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van Bodegraven EA, den Haring FET, Pollemans B, Monselis D, De Pastena M, van Eijck C, Daams F, de Hingh I, Luyer M, Stommel MWJ, van Santvoort HC, Festen S, Mieog JSD, Klaase J, Lips D, Coolsen MME, van der Schelling GP, Manusama ER, Patijn G, van der Harst E, Bosscha K, Marchegiani G, Besselink MG. Nationwide validation of the distal fistula risk score (D-FRS). Langenbecks Arch Surg 2023; 409:14. [PMID: 38114826 DOI: 10.1007/s00423-023-03192-w] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 11/24/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE Distal pancreatectomy (DP) is associated with a high complication rate of 30-50% with postoperative pancreatic fistula (POPF) as a dominant contributor. Adequate risk estimation for POPF enables surgeons to use a tailor-made approach. Assessment of the risk of POPF prior to DP can lead to the application of preventive strategies. The current study aims to validate the recently published preoperative and intraoperative distal fistula risk score (D-FRS) in a nationwide cohort. METHODS This nationwide retrospective Dutch cohort study included all patients after DP for any indication, all of whom were registered in the Dutch Pancreatic Cancer Audit (DPCA) database between 2013 and 2021. The D-FRS was validated by filling in the probability equations with data from this cohort. The predictive capacity of the models was represented by an area under the receiver operating characteristic (AUROC) curve. RESULTS A total of 896 patients underwent DP of which 152 (17%) developed POPF of whom 144 grade B (95%) and 8 grade C (5%). The preoperative D-FRS, consisting of the variables pancreatic neck thickness and pancreatic duct diameter, showed an AUROC of 0.73 (95%CI 0.68-0.78). The intraoperative D-FRS, comprising pancreatic neck, duct diameter, BMI, operating time, and soft pancreatic aspect, showed an AUROC of 0.69 (95%CI 0.64-0.74). CONCLUSION The current study is the first nationwide validation of the preoperative and intraoperative D-FRS showing acceptable distinguishing capacity for only the preoperative D-FRS for POPF. Therefore, the preoperative score could improve prevention and mitigation strategies such as drain management, which is currently investigated in the multicenter PANDORINA trial.
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Affiliation(s)
- Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, De Boelelaan 1117 (ZH-7F), 1081, HV, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Femke E T den Haring
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, De Boelelaan 1117 (ZH-7F), 1081, HV, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Britt Pollemans
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, De Boelelaan 1117 (ZH-7F), 1081, HV, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Damaris Monselis
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, De Boelelaan 1117 (ZH-7F), 1081, HV, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Matteo De Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Casper van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, De Boelelaan 1117 (ZH-7F), 1081, HV, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Ignace de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht (RAKU), Utrecht, the Netherlands
| | - S Festen
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - J S D Mieog
- Department of Surgery, LUMC, Leiden, the Netherlands
| | - J Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - D Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M M E Coolsen
- Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, the Netherlands
| | - G P van der Schelling
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, the Netherlands
| | - E R Manusama
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - G Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - K Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Giovanni Marchegiani
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, De Boelelaan 1117 (ZH-7F), 1081, HV, Amsterdam, the Netherlands.
- Cancer Center Amsterdam, Amsterdam, the Netherlands.
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Taselaar AE, Boes AJ, de Bruin RWF, Kuijper TM, Van Lancker K, van der Harst E, Klaassen RA. PROMISE: effect of protein supplementation on fat-free mass preservation after bariatric surgery, a randomized double-blind placebo-controlled trial. Trials 2023; 24:717. [PMID: 37946272 PMCID: PMC10636856 DOI: 10.1186/s13063-023-07654-w] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 09/13/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Protein malnutrition after bariatric surgery is a severe complication and leads to significant morbidity. Previous studies have shown that protein intake and physical activity are the most important factors in the preservation of fat-free mass during weight loss. Low protein intake is very common in patients undergoing bariatric surgery despite dietary counseling. Protein powder supplements might help patients to achieve the protein intake recommendations after bariatric surgery and could therefore contribute to preserve fat-free mass. This double-blind randomized placebo-controlled intervention study aims to assess the effect of a daily consumed clear protein powder shake during the first 6 months after bariatric surgery on fat-free mass loss in the first 12 months after laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS AND ANALYSIS Inclusion will take place at the outpatient clinic of the bariatric expertise center for obesity of the Maasstad Hospital. Patients will be randomly assigned to either the intervention or control group before surgery. The intervention group will receive a clear protein powder shake of 200 ml containing 20 g of whey protein dissolved in water which should be taken daily during the first 6 months after LRYGB on top of their normal postoperative diet. The control group will receive an isocaloric, clear, placebo shake containing maltodextrine. Postoperative rehabilitation and physiotherapeutical guidance will be standardized and similar in both groups. Also, both groups will receive the same dietary advice from specialized dieticians. The main study parameter is the percentage of fat-free mass loss 6 months after surgery, assessed by multi-frequency bioelectrical impedance analysis (MF-BIA). ETHICS AND DISSEMINATION The protocol, version 2 (February 20, 2022) has been approved by the Medical Research Ethics Committees United (MEC-U) (NL 80414.100.22). The results of this study will be submitted to peer-reviewed journals. TRIAL REGISTRATION ClinicalTrials.gov NCT05570474. Registered on October 5, 2022.
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Affiliation(s)
- A E Taselaar
- Maasstad Ziekenhuis Rotterdam, Maasstadweg 21, Rotterdam, 3079 DZ, The Netherlands.
| | - A J Boes
- Maasstad Ziekenhuis Rotterdam, Maasstadweg 21, Rotterdam, 3079 DZ, The Netherlands
| | - R W F de Bruin
- Department of Surgery, Erasmus MC, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, Netherlands
| | - T M Kuijper
- Maasstad Academy, Maasstad Hospital, Rotterdam, Netherlands
| | - K Van Lancker
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - E van der Harst
- Maasstad Ziekenhuis Rotterdam, Maasstadweg 21, Rotterdam, 3079 DZ, The Netherlands
| | - R A Klaassen
- Maasstad Ziekenhuis Rotterdam, Maasstadweg 21, Rotterdam, 3079 DZ, The Netherlands
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Wijngaarden LH, Taselaar AE, Nuijten F, van der Harst E, Klaassen RA, Kuijper TM, Jongbloed F, Ambagtsheer G, Klepper M, IJzermans JNM, de Bruin RWF, Litjens NHR. T and B Cell Composition and Cytokine Producing Capacity Before and After Bariatric Surgery. Front Immunol 2022; 13:888278. [PMID: 35860273 PMCID: PMC9289114 DOI: 10.3389/fimmu.2022.888278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/31/2022] [Indexed: 12/14/2022] Open
Abstract
Morbid obesity is associated with a chronic state of low-grade inflammation, which may lead to accelerated differentiation of T and B cells. These differentiated immune cells are strongly cytotoxic and have an increased pro-inflammatory cytokine producing capacity. Furthermore, the anti-inflammatory function of the T and B cells decreases. The aim of this study was to evaluate the effect of morbid obesity on the subset profile and cytokine producing capacity of T and B cells. Subsequently, we assessed whether bariatric surgery affected the subset profile and cytokine producing capacity of these cells. We determined the proportion of T and B cell subsets and their cytokine producing capacity in peripheral blood collected from 23 morbidly obese patients before and three months after bariatric surgery using flow-cytometry. We compared this with the results of 25 lean controls. Both CD4+ and CD8+ T cells showed a more differentiated subset profile in morbidly obese patients as compared to lean controls, which was not recovered three months after bariatric surgery. The B cell composition of morbidly obese patients after bariatric surgery adjusted towards the profile of lean controls. However, the IL-2 and IFN-γ producing capacity of CD8+ T cells and the IL-2, IFN-γ, TNF-α and IL-10 producing capacity of B cells was not restored three months after bariatric surgery. In conclusion, the data suggest that the immune system has the capacity to recover from the detrimental effects of morbid obesity within three months after bariatric surgery in terms of cell composition; however, this was not seen in terms of cytokine producing capacity. The full restoration of the immune system after bariatric surgery may thus take longer.
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Affiliation(s)
- L. H. Wijngaarden
- Department of Surgery, Erasmus MC, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, Netherlands
- Department of Surgery, Maasstad Hospital, Rotterdam, Netherlands
| | - A. E. Taselaar
- Department of Surgery, Erasmus MC, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, Netherlands
- Department of Surgery, Maasstad Hospital, Rotterdam, Netherlands
| | - F. Nuijten
- Department of Surgery, Erasmus MC, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, Netherlands
| | - E. van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, Netherlands
| | - R. A. Klaassen
- Department of Surgery, Maasstad Hospital, Rotterdam, Netherlands
| | - T. M. Kuijper
- Maasstad Academy, Maasstad Hospital, Rotterdam, Netherlands
| | - F. Jongbloed
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - G. Ambagtsheer
- Department of Surgery, Erasmus MC, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, Netherlands
| | - M. Klepper
- Department of Internal Medicine, Erasmus MC Transplant Institute, Division Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - J. N. M. IJzermans
- Department of Surgery, Erasmus MC, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, Netherlands
| | - R. W. F. de Bruin
- Department of Surgery, Erasmus MC, Erasmus MC Transplant Institute, University Medical Center, Rotterdam, Netherlands
- *Correspondence: R. W. F. de Bruin,
| | - N. H. R. Litjens
- Department of Internal Medicine, Erasmus MC Transplant Institute, Division Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, Netherlands
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Henry AC, Schouten TJ, Daamen LA, Walma MS, Noordzij P, Cirkel GA, Los M, Besselink MG, Busch OR, Bonsing BA, Bosscha K, van Dam RM, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IHJT, Kazemier G, Liem MS, de Meijer VE, Nieuwenhuijs VB, Roos D, Schreinemakers JMJ, Stommel MWJ, Molenaar IQ, van Santvoort HC. ASO Visual Abstract: Short- and Long-Term Outcomes of Pancreatic Cancer Resection for Elderly Patients: A Nationwide Analysis. Ann Surg Oncol 2022. [PMID: 35543910 DOI: 10.1245/s10434-022-11873-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- A C Henry
- Department of Surgery, Regional Academic Cancer Center Utrecht, , UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - T J Schouten
- Department of Surgery, Regional Academic Cancer Center Utrecht, , UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - L A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, , UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - M S Walma
- Department of Surgery, Regional Academic Cancer Center Utrecht, , UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - P Noordzij
- Department of Anesthesiology and Intensive Care, St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - G A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Meander Medical Center Amersfoort, University Medical Center, Utrecht, The Netherlands
| | - M Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center, Utrecht, The Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - O R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - K Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - R M van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, The Netherlands
| | - S Festen
- Department of Surgery, Onze Lieve Vrouwen Gasthuis, Amsterdam, The Netherlands
| | | | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - G Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - M S Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - V E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | | | - D Roos
- Department of Surgery, Reinier de Graaf Group, Delft, The Netherlands
| | | | - M W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, , UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, , UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands.
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5
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van Goor I, Nagelhout A, Besselink M, Bonsing B, Bosscha K, Brosens L, Busch O, Cirkel G, van Dam R, Festen S, Groot Koerkamp B, van der Harst E, de Hingh I, Kazemier G, Meijer G, de Meijer V, Nieuwenhuijs V, Roos D, Schreinemakers J, Stommel M, Verdonk R, van Santvoort H, Molenaar Q, Daamen L, Intven M. OC-0111 Prognostic factors for isolated local recurrence after resection of pancreatic ductal adenocarcinoma. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)02487-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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6
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Groen JV, Smits FJ, Koole D, Besselink MG, Busch OR, den Dulk M, van Eijck CHJ, Groot Koerkamp B, van der Harst E, de Hingh IH, Karsten TM, de Meijer VE, Pranger BK, Molenaar IQ, Bonsing BA, van Santvoort HC, Mieog JSD. Completion pancreatectomy or a pancreas-preserving procedure during relaparotomy for pancreatic fistula after pancreatoduodenectomy: a multicentre cohort study and meta-analysis. Br J Surg 2021; 108:1371-1379. [PMID: 34608941 PMCID: PMC10364904 DOI: 10.1093/bjs/znab273] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite the fact that primary percutaneous catheter drainage has become standard practice, some patients with pancreatic fistula after pancreatoduodenectomy ultimately undergo a relaparotomy. The aim of this study was to compare completion pancreatectomy with a pancreas-preserving procedure in patients undergoing relaparotomy for pancreatic fistula after pancreatoduodenectomy. METHODS This retrospective cohort study of nine institutions included patients who underwent relaparotomy for pancreatic fistula after pancreatoduodenectomy from 2005-2018. Furthermore, a systematic review and meta-analysis were performed according to the PRISMA guidelines. RESULTS From 4877 patients undergoing pancreatoduodenectomy, 786 (16 per cent) developed a pancreatic fistula grade B/C and 162 (3 per cent) underwent a relaparotomy for pancreatic fistula. Of these patients, 36 (22 per cent) underwent a completion pancreatectomy and 126 (78 per cent) a pancreas-preserving procedure. Mortality was higher after completion pancreatectomy (20 (56 per cent) versus 40 patients (32 per cent); P = 0.009), which remained after adjusting for sex, age, BMI, ASA score, previous reintervention, and organ failure in the 24 h before relaparotomy (adjusted odds ratio 2.55, 95 per cent c.i. 1.07 to 6.08). The proportion of additional reinterventions was not different between groups (23 (64 per cent) versus 84 patients (67 per cent); P = 0.756). The meta-analysis including 33 studies evaluating 745 patients, confirmed the association between completion pancreatectomy and mortality (Mantel-Haenszel random-effects model: odds ratio 1.99, 95 per cent c.i. 1.03 to 3.84). CONCLUSION Based on the current data, a pancreas-preserving procedure seems preferable to completion pancreatectomy in patients in whom a relaparotomy is deemed necessary for pancreatic fistula after pancreatoduodenectomy.
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Affiliation(s)
- J V Groen
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - F J Smits
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - D Koole
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - I H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,Department of Epidemiology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - T M Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (loc. Oost), Amsterdam, the Netherlands
| | - V E de Meijer
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - B K Pranger
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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Giovinazzo F, Linneman R, Riva GVD, Greener D, Morano C, Patijn GA, Besselink MGH, Nieuwenhuijs VB, Abu Hilal M, de Hingh IH, Kazemier G, Festen S, de Jong KP, van Eijck CHJ, Scheepers JJG, van der Kolk M, den Dulk M, Bosscha K, Boerma D, van der Harst E, Armstrong T, Takhar A, Hamady Z. Clinical relevant pancreatic fistula after pancreatoduodenectomy: when negative amylase levels tell the truth. Updates Surg 2021; 73:1391-1397. [PMID: 33770412 DOI: 10.1007/s13304-021-01020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 03/02/2021] [Indexed: 11/29/2022]
Abstract
Drain Amylase level are routinely determined to diagnose pancreatic fistula after Pancreatocoduodenectomy. Consensus is lacking regarding the cut-off value of amylase to diagnosis clinically relevant postoperative pancreatic fistulae (POPF). The present study proposes a model based on Amylase Value in the Drain (AVD) measured in the first three postoperative days to predict a POPF. Amylase cut-offs were selected from a previous published systematic review and the accuracy were validated in a multicentre database from 12 centres in 2 countries. The present study defined POPF the 2016 ISGPS criteria (3 times the upper limit of normal serum amylase). A learning machine method was used to correlate AVD with the diagnosis of POPF. Overall, 454 (27%) of 1638 patients developed POPF. Machine learning excluded a clinically relevant postoperative pancreatic fistulae with an AUC of 0.962 (95% CI 0.940-0.984) in the first five postoperative days. An AVD at a cut-off of 270 U/L in 2 days in the first three postoperative days excluded a POPF with an AUC of 0.869 (CI 0.81-0.90, p < 0.0001). A single AVD in the first three postoperative days may not exclude POPF after pancreatoduodenectomy. The levels should be monitored until day 3 and have two negative values before removing the drain. In the group with a positive level, the drain should be kept in and AVD monitored until postoperative day five.
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Affiliation(s)
- Francesco Giovinazzo
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, E Level, Tremona Road, Southampton, SO166YD, UK.,General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Ralph Linneman
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | | | | | - Christopher Morano
- Master of Data Science, University of British Columbia, Vancouver, Canada
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Mark G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Mohammad Abu Hilal
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, E Level, Tremona Road, Southampton, SO166YD, UK. .,Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy.
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8
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Daamen LA, van Goor IWJM, Schouten TJ, Dorland G, van Roessel SR, Besselink MG, Bonsing BA, Bosscha K, Brosens LAA, Busch OR, van Dam RM, Fariña Sarasqueta A, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IHJT, Intven MPW, Kazemier G, de Meijer VE, Nieuwenhuijs VB, Raicu GM, Roos D, Schreinemakers JMJ, Stommel MWJ, van Velthuysen MF, Verheij J, Verkooijen HM, van Santvoort HC, Molenaar IQ. Microscopic resection margin status in pancreatic ductal adenocarcinoma - A nationwide analysis. Eur J Surg Oncol 2020; 47:708-716. [PMID: 33323293 DOI: 10.1016/j.ejso.2020.11.145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/19/2020] [Accepted: 11/28/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION First, this study aimed to assess the prognostic value of different definitions for resection margin status on disease-free survival (DFS) and overall survival (OS) in pancreatic ductal adenocarcinoma (PDAC). Second, preoperative predictors of direct margin involvement were identified. MATERIALS AND METHODS This nationwide observational cohort study included all patients who underwent upfront PDAC resection (2014-2016), as registered in the prospective Dutch Pancreatic Cancer Audit. Patients were subdivided into three groups: R0 (≥1 mm margin clearance), R1 (<1 mm margin clearance) or R1 (direct margin involvement). Survival was compared using multivariable Cox regression analysis. Logistic regression with baseline variables was performed to identify preoperative predictors of R1 (direct). RESULTS 595 patients with a median OS of 18 months (IQR 10-32 months) months were analysed. R0 (≥1 mm) was achieved in 277 patients (47%), R1 (<1 mm) in 146 patients (24%) and R1 (direct) in 172 patients (29%). R1 (direct) was associated with a worse OS, as compared with both R0 (≥1 mm) (hazard ratio (HR) 1.35 [95% and confidence interval (CI) 1.08-1.70); P < 0.01) and R1 (<1 mm) (HR 1.29 [95%CI 1.01-1.67]; P < 0.05). No OS difference was found between R0 (≥1 mm) and R1 (<1 mm) (HR 1.05 [95% CI 0.82-1.34]; P = 0.71). Preoperative predictors associated with an increased risk of R1 (direct) included age, male sex, performance score 2-4, and venous or arterial tumour involvement. CONCLUSION Resection margin clearance of <1 mm, but without direct margin involvement, does not affect survival, as compared with a margin clearance of ≥1 mm. Given that any vascular tumour involvement on preoperative imaging was associated with an increased risk of R1 (direct) resection with upfront surgery, neoadjuvant therapy might be considered in these patients.
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Affiliation(s)
- L A Daamen
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands; Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, the Netherlands
| | - I W J M van Goor
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands; Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, the Netherlands
| | - T J Schouten
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - G Dorland
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands; Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - S R van Roessel
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - M G Besselink
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - B A Bonsing
- Dept. of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - K Bosscha
- Dept. of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - L A A Brosens
- Dept. of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - O R Busch
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - R M van Dam
- Dept. of Surgery, Maastricht UMC+, Maastricht, the Netherlands
| | - A Fariña Sarasqueta
- Dept. of Pathology, Leiden University Medical Center, Leiden, the Netherlands; Dept. of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - S Festen
- Dept. of Surgery, OLVG, Amsterdam, the Netherlands
| | | | - E van der Harst
- Dept. of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - I H J T de Hingh
- Dept. of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - M P W Intven
- Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, the Netherlands
| | - G Kazemier
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - V E de Meijer
- Dept. of Surgery, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands
| | | | - G M Raicu
- Dept. of Pathology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - D Roos
- Dept. of Surgery, Reinier de Graaf Group, Delft, the Netherlands
| | | | - M W J Stommel
- Dept. of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - J Verheij
- Dept. of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - H M Verkooijen
- Imaging Division, University Medical Centre Utrecht, the Netherlands, Utrecht University, Utrecht, the Netherlands
| | - H C van Santvoort
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - I Q Molenaar
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands.
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9
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Mackay TM, Smits FJ, Latenstein AEJ, Bogte A, Bonsing BA, Bos H, Bosscha K, Brosens LAA, Hol L, Busch ORC, Creemers GJ, Curvers WL, den Dulk M, van Dieren S, van Driel LMJW, Festen S, van Geenen EJM, van der Geest LG, de Groot DJA, de Groot JWB, Haj Mohammad N, Haberkorn BCM, Haver JT, van der Harst E, Hemmink GJM, de Hingh IH, Hoge C, Homs MYV, van Huijgevoort NC, Jacobs MAJM, Kerver ED, Liem MSL, Los M, Lubbinge H, Luelmo SAC, de Meijer VE, Mekenkamp L, Molenaar IQ, van Oijen MGH, Patijn GA, Quispel R, van Rijssen LB, Römkens TEH, van Santvoort HC, Schreinemakers JMJ, Schut H, Seerden T, Stommel MWJ, Ten Tije AJ, Venneman NG, Verdonk RC, Verheij J, van Vilsteren FGI, de Vos-Geelen J, Vulink A, Wientjes C, Wit F, Wessels FJ, Zonderhuis B, van Werkhoven CH, van Hooft JE, van Eijck CHJ, Wilmink JW, van Laarhoven HWM, Besselink MG. Impact of nationwide enhanced implementation of best practices in pancreatic cancer care (PACAP-1): a multicenter stepped-wedge cluster randomized controlled trial. Trials 2020; 21:334. [PMID: 32299515 PMCID: PMC7161112 DOI: 10.1186/s13063-020-4180-z] [Citation(s) in RCA: 8] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/18/2020] [Indexed: 01/05/2023] Open
Abstract
Background Pancreatic cancer has a very poor prognosis. Best practices for the use of chemotherapy, enzyme replacement therapy, and biliary drainage have been identified but their implementation in daily clinical practice is often suboptimal. We hypothesized that a nationwide program to enhance implementation of these best practices in pancreatic cancer care would improve survival and quality of life. Methods/design PACAP-1 is a nationwide multicenter stepped-wedge cluster randomized controlled superiority trial. In a per-center stepwise and randomized manner, best practices in pancreatic cancer care regarding the use of (neo)adjuvant and palliative chemotherapy, pancreatic enzyme replacement therapy, and metal biliary stents are implemented in all 17 Dutch pancreatic centers and their regional referral networks during a 6-week initiation period. Per pancreatic center, one multidisciplinary team functions as reference for the other centers in the network. Key best practices were identified from the literature, 3 years of data from existing nationwide registries within the Dutch Pancreatic Cancer Project (PACAP), and national expert meetings. The best practices follow the Dutch guideline on pancreatic cancer and the current state of the literature, and can be executed within daily clinical practice. The implementation process includes monitoring, return visits, and provider feedback in combination with education and reminders. Patient outcomes and compliance are monitored within the PACAP registries. Primary outcome is 1-year overall survival (for all disease stages). Secondary outcomes include quality of life, 3- and 5-year overall survival, and guideline compliance. An improvement of 10% in 1-year overall survival is considered clinically relevant. A 25-month study duration was chosen, which provides 80% statistical power for a mortality reduction of 10.0% in the 17 pancreatic cancer centers, with a required sample size of 2142 patients, corresponding to a 6.6% mortality reduction and 4769 patients nationwide. Discussion The PACAP-1 trial is designed to evaluate whether a nationwide program for enhanced implementation of best practices in pancreatic cancer care can improve 1-year overall survival and quality of life. Trial registration ClinicalTrials.gov, NCT03513705. Trial opened for accrual on 22th May 2018.
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Affiliation(s)
- T M Mackay
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - F J Smits
- Department of surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A E J Latenstein
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - A Bogte
- Department of gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - B A Bonsing
- Department of surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - H Bos
- Department of medical oncology, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - K Bosscha
- Department of surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - L A A Brosens
- Department of pathology, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of pathology, Radboud University, Nijmegen, the Netherlands
| | - L Hol
- Department of gastroenterology, Maasstad Hospital, Rotterdam, the Netherlands
| | - O R C Busch
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - G J Creemers
- Department of medical oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - W L Curvers
- Department of gastroenterology, Catharina Hospital, Eindhoven, the Netherlands
| | - M den Dulk
- Department of surgery, Maastricht UMC+, Maastricht, the Netherlands
| | - S van Dieren
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - L M J W van Driel
- Department of gastroenterology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - S Festen
- Department of surgery, OLVG, Amsterdam, the Netherlands
| | - E J M van Geenen
- Department of gastroenterology, Radboud UMC, Nijmegen, the Netherlands
| | - L G van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - D J A de Groot
- Department of medical oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - J W B de Groot
- Department of medical oncology, Oncology Center Isala, Zwolle, the Netherlands
| | - N Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - B C M Haberkorn
- Department of medical oncology, Maasstad Hospital, Rotterdam, the Netherlands
| | - J T Haver
- Department of nutrition and dietetics, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - E van der Harst
- Department of surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - G J M Hemmink
- Department of gastroenterology, Oncology Center Isala, Zwolle, the Netherlands
| | - I H de Hingh
- Department of surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - C Hoge
- Department of gastroenterology, Maastricht UMC+, Maastricht, the Netherlands
| | - M Y V Homs
- Department of medical oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - N C van Huijgevoort
- Department of gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M A J M Jacobs
- Department of gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - E D Kerver
- Department of medical oncology, OLVG, Amsterdam, the Netherlands
| | - M S L Liem
- Department of surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - H Lubbinge
- Department of gastroenterology, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - S A C Luelmo
- Department of medical oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - V E de Meijer
- Department of surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - L Mekenkamp
- Department of medical oncology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - I Q Molenaar
- Department of surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - M G H van Oijen
- Department of medical oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - G A Patijn
- Department of surgery, Oncology Center Isala, Zwolle, the Netherlands
| | - R Quispel
- Department of gastroenterology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - L B van Rijssen
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - T E H Römkens
- Department of gastroenterology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - H C van Santvoort
- Department of surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - H Schut
- Department of medical oncology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - T Seerden
- Department of gastroenterology, Amphia Hospital, Breda, the Netherlands
| | - M W J Stommel
- Department of surgery, Radboud UMC, Nijmegen, the Netherlands
| | - A J Ten Tije
- Department of medical oncology, Amphia Hospital, Breda, the Netherlands
| | - N G Venneman
- Department of gastroenterology and hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - R C Verdonk
- Department of gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - J Verheij
- Department of pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - F G I van Vilsteren
- Department of gastroenterology, University Medical Center Groningen, Groningen, the Netherlands
| | - J de Vos-Geelen
- Department of medical oncology, Maastricht UMC+, Maastricht, the Netherlands
| | - A Vulink
- Department of medical oncology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - C Wientjes
- Department of gastroenterology, OLVG, Amsterdam, the Netherlands
| | - F Wit
- Department of surgery, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - F J Wessels
- Department of radiology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - B Zonderhuis
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - C H van Werkhoven
- Julius Center for Health Sciences and primary care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J E van Hooft
- Department of gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C H J van Eijck
- Department of surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - J W Wilmink
- Department of medical oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - H W M van Laarhoven
- Department of medical oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M G Besselink
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands.
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10
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Linnemann RJA, Patijn GA, van Rijssen LB, Besselink MG, Mungroop TH, de Hingh IH, Kazemier G, Festen S, de Jong KP, van Eijck CHJ, Scheepers JJG, van der Kolk M, Dulk MD, Bosscha K, Busch OR, Boerma D, van der Harst E, Nieuwenhuijs VB. The role of abdominal drainage in pancreatic resection - A multicenter validation study for early drain removal. Pancreatology 2019; 19:888-896. [PMID: 31378583 DOI: 10.1016/j.pan.2019.07.041] [Citation(s) in RCA: 17] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/20/2019] [Accepted: 07/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Abdominal drainage and the timing of drain removal in patients undergoing pancreatic resection are under debate. Early drain removal after pancreatic resection has been reported to be safe with a low risk for clinical relevant postoperative pancreatic fistula (CR-POPF) when drain amylase on POD1 is < 5000U/L. The aim of this study was to validate this algorithm in a large national cohort. METHODS Patients registered in the Dutch Pancreatic Cancer Audit (2014-2016) who underwent pancreatoduodenectomy, distal pancreatectomy or enucleation were analysed. Data on post-operative drain amylase levels, drain removal, postoperative pancreatic fistulae were collected. Univariate and multivariate analysis using a logistic regression model were performed. The primary outcome measure was grade B/C pancreatic fistula (CR-POPF). RESULTS Among 1402 included patients, 433 patients with a drain fluid amylase level of <5000U/L on POD1, 7% developed a CR-POPF. For patients with an amylase level >5000U/L the CR-POPF rate was 28%. When using a cut-off point of 2000U/L or 1000U/L during POD1-3, the CR-POPF rates were 6% and 5% respectively. For patients with an amylase level of >2000U/L and >1000UL during POD 1-3 the CR-POPF rates were 26% and 22% respectively (n = 223). Drain removal on POD4 or thereafter was associated with more complications (p = 0.004). Drain amylase level was shown to be the most statistically significant predicting factor for CR-POPF (Wald = 49.7; p < 0.001). CONCLUSION Our data support early drain removal after pancreatic resection. However, a cut-off of 5000U/L drain amylase on POD1 was associated with a relatively high CR-POPF rate of 7%. A cut-off point of 1000U/L during POD1-3 resulted in 5% CR-POPF and might be a safer alternative.
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Affiliation(s)
| | - G A Patijn
- Isala, Department of Surgery, Zwolle, the Netherlands
| | - L B van Rijssen
- Academic Medical Center, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - M G Besselink
- Academic Medical Center, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - T H Mungroop
- Academic Medical Center, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - I H de Hingh
- Catharina Hospital, Department of Surgery, Eindhoven, the Netherlands
| | - G Kazemier
- VU Medical Center, Department of Surgery, Amsterdam, the Netherlands
| | - S Festen
- OLVG Oost, Department of Surgery, Amsterdam, the Netherlands
| | - K P de Jong
- University of Groningen, University Medical Center Groningen, Department of HPB Surgery and Liver Transplantation, Groningen, the Netherlands
| | - C H J van Eijck
- Erasmus Medical Center, Department of Surgery, Rotterdam, the Netherlands
| | - J J G Scheepers
- Reinier de Graaf Hospital, Department of Surgery, Delft, the Netherlands
| | - M van der Kolk
- Radboud University Medical Center, Department of Surgery, Nijmegen, the Netherlands
| | - M den Dulk
- Maastricht University Medical Center, Department of Surgery, Maastricht, the Netherlands
| | - K Bosscha
- Jeroen Bosch Hospital, Department of Surgery, 's-Hertogenbosch, the Netherlands
| | - O R Busch
- Academic Medical Center, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - D Boerma
- St. Antonius Hospital, Department of Surgery, Nieuwegein, the Netherlands
| | - E van der Harst
- Maasstad Hospital, Department of Surgery, Rotterdam, the Netherlands
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11
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Suker M, Koerkamp BG, Coene PP, van der Harst E, Bonsing BA, Vahrmeijer AL, Mieog JSD, Swijnenburg RJ, Dwarkasing RS, Roos D, van Eijck CHJ. Yield of staging laparoscopy before treatment of locally advanced pancreatic cancer to detect occult metastases. Eur J Surg Oncol 2019; 45:1906-1911. [PMID: 31186205 DOI: 10.1016/j.ejso.2019.06.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/16/2019] [Accepted: 06/01/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Locally advanced pancreatic cancer (LAPC) is found in 35% of patients with pancreatic cancer. However, these patients often have occult metastatic disease. Patients with occult metastases are unlikely to benefit from locoregional treatments. This study evaluated the yield of occult metastases during staging laparoscopy in patients with LAPC. METHODS Between January 2013 and January 2017 all patients with LAPC underwent a staging laparoscopy after a recent tri-phasic CT-scan of the chest and abdomen. Data were retrospectively reviewed from a prospectively maintained database. Univariate and multivariable logistic regression analysis was conducted to predict metastasis found at laparoscopy. RESULTS A total of 91 (41% male, median age 64 years) LAPC patients were included. The median time between CT-scan and staging laparoscopy was 21 days. During staging laparoscopy metastases were found in 17 patients (19%, 95% CI: 12%-28%). Seven (8%) patients had liver-only, 9 (10%) patients peritoneal-only, and 1 (1%) patient both liver and peritoneal metastases. Univariate logistic regression analysis showed that CEA (OR 1.056, 95% CI 1.007-1.107, p = 0.02) was the only preoperative predictor for occult metastases. In a multivariable logistic regression analysis of the preoperative risk factors again only CEA was an independent predictor for occult metastatic disease (p = 0.03). Patients with a CEA above 5 μg/L had a risk of occult metastasis of 91%. FOLFIRINOX was given to 69 (76%) of the patients with a median number of cycles of 8. Subsequent radiotherapy was given to 44 (48%) patients after the FOLFIRINOX treatment. Six (14%) patients underwent a resection after FOLFIRINOX and radiotherapy. The overall 1-year survival was 53% in patients without occult metastasis versus 29% with occult metastasis (p = 0.11). The 1-year OS for patients that completed FOLFIRINOX and radiotherapy was 84%. CONCLUSION The yield of staging laparoscopy for occult intrahepatic or peritoneal metastases in patients with locally advanced pancreatic cancer was 19%. Staging laparoscopy is recomended for patients with LAPC for accurate staging to determine optimal treatment.
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Affiliation(s)
- M Suker
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
| | - B Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - P P Coene
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - R J Swijnenburg
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - R S Dwarkasing
- Department of Radiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - D Roos
- Department of Surgery, Reinier de Graaf Group, Delft, the Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
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12
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Jongbloed F, Meijers RWJ, IJzermans JNM, Klaassen RA, Dollé MET, van den Berg S, Betjes MGH, de Bruin RWF, van der Harst E, Litjens NHR. Effects of bariatric surgery on telomere length and T-cell aging. Int J Obes (Lond) 2019; 43:2189-2199. [PMID: 30979972 DOI: 10.1038/s41366-019-0351-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 07/02/2018] [Revised: 01/29/2019] [Accepted: 02/07/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Obesity adversely affects health and is associated with subclinical systemic inflammation and features of accelerated aging, including the T-cell immune system. The presence of metabolic syndrome (MetS) may accelerate, while bariatric surgery might reverse these phenomena. To examine the effects of MetS and bariatric surgery on T-cell aging, we measured relative telomere length (RTL) and T-cell differentiation status in obese patients before and after bariatric surgery. METHODS WHO II/III classified obese patients scheduled for bariatric surgery were included: 41 without MetS and 67 with MetS. RTL and T-cell differentiation status were measured in circulating CD4+ and CD8+ T cells via flow cytometry. T-cell characteristics were compared between patients with and without MetS prior to and at 3, 6, and 12 months after surgery considering effects of age, cytomegalovirus-serostatus, and weight loss. RESULTS Thymic output, represented by numbers of CD31-expressing naive T cells, showed an age-related decline in patients with MetS. MetS significantly enhanced CD8+ T-cell differentiation. Patients with MetS had significant lower CD4+ RTL than patients without MetS. Within the first 6 months after bariatric surgery, RTL increased in CD4+ T cells after which it decreased at month 12. A decline in both thymic output and more differentiated T cells was seen following bariatric surgery, more pronounced in the MetS group and showing an association with percentage of body weight loss. CONCLUSIONS In obese patients, MetS results in attrition of RTL and accelerated T-cell differentiation. Bariatric surgery temporarily reverses these effects. These data suggest that MetS is a risk factor for accelerated aging of T cells and that MetS should be a more prominent factor in the decision making for eligibility for bariatric surgery.
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Affiliation(s)
- F Jongbloed
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.,Laboratory of Health Protection Research, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - R W J Meijers
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J N M IJzermans
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - R A Klaassen
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - M E T Dollé
- Laboratory of Health Protection Research, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - S van den Berg
- Laboratory of Health Protection Research, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - M G H Betjes
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - R W F de Bruin
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - N H R Litjens
- Department of Internal Medicine, Section Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, The Netherlands
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13
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van der Werf LR, Eshuis WJ, Draaisma WA, van Etten B, Gisbertz SS, van der Harst E, Liem MSL, Lemmens VEPP, Wijnhoven BPL, Besselink MG, van Berge Henegouwen MI. Nationwide Outcome of Gastrectomy with En-Bloc Partial Pancreatectomy for Gastric Cancer. J Gastrointest Surg 2019; 23:2327-2337. [PMID: 30820797 PMCID: PMC6877485 DOI: 10.1007/s11605-019-04133-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 11/06/2018] [Accepted: 01/22/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Radical gastrectomy is the cornerstone of the treatment of gastric cancer. For tumors invading the pancreas, en-bloc partial pancreatectomy may be needed for a radical resection. The aim of this study was to evaluate the outcome of gastrectomies with partial pancreatectomy for gastric cancer. METHODS Patients who underwent gastrectomy with or without partial pancreatectomy for gastric or gastro-oesophageal junction cancer between 2011 and 2015 were selected from the Dutch Upper GI Cancer Audit (DUCA). Outcomes were resection margin (pR0) and Clavien-Dindo grade ≥ III postoperative complications and survival. The association between partial pancreatectomy and postoperative complications was analyzed with multivariable logistic regression. Overall survival of patients with partial pancreatectomy was estimated using the Kaplan-Meier method. RESULTS Of 1966 patients that underwent gastrectomy, 55 patients (2.8%) underwent en-bloc partial pancreatectomy. A pR0 resection was achieved in 45 of 55 patients (82% versus 85% in the group without additional resection, P = 0.82). Clavien-Dindo grade ≥ III complications occurred in 21 of 55 patients (38% versus 17%, P < 0.001). Median overall survival [95% confidence interval] was 15 [6.8-23.2] months. For patients with and without perioperative systemic therapy, median survival was 20 [12.3-27.7] and 10 [5.7-14.3] months, and for patients with pR0 and pR1 resection, it was 20 [11.8-28.3] and 5 [2.4-7.6] months, respectively. CONCLUSIONS Gastrectomy with partial pancreatectomy is not only associated with a pR0 resection rate of 82% but also with increased postoperative morbidity. It should only be performed if a pR0 resection is feasible.
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Affiliation(s)
- L. R. van der Werf
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - W. J. Eshuis
- grid.7177.60000000084992262Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - W. A. Draaisma
- grid.414725.10000 0004 0368 8146Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands
| | - B. van Etten
- grid.4494.d0000 0000 9558 4598Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - S. S. Gisbertz
- grid.7177.60000000084992262Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - E. van der Harst
- grid.416213.30000 0004 0460 0556Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - M. S. L. Liem
- grid.415214.70000 0004 0399 8347Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - V. E. P. P. Lemmens
- grid.5645.2000000040459992XDepartment of Pubic Health, Erasmus University Medical Centre, Rotterdam, the Netherlands ,Department of Research, Comprehensive Cancer Organisation the Netherlands, Utrecht, the Netherlands
| | - B. P. L. Wijnhoven
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M. G. Besselink
- grid.7177.60000000084992262Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - M. I. van Berge Henegouwen
- grid.7177.60000000084992262Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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Klaassen RA, Selles CA, van den Berg JW, Poelman MM, van der Harst E. Tranexamic acid therapy for postoperative bleeding after bariatric surgery. BMC Obes 2018; 5:36. [PMID: 30524741 PMCID: PMC6276262 DOI: 10.1186/s40608-018-0213-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 09/14/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Tranexamic acid reduces blood loss associated with various surgical procedures. Postoperative bleeding caused by dissection or bleeding of the enteric staple lines is a well-known complication following bariatric surgery. Reoperation in order to restore hemostasis is frequently necessary (up to 2.5% in literature). The effect of conservative therapy using tranexamic acid for postoperative hemorrhage after bariatric surgery is still very much a novel technique. The aim is to present our results (reoperation rate and thrombo-embolic complication rate) of tranexamic acid therapy for postoperative bleeding after bariatric surgery in comparison to those in existing literature. METHODS We retrospectively reviewed 1388 patients who underwent bariatric surgery (laparoscopic gastric bypass or laparoscopic gastric sleeve). Use of tranexamic acid, reoperation rate, transfusion rate and rate of thrombo-embolic complications were reviewed. RESULTS Forty-five of 1388 (3.2%) total patients experienced significant hemorrhage after bariatric surgery. Tranexamic acid was administered in 44 of these patients. A failure of the treatment with tranexamic acid was observed in four patients. The incidence of reoperation was 0.4% for the entire population. No thrombo-embolic complications were registered for patients receiving tranexamic acid. CONCLUSION These findings suggest that the administration of tranexamic acid appears to be safe in reducing the reoperation rate for bleeding after bariatric surgery.
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Affiliation(s)
- R A Klaassen
- 1Department of Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands
| | - C A Selles
- 1Department of Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands
| | - J W van den Berg
- 1Department of Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands
| | - M M Poelman
- 2Department of Surgery, Franciscus Gasthuis & Vlietland, Kleiweg 500, 3045 PM Rotterdam, The Netherlands
| | - E van der Harst
- 1Department of Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands
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15
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Noordman BJ, de Bekker-Grob EW, Coene PPLO, van der Harst E, Lagarde SM, Shapiro J, Wijnhoven BPL, van Lanschot JJB. Patients' preferences for treatment after neoadjuvant chemoradiotherapy for oesophageal cancer. Br J Surg 2018; 105:1630-1638. [DOI: 10.1002/bjs.10897] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 05/01/2018] [Accepted: 05/03/2018] [Indexed: 12/20/2022]
Abstract
Abstract
Background
After neoadjuvant chemoradiotherapy (nCRT) plus surgery for oesophageal cancer, 29 per cent of patients have a pathologically complete response in the resection specimen. Active surveillance after nCRT (instead of standard oesophagectomy) may improve health-related quality of life (HRQoL), but patients need to undergo frequent diagnostic tests and it is unknown whether survival is worse than that after standard oesophagectomy. Factors that influence patients' preferences, and trade-offs that patients are willing to make in their choice between surgery and active surveillance were investigated here.
Methods
A prospective discrete-choice experiment was conducted. Patients with oesophageal cancer completed questionnaires 4–6 weeks after nCRT, before surgery. Patients' preferences were quantified using scenarios based on five aspects: 5-year overall survival, short-term HRQoL, long-term HRQoL, the risk that oesophagectomy is still necessary, and the frequency of clinical examinations using endoscopy and PET–CT. Panel latent class analysis was used.
Results
Some 100 of 104 patients (96·2 per cent) responded. All aspects, except the frequency of clinical examinations, influenced patients' preferences. Five-year overall survival, the chance that oesophagectomy is still necessary and long-term HRQoL were the most important attributes. On average, based on calculation of the indifference point between standard surgery and active surveillance, patients were willing to trade off 16 per cent 5-year overall survival to reduce the risk that oesophagectomy is necessary from 100 per cent (standard surgery) to 35 per cent (active surveillance).
Conclusion
Patients are willing to trade off substantial 5-year survival to achieve a reduction in the risk that oesophagectomy is necessary.
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Affiliation(s)
- B J Noordman
- Department of Surgery, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - E W de Bekker-Grob
- Department of Public Health, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - P P L O Coene
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - S M Lagarde
- Department of Surgery, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - J Shapiro
- Department of Surgery, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - J J B van Lanschot
- Department of Surgery, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
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16
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Tol JAMG, van Hooft JE, Timmer R, Kubben FJGM, van der Harst E, de Hingh IHJT, Vleggaar FP, Molenaar IQ, Keulemans YCA, Boerma D, Bruno MJ, Schoon EJ, van der Gaag NA, Besselink MGH, Fockens P, van Gulik TM, Rauws EAJ, Busch ORC, Gouma DJ. Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer. Gut 2016; 65:1981-1987. [PMID: 26306760 DOI: 10.1136/gutjnl-2014-308762] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [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: 11/01/2014] [Revised: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In pancreatic cancer, preoperative biliary drainage (PBD) increases complications compared with surgery without PBD, demonstrated by a recent randomised controlled trial (RCT). This outcome might be related to the plastic endoprosthesis used. Metal stents may reduce the PBD-related complications risk. METHODS A prospective multicentre cohort study was performed including patients with obstructive jaundice due to pancreatic cancer, scheduled to undergo PBD before surgery. This cohort was added to the earlier RCT (ISRCTN31939699). The RCT protocol was adhered to, except PBD was performed with a fully covered self-expandable metal stent (FCSEMS). This FCSEMS cohort was compared with the RCT's plastic stent cohort. PBD-related complications were the primary outcome. Three-group comparison of overall complications including early surgery patients was performed. RESULTS 53 patients underwent PBD with FCSEMS compared with 102 patients treated with plastic stents. Patients' characteristics did not differ. PBD-related complication rates were 24% in the FCSEMS group vs 46% in the plastic stent group (relative risk of plastic stent use 1.9, 95% CI 1.1 to 3.2, p=0.011). Stent-related complications (occlusion and exchange) were 6% vs 31%. Surgical complications did not differ, 40% vs 47%. Overall complication rates for the FCSEMS, plastic stent and early surgery groups were 51% vs 74% vs 39%. CONCLUSIONS For PBD in pancreatic cancer, FCSEMS yield a better outcome compared with plastic stents. Although early surgery without PBD remains the treatment of choice, FCSEMS should be preferred over plastic stents whenever PBD is indicated. TRIAL REGISTRATION NUMBER Dutch Trial Registry (NTR3142).
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Affiliation(s)
- J A M G Tol
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - J E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - R Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - F J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - F P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Q Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Y C A Keulemans
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - D Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - N A van der Gaag
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - E A J Rauws
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - D J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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17
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Boersema GSA, Utomo L, Bayon Y, Kops N, van der Harst E, Lange JF, Bastiaansen-Jenniskens YM. Monocyte subsets in blood correlate with obesity related response of macrophages to biomaterials in vitro. Biomaterials 2016; 109:32-39. [PMID: 27662579 DOI: 10.1016/j.biomaterials.2016.09.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/31/2016] [Accepted: 09/11/2016] [Indexed: 02/07/2023]
Abstract
Macrophages play a key role in the foreign body response. In this study it was investigated whether obesity affects the acute response of macrophages to biomaterials in vitro and whether this response is associated with biomarkers in blood. CD14 + monocytes were isolated from blood from obese and age and gender matched lean persons. Monocyte subsets were determined based on CD14 and CD16 on their surface. C-reactive protein (CRP) was measured in peripheral blood. The response of monocyte-derived macrophages to polypropylene (PP), polylactic acid (PLA), polyethylene terephthalate (PET) monofilament, and PET-multifilament (mPET) in culture was based on cytokine production. More IL-6 (for PET), less CCL18 (all materials) and IL-1ra (for PLA) was produced by macrophages from obese patients than lean subjects. Body mass index, serum CRP and to a lesser extend percentages of monocyte subtypes correlated with IL-6, TNFα, CCL18, and IL-1ra production. Taken together, monocyte-derived macrophages of obese patients respond more pro-inflammatory and less anti-inflammatory to biomaterials than macrophages from lean subjects, depending on the material. These results are a step towards personalized medicine for the development of a model or even a blood test to decide which biomaterial might be suitable for each patient.
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Affiliation(s)
- G S A Boersema
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Orthopaedics, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - L Utomo
- Department of Orthopaedics, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Y Bayon
- Medtronic-Sofradim Production, 116 Avenue Formans, 01600 Trévoux, France
| | - N Kops
- Department of Orthopaedics, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - J F Lange
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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18
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Jonker FHW, Tanis PJ, Coene PPLO, Gietelink L, van der Harst E. Comparison of a low Hartmann's procedure with low colorectal anastomosis with and without defunctioning ileostomy after radiotherapy for rectal cancer: results from a national registry. Colorectal Dis 2016; 18:785-92. [PMID: 26788679 DOI: 10.1111/codi.13281] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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: 04/27/2015] [Accepted: 09/21/2015] [Indexed: 02/08/2023]
Abstract
AIM This study used a national registry to compare the outcome after a low Hartmann's procedure (LHP), defined as removal of most of the rectum to leave a short anorectal stump and an end colostomy, and low anterior resection (LA) with or without a diverting ileostomy (DI) in rectal cancer patients all of whom had received preoperative neoadjuvant radiotherapy (RT). METHOD Patients who underwent LHP or LA with or without DI for rectal cancer after RT between 2009 and 2013 were identified from the Dutch Surgical Colorectal Audit. The postoperative outcome was compared between the three groups and risk of complications, reoperation and mortality were analysed in a multivariable model. RESULTS The study included 4288 patients were included, of whom 27.8% underwent LHP, 20.2% LA and 52.0% LA with DI. Thirty-day mortality was higher after LHP (3.2% vs 1.3% and 1.3% for LA with or without DI, P < 0.001), but LHP was not an independent predictor of mortality in multivariable analysis. LHP and LA with DI were associated with a lower rate of abdominal infective complications (6.5% and 10.1% vs 16.2%, P < 0.001) and reoperation (7.3% and 8.1% vs 16.5%, P < 0.001). In multivariable analysis, LHP (OR 0.35, 95% CI 0.26-0.47) and LA with DI (OR 0.43, 95% CI 0.33-0.54) were associated with a lower risk of reoperation than LA alone. LHP was associated with a lower risk of any postoperative complication than LA with or without DI (OR 0.81, 95% CI 0.66-0.98). CONCLUSION LHP and LA with DI were associated with fewer infective complications and reoperations than LA alone. The rate of any complication was less after LHR than LA with or without DI.
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Affiliation(s)
- F H W Jonker
- Department of Surgery, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - P P L O Coene
- Department of Surgery, Maasstad Hospital Rotterdam, Rotterdam, The Netherlands
| | - L Gietelink
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital Rotterdam, Rotterdam, The Netherlands
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19
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Ditzel M, van Ginhoven TM, van der Wal JBC, Hop W, Coene PPLO, Lange JF, van der Harst E. What patients and surgeons should know about the consequences of appendectomy for acute appendicitis after long-term follow-up: factors influencing the incidence of chronic abdominal complaints. J Gastrointest Surg 2013; 17:1471-6. [PMID: 23733362 DOI: 10.1007/s11605-013-2235-0] [Citation(s) in RCA: 7] [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] [Received: 03/03/2013] [Accepted: 05/13/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Abscess formation and perforation are complications of acute appendicitis that lead to localized or generalized peritonitis. The long-term implications of complicated appendectomy remain largely unknown. MATERIALS AND METHODS In the present study, it was investigated whether patients with complicated appendicitis experienced more abdominal complaints after long-term follow-up when compared to uncomplicated cases. In addition, the influence of operation technique (open versus laparoscopic) was studied. A retrospective analysis of 1,481 appendectomies for acute appendicitis was performed in two centers from January 2000 until January 2006. Demographic data, operative reports, intraoperatively adhesions and complications, abdominal pain, and satisfaction were monitored. In total, 1,433 patients were invited to fill out a questionnaire with a median follow-up of 7.1 years. Questionnaires of 526 (37 %) patients were suitable for analysis. RESULTS Perforation, abdominal abscesses, or adhesions at initial operation did not result in more abdominal complaints when compared to appendectomy for uncomplicated acute appendicitis. Additionally, no significant differences in abdominal complaints were seen between laparoscopic and open techniques. CONCLUSION In conclusion, the results of our study show that after follow-up of 7 years, the incidence of abdominal complaints was not influenced by operative technique or whether acute appendicitis was complicated or not. This finding does not support a causative role for adhesions with regard to chronic abdominal complaints. Our data enables surgeons to inform their patients about the long-term results of appendectomy, whether it was complicated or not.
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Affiliation(s)
- M Ditzel
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 50, 3015, Rotterdam, The Netherlands.
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20
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Kolfschoten NE, Gooiker GA, Bastiaannet E, van Leersum NJ, van de Velde CJH, Eddes EH, Marang-van de Mheen PJ, Kievit J, van der Harst E, Wiggers T, Wouters MWJM, Tollenaar RAEM. Combining process indicators to evaluate quality of care for surgical patients with colorectal cancer: are scores consistent with short-term outcome? BMJ Qual Saf 2012; 21:481-9. [DOI: 10.1136/bmjqs-2011-000439] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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21
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Vermeulen J, Gosselink MP, Hop WCJ, van der Harst E, Hansen BE, Mannaerts GHH, Coene PPLO, Weidema WF, Lange JF. Long-term survival after perforated diverticulitis. Colorectal Dis 2011; 13:203-9. [PMID: 19895594 DOI: 10.1111/j.1463-1318.2009.02112.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [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] [Indexed: 02/08/2023]
Abstract
AIM Short-term survival after emergency surgery for perforated diverticulitis is poor. Less is known about long-term survival. The aims of this study were to evaluate long-term survival after discharge from hospital and to identify factors associated with prognosis. METHOD All patients who underwent emergency surgery for perforated diverticulitis in five hospitals in Rotterdam, the Netherlands, between 1990 and 2005, were included. The association between type of surgery (Hartmann's procedure or primary anastomosis) and long-term survival was analysed using multivariate Cox regression analysis, taking into account age American Society of Anesthesiology (ASA) classification, Hinchey score, Mannheim Peritonitis Index (MPI) and surgeon's experience. In addition, survival of the patients was compared with that of the matched general Dutch population. RESULTS Of 340 patients included in the study, 250 were discharged alive from hospital. The overall 5-year survival was 53%. Survival was significantly impaired compared with the expected matched gender-, age- and calendar time-specific survival. Overall survival was significantly related to age and ASA classification. Hinchey score, MPI, number of re-interventions, the surgeon's experience and type of procedure did not influence long-term survival, although a trend was found for Hartmann's procedure to be a risk factor for poorer survival compared with primary anastomosis (hazard ratio for mortality: 1.88; 95% confidence interval, 0.96-3.67; P = 0.07). CONCLUSION Long-term survival of patients after perforated diverticulitis is limited and mainly caused by the poor general condition of the patients, rather than by the severity of the primary disease or calendar-time and type of procedure.
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Affiliation(s)
- J Vermeulen
- Erasmus Medical Center, Department of Surgery Rotterdam, The Netherlands.
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22
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Nieuwenhuizen J, van Ramshorst GH, ten Brinke JG, de Wit T, van der Harst E, Hop WCJ, Jeekel J, Lange JF. The use of mesh in acute hernia: frequency and outcome in 99 cases. Hernia 2011; 15:297-300. [PMID: 21259032 PMCID: PMC3114066 DOI: 10.1007/s10029-010-0779-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 12/31/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Incarceration of inguinal, umbilical and cicatricial hernias is a frequent problem. However, little is known about the relationship between the use of mesh and outcome after surgery. The goal of this study was to describe the relationship between the use of mesh in incarcerated hernia and the clinical outcome. PATIENTS AND METHODS Correspondence, operation reports and patient files between January 1995 and December 2005 of patients presented at one academic and one teaching hospital in Rotterdam were searched for the following keywords: incarceration, strangulation and hernia. The patient characteristics, clinical presentation, pre-operative findings and clinical course were scored and analysed. RESULTS A total of 203 patients could be identified: 76 inguinal, 52 umbilical, 39 incisional, 14 epigastric, 14 femoral, five trocar and three spigelian hernias. In the statistical analysis, epigastric, femoral, trocar and spigelian hernias were pooled, due to their small group sizes. One patient was excluded from the analysis because the hernia was not corrected during operation. In total, 99 hernias were repaired using mesh versus 103 primary suture repairs. Twenty-five wound infections were registered (12.3%). One mesh was removed during a reintervention for anastomotic leakage, although no signs of wound infection were present. Nine patients died, none of them due to wound-related problems [one cardiovascular, one ruptured aneurysm, two anastomotic leakage, two sepsis e causa incognita (e.c.i.), three pulmonary complications]. Univariate analysis showed that female patients (P = 0.007), adipose patients (P = 0.016), patients with an umbilical hernia (P = 0.01) and patients who underwent a bowel resection (P = 0.015) had a significantly higher rate of wound infections. The type of repair (e.g. primary suture or mesh), use of antibiotic prophylaxis, gender, ASA class and age showed no significant relation with post-operative wound infection. After logistic regression analysis, only bowel resection (P = 0.020) showed a significant relation with post-operative wound infection. CONCLUSIONS Wound infection rates are high after the correction of acute hernia, but clinical consequences are relatively low. Mesh correction of an acute hernia seems to be safe and should be considered in every incarcerated hernia.
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Affiliation(s)
- J Nieuwenhuizen
- Department of Surgery, 10M, Erasmus MC, University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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23
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de Bruin AFJ, Gosselink MP, van der Harst E, Rutten HJT. Local application of gentamicin collagen implants in the prophylaxis of surgical site infections following gastrointestinal surgery: a review of clinical experience. Tech Coloproctol 2010; 14:301-10. [PMID: 20585822 PMCID: PMC2988990 DOI: 10.1007/s10151-010-0593-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 06/10/2010] [Indexed: 01/15/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is a common type of healthcare-associated infection in gastrointestinal (GI) surgical procedures, which often has major consequences for patient recovery and increased healthcare costs due to prolonged hospital stay. This article provides an overview of the efficacy and safety of prophylactic application of resorbable gentamicin-containing collagen implants (GCI) in the prevention of SSI following high-risk GI surgical procedures. METHOD Nine publications were identified using the PubMed online database and search terms 'gentamicin collagen implant' plus 'surgical site infection', 'wound infection' and 'gastrointestinal surgery'. RESULTS Data from 483 patients treated prophylactically have demonstrated that GCI can reduce the wound infection rate in high-risk GI surgical procedures and improve wound healing after pilonidal sinus excision. In a study of 221 patients who underwent colorectal surgery, the wound infection rate was reduced to 5.6% in the GCI group compared to 18.4% in the control group (P < 0.01). GCI also positively influences the post-operative course for patients undergoing particularly risky procedures e.g. abdominoperineal resection (APR) combined with neoadjuvant radiotherapy. In one such patient series, GCI reduced the wound infection rate by over 70% and the length of hospital stay by 40%. Few side effects of GCI were noted in the 9 clinical studies. CONCLUSIONS This review demonstrates that GCI can have a positive effect on wound infection rates in high-risk GI surgery and can also improve wound healing after pilonidal sinus excision.
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Affiliation(s)
- A F J de Bruin
- Department of Surgery, Division of Colon and Rectal Surgery, Medisch Centrum Rijnmond Zuid, Maasstad Ziekenhuis, Olympiaweg 350, 3078 HT, Rotterdam, The Netherlands.
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24
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Vermeulen J, van der Harst E, Lange JF. Pathophysiology and prevention of diverticulitis and perforation. Neth J Med 2010; 68:303-309. [PMID: 21071775] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE This article gives an overview of the current evidence and theories in the pathophysiology of diverticulosis, diverticulitis and perforation and discusses its prevention. BACKGROUND Diverticular disease is one of the most common diseases related to the gastrointestinal tract in Western countries. The pathogenesis of this disease process is probably multifactorial, but remains poorly understood and inadequately investigated. METHODS A literature search was performed in order to give an overview of the current evidence and theories in the pathophysiology of diverticula formation and the factors related to progression towards inflammation and even perforation. Strategies for prevention of (perforated) diverticulitis are also discussed. RESULTS/CONCLUSION The pathogenesis of diverticular disease and its complications seems to be a result of a complex interaction between exposure to a low-fibre diet, possible genetic influences, the coexistence of other bowel diseases and the impact of medicine use. This eventually leads to alterations in colonic pressures and motility and structural changes of the colon wall. Unfortunately the evidence is frequently conflicting in the present literature or lacking altogether.
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Affiliation(s)
- J Vermeulen
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
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De Bruin AFJ, Schouten SB, de Kort PPS, Gosselink MP, van der Harst E. The impact of chronic smoking on rectal mucosal blood flow. Tech Coloproctol 2010; 13:269-72. [PMID: 19730785 DOI: 10.1007/s10151-009-0529-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [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: 06/16/2009] [Accepted: 08/17/2009] [Indexed: 01/12/2023]
Abstract
BACKGROUND Chronic smoking adversely affects peripheral vasculature. The aim of the present study was to investigate the effect of chronic cigarette smoking on rectal microvascular blood flow. METHODS Rectal mucosal blood flow (MBF) was measured in 80 subjects (44 smokers and 36 non-smokers). The MBF was measured in the four quadrants of the rectum by laser Doppler flowmetry. RESULTS Rectal perfusion was found to be significantly lower in posterior midline compared to the other sites. In chronic smokers the observed MBF measured at the posterior and ventral sites was significantly lower compared to non-smokers (P = 0.04 and P = 0.03, respectively). CONCLUSIONS Our results suggest that rectal mucosal blood flow is reduced in chronic smokers.
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Affiliation(s)
- A F J De Bruin
- Division of Colon and Rectal surgery, Department of Surgery, Maasstad Ziekenhuis, Brede Hilledijk 315, 3075 EA Rotterdam, The Netherlands.
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Vermeulen J, Coene PPLO, Van Hout NM, van der Harst E, Gosselink MP, Mannaerts GHH, Weidema WF, Lange JF. Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure? Colorectal Dis 2009; 11:619-24. [PMID: 18727727 DOI: 10.1111/j.1463-1318.2008.01667.x] [Citation(s) in RCA: 107] [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] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Hartmann's procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis. METHOD All 158 patients who had survived emergency surgery for acute perforated diverticulitis in five teaching hospitals in The Netherlands between 1995 and 2005 and underwent HP or PA with DI were retrospectively studied. Age, gender, ASA-classification, severity of primary disease, delay of stoma reversal, surgeon's experience, surgical procedure and type of anastomosis were analysed in relation to outcome after stoma reversal. RESULTS Of the 158 patients, 139 had undergone HP and 19 PA with DI. The reversal-rate was higher in patients with DI (14/19; 74%) compared to HP (63/139; 45%) (P = 0.027) Delay between primary surgery and stoma reversal was shorter after PA with DI compared with HP (3.9 vs 9.1 months; P < 0.001). Cumulative postreversal morbidity after HP was 44%. Early surgical complications occurred in 22 of 63 patients. Morbidity after DI reversal was 15% (P < 0.001). Three patients died after HP reversal, none died after DI reversal. Anastomotic leakage was observed in 10 patients after HP reversal. This was less frequently observed when the operation was performed by a specialist colorectal surgeon (10%vs 33%; P = 0.049) and when a stapled anastomosis was performed (4%vs 24%; P = 0.037). CONCLUSIONS Reversal of HP should only be performed by an experienced colorectal surgeon, preferably performing a stapled anastomosis, or probably not be performed at all, as it is accompanied by high postoperative morbidity and even mortality. It is important that these findings are taken in account for when performing primary emergency surgery for acute perforated diverticulitis.
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Affiliation(s)
- J Vermeulen
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands.
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Buunen M, Bonjer HJ, Hop WCJ, Haglind E, Kurlberg G, Rosenberg J, Lacy AM, Cuesta MA, D'Hoore A, Fürst A, Lange JF, Jess P, Bulut O, Poornoroozy P, Jensen KJ, Christensen MM, Lundhus E, Ovesen H, Birch D, Iesalnieks I, Jäger C, Kreis M, van riet Y, van der Harst E, Gerhards MF, Bemelman WA, Hansson BME, Neijenhuis PA, Prins HA, Balague C, Targarona E, Luján Mompeán JA, Franco Osorio JD, Garcia Molina FJ, Skullman S, Läckberg Z, Kressner U, Matthiessen P, Kim SH, Poza AA. COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer. Dan Med Bull 2009; 56:89-91. [PMID: 19486621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Laparoscopic resection of rectal cancer has been proven efficacious but morbidity and oncological outcome need to be investigated in a randomized clinical trial. TRIAL DESIGN Non-inferiority randomized clinical trial. METHODS The COLOR II trial is an ongoing international randomized clinical trial. Currently 27 hospitals from Europe, South Korea and Canada are including patients. The primary endpoint is loco-regional recurrence rate three years post-operatively. Secondary endpoints cover quality of life, overall and disease free survival, post-operative morbidity and health economy analysis. RESULTS By July 2008, 27 hospitals from the Netherlands, Belgium, Germany, Sweden, Spain, Denmark, South Korea and Canada had included 739 patients. The intra-operative conversion rate in the laparoscopic group was 17%. Distribution of age, location of the tumor and radiotherapy were equal in both treatment groups. Most tumors are located in the mid-rectum (41%). CONCLUSION Laparoscopic surgery in the treatment of rectal cancer is feasible. The results and safety of laparoscopic surgery in the treatment of rectal cancer remain unknown, but are subject of interim analysis within the COLOR II trial. Completion of inclusion is expected by the end of 2009. TRIAL REGISTRATION Clinicaltrials.gov, identifier: NCT00297791 (www.clinicaltrials.gov).
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Vermeulen J, Lange JF, Sikkenk AC, van der Harst E. Anterolateral rectopexy for correction of rectoceles leads to good anatomical but poor functional results. Tech Coloproctol 2009; 9:35-41; discussion 41. [PMID: 15868497 DOI: 10.1007/s10151-005-0190-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [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: 10/03/2004] [Accepted: 11/25/2004] [Indexed: 12/24/2022]
Abstract
BACKGROUND Several different surgical repair procedures for symptomatic rectocele have been described with variable results. In our clinic, a modified anterolateral rectopexy is used. In this article we evaluate our results, with emphasis on patient satisfaction. METHODS From 2001 until 2003, twenty patients with a symptomatic rectocele were treated by anterolateral rectopexy. The preoperative dynamic defecogram and anorectal complaints were analyzed and compared to postoperative outcome via a standardized questionnaire. RESULTS After surgery, all rectoceles were restored as shown by postoperative defecogram. Anorectal symptoms (incomplete evacuation, continuous urge, prolapse, digital evacuation) were improved in 40%. As new-onset symptoms, dyspareunia (50%), digital support (55%) and incomplete evacuation (75%) were mentioned frequently. Most of the patients with larger rectoceles (>3.5 cm) had increased anorectal complaints after surgery. CONCLUSIONS Anterolateral rectopexy for treatment of rectocele give limited improvement of anorectal complaints. Besides, many patients developed new complaints postoperatively and hence overall satisfaction was low.
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Affiliation(s)
- J Vermeulen
- MCRZ locatie Zuider, Department of Surgery, Medisch Centrum Rijnmond Zuid, Olympiaweg 350, Rotterdam, The Netherlands.
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in 't Hof KH, Kazemier G, van der Harst E, Bonjer HJ, Lange JF. Is less more? A prospective trial on one trocar appendectomy. Hepatogastroenterology 2009; 56:424-426. [PMID: 19579613] [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: 05/28/2023]
Abstract
One trocar appendectomy is a combination of laparoscopic and open appendectomy. The advantage, along with improved cosmesis, is the possibility to introduce a dissection instrument through the optical trocar without an additional incision. In this prospective study the sense of one trocar appendectomy is evaluated in daily practise for a cohort of consecutive patients with suspected acute appendicitis. Twenty-two patients were enrolled. One-trocar appendectomy was successful in 13 patients. In 8 patients one extra 2, 5 or 10 millimetre trocar was necessary. In one patient a third trocar was necessary. Conversion to an open appendectomy through a grid iron incision was not necessary. The pathologist confirmed the diagnosis of acute appendicitis in all patients. The average operation time was 53 minutes. Complications included one wound abscess and one wound haematoma. In conclusion one trocar appendectomy is a good and safe technique in patients with the suspicion of acute appendicitis, provided that the operative team must be experienced in laparoscopic surgery and the constitution of the patient is suitable for this technique.
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Affiliation(s)
- K H in 't Hof
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands.
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Abstract
In view of constructing a gastric tube after esophagus resection, the vascular anatomy of the greater curvature of the stomach, especially the connection between the left and right gastro-epiploic arteries, was investigated. The vascular anatomy was studied in 20 embalmed human specimens. After dissection a gastric tube of 4 cm wide was constructed, using the greater gastric curvature. Various lengths of the arterial arcades were measured. In 70% an anastomosis between the right and left gastro-epiploic arteries was present. With the construction of an isoperistaltic gastric tube, in which the left gastro-epiploic artery is left in situ (ligating it at the splenic hilus), there is an 18.7% increase of length of arterial arcade along the gastric tube. Leaving the left gastro-epiploic artery in situ increases the feeding arterial arcaded-length along the gastric tube with 5.0 cm (19%).
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Affiliation(s)
- M Buunen
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.
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Besselink MGH, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman HM, Nieuwenhuijs VB, Bollen TL, van Ramshorst B, Witteman BJM, Rosman C, Ploeg RJ, Brink MA, Schaapherder AFM, Dejong CHC, Wahab PJ, van Laarhoven CJHM, van der Harst E, van Eijck CHJ, Cuesta MA, Akkermans LMA, Gooszen HG. [Probiotic prophylaxis in patients with predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial]. Ned Tijdschr Geneeskd 2008; 152:685-696. [PMID: 18438065] [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: 05/26/2023]
Abstract
OBJECTIVE To evaluate whether enteral prophylaxis with probiotics in patients with predicted severe acute pancreatitis prevents infectious complications. DESIGN Multicentre, randomised, double-blind, placebo-controlled trial. METHOD A total of 296 patients with predicted severe acute pancreatitis (APACHE II score > or = 8, Imrie score > or = 3 or C-reactive protein concentration > 150 mg/l) were included and randomised to one of two groups. Within 72 hours after symptom onset, patients received a multispecies preparation of probiotics or placebo given twice daily via a jejunal catheter for 28 days. The primary endpoint was the occurrence of one of the following infections during admission and go-day follow-up: infected pancreatic necrosis, bacteraemia, pneumonia, urosepsis or infected ascites. Secondary endpoints were mortality and adverse reactions. The study registration number is ISRCTN38327949. RESULTS Treatment groups were similar at baseline with regard to patient characteristics and disease severity. Infections occurred in 30% of patients in the probiotics group (46 of 152 patients) and 28% of those in the placebo group (41 of 144 patients; relative risk (RR): 1.1; 95% CI: 0.8-1.5). The mortality rate was 16% in the probiotics group (24 of 152 patients) and 6% (9 of 144 patients) in the placebo group (RR: 2.5; 95% CI: 1.2-5.3). In the probiotics group, 9 patients developed bowel ischaemia (of whom 8 patients died), compared with none in the placebo group (p = 0.004). CONCLUSION In patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients.
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Affiliation(s)
- M G H Besselink
- Afd. Heelkunde, Universitair Medisch Centrum Utrecht, Utrecht.
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Vermaas M, Gosselink MP, Ferenschild FTJ, van den Aardweg E, Lont HE, Kemperman HWPM, van der Harst E, Tetteroo GWM, Oostenbroek RJ, Dijkhuis CM, Eggermont AMM, de Wilt JHW. Introduction of preoperative radiotherapy in the treatment of operable rectal cancer in the Southwest region of the Netherlands. Eur J Surg Oncol 2007; 33:862-7. [PMID: 17257804 DOI: 10.1016/j.ejso.2006.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Accepted: 12/05/2006] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION After publication of the results of the Dutch TME-trial preoperative radiotherapy followed by TME-surgery was introduced in July 2001 in the region of the comprehensive cancer centre Rotterdam as standard treatment for rectal cancer. The aim of this study is to identify the compliance to a new standardized treatment protocol i.e. the introduction of preoperative radiotherapy and to analyze the results of rectal cancer treatment in the Cancer Centre Rotterdam Region. PATIENTS AND METHODS A total of 521 patients with adenocarcinoma of the rectum were included in the period from 2001 to 2003. All patients were treated with curative intent. RESULTS There was a significant increase of preoperative radiotherapy for patients with a tumour in the lower two-third of the rectum (21% versus 69%, p<0.001). Peri-operative mortality rate was 2.7% and overall anastomotic leakage rate was 10.3%. There was a significant increase in the occurrence of anastomotic leakage in end-to-end anastomoses (p<0.0001). Most anastomotic leakages occurred when patients were operated in between 4 and 8 days after the end of radiotherapy. Several aspects such as continence for urine and faeces and sexual functions were poorly registered. The total number of lymph nodes registered in pathology reports was low. The rate of reported circumferential margins increased from 37% to 70% after feedback to the regional pathology working group. CONCLUSION The regional quality of rectal cancer surgery is conform preset quality-demands. There was a significant increase in the percentage preoperative radiotherapy, but still about 25% of patients who qualified for radiotherapy did not receive radiation. Pathology reports improved during registration, which illustrates the importance of registration to assess and improve quality of rectal cancer treatment.
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Affiliation(s)
- M Vermaas
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
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Vermulst N, Vermeulen J, Hazebroek EJ, Coene PPLO, van der Harst E. Primary closure of the skin after stoma closure. Management of wound infections is easy without (long-term) complications. Dig Surg 2006; 23:255-8. [PMID: 16943674 DOI: 10.1159/000095399] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [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] [Received: 07/12/2006] [Accepted: 07/15/2006] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Whether or not the skin can be closed primarily after stoma closure is still debated in the existing literature. Therefore, this present study was undertaken to compare the complications and consequences between primary or delayed closure of the skin after stoma closure. PATIENTS AND METHODS All consecutive stoma closures between January 2001 and August 2004 were included. In 25 patients (group I), the skin at the stoma site was closed primarily. In 37 patients (group II), the skin was left open. Patient characteristics, comorbidity, medication use, hospital stay and long-term complications were recorded and retrospectively compared between the two groups. RESULTS In group I, wound infection rate was 36% versus 5% in group II (p = 0.005). Infected wounds were mostly found after ileostomy closure with primary closure of the skin (p = 0.018). The occurrence of a wound infection was not related to the use of corticosteroids, diabetes mellitus, fistula formation, anastomotic leakage, or primary disease and did not lead to a prolonged hospital stay or an increased number of incisional hernias. conclusion: In our opinion, it is safe to close the skin after stoma closure, but patients should be informed carefully about the advantages and disadvantages of this strategy, especially in case of ileostomy closure.
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Affiliation(s)
- N Vermulst
- Department of Surgery, Medisch Centrum Rijnmond Zuid, NL-3078 HT Rotterdam, The Netherlands
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de Schipper JP, Liem RSL, van den Ingh HFGM, van der Harst E. Revision of gastrointestinal mesenchymal tumours with CD117. Eur J Surg Oncol 2005; 30:959-62. [PMID: 15498641 DOI: 10.1016/j.ejso.2004.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2004] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Tyrosinekinase inhibitors improve the treatment of gastrointestinal stromal tumours (GISTs) and their diagnosis has been facilitated by recently developed immunohistochemical markers. It is hypothesised that in the past, the true incidence of GISTs has been underestimated. AIMS To study the clinicopathological features of previously resected mesenchymal tumours of the gastrointestinal tract and determine the accuracy of previous diagnostic results. PATIENTS AND METHODS Patients with mesenchymal tumours of the gastrointestinal tract operated on between 1987 and 2002 were identified using medical and pathologic files. Immunohistochemical staining for CD117, CD34, desmin and S100 was performed, and diagnosis reviewed. RESULTS Thirty-six mesenchymal tumours were reanalysed. Before revision, diagnosis of GIST was correctly made in only six cases. Supportive use of immunohistochemical markers for accurate diagnosis of the remaining 30 previously undefined mesenchymal tumours yielded 17 additional GISTs. Therefore, 23 of 36 (63%) gastrointestinal mesenchymal tumours were shown to be GISTs. CONCLUSIONS The true incidence of GISTs has been underestimated. There is merit in reviewing the clinical diagnoses of all mesenchymal tumours of the gastrointestinal tract with modern immunohistochemical markers. This may enhance clinical decision making.
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Affiliation(s)
- J P de Schipper
- Department of Surgery, Medisch Centrum Rijnmond-Zuid locatie Clara, Olympiaweg 350, 3078 HT Rotterdam, The Netherlands
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van der Harst E, de Herder WW, de Krijger RR, Bruining HA, Bonjer HJ, Lamberts SWJ, van den Meiracker AH, Stijnen TH, Boomsma F. The value of plasma markers for the clinical behaviour of phaeochromocytomas. Eur J Endocrinol 2002; 147:85-94. [PMID: 12088924 DOI: 10.1530/eje.0.1470085] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [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: 11/08/2022]
Abstract
OBJECTIVE Phaeochromocytomas (PCCs) are widely known for their clinical unpredictability. This study intends to define predictive plasma markers for their variable postoperative behaviour. Furthermore, the diagnostic accuracy of these plasma tests was determined. DESIGN AND METHODS A retrospective correlative study was performed in a series of 83 operated and four autopsied patients in order to correlate preoperative catecholamine (CAT) levels of 103 PCCs with their clinical behaviour. In a subset of cases, chromogranin-A (Chr-A) and enzymes/precursors of the CAT biosynthesis were studied for their predictive value. RESULTS Basal CAT levels were elevated in 81/87 instances (sensitivity: 93%). Four of six cases with normal measurements showed only medullary hyperplasia. Larger PCCs, particularly those showing necrosis, capsular and vascular invasion, secreted higher CAT levels. Bilateral, hereditary tumours were less productive than their unilateral counterparts. Extra-adrenal PCCs secreted significantly lower levels of epinephrine (EPI) than intra-adrenal tumours. Fourteen patients developed metastases. According to Kaplan-Meier estimations, patients with higher levels of dopamine, norepinephrine (NE) and aromatic l-amino acid decarboxylase as well as lower ratios of EPI/EPI+NE, had significantly shorter metastases-free intervals. Existence of preoperative hypertension, left ventricular hypertrophy and measured blood pressures showed significant positive relationships with CAT levels, but not with Chr-A. CONCLUSIONS These data showed that plasma CAT measurement is a sensitive method in the diagnostic work-up of PCCs. Those tumours producing normal levels are commonly small and asymptomatic. Furthermore, certain secretion patterns are indicative of the presence of metastases as well as the size and site of sporadic and syndrome-related PCCs.
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Affiliation(s)
- E van der Harst
- Department of Surgery, Erasmus University Hospital and MCRZ location Clara, Rotterdam, The Netherlands.
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van der Harst E, de Herder WW, Bruining HA, Bonjer HJ, de Krijger RR, Lamberts SW, van de Meiracker AH, Boomsma F, Stijnen T, Krenning EP, Bosman FT, Kwekkeboom DJ. [(123)I]metaiodobenzylguanidine and [(111)In]octreotide uptake in begnign and malignant pheochromocytomas. J Clin Endocrinol Metab 2001; 86:685-93. [PMID: 11158032 DOI: 10.1210/jcem.86.2.7238] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [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: 12/19/2022]
Abstract
Selecting the appropriate approach for resection and follow-up of pheochromocytomas (PCCs) is highly dependent upon reliable localization and exclusion of multifocal, bilateral, or metastatic disease. Metaiodobenzylguanidine (MIBG) scintigraphy was developed for functional localization of catecholamine-secreting tissues. Somatostatin receptor imaging (SRI) has a high sensitivity for localizing head and neck paragangliomas, but studies of intraabdominal PCCs are rare. In this study we review our experience of [(123)I]MIBG and SRI, performed since 1983 and 1989, respectively, in the work-up of primary and recurrent PCCs. Scintigraphic results were correlated with catecholamine secretion, size and site, malignancy, associated tumor syndromes, and morphological features. [(123)I]MIBG scans were performed in a total of 75 patients, in 70 cases before resection of primary PCCs and in 5 cases because of recurrent disease. Ninety-one PCCs were resected. The overall detection rates were 83.3% and 89.8% for PCCs larger than 1.0 cm. Multifocal disease was detected in 4 patients with [(123)I]MIBG. [(123)I]MIBG uptake correlated with greater size of PCC (r = 0.33; P = 0.008) and greater concentration of plasma epinephrine (r = 0.32; P = 0.006). [(123)I]MIBG-negative PCCs (n = 14) had significantly (P = 0.01) smaller diameters than [(123I)]MIBG-positive tumors. Furthermore, [(123)I]MIBG uptake was significantly higher in unilateral (P = 0.02), benign (P = 0.02), sporadic (P = 0.02), intraadrenal (P = 0.02), and capsular invasive (P = 0.03) PCCs than in bilateral, malignant, MEN2A/2B-related, extraadrenal, and noninvasive PCCs, respectively. The detection rate of SRI was only 25% (8 of 32) for primary benign PCCs. In 14 patients metastases occurred, which were effectively visualized with [(123)I]MIBG in 8 of 14 cases. SRI was able to detect metastases in 7 of 8 cases, including 3 [(123)I]MIBG-negative metastatic cases. In addition, [(123)I]MIBG and SRI detected 2 recurrences. In conclusion, [(123)I]MIBG uptake is correlated with the size, epinephrine production, and site of PCCs. Its role in bilateral and MEN2A/2B-related PCCs seems limited. In cases of recurrent elevation of catecholamines, localization of metastases and/or recurrence should be attempted with [(123)I]MIBG scintigraphy. In suspicious metastatic PCCs, SRI might be considered to supplement [(123)I]MIBG scintigraphy.
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Affiliation(s)
- E van der Harst
- Department of Surgery, Erasmus University Hospital, 3000 CA Rotterdam, The Netherlands.
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Abstract
The malignant mesothelioma is a rare tumour with a rising incidence during the past decades [Lancet 1 (1986) 1275; Br J Int Med 28 (1971) 59; Am J Int Med 9 (1986) 397]. The tumour is derived from the mesothelial lining of the pleural cavity, the pericardium or the peritoneum. Mesotheliomas solely involving the peritoneum are particularly rare. Two cases of malignant peritoneal mesotheliomas are described to demonstrate the difficulties in diagnosing this disease. Surgical exploration, either by laparotomy, or preferably by laparoscopy, has been proven valuable as a diagnostic method.
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Affiliation(s)
- S M Yoo
- Department of Internal Medicine, St. Clara Hospital, Rotterdam, The Netherlands
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de Krijger RR, van der Harst E, Muletta-Feurer S, Bruining HA, Lamberts SW, Dinjens WN, Roth J, Heitz PU, Komminoth P. RET is expressed but not mutated in extra-adrenal paragangliomas. J Pathol 2000; 191:264-8. [PMID: 10878547 DOI: 10.1002/1096-9896(2000)9999:9999<::aid-path638>3.0.co;2-i] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study has investigated the role of the RET proto-oncogene, which has been identified as the susceptibility gene for multiple endocrine neoplasia (MEN) type 2, in the development of sporadic and familial extra-adrenal paragangliomas. RET protein expression was analysed by immunohistochemistry. Subsequently, DNA extracted from 52 tumours of 44 patients was screened for somatic RET point mutations in exons 10, 11, and 13-16, where oncogenic mutations have recently been described in a subset of sporadic medullary thyroid carcinomas and phaeochromocytomas. The methods employed included non-isotopic polymerase chain reaction-based single strand conformation polymorphism (PCR-SSCP) analysis and heteroduplex gel electrophoresis, followed by direct sequencing of PCR products. RET protein expression was demonstrated in all ten paragangliomas tested. However, none of the familial or sporadic extra-adrenal paragangliomas contained somatic mutations in exons 10, 11, or 13-16 of the RET proto-oncogene, whereas control samples with known mutations in these exons exhibited the expected band shift, or yielded an additional band with retarded migration. Although paragangliomas exhibit RET protein expression, these data indicate that oncogenic RET proto-oncogene mutations do not appear to be generally important in the formation of sporadic paragangliomas.
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Affiliation(s)
- R R de Krijger
- Department of Pathology, Erasmus University and University Hospital, Rotterdam, The Netherlands.
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van der Harst E, Bruining HA, Jaap Bonjer H, van der Ham F, Dinjens WN, Lamberts SW, de Herder WW, Koper JW, Stijnen T, Proye C, Lecomte-Houcke M, Bosman FT, de Krijger RR. Proliferative index in phaeochromocytomas: does it predict the occurrence of metastases? J Pathol 2000; 191:175-80. [PMID: 10861578 DOI: 10.1002/(sici)1096-9896(200006)191:2<175::aid-path615>3.0.co;2-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Evaluation of the malignant potential of phaeochromocytomas in the absence of metastases presents a formidable challenge to both clinicians and pathologists. Until now, no widely accepted clinical, histological, immunohistochemical or molecular method has become available to discriminate malignant from benign phaeochromocytomas. In other endocrine tumours, estimation of proliferative activity by MIB-1 immunostaining has emerged as a promising approach for the determination of metastatic potential. In this study, the utility of MIB-1 immunostaining as a predictive marker for the occurrence of metastases in phaeochromocytomas was evaluated. In addition, the density of S100-positive sustentacular cells was studied, since their depletion has been identified as a negative predictive marker in smaller series. Furthermore, several clinicopathological parameters were evaluated. One hundred and ten patients operated on for a total of 99 benign and 37 malignant phaeochromocytomas were studied. All malignant tumours had documented metastases. The histopathological diagnosis of primary tumours and metastases was reviewed and graded for angioinvasion, capsular extension, and intra-tumoural necrosis. The proliferative index (percentage of MIB-1-positive cells) and the density of S100-positive cells were assessed. In addition, age at resection, associated familial tumour syndromes, tumour size, and tumour location were recorded. Univariate analysis revealed statistically significant correlations between malignancy and proliferative index (p<0.0005) and depletion of S100-positive sustentacular cells (p<0.0005). Fifty per cent of the malignant, but none of the benign phaeochromocytomas had a proliferative index greater than 2.5%. Higher age at resection (p=0. 03), sporadic occurrence (p<0.0005), extra-adrenal location (p<0. 0005), tumour size (p<0.0005), and necrosis (p=0.03) were also significantly associated with malignancy. Logistic regression showed that proliferative index (p=0.0072), size (p=0.0022), and extra-adrenal location (p=0.0012) of the primary tumour were independently predictive for malignancy. In conclusion, this study indicates that assessing the proliferative activity of phaeochromocytomas by MIB-1 immunohistochemistry can predict the occurrence of metastases. The predictive value of S100 immunostaining, tumour size, and extra-adrenal location of the tumour was also confirmed.
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Affiliation(s)
- E van der Harst
- Department of Surgery, Erasmus University Hospital, Rotterdam, The Netherlands.
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de Krijger RR, van der Harst E, van der Ham F, Stijnen T, Dinjens WN, Koper JW, Bruining HA, Lamberts SW, Bosman FT. Prognostic value of p53, bcl-2, and c-erbB-2 protein expression in phaeochromocytomas. J Pathol 1999; 188:51-5. [PMID: 10398140 DOI: 10.1002/(sici)1096-9896(199905)188:1<51::aid-path310>3.0.co;2-r] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Many studies have tried to discriminate malignant from benign phaeochromocytomas, but until now no widely accepted histological, immunohistochemical, or molecular methods have been available. In this study of 29 malignant and 85 benign phaeochromocytomas from 102 patients, immunohistochemistry was performed with antibodies to the tumour suppressor gene product p53 and the proto-oncogene products bcl-2 and c-erbB-2, using the avidin-biotin complex method. Malignant phaeochromocytomas showed a statistically significant higher frequency of p53 (p=0.042) and bcl-2 (p=0.037) protein expression than their benign counterparts. The combination of both markers showed an even higher significance (p=0.004), to which both markers contributed equally. Overexpression of c-erbB-2 was associated with the occurrence of familial phaeochromocytomas (p=0. 001), but no difference was found between benign and malignant cases. In conclusion, p53, bcl-2, and c-erbB-2 all appear to be involved in the pathogenesis of a proportion of phaeochromocytomas. Immunoreactivity to p53 and bcl-2 proteins may help to predict the clinical behaviour of phaeochromocytomas.
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Affiliation(s)
- R R de Krijger
- Department of Pathology, Erasmus University and University Hospital, Rotterdam, The Netherlands.
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Bonjer HJ, van der Harst E, Steyerberg EW, de Herder WW, Kazemier G, Mohammedamin RS, Bruining HA. Retroperitoneal adrenalectomy: open or endoscopic? World J Surg 1998; 22:1246-9. [PMID: 9841752 DOI: 10.1007/s002689900553] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Conventional adrenalectomy requires relatively large incisions. To assess the value of retroperitoneal endoscopic adrenalectomy, a case-control study was performed comparing the endoscopic technique to conventional posterior adrenalectomy. All patients had adrenal tumors less than 7 cm in diameter. Endoscopic retroperitoneal adrenalectomy required more operative time (90 vs. 60 minutes, p < 0.0001) than the open approach but was associated with less blood loss (20 vs. 125 ml, p < 0.0001). Endoscopic adrenalectomy caused less pain postoperatively (p = 0.0005) and was associated with fewer complications (p = 0.035). The hospital stay was shorter after endoscopic adrenalectomy than after open adrenalectomy (p < 0.0001). In conclusion, we advocate endoscopic retroperitoneal adrenalectomy in patients with small adrenal tumors.
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Affiliation(s)
- H J Bonjer
- Department of Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands
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van der Harst E, de Krijger RR, Bruining HA, Lamberts SW, Bonjer HJ, Dinjes WN, Proye C, Koper JW, Bosman FT, Roth J, Heitz PU, Komminoth P. Prognostic value of RET proto-oncogene point mutations in malignant and benign, sporadic phaeochromocytomas. Int J Cancer 1998; 79:537-40. [PMID: 9761126 DOI: 10.1002/(sici)1097-0215(19981023)79:5<537::aid-ijc16>3.0.co;2-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Somatic mutations in the RET proto-oncogene are involved in the pathogenesis of an important subset (40-60%) of sporadic medullary thyroid carcinomas (MTCs) and less frequently (0-31%) in benign, sporadic phaeochromocytomas. Since limited data exist regarding the significance of somatic RET mutations in malignant phaeochromocytomas, we analysed a multicentre series of proven malignant (i.e., metastasised) phaeochromocytomas. Analogous with MTCs, where RET mutations lead to an aggressive behaviour, we hypothesised that somatic mutations would occur more frequently in malignant than in benign phaeochromocytomas. Paraffin-embedded tissue was available from 29 malignant and 27 benign phaeochromocytomas. Exons 10, 11 and 16 were analysed by non-radioactive single-strand conformation polymorphism, heteroduplex gel electrophoresis, restriction enzyme digestion and aberrant band patterns by non-isotopic sequencing. In only 1 of 29 malignant phaeochromocytomas was a mis-sense mutation found (at codon 634 of exon 11), whereas in 15% (4/27) of the benign tumours a point mutation was detected (in 3 tumours in exon 16 at codon 918 and in 1 tumour in exon 10 at codon 618). Absence of these mutations in non-tumourous DNA proved their somatic origin. Contrary to what has been reported for MTCs, oncogenic RET mutations are not associated with an aggressive tumour behaviour in sporadic phaeochromocytomas.
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Affiliation(s)
- E van der Harst
- Department of Surgery, University Hospital Rotterdam Dijkzigt, The Netherlands
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de Krijger RR, Brooks A, van der Harst E, Hofstra RM, Bruining HA, Molenaar JC, Meijers C. Constipation as the presenting symptom in de novo multiple endocrine neoplasia type 2B. Pediatrics 1998; 102:405-8. [PMID: 9714654 DOI: 10.1542/peds.102.2.405] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- R R de Krijger
- Department of Pathology, University Hospital Dijkzigt, Rotterdam, The Netherlands
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Abstract
It has been shown that an appreciable percentage of patients presenting with primary, apparently sporadic phaeochromocytomas may in fact have von-Hippel-Lindau (VHL) disease. In order to investigate this, we retrospectively screened 68 patients, who had been operated on for phaeochromocytomas, for the presence of germline mutations in the vhl gene. DNA was isolated from peripheral-blood leukocytes and used to screen the entire coding sequence and the intron-exon boundaries of the vhl gene for mutations, using a PCR-based SSCP strategy. When an abnormal pattern was found in the SSCP analysis, sequence analysis was carried out. We found SSC variants in the vhl gene in 8 of the 68 patients. Of 6 patients, 2 turned out to be related (an uncle and his nephew), and they carried the same mis-sense mutation: R64P. In 4 other patients, mis-sense mutations, P25L, L63P, G144Q and I147T, were also identified. None of these mutations has been described, and 3 of them (P25L, L63P and R64P) are located closer to the N terminus of the vhl protein than any reported vhl mutation. In the remaining 2 cases, the mutations were localized not in the coding sequence but in the intronic sequence (but not within splice-sites), adjacent to the exon, so they were probably not related to the disease. Our results show that a relatively high proportion (6/68, or 8.8%), though not as high as the 20% reported earlier, of patients with apparently sporadic phaeochromocytomas may carry germline mutations in the vhl gene.
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Affiliation(s)
- E van der Harst
- Department of Surgery, Erasmus University Rotterdam Medical School and Dijkzigt University Hospital, The Netherlands
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Bonjer HJ, Bruining HA, Valkema R, Lameris JS, de Herder WW, van der Harst E, Pols HA. Single radionuclide scintigraphy with 99mtechnetium-sestamibi and ultrasonography in hyperparathyroidism. Eur J Surg 1997; 163:27-32. [PMID: 9116107] [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: 02/04/2023]
Abstract
OBJECTIVE Assessment of 99mTechnetium-sestamibi scintigraphy and ultrasonography as methods of locating enlarged parathyroid glands before operation. DESIGN Retrospective analysis. SETTING University hospital, The Netherlands. SUBJECTS 21 patients with primary hyperparathyroidism and 6 patients with persistent or recurrent hyperparathyroidism. INTERVENTIONS Single radionuclide scintigraphy with 99mTc-sestamibi, ultrasonography of the neck, and parathyroidectomy. MAIN OUTCOME MEASURES Operative findings, postoperative serum calcium concentrations. RESULTS 99mTc-sestamibi scintigraphy correctly identified 17 of 21 parathyroid tumours in patients who were about to undergo their first parathyroidectomy (sensitivity = 81%) with a positive predictive value of 94% and all 6 in patients with persistent or recurrent hyperparathyroidism. Ultrasonography correctly identified 13 parathyroid tumours in 18 patients about to undergo their first parathyroidectomy (sensitivity = 72%) with a positive predictive value of 93%, but only 3 among the 6 patients with persistent or recurrent hyperparathyroidism. CONCLUSION Single radionuclide scintigraphy with 99mTc-sestamibi seems to identify the sites of parathyroid tumours accurately in patients with persistent or recurrent hyperparathyroidism but is not recommended for patients with primary hyperparathyroidism. Combining scintigraphy with ultrasonography does not improve the accuracy.
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Affiliation(s)
- H J Bonjer
- Department of Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands
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van der Harst E, Bonjer HJ, Pols HA, Laméris JS, Oei HY, Bruining HA. [Preoperative noninvasive tests for localization of enlarged parathyroid glands in 115 patients with hyperparathyroidism]. Ned Tijdschr Geneeskd 1994; 138:1660-4. [PMID: 8090232] [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: 01/28/2023]
Abstract
OBJECTIVE To evaluate results of preoperative localisation techniques in patients operated for hyperparathyroidism (HPT). SETTING Rotterdam University Hospital. DESIGN Retrospective study. METHOD Results of 4 non-invasive preoperative localisation techniques in 115 patients with HPT were compared with operative findings of 116 explorations. Sensitivity and specificity were calculated for single versus multiple gland disease, primary exploration versus re-explorations and anatomical versus ectopic localisation. RESULTS Sensitivity of preoperative ultrasound, thallium-technetium subtraction scintigraphy, computed tomography and 99mTc-sestamibi (MIBI) scanning in patients with single gland disease was 56%, 65%, 67% and 83% respectively. In multiple gland disease preoperative localisation techniques were much less successful. For MIBI scintiscanning this question remains unanswered. Specificity of all techniques was high. Success rates of preoperative localisation studies for primary operations and re-explorations were similar. Mean weight of parathyroid tumours that were missed preoperatively was lower than of successfully localised tumours. Only computed tomography and thallium-technetium scintigraphy were able to localise retrosternal parathyroid tumours. CONCLUSION Review of the literature reveals that there is additional benefit of the preoperative localisation studies in re-exploration for HPT, in contrast to primary exploration. By combining localisation techniques more tumours are visualised. Preliminary results of MIBI scanning are favourable.
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Affiliation(s)
- E van der Harst
- Afd. Algemene Heelkunde, Academisch Ziekenhuis Rotterdam-Dijkzigt
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Abstract
A case of malignant peritoneal mesothelioma without development of ascites is described. The patient had a 1-year history of non-specific symptoms preceding this diagnosis. The insidious onset of clinical signs, the diagnostic procedures, and the pathologic findings are discussed.
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Affiliation(s)
- E van der Harst
- Dept. of Internal Medicine, Gemini Hospital, Den Helder, The Netherlands
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Abstract
Four cases are described of acute non-traumatic rhabdomyolysis with subsequent development of a compartmental syndrome, requiring extensive fasciotomies. All the patients were young male alcoholics who were taking benzodiazepines as part of an addiction treatment programme. In this risk group clinicians should be aware of two serious complications of non-traumatic rhabdomyolysis: acute renal failure and compartmental syndrome.
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Affiliation(s)
- P H Rutgers
- Department of Surgery, Westeinde Hospital, Hague, The Netherlands
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