1
|
Umans DS, Timmerhuis HC, Anten MPGF, Bhalla A, Bijlsma RA, Boxhoorn L, Brink MA, Bruno MJ, Curvers WL, van Eijck BC, Erkelens GW, van Geenen EJM, Hazen WL, Hoge CV, Hol L, Inderson A, Kager LM, Kuiken SD, Perk LE, Quispel R, Römkens TEH, Sperna Weiland CJ, Thijssen AY, Venneman NG, Verdonk RC, van Wanrooij RLJ, Witteman BJ, Besselink MG, van Hooft JE. Prospective multicentre study of indications for surgery in patients with idiopathic acute pancreatitis following endoscopic ultrasonography (PICUS). Br J Surg 2023; 110:1877-1882. [PMID: 37811814 PMCID: PMC10638543 DOI: 10.1093/bjs/znad318] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/21/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Cholecystectomy in patients with idiopathic acute pancreatitis (IAP) is controversial. A randomized trial found cholecystectomy to reduce the recurrence rate of IAP but did not include preoperative endoscopic ultrasonography (EUS). As EUS is effective in detecting gallstone disease, cholecystectomy may be indicated only in patients with gallstone disease. This study aimed to determine the diagnostic value of EUS in patients with IAP, and the rate of recurrent pancreatitis in patients in whom EUS could not determine the aetiology (EUS-negative IAP). METHODS This prospective multicentre cohort study included patients with a first episode of IAP who underwent outpatient EUS. The primary outcome was detection of aetiology by EUS. Secondary outcomes included adverse events after EUS, recurrence of pancreatitis, and quality of life during 1-year follow-up. RESULTS After screening 957 consecutive patients with acute pancreatitis from 24 centres, 105 patients with IAP were included and underwent EUS. In 34 patients (32 per cent), EUS detected an aetiology: (micro)lithiasis and biliary sludge (23.8 per cent), chronic pancreatitis (6.7 per cent), and neoplasms (2.9 per cent); 2 of the latter patients underwent pancreatoduodenectomy. During 1-year follow-up, the pancreatitis recurrence rate was 17 per cent (12 of 71) among patients with EUS-negative IAP versus 6 per cent (2 of 34) among those with positive EUS. Recurrent pancreatitis was associated with poorer quality of life. CONCLUSION EUS detected an aetiology in a one-third of patients with a first episode of IAP, requiring mostly cholecystectomy or pancreatoduodenectomy. The role of cholecystectomy in patients with EUS-negative IAP remains uncertain and warrants further study.
Collapse
Affiliation(s)
- Devica S Umans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Hester C Timmerhuis
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, Haga Hospital, The Hague, the Netherlands
| | - Rina A Bijlsma
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, the Netherlands
| | - Lotte Boxhoorn
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Menno A Brink
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Brechje C van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, the Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, Apeldoorn, the Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Chantal V Hoge
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Liesbeth M Kager
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, the Netherlands
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Medical Centre Haaglanden, The Hague, the Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Christina J Sperna Weiland
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Annemieke Y Thijssen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Roy L J van Wanrooij
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, the Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, the Netherlands
| | - Marc G Besselink
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| |
Collapse
|
2
|
Valkema MJ, Spaander MCW, Boonstra JJ, van Dieren JM, Hazen WL, Erkelens GW, Holster IL, van der Linden A, van der Linde K, Oostenbrug LE, Quispel R, Schoon EJ, Siersema PD, Doukas M, Eyck BM, van der Wilk BJ, van der Sluis PC, Wijnhoven BPL, Lagarde SM, van Lanschot JJB. Active surveillance of oesophageal cancer after response to neoadjuvant chemoradiotherapy: dysphagia is uncommon. Br J Surg 2023; 110:1381-1386. [PMID: 37418342 PMCID: PMC10480037 DOI: 10.1093/bjs/znad211] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/25/2023] [Accepted: 05/26/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Active surveillance is being investigated as an alternative to standard surgery after neoadjuvant chemoradiotherapy for oesophageal cancer. It is unknown whether dysphagia persists or develops when the oesophagus is preserved after neoadjuvant chemoradiotherapy. The aim of this study was to assess the prevalence and severity of dysphagia during active surveillance in patients with an ongoing response. METHODS Patients who underwent active surveillance were identified from the Surgery As Needed for Oesophageal cancer ('SANO') trial. Patients without evidence of residual oesophageal cancer until at least 6 months after neoadjuvant chemoradiotherapy were included. Study endpoints were assessed at time points that patients were cancer-free and remained cancer-free for the next 4 months. Dysphagia scores were evaluated at 6, 9, 12, and 16 months after neoadjuvant chemoradiotherapy. Scores were based on the European Organisation for Research and Treatment of Cancer oesophago-gastric quality-of-life questionnaire 25 (EORTC QLQ-OG25) (range 0-100; no to severe dysphagia). The rate of patients with a (non-)traversable stenosis was determined based on all available endoscopy reports. RESULTS In total, 131 patients were included, of whom 93 (71.0 per cent) had adenocarcinoma, 93 (71.0 per cent) had a cT3-4a tumour, and 33 (25.2 per cent) had a tumour circumference of greater than 75 per cent at endoscopy; 60.8 to 71.0 per cent of patients completed questionnaires per time point after neoadjuvant chemoradiotherapy. At all time points after neoadjuvant chemoradiotherapy, median dysphagia scores were 0 (interquartile range 0-0). Two patients (1.5 per cent) underwent an intervention for a stenosis: one underwent successful endoscopic dilatation; and the other patient required temporary tube feeding. Notably, these patients did not participate in questionnaires. CONCLUSION Dysphagia and clinically relevant stenosis are uncommon during active surveillance.
Collapse
Affiliation(s)
- Maria J Valkema
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jolanda M van Dieren
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | | | - I Lisanne Holster
- Department of Gastroenterology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Klaas van der Linde
- Department of Gastroenterology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Liekele E Oostenbrug
- Department of Gastroenterology and Hepatology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ben M Eyck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | | | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | |
Collapse
|
3
|
Umans DS, Timmerhuis HC, Hallensleben ND, Bouwense SA, Anten MPG, Bhalla A, Bijlsma RA, Boermeester MA, Brink MA, Hol L, Bruno MJ, Curvers WL, van Dullemen HM, van Eijck BC, Erkelens GW, Fockens P, van Geenen EJM, Hazen WL, Hoge CV, Inderson A, Kager LM, Kuiken SD, Perk LE, Poley JW, Quispel R, Römkens TE, van Santvoort HC, Tan AC, Thijssen AY, Venneman NG, Vleggaar FP, Voorburg AM, van Wanrooij RL, Witteman BJ, Verdonk RC, Besselink MG, van Hooft JE. Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study. BMJ Open 2020; 10:e035504. [PMID: 32819938 PMCID: PMC7440829 DOI: 10.1136/bmjopen-2019-035504] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 06/10/2020] [Accepted: 07/15/2020] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Idiopathic acute pancreatitis (IAP) remains a dilemma for physicians as it is uncertain whether patients with IAP may actually have an occult aetiology. It is unclear to what extent additional diagnostic modalities such as endoscopic ultrasonography (EUS) are warranted after a first episode of IAP in order to uncover this aetiology. Failure to timely determine treatable aetiologies delays appropriate treatment and might subsequently cause recurrence of acute pancreatitis. Therefore, the aim of the Pancreatitis of Idiopathic origin: Clinical added value of endoscopic UltraSonography (PICUS) Study is to determine the value of routine EUS in determining the aetiology of pancreatitis in patients with a first episode of IAP. METHODS AND ANALYSIS PICUS is designed as a multicentre prospective cohort study of 106 patients with a first episode of IAP after complete standard diagnostic work-up, in whom a diagnostic EUS will be performed. Standard diagnostic work-up will include a complete personal and family history, laboratory tests including serum alanine aminotransferase, calcium and triglyceride levels and imaging by transabdominal ultrasound, magnetic resonance imaging or magnetic resonance cholangiopancreaticography after clinical recovery from the acute pancreatitis episode. The primary outcome measure is detection of aetiology by EUS. Secondary outcome measures include pancreatitis recurrence rate, severity of recurrent pancreatitis, readmission, additional interventions, complications, length of hospital stay, quality of life, mortality and costs, during a follow-up period of 12 months. ETHICS AND DISSEMINATION PICUS is conducted according to the Declaration of Helsinki and Guideline for Good Clinical Practice. Five medical ethics review committees assessed PICUS (Medical Ethics Review Committee of Academic Medical Center, University Medical Center Utrecht, Radboud University Medical Center, Erasmus Medical Center and Maastricht University Medical Center). The results will be submitted for publication in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER Netherlands Trial Registry (NL7066). Prospectively registered.
Collapse
Affiliation(s)
- Devica S Umans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Hester C Timmerhuis
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Surgery, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Nora D Hallensleben
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Marie-Paule Gf Anten
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HagaZiekenhuis, Den Haag, Zuid-Holland, The Netherlands
| | - Rina A Bijlsma
- Department of Gastroenterology and Hepatology, Martini Ziekenhuis, Groningen, Groningen, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
| | - Menno A Brink
- Department of Gastroenterology and Hepatology, Meander MC, Amersfoort, Utrecht, The Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, North Brabant, The Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, UMCG, Groningen, Groningen, The Netherlands
| | - Brechje C van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Ziekenhuizen, Apeldoorn, Gelderland, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud university medical center, Nijmegen, the Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Noord-Brabant, The Netherlands
| | - Chantal V Hoge
- Department of Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, LUMC, Leiden, Zuid-Holland, The Netherlands
| | - Liesbeth M Kager
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, Noord-Holland, The Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, Zuid-Holland, The Netherlands
| | - Tessa Eh Römkens
- Department of Gastroenteroloy and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, Noord-Brabant, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Adriaan Citl Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, Gelderland, The Netherlands
| | - Annemieke Y Thijssen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, Zuid-Holland, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Overijssel, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Annet McJ Voorburg
- Department of Gastroenterology and Hepatology, Diakonessenhuis Utrecht Zeist Doorn, Utrecht, Utrecht, The Netherlands
| | - Roy Lj van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
| | | |
Collapse
|
4
|
Schepers NJ, Hallensleben NDL, Besselink MG, Anten MPGF, Bollen TL, da Costa DW, van Delft F, van Dijk SM, van Dullemen HM, Dijkgraaf MGW, van Eijck CHJ, Erkelens GW, Erler NS, Fockens P, van Geenen EJM, van Grinsven J, Hollemans RA, van Hooft JE, van der Hulst RWM, Jansen JM, Kubben FJGM, Kuiken SD, Laheij RJF, Quispel R, de Ridder RJJ, Rijk MCM, Römkens TEH, Ruigrok CHM, Schoon EJ, Schwartz MP, Smeets XJNM, Spanier BWM, Tan ACITL, Thijs WJ, Timmer R, Venneman NG, Verdonk RC, Vleggaar FP, van de Vrie W, Witteman BJ, van Santvoort HC, Bakker OJ, Bruno MJ. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicentre randomised controlled trial. Lancet 2020; 396:167-176. [PMID: 32682482 DOI: 10.1016/s0140-6736(20)30539-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND It remains unclear whether urgent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy improves the outcome of patients with gallstone pancreatitis without concomitant cholangitis. We did a randomised trial to compare urgent ERCP with sphincterotomy versus conservative treatment in patients with predicted severe acute gallstone pancreatitis. METHODS In this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, patients with predicted severe (Acute Physiology and Chronic Health Evaluation II score ≥8, Imrie score ≥3, or C-reactive protein concentration >150 mg/L) gallstone pancreatitis without cholangitis were assessed for eligibility in 26 hospitals in the Netherlands. Patients were randomly assigned (1:1) by a web-based randomisation module with randomly varying block sizes to urgent ERCP with sphincterotomy (within 24 h after hospital presentation) or conservative treatment. The primary endpoint was a composite of mortality or major complications (new-onset persistent organ failure, cholangitis, bacteraemia, pneumonia, pancreatic necrosis, or pancreatic insufficiency) within 6 months of randomisation. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN97372133. FINDINGS Between Feb 28, 2013, and March 1, 2017, 232 patients were randomly assigned to urgent ERCP with sphincterotomy (n=118) or conservative treatment (n=114). One patient from each group was excluded from the final analysis because of cholangitis (urgent ERCP group) and chronic pancreatitis (conservative treatment group) at admission. The primary endpoint occurred in 45 (38%) of 117 patients in the urgent ERCP group and in 50 (44%) of 113 patients in the conservative treatment group (risk ratio [RR] 0·87, 95% CI 0·64-1·18; p=0·37). No relevant differences in the individual components of the primary endpoint were recorded between groups, apart from the occurrence of cholangitis (two [2%] of 117 in the urgent ERCP group vs 11 [10%] of 113 in the conservative treatment group; RR 0·18, 95% CI 0·04-0·78; p=0·010). Adverse events were reported in 87 (74%) of 118 patients in the urgent ERCP group versus 91 (80%) of 114 patients in the conservative treatment group. INTERPRETATION In patients with predicted severe gallstone pancreatitis but without cholangitis, urgent ERCP with sphincterotomy did not reduce the composite endpoint of major complications or mortality, compared with conservative treatment. Our findings support a conservative strategy in patients with predicted severe acute gallstone pancreatitis with an ERCP indicated only in patients with cholangitis or persistent cholestasis. FUNDING The Netherlands Organization for Health Research and Development, Fonds NutsOhra, and the Dutch Patient Organization for Pancreatic Diseases.
Collapse
Affiliation(s)
- Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands.
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Franciscus and Vlietland Hospital, Rotterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - David W da Costa
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Sven M van Dijk
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, Netherlands
| | - Marcel G W Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, Apeldoorn, Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Janneke van Grinsven
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | | | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | | | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Frank J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Robert J F Laheij
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, Netherlands
| | - Carola H M Ruigrok
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - Xavier J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| |
Collapse
|
5
|
Nissen LHC, Derikx LAAP, Jacobs AME, van Herpen CM, Kievit W, Verhoeven R, van den Broek E, Bekers E, van den Heuvel T, Pierik M, Rahamat-Langendoen J, Takes RP, Melchers WJG, Nagtegaal ID, Hoentjen F, Peutz-Kootstra C, Roelofs JJTH, Willems SM, Willig AP, van Bodegraven AA, Tan ACITL, Meeuse JJ, van der Meulen–de Jong AE, Oldenburg B, Loffeld BCAJ, Durfeld BM, van der Woude CJ, Cahen DL, D’Haens G, Janik D, Mares WGM, Gilissen LPL, Wolters FL, Dijkstra G, Erkelens GW, Tang TJ, Breumelhof R, Smalbraak HJT, Thijs JC, Voskuil JH, Kuyvenhoven JP, Vecht J, Rijk MCM, Janssen JM, Sarneel JT, Tjhie-Wensing JWM, Lai JYL, Vlasveld LT, Oostenbrug LE, Gerretsen M, Van Herwaarden MA, Mahmmod N, Russel MGVM, Grubben MJAL, Vu MK, Verhulst ML, Dewint P, Stokkers PCF, Bus PJ, Wismans PJ, van der Haeck PWE, Stuyt RJL, Zeijen RNM, Dahlmans RPM, Vandebosch S, Romkens TEH, Moolenaar W, ten Hove WR, Boot H, van der Linde K, Wahab P, de Boer SY, Thurnau K, Thijs WJ, Josemanders DFGM, West RL, Pierik MJ, Depla ACTM, Keulen ETP, de Boer WA, Naber AHJ, Vermeijden JR, Mallant-Hent RC, Beukers R, Ter Borg PCJ, Halet ECR, Bruin KF, Linskens RK, Bruins Slot W. Risk Factors and Clinical Outcomes of Head and Neck Cancer in Inflammatory Bowel Disease: A Nationwide Cohort Study. Inflamm Bowel Dis 2018; 24:2015-2026. [PMID: 30759216 DOI: 10.1093/ibd/izy096] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 09/18/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immunosuppressed inflammatory bowel disease (IBD) patients are at increased risk to develop extra-intestinal malignancies. Immunosuppressed transplant patients show increased incidence of head and neck cancer with impaired survival. This study aims to identify risk factors for oral cavity (OCC) and pharyngeal carcinoma (PC) development in IBD, to compare clinical characteristics in IBD with the general population, and to assess the influence of immunosuppressive medication on survival. METHODS We retrospectively searched the Dutch Pathology Database to identify all IBD patients with OCC and PC between 1993 and 2011. Two case-control studies were performed: We compared cases with the general IBD population to identify risk factors, and we compared cases with non-IBD cancer patients for outcome analyses. RESULTS We included 66 IBD patients and 2141 controls with OCC, 31 IBD patients and 1552 controls with PC, and 1800 IBD controls. Age at IBD diagnosis was a risk factor for OCC development, Crohn's disease (CD; odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.07), and ulcerative colitis (UC; OR, 1.03; 95% CI, 1.01-1.06). For PC, this applied to UC (OR, 1.05; 95% CI, 1.01-1.06). IBD OCC cases showed impaired survival (P = 0.018); in PC, survival was similar. There was no effect of immunosuppression on survival. Human papillomavirus (HPV) testing of IBD cases revealed 52.2% (12/23) HPV-positive oropharyngeal carcinomas (OPCs). CONCLUSION This study shows that IBD is associated with impaired OCC survival. Higher age at IBD diagnosis is a risk factor for OCC development. We found no influence of immunosuppression on survival; 52.2% of OPC in IBD contained HPV.
Collapse
Affiliation(s)
- Loes H C Nissen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology.,Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | | | - Anouk M E Jacobs
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology
| | - Carla M van Herpen
- Department of Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Wietske Kievit
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Rob Verhoeven
- Netherlands Cancer Registry/Netherlands Comprehensive Cancer Organization
| | | | - Elise Bekers
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Tim van den Heuvel
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marieke Pierik
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Robert P Takes
- Department of Otorhinolaryngology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Frank Hoentjen
- Inflammatory Bowel Disease Centre, Department of Gastroenterology and Hepatology
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Lammers WJ, Leeman M, Ponsioen CIJ, Boonstra K, van Erpecum KJ, Wolfhagen FHJ, Kuyvenhoven JP, Vrolijk JM, Drenth JPH, Witteman EM, van Nieuwkerk CMJ, van der Spek BW, Witteman BJM, Erkelens GW, Verhagen MAMT, van Tuyl SAC, Poen AC, Brouwer JT, Ter Borg F, Koek GH, van Ditzhuijsen TJM, Hansen BE. How the concept of biochemical response influenced the management of primary biliary cholangitis over time. Neth J Med 2016; 74:240-246. [PMID: 27571721] [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: 06/06/2023]
Abstract
BACKGROUND Criteria assessing biochemical response to ursodeoxycholic acid (UDCA) are established risk stratification tools in primary biliary cholangitis (PBC). We aimed to evaluate to what extent liver tests influenced patient management during a three decade period, and whether this changed over time. METHODS 851 Dutch PBC patients diagnosed between 1988 and 2012 were reviewed to assess patient management in relation to liver test results during UDCA treatment. To do so, biochemical response at one year was analysed retrospectively according to Paris-1 criteria. RESULTS Response was assessable for 687/851 (81%) patients; 157/687 non-responders. During a follow-up of 8.8 years (IQR 4.8-13.9), 141 died and 30 underwent liver transplantation. Transplant-free survival of non-responders (60%) was significantly worse compared with responders (87%) (p < 0.0001). Management was modified in 46/157 (29%) non-responders. The most frequent change observed, noted in 26/46 patients, was an increase in UDCA dosage. Subsequently, 9/26 (35%) non-responders became responders within the next two years. Steroid treatment was started in one patient; 19 patients were referred to a tertiary centre. No trend towards more frequent changes in management over time was observed (p = 0.10). CONCLUSION Changes in medical management occurred in a minority of non-responders. This can largely be explained by the lack of accepted response criteria and of established second-line treatments for PBC. Nevertheless, the observation that response-guided management did not increase over time suggests that awareness of the concept of biochemical response requires further attention,particularly since new treatment options for PBC will soon become available.
Collapse
Affiliation(s)
- W J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, the Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Schepers NJ, Bakker OJ, Besselink MGH, Bollen TL, Dijkgraaf MGW, van Eijck CHJ, Fockens P, van Geenen EJM, van Grinsven J, Hallensleben NDL, Hansen BE, van Santvoort HC, Timmer R, Anten MPGF, Bolwerk CJM, van Delft F, van Dullemen HM, Erkelens GW, van Hooft JE, Laheij R, van der Hulst RWM, Jansen JM, Kubben FJGM, Kuiken SD, Perk LE, de Ridder RJJ, Rijk MCM, Römkens TEH, Schoon EJ, Schwartz MP, Spanier BWM, Tan ACITL, Thijs WJ, Venneman NG, Vleggaar FP, van de Vrie W, Witteman BJ, Gooszen HG, Bruno MJ. Early biliary decompression versus conservative treatment in acute biliary pancreatitis (APEC trial): study protocol for a randomized controlled trial. Trials 2016; 17:5. [PMID: 26729193 PMCID: PMC4700728 DOI: 10.1186/s13063-015-1132-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 12/17/2015] [Indexed: 01/25/2023] Open
Abstract
Background Acute pancreatitis is mostly caused by gallstones or sludge. Early decompression of the biliary tree by endoscopic retrograde cholangiography (ERC) with sphincterotomy may improve outcome in these patients. Whereas current guidelines recommend early ERC in patients with concomitant cholangitis, early ERC is not recommended in patients with mild biliary pancreatitis. Evidence on the role of routine early ERC with endoscopic sphincterotomy in patients without cholangitis but with biliary pancreatitis at high risk for complications is lacking. We hypothesize that early ERC with sphincterotomy improves outcome in these patients. Methods/Design The APEC trial is a randomized controlled, parallel group, superiority multicenter trial. Within 24 hours after presentation to the emergency department, patients with biliary pancreatitis without cholangitis and at high risk for complications, based on an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 8 or greater, Modified Glasgow score of 3 or greater, or serum C-reactive protein above 150 mg/L, will be randomized. In 27 hospitals of the Dutch Pancreatitis Study Group, 232 patients will be allocated to early ERC with sphincterotomy or to conservative treatment. The primary endpoint is a composite of major complications (that is, organ failure, pancreatic necrosis, pneumonia, bacteremia, cholangitis, pancreatic endocrine, or exocrine insufficiency) or death within 180 days after randomization. Secondary endpoints include ERC-related complications, infected necrotizing pancreatitis, length of hospital stay and an economical evaluation. Discussion The APEC trial investigates whether an early ERC with sphincterotomy reduces the composite endpoint of major complications or death compared with conservative treatment in patients with biliary pancreatitis at high risk of complications. Trial registration Current Controlled Trials ISRCTN97372133 (date registration: 17-12-2012) Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1132-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands. .,Department of Gastroenterology and Hepatology, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, PO 85500, 3508, GA, Utrecht, The Netherlands.
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Marcel G W Dijkgraaf
- Clinical Research Unit, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, HP 690, PO 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Janneke van Grinsven
- Department of Surgery, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands. .,Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands. .,Department of Surgery, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Gasthuis, PO 10900, 3004, BA, Rotterdam, The Netherlands.
| | - Clemens J M Bolwerk
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Reinier de Graafweg 3-11, 2625, AD, Delft, The Netherlands.
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, VU University Medical Center Amsterdam, PO Box 7057, 1007, MB, Amsterdam, The Netherlands.
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, PO 30001, 9700, RB, Groningen, The Netherlands.
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, PO 9014, 7300, DS, Apeldoorn, The Netherlands.
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Robert Laheij
- Department of Gastroenterology and Hepatology, St. Elisabeth Hospital, PO 90151, 5000, LC, Tilburg, The Netherlands.
| | - René W M van der Hulst
- Department of Gastroenterology and Hepatology, Kennemer Gasthuis, PO 417, 2000, AK, Haarlem, The Netherlands.
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Postbus 95500, 1090, HM, Amsterdam, The Netherlands.
| | - Frank J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Maasstadweg 21, 3079, DZ, Rotterdam, The Netherlands.
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, Sint Lucas Andreas Hospital, PO 9243, 1006, AE, Amsterdam, The Netherlands.
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden, PO 432, 2501, CK Den Haag, The Netherlands.
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, PO 5800, 6202, AZ, Maastricht, The Netherlands.
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, PO 90158, 4800, RK, Breda, The Netherlands.
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, PO 90153, 5200, ME 's-Hertogenbosch, The Netherlands.
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, PO 1350, 5602, ZA, Eindhoven, The Netherlands.
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, PO 1502, 3800, BM, Amersfoort, The Netherlands.
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, PO 9555, 6800, TA, Arnhem, The Netherlands.
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina Hospital, PO 9015, 6500, GS, Nijmegen, The Netherlands.
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, PO 30033, 9700, RM, Groningen, The Netherlands.
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO 50000, 7500, KA, Enschede, The Netherlands.
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, PO 85500, 3508, GA, Utrecht, The Netherlands.
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, PO 444, 3300, AK, Dordrecht, The Netherlands.
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei Ede, PO 9025, 6710, HN, Ede, The Netherlands.
| | - Hein G Gooszen
- Department of Operating Rooms - Evidence Based Surgery, Radboud University Nijmegen Medical Centre, HP 690, PO 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | | |
Collapse
|
8
|
Gerritsen A, de Rooij T, Dijkgraaf MG, Busch OR, Bergman JJ, Ubbink DT, van Duijvendijk P, Erkelens GW, Molenaar IQ, Monkelbaan JF, Rosman C, Tan AC, Kruyt PM, Bac DJ, Mathus-Vliegen EM, Besselink MG. Electromagnetic guided bedside or endoscopic placement of nasoenteral feeding tubes in surgical patients (CORE trial): study protocol for a randomized controlled trial. Trials 2015; 16:119. [PMID: 25872782 PMCID: PMC4390000 DOI: 10.1186/s13063-015-0633-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 03/04/2015] [Indexed: 12/12/2022] Open
Abstract
Background Gastroparesis is common in surgical patients and frequently leads to the need for enteral tube feeding. Nasoenteral feeding tubes are usually placed endoscopically by gastroenterologists, but this procedure is relatively cumbersome for patients and labor-intensive for hospital staff. Electromagnetic (EM) guided bedside placement of nasoenteral feeding tubes by nurses may reduce patient discomfort, workload and costs, but randomized studies are lacking, especially in surgical patients. We hypothesize that EM guided bedside placement of nasoenteral feeding tubes is at least as effective as endoscopic placement in surgical patients, at lower costs. Methods/Design The CORE trial is an investigator-initiated, parallel-group, pragmatic, multicenter randomized controlled non-inferiority trial. A total of 154 patients admitted to gastrointestinal surgical wards in five hospitals, requiring nasoenteral feeding, will be randomly allocated to undergo EM guided or endoscopic nasoenteral feeding tube placement. Primary outcome is reinsertion of the feeding tube, defined as the insertion of an endoscope or tube in the nose/mouth and esophagus for (re)placement of the feeding tube (e.g. after failed initial placement or dislodgement or blockage of the tube). Secondary outcomes include patient-reported outcomes, costs and tube (placement) related complications. Discussion The CORE trial is designed to generate evidence on the effectiveness of EM guided placement of nasoenteral feeding tubes in surgical patients and the impact on costs as compared to endoscopic placement. The trial potentially offers a strong argument for wider implementation of this technique as method of choice for placement of nasoenteral feeding tubes. Trial registration Dutch Trial Register: NTR4420, date registered 5-feb-2014 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0633-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Arja Gerritsen
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands. .,Department of Surgery, University Medical Center Utrecht, PO Box 85500, , 3508, GA, Utrecht, the Netherlands.
| | - Thijs de Rooij
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
| | - Dirk T Ubbink
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| | - Peter van Duijvendijk
- Department of Surgery, Gelre Hospital, PO Box 9014, 7300, DS, Apeldoorn, the Netherlands.
| | - G Willemien Erkelens
- Department of Gastroenterology, Gelre Hospital, PO Box 9014, 7300, DS, Apeldoorn, the Netherlands.
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, , 3508, GA, Utrecht, the Netherlands.
| | - Jan F Monkelbaan
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands.
| | - Camiel Rosman
- Department of Surgery, Canisius Wilhelmina Hospital, PO Box 9015, 6500, GS, Nijmegen, the Netherlands.
| | - Adriaan C Tan
- Department of Gastroenterology, Canisius Wilhelmina Hospital, PO Box 9015, 6500, GS, Nijmegen, the Netherlands.
| | - Philip M Kruyt
- Department of Surgery, Hospital Gelderse Vallei, PO Box 9025, 6710, HN, Ede, the Netherlands.
| | - Dirk Jan Bac
- Department of Gastroenterology, Hospital Gelderse Vallei, PO Box 9025, 6710, HN, Ede, the Netherlands.
| | - Elisabeth M Mathus-Vliegen
- Department of Gastroenterology and Hepatology, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| |
Collapse
|
9
|
van Brunschot S, van Grinsven J, Voermans RP, Bakker OJ, Besselink MGH, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, Dijkgraaf MGW, van Eijck CH, Erkelens GW, van Goor H, Hadithi M, Haveman JW, Hofker SH, Jansen JJM, Laméris JS, van Lienden KP, Manusama ER, Meijssen MA, Mulder CJ, Nieuwenhuis VB, Poley JW, de Ridder RJ, Rosman C, Schaapherder AF, Scheepers JJ, Schoon EJ, Seerden T, Spanier BWM, Straathof JWA, Timmer R, Venneman NG, Vleggaar FP, Witteman BJ, Gooszen HG, van Santvoort HC, Fockens P. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol 2013; 13:161. [PMID: 24274589 PMCID: PMC4222267 DOI: 10.1186/1471-230x-13-161] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/13/2013] [Indexed: 02/06/2023] Open
Abstract
Background Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes. Methods/Design The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs. Discussion The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.
Collapse
Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
van Buuren HR, Vleggaar FP, Willemien Erkelens G, Zondervan PE, Lesterhuis W, Van Eijck CHJ, Puylaert JBCM, Van Der Werf SDJ. Autoimmune pancreatocholangitis: a series of ten patients. Scand J Gastroenterol 2007:70-8. [PMID: 16782625 DOI: 10.1080/00365520600664326] [Citation(s) in RCA: 19] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND During a 10-year period we observed 10 patients who suffered from an inflammatory-fibrosing disease mimicking pancreatic carcinoma and primary sclerosing cholangitis (PSC). METHODS A review of the presenting features, the clinical course and the relevant literature. RESULTS Ten male patients (mean age 55 years) presented with weight loss, jaundice and pruritus. Pancreatic cancer was suggested by imaging studies, which showed focal or generalized pancreatic enlargement and compression of the distal common bile duct. Cholangiography also demonstrated intrahepatic biliary stenoses consistent with sclerosing cholangitis. None had evidence of IBD. Exocrine pancreatic insufficiency was found in six cases and diabetes in four. Pancreatic histology (n=3) showed fibrosis and extensive inflammatory infiltrates. Immunosuppressive treatment was instituted in five patients. Clinical and biochemical remission occurred in three; in one other patient, previously documented intrahepatic biliary strictures had disappeared after 3 months. One patient had concomitant Sjögren's disease. The clinical features, pancreatic involvement, age at presentation, absence of IBD and response to steroids all plead against a diagnosis of "classical" PSC. The natural course of the disease was highly variable. Thirty-five comparable cases, with a largest series of three, have been reported in the literature. The disease has been associated with Sjögren's disease, retroperitoneal fibrosis and other fibrosing conditions, and may be a manifestation of a systemic fibro-inflammatory disorder. CONCLUSION Autoimmune pancreatocholangitis is a distinct inflammatory disorder involving the pancreas and biliary tree. The disease may mimick pancreatic carcinoma and PSC and responds to immunosuppressives.
Collapse
Affiliation(s)
- Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Bogaard HJ, Erkelens GW, Faber WR, de Vries PJ. [Cutaneous nocardiosis as an opportunistic infection]. Ned Tijdschr Geneeskd 2004; 148:533-6. [PMID: 15054953] [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: 04/29/2023]
Abstract
A 46-year-old man who had been treated with azathioprine and budesonide for Crohn's disease for the past eight years developed a purulent skin condition on the right ring finger. Despite surgical drainage and treatment with amoxicillin and flucloxacillin, the condition spread itself over the hand and lower arm, partly per continuum and partly in jumps. The patient did not feel ill and there were no systemic symptoms. Ultimately, Nocardia asteroides was cultured from the wound and complete cure was achieved after 8 months' treatment with co-trimoxazole. Infections with Nocardia spp. are rare but may occur more often and run a more fulminant course in patients under treatment with immunosuppressants. Cutaneous nocardiosis generally has a characteristic lymphogenous spreading pattern, but an atypical picture with pustules, pyoderma, cellulitis or abscess formation is also possible. In non-cutaneous nocardiosis there is usually pneumonia or lung abscess, possibly with secondary haematogenous spread to the central nervous system or skin. Culturing Nocardia requires more time than usual but can be promoted by special culture media. Treatment of the infection with co-trimoxazole is the method of choice and is almost always successful in cases of cutaneous nocardiosis.
Collapse
Affiliation(s)
- H J Bogaard
- Afd. Longziekten, Academisch Medisch Centrum/Universiteit van Amsterdam, Postbus 22.660, 1100 DD Amsterdam.
| | | | | | | |
Collapse
|
12
|
Abstract
Patients with Crohn's disease often develop (recurring) intestinal stenosis. This is a result of continuous activation of fibrogenic cells by ongoing inflammation. Surgery is usually needed and consists of intestinal resection or strictureplasty. Medical therapy has not proven to be successful. Over the years endoscopic treatment has become more important. Uncomplicated stenosis, with a maximal length of 4 cm, can be treated by balloon dilatation. Indications, procedure and results are discussed. More recently, local corticosteroid injection in addition to balloon dilatation has been studied, but it remains to be seen whether long-term prevention of re-stenosis occurs. Other endoscopic therapies and new developments are also discussed in this chapter.
Collapse
Affiliation(s)
- G W Erkelens
- Department of Gastroenterology, Reinier de Graaf Group, Postbus 5011, 2600 GA Delft, Amsterdam, The Netherlands
| | | |
Collapse
|
13
|
Abstract
Four patients with weight loss, jaundice, a sonolucent swelling of the pancreas, and multiple bile-duct strictures are described. These cases of sclerosing pancreato-cholangitis responded to steroid therapy.
Collapse
|
14
|
Tak PP, Kummer JA, Hack CE, Daha MR, Smeets TJ, Erkelens GW, Meinders AE, Kluin PM, Breedveld FC. Granzyme-positive cytotoxic cells are specifically increased in early rheumatoid synovial tissue. Arthritis Rheum 1994; 37:1735-43. [PMID: 7986219 DOI: 10.1002/art.1780371205] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To define the expression and the phenotype of granzyme (Gran) A and B positive cytotoxic cells in synovial tissue (ST) from patients with rheumatoid arthritis (RA) with respect to disease duration and activity. METHODS Using antibodies against GranA and GranB, which serve as markers of activated natural killer (NK) cells and cytotoxic T lymphocytes, ST sections from 10 patients with early RA, 10 patients with longstanding RA, and 10 patients with osteoarthritis were examined. The phenotype of Gran+ cells was determined with double-labeling techniques. RESULTS Gran+ cells, the majority of which were NK cells, were found in ST from patients in all groups. Several of these cells did not express the surface markers CD16, CD56, and CD57. The highest ST expression of GranB was found in patients with early RA. In RA patients, there was a positive correlation of GranB expression with serum levels of acute-phase reactants, but not with histologic scores for inflammation. CONCLUSION Gran+ cells are mainly NK cells, a substantial proportion of which do not express conventional NK cell surface markers. GranB expression is specifically increased in the synovial tissues of patients with RA of short duration.
Collapse
Affiliation(s)
- P P Tak
- University Hospital of Leiden, The Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|