an increased risk of cholecystectomy-related complications with this approach. In this study, we aimed to compare same-admission and interval cholecystectomy, with the hypothesis that same-admission cholecystectomy would reduce the risk of recurrent gallstone-related complications without increasing the difficulty of surgery. METHODS For this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, inpatients recovering from mild gallstone pancreatitis at 23 hospitals in the Netherlands (with hospital discharge foreseen within 48 h) were assessed for eligibility. Adult patients (aged ≥18 years) were eligible for randomisation if they had a serum C-reactive protein concentration less than 100 mg/L, no need for opioid analgesics, and could tolerate a normal oral diet. Patients with American Society of Anesthesiologists (ASA) class III physical status who were older than 75 years of age, all ASA class IV patients, those with chronic pancreatitis, and those with ongoing alcohol misuse were excluded. A central study coordinator randomly assigned eligible patients (1:1) by computer-based randomisation, with varying block sizes of two and four patients, to cholecystectomy within 3 days of randomisation (same-admission cholecystectomy) or to discharge and cholecystectomy 25-30 days after randomisation (interval cholecystectomy). Randomisation was stratified by centre and by whether or not endoscopic sphincterotomy had been done. Neither investigators nor participants were masked to group assignment. The primary endpoint was a composite of readmission for recurrent gallstone-related complications (pancreatitis, cholangitis, cholecystitis, choledocholithiasis needing endoscopic intervention, or gallstone colic) or mortality within 6 months after randomisation, analysed by intention to treat. The trial was designed to reduce the incidence of the primary endpoint from 8% in the interval group to 1% in the same-admission group. Safety endpoints included bile duct leakage and other complications necessitating re-intervention. This trial is registered with Current Controlled Trials, number ISRCTN72764151, and is complete. FINDINGS Between Dec 22, 2010, and Aug 19, 2013, 266 inpatients from 23 hospitals in the Netherlands were randomly assigned to interval cholecystectomy (n=137) or same-admission cholecystectomy (n=129). One patient from each group was excluded from the final analyses, because of an incorrect diagnosis of pancreatitis in one patient (in the interval group) and discontinued follow-up in the other (in the same-admission group). The primary endpoint occurred in 23 (17%) of 136 patients in the interval group and in six (5%) of 128 patients in the same-admission group (risk ratio 0·28, 95% CI 0·12-0·66; p=0·002). Safety endpoints occurred in four patients: one case of bile duct leakage and one case of postoperative bleeding in each group. All of these were serious adverse events and were judged to be treatment related, but none led to death. INTERPRETATION Compared with interval cholecystectomy, same-admission cholecystectomy reduced the rate of recurrent gallstone-related complications in patients with mild gallstone pancreatitis, with a very low risk of cholecystectomy-related complications. FUNDING Dutch Digestive Disease Foundation.
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Affiliation(s)
- David W da Costa
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Stefan A Bouwense
- Department of Operating Room/Evidence-Based Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicolien J Schepers
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands; Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | | | | | - Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Robin Timmer
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Bas L Weusten
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Esther C Consten
- Department of Surgery, Meander Medical Center, Amersfoort, Netherlands
| | - Menno A Brink
- Department of Gastroenterology, Meander Medical Center, Amersfoort, Netherlands
| | | | | | | | - H Sijbrand Hofker
- Department of Surgery, University Medical Center Groningen, Netherlands
| | - Camiel Rosman
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands
| | - Annet M Voorburg
- Department of Gastroenterology, Diakonessenhuis, Utrecht, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | | | - Jos J Gerritsen
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | | | | | - Ben J Witteman
- Department of Gastroenterology, Gelderse Vallei Hospital, Ede, Netherlands
| | - Philip M Kruyt
- Department of Surgery, Gelderse Vallei Hospital, Ede, Netherlands
| | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Hospital, Delft, Netherlands
| | | | | | - Eric R Manusama
- Department of Surgery, Medical Center Leeuwarden, Netherlands
| | | | - Jacco van Unen
- Department of Surgery, Laurentius Hospital, Roermond, Netherlands
| | | | | | - Hein G Gooszen
- Department of Operating Room/Evidence-Based Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands.
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15
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Ahmed Ali U, Issa Y, van Goor H, van Eijck CH, Nieuwenhuijs VB, Keulemans Y, Fockens P, Busch OR, Drenth JP, Dejong CH, van Dullemen HM, van Hooft JE, Siersema PD, Spanier BWM, Poley JW, Poen AC, Timmer R, Seerden T, Tan AC, Thijs WJ, Witteman BJM, Romkens TEH, Roeterdink AJ, Gooszen HG, van Santvoort HC, Bruno MJ, Boermeester MA. Dutch Chronic Pancreatitis Registry (CARE): design and rationale of a nationwide prospective evaluation and follow-up. Pancreatology 2014; 15:46-52. [PMID: 25511908 DOI: 10.1016/j.pan.2014.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 10/30/2014] [Accepted: 11/14/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic pancreatitis is a complex disease with many unanswered questions regarding the natural history and therapy. Prospective longitudinal studies with long-term follow-up are warranted. METHODS The Dutch Chronic Pancreatitis Registry (CARE) is a nationwide registry aimed at prospective evaluation and follow-up of patients with chronic pancreatitis. All patients with (suspected) chronic or recurrent pancreatitis are eligible for CARE. Patients are followed-up by yearly questionnaires and review of medical records. Study outcomes are pain, disease complications, quality of life, and pancreatic function. The target sample size was set at 500 for the first year and 1000 patients within 3 years. RESULTS A total of 1218 patients were included from February 2010 until June 2013 by 76 participating surgeons and gastroenterologist from 33 hospitals. Participation rate was 90% of eligible patients. Eight academic centers included 761 (62%) patients, while 25 community hospitals included 457 (38%). Patient centered outcomes were assessed by yearly questionnaires, which had a response rate of 85 and 82% for year 1 and 2, respectively. The median age of patients was 58 years, 814 (67%) were male, and 38% had symptoms for less than 5 years. DISCUSSION The CARE registry has successfully recruited over 1200 patients with chronic and recurrent pancreatitis in about 3 years. The defined inclusion criteria ensure patients are included at an early disease stage. Participation and compliance rates are high. CARE offers a unique opportunity with sufficient power to investigate many clinical questions regarding natural course, complications, and efficacy and timing of treatment strategies.
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Affiliation(s)
- U Ahmed Ali
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands.
| | - Y Issa
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - H van Goor
- Department of Surgery, RadboudUMC, Nijmegen, Netherlands
| | - C H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Y Keulemans
- Department of Gastroenterology, Maastricht University Medical Center, Maastricht, Netherlands
| | - P Fockens
- Department of Gastroenterology, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - O R Busch
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - J P Drenth
- Department of Gastroenterology, RadboudUMC, Nijmegen, Netherlands
| | - C H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - H M van Dullemen
- Department of Gastroenterology, University Medical Center Groningen, Groningen, Netherlands
| | - J E van Hooft
- Department of Gastroenterology, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - P D Siersema
- Department of Gastroenterology, University Medical Center Utrecht, Utrecht, Netherlands
| | - B W M Spanier
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, Netherlands
| | - J W Poley
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, Netherlands
| | - A C Poen
- Department of Gastroenterology, Isala Clinics, Zwolle, Netherlands
| | - R Timmer
- Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - T Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, Netherlands
| | - A C Tan
- Department of Gastroenterology, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands
| | - W J Thijs
- Department of Gastroenterology, Martini Hospital, Groningen, Netherlands
| | - B J M Witteman
- Department of Gastroenterology, Gelderse Vallei Hospital, Ede, Netherlands
| | - T E H Romkens
- Department of Gastroenterology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - A J Roeterdink
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - H G Gooszen
- Department of OR and Evidence Based Surgery, RadboudUMC, Nijmegen, Netherlands
| | - H C van Santvoort
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - M J Bruno
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
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Bakker OJ, van Brunschot S, van Santvoort HC, Besselink MG, Bollen TL, Boermeester MA, Dejong CH, van Goor H, Bosscha K, Ahmed Ali U, Bouwense S, van Grevenstein WM, Heisterkamp J, Houdijk AP, Jansen JM, Karsten TM, Manusama ER, Nieuwenhuijs VB, Schaapherder AF, van der Schelling GP, Schwartz MP, Spanier BWM, Tan A, Vecht J, Weusten BL, Witteman BJ, Akkermans LM, Bruno MJ, Dijkgraaf MG, van Ramshorst B, Gooszen HG. Early versus on-demand nasoenteric tube feeding in acute pancreatitis. N Engl J Med 2014; 371:1983-93. [PMID: 25409371 DOI: 10.1056/nejmoa1404393] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Early enteral feeding through a nasoenteric feeding tube is often used in patients with severe acute pancreatitis to prevent gut-derived infections, but evidence to support this strategy is limited. We conducted a multicenter, randomized trial comparing early nasoenteric tube feeding with an oral diet at 72 hours after presentation to the emergency department in patients with acute pancreatitis. METHODS We enrolled patients with acute pancreatitis who were at high risk for complications on the basis of an Acute Physiology and Chronic Health Evaluation II score of 8 or higher (on a scale of 0 to 71, with higher scores indicating more severe disease), an Imrie or modified Glasgow score of 3 or higher (on a scale of 0 to 8, with higher scores indicating more severe disease), or a serum C-reactive protein level of more than 150 mg per liter. Patients were randomly assigned to nasoenteric tube feeding within 24 hours after randomization (early group) or to an oral diet initiated 72 hours after presentation (on-demand group), with tube feeding provided if the oral diet was not tolerated. The primary end point was a composite of major infection (infected pancreatic necrosis, bacteremia, or pneumonia) or death during 6 months of follow-up. RESULTS A total of 208 patients were enrolled at 19 Dutch hospitals. The primary end point occurred in 30 of 101 patients (30%) in the early group and in 28 of 104 (27%) in the on-demand group (risk ratio, 1.07; 95% confidence interval, 0.79 to 1.44; P=0.76). There were no significant differences between the early group and the on-demand group in the rate of major infection (25% and 26%, respectively; P=0.87) or death (11% and 7%, respectively; P=0.33). In the on-demand group, 72 patients (69%) tolerated an oral diet and did not require tube feeding. CONCLUSIONS This trial did not show the superiority of early nasoenteric tube feeding, as compared with an oral diet after 72 hours, in reducing the rate of infection or death in patients with acute pancreatitis at high risk for complications. (Funded by the Netherlands Organization for Health Research and Development and others; PYTHON Current Controlled Trials number, ISRCTN18170985.).
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Affiliation(s)
- Olaf J Bakker
- The authors' affiliations are listed in the Appendix
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17
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Boonstra K, Weersma RK, van Erpecum KJ, Rauws EA, Spanier BWM, Poen AC, van Nieuwkerk KM, Drenth JP, Witteman BJ, Tuynman HA, Naber AH, Kingma PJ, van Buuren HR, van Hoek B, Vleggaar FP, van Geloven N, Beuers U, Ponsioen CY. Population-based epidemiology, malignancy risk, and outcome of primary sclerosing cholangitis. Hepatology 2013; 58:2045-55. [PMID: 23775876 DOI: 10.1002/hep.26565] [Citation(s) in RCA: 427] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 05/27/2013] [Indexed: 12/11/2022]
Abstract
UNLABELLED Extensive population-based studies are much needed to accurately establish epidemiology and disease course in patients with primary sclerosing cholangitis (PSC). We aimed to obtain population-based prevalence and incidence figures, insight in disease course with regard to survival, liver transplantation (LT), and occurrence of malignancies, as well as risk factors thereof. Four independent hospital databases were searched in 44 hospitals in a large geographically defined area of the Netherlands, comprising 50% of the population. In addition, all PSC patients in the three Dutch liver transplant centers and all inflammatory bowel disease (IBD) patients in the adherence area of a large district hospital were identified. All medical records were reviewed on-site, verifying diagnosis. Five hundred and ninety PSC patients were identified, resulting in an incidence of 0.5 and a point prevalence of 6.0 per 100,000. Median follow up was 92 months. Estimated median survival from diagnosis until LT or PSC-related death in the entire cohort was 21.3 years, as opposed to 13.2 years in the combined transplant centers cohort (n = 422; P < 0.0001). Colorectal carcinoma (CRC) risk was 10-fold increased, as compared to ulcerative colitis controls, and developed at a much younger age (39 years; range, 26-64), compared to IBD controls (59 years; range, 34-73; P = 0.019). Colonoscopic surveillance was associated with significantly better outcome. CONCLUSION This study exemplifies that, for relatively rare diseases, it is paramount to collect observational data from large, population-based cohorts, because incidence and prevalence rates of PSC are markedly lower and survival much longer than previously reported. The selection of a bias-free, population-based cohort showed a significantly longer survival, compared to the tertiary referral cohort. CRC can develop at an early age, warranting surveillance from time of PSC diagnosis.
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Affiliation(s)
- Kirsten Boonstra
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
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18
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van Brunschot S, van Grinsven J, Voermans RP, Bakker OJ, Besselink MGH, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, Dijkgraaf MGW, van Eijck CH, Erkelens GW, van Goor H, Hadithi M, Haveman JW, Hofker SH, Jansen JJM, Laméris JS, van Lienden KP, Manusama ER, Meijssen MA, Mulder CJ, Nieuwenhuis VB, Poley JW, de Ridder RJ, Rosman C, Schaapherder AF, Scheepers JJ, Schoon EJ, Seerden T, Spanier BWM, Straathof JWA, Timmer R, Venneman NG, Vleggaar FP, Witteman BJ, Gooszen HG, van Santvoort HC, Fockens P. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol 2013; 13:161. [PMID: 24274589 PMCID: PMC4222267 DOI: 10.1186/1471-230x-13-161] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/13/2013] [Indexed: 02/06/2023] Open
Abstract
Background Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes. Methods/Design The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs. Discussion The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, The Netherlands.
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Burger JPW, Groenen MJM, Spanier BWM. A rare cause of colitis. Gastroenterology 2013; 145:e8-e9. [PMID: 23727483 DOI: 10.1053/j.gastro.2013.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 03/19/2013] [Accepted: 03/27/2013] [Indexed: 12/02/2022]
Affiliation(s)
- Jordy P W Burger
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Marcel J M Groenen
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, The Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, The Netherlands
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21
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Derikx MHM, Spanier BWM, Vrolijk JM. [Hepatitis B; sometimes co-infection with hepatitis D]. Ned Tijdschr Geneeskd 2011; 155:A3513. [PMID: 21854665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND The Hepatitis delta virus (HDV) is a defect RNA virus that requires the presence of the hepatitis B virus (HBV) for cellular infection. Worldwide, 350 million people are infected with HBV; 5% of these are superinfected with HDV. A chronic superinfection with HDV has a higher morbidity and mortality rate. It is clinically difficult to differentiate between an HBV and an HDV infection. Diagnosis is made via detection of HDV antibodies and HDV-RNA using PCR techniques. The only treatment option is peginterferon-alpha 180 μg subcutaneously once a week for 48 weeks. CASE DESCRIPTION A 37-year-old man with a Syrian background and a chronic HBV infection presented with high levels of ALT indicating severe hepatitis. The level of detected HBV-DNA-particles was low, however, indicating that the HBV infection alone could not be responsible for the inflammation. Further investigations revealed a superinfection with HDV. The patient was successfully treated with peginterferon-alpha. CONCLUSION Severe hepatitis (high ALT level) in combination with a low HBV-DNA-particle level can indicate a HDV superinfection.
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Spanier BWM, Nio Y, van der Hulst RWM, Tuynman HARE, Dijkgraaf MGW, Bruno MJ. Practice and yield of early CT scan in acute pancreatitis: a Dutch Observational Multicenter Study. Pancreatology 2010; 10:222-8. [PMID: 20484959 DOI: 10.1159/000243731] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Accepted: 09/21/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early computed tomography (CT) (within 4 full days after symptom onset) may be performed to distinguish acute pancreatitis (AP) from other intra-abdominal conditions or to identify early pancreatic necrosis. We analyzed practice and yield of early CT in patients with an established clinical diagnosis of AP in a Dutch cohort (EARL study). METHODS Multicenter observational study. Etiology, disease course, CT timing, Balthazar CT score, and clinical management were evaluated. RESULTS First documented hospital admissions of 166 patients were analyzed. Etiology was biliary (42.8%), unknown (20.5%), alcoholic (18.1%), post-endoscopic retrograde cholangiopancreatography (11.4%), and miscellaneous (7.2%). In 89.2% (148/166), the disease course was mild. Out of 18 patients with severe AP, 11 eventually developed (peri)pancreatic necrosis. At least one CT (range 1-12) was performed in 47% (78/166) of all patients and in 62.8% (49/78) it was acquired within 4 full days after symptom onset. Practice, timing, and Balthazar CT score of early CTs were not significantly different between mild and severe AP. None of the early CTs showed necrosis and no alternative diagnoses were established. In 89.8% (44/49), clinical management was not altered after early CT. In 10.2% (5/49), prophylactic antibiotics were started, but in absence of necrosis. CONCLUSIONS A CT scan was frequently acquired early in the course of AP, but its yield was low and had no implications with regard to clinical management. It seems prudent that clinicians should be more restrictive in the use of early CT, in particular in mild AP, to prevent unnecessary radiation exposure and to save costs.
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Affiliation(s)
- B W M Spanier
- Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands.
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Spanier BWM, Mathus-Vliegen EMH, Tuynman HARE, Van der Hulst RWM, Dijkgraaf MGW, Bruno MJ. Nutritional management of patients with acute pancreatitis: a Dutch observational multicentre study. Aliment Pharmacol Ther 2008; 28:1159-65. [PMID: 18657130 DOI: 10.1111/j.1365-2036.2008.03814.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Following a nil per os (NPO) regimen, most patients with acute pancreatitis (AP) can resume normal oral intake within 1 week. If not tolerated, it is recommended to initiate artificial feeding, preferably by the enteral route. AIM To evaluate the nutritional management of patients with AP in a Dutch cohort (EARL study). METHODS Observational study in 18 hospitals. Total days of NPO, tube feeding (TF) with/without oral feeding, total parenteral nutrition (TPN) and total starvation time were analysed. RESULTS In mild AP, a majority of cases (80.7%, 117/145) were managed with an NPO regimen only. Twenty-seven patients (18.6%) with mild AP additionally received TF; one received TPN. Of those with severe AP, more than half of the patients (56.2%, nine of 16) were treated with TF besides an NPO regimen; four received TPN. TF was delivered preferably via the jejunal route. The median period of total starvation was 2 days for both mild and severe AP. Only 5.5% (nine of 164) of patients had a prolonged starvation time of more than 5 days. CONCLUSIONS The total time of starvation was limited in a majority of patients admitted for AP. According to international guidelines, additional nutritional interventions were quickly undertaken with enteral feeding via the jejunum as the preferred route.
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Affiliation(s)
- B W M Spanier
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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Spanier BWM, Schreuder D, Dijkgraaf MGW, Bruno MJ. Source validation of pancreatitis-related hospital discharge diagnoses notified to a national registry in the Netherlands. Pancreatology 2008; 8:498-503. [PMID: 18765954 DOI: 10.1159/000151777] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Accepted: 09/24/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND National and regional disease registries are often used for epidemiological studies and validation analyses are scarce. We analyzed the reliability of the National Information System on Hospital Care (NISHC) registry used to classify admissions for acute and chronic pancreatitis in the Netherlands. METHODS All pancreas-related discharge diagnoses notified by the Academic Medical Center to the NISHC were retrieved for a 2-year time period. A review of multidisciplinary patient reports was conducted to verify these diagnoses. RESULTS 284 patients were notified to the NISHC, relating to 483 admissions with 523 pancreas-related discharge diagnoses. Of these diagnoses, 112 were coded as acute pancreatitis, 250 as chronic pancreatitis and 161 were classified as pseudocysts and other pancreatic diseases. The positive predictive value for acute pancreatitis diagnosis codes was 77.7% and 46 additional acute pancreatitis diagnoses were identified, ultimately leading to an underestimation of the total number of acute pancreatitis diagnoses of 15.8%. The positive predictive value for discharge diagnoses regarding chronic pancreatitis was 83.6% and 57 additional chronic pancreatitis diagnoses were identified, finally resulting in an underestimation of the total number of chronic pancreatitis diagnoses of 6%. CONCLUSION There is a substantial miscoding on a person level of discharge diagnoses of acute and chronic pancreatitis. On a group level, when miscoding between categories is leveled out, actual numbers of admission are only slightly underestimated.
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Affiliation(s)
- B W M Spanier
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Eshuis EJ, Bemelman WA, van Bodegraven AA, Sprangers MAG, Bossuyt PMM, van Milligen de Wit AWM, Crolla RMPH, Cahen DL, Oostenbrug LE, Sosef MN, Voorburg AMCJ, Davids PHP, van der Woude CJ, Lange J, Mallant RC, Boom MJ, Lieverse RJ, van der Zaag ES, Houben MHMG, Vecht J, Pierik REGJM, van Ditzhuijsen TJM, Prins HA, Marsman WA, Stockmann HB, Brink MA, Consten ECJ, van der Werf SDJ, Marinelli AWKS, Jansen JM, Gerhards MF, Bolwerk CJM, Stassen LPS, Spanier BWM, Bilgen EJS, van Berkel AM, Cense HA, van Heukelem HA, van de Laar A, Slot WB, Eijsbouts QA, van Ooteghem NAM, van Wagensveld B, van den Brande JMH, van Geloven AAW, Bruin KF, Maring JK, Oldenburg B, van Hillegersberg R, de Jong DJ, Bleichrodt R, van der Peet DL, Dekkers PEP, Goei TH, Stokkers PCF. Laparoscopic ileocolic resection versus infliximab treatment of distal ileitis in Crohn's disease: a randomized multicenter trial (LIR!C-trial). BMC Surg 2008; 8:15. [PMID: 18721465 PMCID: PMC2533646 DOI: 10.1186/1471-2482-8-15] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Accepted: 08/22/2008] [Indexed: 12/24/2022] Open
Abstract
Background With the availability of infliximab, nowadays recurrent Crohn's disease, defined as disease refractory to immunomodulatory agents that has been treated with steroids, is generally treated with infliximab. Infliximab is an effective but expensive treatment and once started it is unclear when therapy can be discontinued. Surgical resection has been the golden standard in recurrent Crohn's disease. Laparoscopic ileocolic resection proved to be safe and is characterized by a quick symptom reduction. The objective of this study is to compare infliximab treatment with laparoscopic ileocolic resection in patients with recurrent Crohn's disease of the distal ileum with respect to quality of life and costs. Methods/design The study is designed as a multicenter randomized clinical trial including patients with Crohn's disease located in the terminal ileum that require infliximab treatment following recent consensus statements on inflammatory bowel disease treatment: moderate to severe disease activity in patients that fail to respond to steroid therapy or immunomodulatory therapy. Patients will be randomized to receive either infliximab or undergo a laparoscopic ileocolic resection. Primary outcomes are quality of life and costs. Secondary outcomes are hospital stay, early and late morbidity, sick leave and surgical recurrence. In order to detect an effect size of 0.5 on the Inflammatory Bowel Disease Questionnaire at a 5% two sided significance level with a power of 80%, a sample size of 65 patients per treatment group can be calculated. An economic evaluation will be performed by assessing the marginal direct medical, non-medical and time costs and the costs per Quality Adjusted Life Year (QALY) will be calculated. For both treatment strategies a cost-utility ratio will be calculated. Patients will be included from December 2007. Discussion The LIR!C-trial is a randomized multicenter trial that will provide evidence whether infliximab treatment or surgery is the best treatment for recurrent distal ileitis in Crohn's disease. Trial registration Nederlands Trial Register NTR1150
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Affiliation(s)
- Emma J Eshuis
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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Spanier BWM, Stokkers PCF, Bartelsman JFWM. An unusual bleeding duodenal ulcer. Gut 2008; 57:373, 382. [PMID: 18268055 DOI: 10.1136/gut.2006.115451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- B W M Spanier
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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Spanier BWM, Bruno MJ. Genetic testing. N Engl J Med 2003; 348:1066-7; author reply 1066-7. [PMID: 12637623 DOI: 10.1056/nejm200303133481119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Affiliation(s)
- B W M Spanier
- Department of Internal Medicine, Spaarne Ziekenhuis Heemstede, Händellaan 2, 2102 CW Heemstede, the Netherlands
| | - J Frederiks
- Department of Internal Medicine, Spaarne Ziekenhuis Heemstede, Händellaan 2, 2102 CW Heemstede, the Netherlands
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Affiliation(s)
- B W M Spanier
- Department of Internal Medicine and Gastroenterology, Spaarne Ziekenhuis Heemstede, 2012 CE, Heemstede, Netherlands
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