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Hallensleben ND, Stassen PMC, Schepers NJ, Besselink MG, Anten MPGF, Bakker OJ, Bollen TL, da Costa DW, van Dijk SM, van Dullemen HM, Dijkgraaf MGW, van Eijck B, van Eijck CHJ, Erkelens W, Erler NS, Fockens P, van Geenen EJM, van Grinsven J, Hazen WL, Hollemans RA, van Hooft JE, Jansen JM, Kubben FJGM, Kuiken SD, Poen AC, Quispel R, de Ridder RJ, Römkens TEH, Schoon EJ, Schwartz MP, Seerden TCJ, Smeets XJNM, Spanier BWM, Tan ACITL, Thijs WJ, Timmer R, Umans DS, Venneman NG, Verdonk RC, Vleggaar FP, van de Vrie W, van Wanrooij RLJ, Witteman BJ, van Santvoort HC, Bouwense SAW, Bruno MJ. Patient selection for urgent endoscopic retrograde cholangio-pancreatography by endoscopic ultrasound in predicted severe acute biliary pancreatitis (APEC-2): a multicentre prospective study. Gut 2023:gutjnl-2022-328258. [PMID: 36849226 DOI: 10.1136/gutjnl-2022-328258] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 02/13/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVE Routine urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic biliary sphincterotomy (ES) does not improve outcome in patients with predicted severe acute biliary pancreatitis. Improved patient selection for ERCP by means of endoscopic ultrasonography (EUS) for stone/sludge detection may challenge these findings. DESIGN A multicentre, prospective cohort study included patients with predicted severe acute biliary pancreatitis without cholangitis. Patients underwent urgent EUS, followed by ERCP with ES in case of common bile duct stones/sludge, within 24 hours after hospital presentation and within 72 hours after symptom onset. The primary endpoint was a composite of major complications or mortality within 6 months after inclusion. The historical control group was the conservative treatment arm (n=113) of the randomised APEC trial (Acute biliary Pancreatitis: urgent ERCP with sphincterotomy versus conservative treatment, patient inclusion 2013-2017) applying the same study design. RESULTS Overall, 83 patients underwent urgent EUS at a median of 21 hours (IQR 17-23) after hospital presentation and at a median of 29 hours (IQR 23-41) after start of symptoms. Gallstones/sludge in the bile ducts were detected by EUS in 48/83 patients (58%), all of whom underwent immediate ERCP with ES. The primary endpoint occurred in 34/83 patients (41%) in the urgent EUS-guided ERCP group. This was not different from the 44% rate (50/113 patients) in the historical conservative treatment group (risk ratio (RR) 0.93, 95% CI 0.67 to 1.29; p=0.65). Sensitivity analysis to correct for baseline differences using a logistic regression model also showed no significant beneficial effect of the intervention on the primary outcome (adjusted OR 1.03, 95% CI 0.56 to 1.90, p=0.92). CONCLUSION In patients with predicted severe acute biliary pancreatitis without cholangitis, urgent EUS-guided ERCP with ES did not reduce the composite endpoint of major complications or mortality, as compared with conservative treatment in a historical control group. TRIAL REGISTRATION NUMBER ISRCTN15545919.
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Affiliation(s)
- Nora D Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Pauline M C Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Noord-Holland, The Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Vlietland Groep, Rotterdam, Zuid-Holland, The Netherlands
| | - Olaf J Bakker
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Thomas L Bollen
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - David W da Costa
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Sven M van Dijk
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology, Universtiy of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Methodology department, Amsterdam Public Health Research Institute, Amsterdam, North Holland, The Netherlands
| | - Brechje van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospitals, Apeldoorn, Gelderland, The Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | | | | | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Noord-Brabant, The Netherlands
| | - Robbert A Hollemans
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Frank J G M Kubben
- Department of Gastroenterology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, Overijssel, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, Zuid-Holland, The Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, Den Bosch, Noord-Brabant, The Netherlands
| | - Erik J Schoon
- Gastroenterology, Catharina Hospital, Eindhoven, The Netherlands
| | - Matthijs P Schwartz
- Department of Internal Medicine and Gastroenterology, Meander Medical Center, Amersfoort, The Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Xavier J N M Smeets
- Gastroenterology and Hepatology, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, Groningen, The Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Devica S Umans
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Heptatology, Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, The Netherlands
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Dutch Acute Pancreatitis Study Group, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht Universitair Medisch Centrum+, Maastricht, Limburg, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Onnekink AM, Boxhoorn L, Timmerhuis HC, Bac ST, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SAW, Bruno MJ, van Brunschot S, Cappendijk VC, Consten ECJ, Dejong CH, Dijkgraaf MGW, van Eijck CHJ, Erkelens WG, van Goor H, van Grinsven J, Haveman JW, van Hooft JE, Jansen JM, van Lienden KP, Meijssen MAC, Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Römkens TEH, van Santvoort HC, Scheepers JJ, Schwartz MP, Seerden T, Spanier MBW, Straathof JWA, Timmer R, Venneman NG, Verdonk RC, Vleggaar FP, van Wanrooij RL, Witteman BJM, Fockens P, Voermans RP. Endoscopic Versus Surgical Step-Up Approach for Infected Necrotizing Pancreatitis (ExTENSION): Long-term Follow-up of a Randomized Trial. Gastroenterology 2022; 163:712-722.e14. [PMID: 35580661 DOI: 10.1053/j.gastro.2022.05.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/02/2022] [Accepted: 05/11/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND & AIMS Previous randomized trials, including the Transluminal Endoscopic Step-Up Approach Versus Minimally Invasive Surgical Step-Up Approach in Patients With Infected Pancreatic Necrosis (TENSION) trial, demonstrated that the endoscopic step-up approach might be preferred over the surgical step-up approach in patients with infected necrotizing pancreatitis based on favorable short-term outcomes. We compared long-term clinical outcomes of both step-up approaches after a period of at least 5 years. METHODS In this long-term follow-up study, we reevaluated all clinical data on 83 patients (of the originally 98 included patients) from the TENSION trial who were still alive after the initial 6-month follow-up. The primary end point, similar to the TENSION trial, was a composite of death and major complications. Secondary end points included individual major complications, pancreaticocutaneous fistula, reinterventions, pancreatic insufficiency, and quality of life. RESULTS After a mean follow-up period of 7 years, the primary end point occurred in 27 patients (53%) in the endoscopy group and in 27 patients (57%) in the surgery group (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.65-1.32; P = .688). Fewer pancreaticocutaneous fistulas were identified in the endoscopy group (8% vs 34%; RR, 0.23; 95% CI, 0.08-0.83). After the initial 6-month follow-up, the endoscopy group needed fewer reinterventions than the surgery group (7% vs 24%; RR, 0.29; 95% CI, 0.09-0.99). Pancreatic insufficiency and quality of life did not differ between groups. CONCLUSIONS At long-term follow-up, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing death or major complications in patients with infected necrotizing pancreatitis. However, patients assigned to the endoscopic approach developed overall fewer pancreaticocutaneous fistulas and needed fewer reinterventions after the initial 6-month follow-up. Netherlands Trial Register no: NL8571.
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Affiliation(s)
- Anke M Onnekink
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Lotte Boxhoorn
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology 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
| | - Simon T Bac
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands
| | - Marc G Besselink
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Marja A Boermeester
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sandra van Brunschot
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Vincent C Cappendijk
- Department of Radiology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Esther C J Consten
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, the Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Marcel G W Dijkgraaf
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Epidemiology and Data Science, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Willemien G Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, Apeldoorn, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboudumc, University Medical Center, Nijmegen, the Netherlands
| | - Janneke van Grinsven
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Jan-Willem Haveman
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Maarten A C Meijssen
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | | | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, the Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Group, Delft, the Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, the Netherlands
| | - Tom Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, the Netherlands
| | - Marcel B W Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Jan Willem A Straathof
- Department of Gastroenterology and Hepatology, Máxima Medical Center, Veldhoven, the Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, 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
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Roy L van Wanrooij
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Ben J M Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, the Netherlands.
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Kempeneers MA, Issa Y, Verdonk RC, Bruno M, Fockens P, van Goor H, Alofs E, Bollen TL, Bouwense S, van Dalen ASHM, van Dieren S, van Dullemen HM, van Geenen EJ, Hoge C, van Hooft JE, Kager LM, Keulemans Y, Nooijen LE, Poley JW, Seerden TCJ, Tan A, Thijs W, Timmer R, Vleggaar F, Witteman B, Ahmed Ali U, Besselink MG, Boermeester MA, van Santvoort HC. Pain patterns in chronic pancreatitis: a nationwide longitudinal cohort study. Gut 2021; 70:1724-1733. [PMID: 33158979 DOI: 10.1136/gutjnl-2020-322117] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/12/2020] [Accepted: 10/21/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Pain in chronic pancreatitis is subdivided in a continuous or intermittent pattern, each thought to represent a different entity, requiring specific treatment. Because evidence is missing, we studied pain patterns in a prospective longitudinal nationwide study. DESIGN 1131 patients with chronic pancreatitis (fulfilling M-ANNHEIM criteria) were included between 2011 and 2018 in 30 Dutch hospitals. Patients with continuous or intermittent pain were compared for demographics, pain characteristics, quality of life (Short-Form 36), imaging findings, disease duration and treatment. Alternation of pain pattern and associated variables were longitudinally assessed using a multivariable multinomial logistic regression model. RESULTS At inclusion, 589 patients (52%) had continuous pain, 231 patients (20%) had intermittent pain and 311 patients (28%) had no pain. Patients with continuous pain had more severe pain, used more opioids and neuropathic pain medication, and had a lower quality of life. There were no differences between pain patterns for morphological findings on imaging, disease duration and treatment. During a median follow-up of 47 months, 552 of 905 patients (61%) alternated at least once between pain patterns. All alternations were associated with the Visual Analogue Scale pain intensity score and surgery was only associated with the change from pain to no pain. CONCLUSION Continuous and intermittent pain patterns in chronic pancreatitis do not seem to be the result of distinctly different pathophysiological entities. The subjectively reported character of pain is not related to imaging findings or disease duration. Pain patterns often change over time and are merely a feature of how severity of pain is experienced.
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Affiliation(s)
- Marinus A Kempeneers
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - Yama Issa
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Eline Alofs
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Stefan Bouwense
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Anne S H M van Dalen
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Erwin-Jan van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Chantal Hoge
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - Liesbeth M Kager
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Yolande Keulemans
- Department of Gastroenterology and Hepatology, Zuyderland Medical Centre, Heerlen, Limburg, The Netherlands
| | - Lynn E Nooijen
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Adriaan Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Willem Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, The Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Frank Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, The Netherlands
| | - Ben Witteman
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands.,Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands
| | - Usama Ahmed Ali
- Department of Surgery, University Medical Centre, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Centre, Utrecht, The Netherlands .,Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
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de Jong DM, Stassen PM, Poley JW, Fockens P, Timmer R, Voermans RP, Verdonk RC, Bruno MJ, de Jonge PJ. Clinical outcome of endoscopic therapy in patients with symptomatic pancreas divisum: a Dutch cohort study. Endosc Int Open 2021; 9:E1164-E1170. [PMID: 34222643 PMCID: PMC8216775 DOI: 10.1055/a-1460-7899] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 12/09/2020] [Accepted: 02/15/2021] [Indexed: 10/28/2022] Open
Abstract
Background and study aims Although the majority of patients with pancreas divisum (PDiv) are asymptomatic, a subgroup present with recurrent pancreatitis or pain for which endoscopic therapy may be indicated. The aim of this study was to evaluate success rates and long-term outcomes of endoscopic treatment in patients with symptomatic PDiv. Patients and methods A multicenter, retrospective cohort study was performed. Patients with symptomatic PDiv presenting with recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic abdominal pancreatic-type pain (CAP) who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2000 and December 2019 were included. The primary outcome was clinical success, defined as either no recurrent episode of acute pancreatitis (AP) for RAP patients, no flares for CP patients, or absence of abdominal pain for patients with CAP after technically successful ERCP. Results In 60 of 81 patients (74.1 %) a technically successful papilla minor intervention was performed. Adverse events were reported in 30 patients (37 %), with post-ERCP pancreatitis in 18 patients. The clinical success rate for patients with at least 3 months of follow-up was 42.6 %, with higher rates of success among patients presenting with RAP (44.4 %) as compared to those with CP (33.3 %) or CAP (33.3 %). Long-term sustained response was present in 40.9 % of patients with a technically successful intervention. In patients with RAP who did not completely respond to treatment, the mean number of AP episodes after treatment decreased significantly from 3.5 to 1.1 per year, and subsequently the interval between AP episodes increased from 278 to 690 days ( P = 0.0006). A potential predictive factor of failure of clinical success after technically successful ERCP, at univariate analysis, was male sex (OR = 0.25, P = 0.02). Conclusions Endoscopic therapy in patients with symptomatic PDiv is moderately effective, with its highest yield in patients presenting with RAP. Future studies are needed to assess factors predictive for success of endoscopic therapy and potential risk factors for relapse after ERCP.
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Affiliation(s)
- David M. de Jong
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pauline M. Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jan Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, the Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, the Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter J.F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Quispel R, Schutz HM, Hallensleben ND, Bhalla A, Timmer R, van Hooft JE, Venneman NG, Erler NS, Veldt BJ, van Driel LM, Bruno MJ. Do endosonographers agree on the presence of bile duct sludge and the subsequent need for intervention? Endosc Int Open 2021; 9:E911-E917. [PMID: 34079877 PMCID: PMC8159618 DOI: 10.1055/a-1452-8919] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/20/2021] [Indexed: 11/11/2022] Open
Abstract
Background and study aims Endoscopic ultrasonography (EUS) is a tool widely used to diagnose bile duct lithiasis. In approximately one out of five patients with positive findings at EUS, sludge is detected in the bile duct instead of stones. The objective of this study was to establish the agreement among endosonographers regarding: 1. presence of common bile duct (CBD) stones, microlithiasis and sludge; and 2. the need for subsequent treatment. Patients and methods 30 EUS videos of patients with an intermediate probability of CBD stones were evaluated by 41 endosonographers. Experience in EUS and endoscopic retrograde cholangiopancreatography, and the endosonographers' type of practices were recorded. Fleiss' kappa statistics were used to quantify the agreement. Associations between levels of experience and both EUS ratings and treatment decisions were investigated using mixed effects models. Results A total of 1230 ratings and treatment decisions were evaluated. The overall agreement on EUS findings was fair (Fleiss' κ 0.32). The agreement on presence of stones was moderate (κ 0.46). For microlithiasis it was fair (κ 0.25) and for sludge it was slight (κ 0.16). In cases with CBD stones there was an almost perfect agreement for the decision to subsequently perform an ERC + ES. In case of presumed microlithiasis or sludge an ERC was opted for in 78 % and 51 % of cases, respectively. Differences in experience and types of practice appear unrelated to the agreement on both EUS findings and the decision for subsequent treatment. Conclusions There is only slight agreement among endosonographers regarding the presence of bile duct sludge. Regarding the need for subsequent treatment of bile duct sludge there is no consensus.
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Affiliation(s)
- Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, Netherlands
| | - Hannah M. Schutz
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, Netherlands
| | - Nora D. Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HAGA Hospital, Den Haag, Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands,Department of Gastroenterology and Hepatology, Leiden University Medical Center Leiden, Netherlands
| | - Niels G. Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Nicole S. Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Bart J. Veldt
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, Netherlands
| | - Lydi M.J.W. van Driel
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
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6
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Schepers NJ, Hallensleben NDL, Besselink MG, Anten MPGF, Bollen TL, da Costa DW, van Delft F, van Dijk SM, van Dullemen HM, Dijkgraaf MGW, van Eijck CHJ, Erkelens GW, Erler NS, Fockens P, van Geenen EJM, van Grinsven J, Hollemans RA, van Hooft JE, van der Hulst RWM, Jansen JM, Kubben FJGM, Kuiken SD, Laheij RJF, Quispel R, de Ridder RJJ, Rijk MCM, Römkens TEH, Ruigrok CHM, Schoon EJ, Schwartz MP, Smeets XJNM, Spanier BWM, Tan ACITL, Thijs WJ, Timmer R, Venneman NG, Verdonk RC, Vleggaar FP, van de Vrie W, Witteman BJ, van Santvoort HC, Bakker OJ, Bruno MJ. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicentre randomised controlled trial. Lancet 2020; 396:167-176. [PMID: 32682482 DOI: 10.1016/s0140-6736(20)30539-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND It remains unclear whether urgent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy improves the outcome of patients with gallstone pancreatitis without concomitant cholangitis. We did a randomised trial to compare urgent ERCP with sphincterotomy versus conservative treatment in patients with predicted severe acute gallstone pancreatitis. METHODS In this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, patients with predicted severe (Acute Physiology and Chronic Health Evaluation II score ≥8, Imrie score ≥3, or C-reactive protein concentration >150 mg/L) gallstone pancreatitis without cholangitis were assessed for eligibility in 26 hospitals in the Netherlands. Patients were randomly assigned (1:1) by a web-based randomisation module with randomly varying block sizes to urgent ERCP with sphincterotomy (within 24 h after hospital presentation) or conservative treatment. The primary endpoint was a composite of mortality or major complications (new-onset persistent organ failure, cholangitis, bacteraemia, pneumonia, pancreatic necrosis, or pancreatic insufficiency) within 6 months of randomisation. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN97372133. FINDINGS Between Feb 28, 2013, and March 1, 2017, 232 patients were randomly assigned to urgent ERCP with sphincterotomy (n=118) or conservative treatment (n=114). One patient from each group was excluded from the final analysis because of cholangitis (urgent ERCP group) and chronic pancreatitis (conservative treatment group) at admission. The primary endpoint occurred in 45 (38%) of 117 patients in the urgent ERCP group and in 50 (44%) of 113 patients in the conservative treatment group (risk ratio [RR] 0·87, 95% CI 0·64-1·18; p=0·37). No relevant differences in the individual components of the primary endpoint were recorded between groups, apart from the occurrence of cholangitis (two [2%] of 117 in the urgent ERCP group vs 11 [10%] of 113 in the conservative treatment group; RR 0·18, 95% CI 0·04-0·78; p=0·010). Adverse events were reported in 87 (74%) of 118 patients in the urgent ERCP group versus 91 (80%) of 114 patients in the conservative treatment group. INTERPRETATION In patients with predicted severe gallstone pancreatitis but without cholangitis, urgent ERCP with sphincterotomy did not reduce the composite endpoint of major complications or mortality, compared with conservative treatment. Our findings support a conservative strategy in patients with predicted severe acute gallstone pancreatitis with an ERCP indicated only in patients with cholangitis or persistent cholestasis. FUNDING The Netherlands Organization for Health Research and Development, Fonds NutsOhra, and the Dutch Patient Organization for Pancreatic Diseases.
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Affiliation(s)
- Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands.
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Franciscus and Vlietland Hospital, Rotterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - David W da Costa
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Sven M van Dijk
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, Netherlands
| | - Marcel G W Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, Apeldoorn, Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Janneke van Grinsven
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | | | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | | | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Frank J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Robert J F Laheij
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, Netherlands
| | - Carola H M Ruigrok
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - Xavier J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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7
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Issa Y, Kempeneers MA, Bruno MJ, Fockens P, Poley JW, Ahmed Ali U, Bollen TL, Busch OR, Dejong CH, van Duijvendijk P, van Dullemen HM, van Eijck CH, van Goor H, Hadithi M, Haveman JW, Keulemans Y, Nieuwenhuijs VB, Poen AC, Rauws EA, Tan AC, Thijs W, Timmer R, Witteman BJ, Besselink MG, van Hooft JE, van Santvoort HC, Dijkgraaf MG, Boermeester MA. Effect of Early Surgery vs Endoscopy-First Approach on Pain in Patients With Chronic Pancreatitis: The ESCAPE Randomized Clinical Trial. JAMA 2020; 323:237-247. [PMID: 31961419 PMCID: PMC6990680 DOI: 10.1001/jama.2019.20967] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier surgery could mitigate disease progression, providing better pain control and preserving pancreatic function. OBJECTIVE To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for ≤2 months or weak opioids for ≤6 months) were included. The 18-month follow-up period ended in March 2018. INTERVENTIONS There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed. MAIN OUTCOMES AND MEASURES The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 [increasing score indicates more pain severity]). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey [SF-36]); and mortality. RESULTS Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, -12 points [95% CI, -22 to -2]; P = .02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P = .10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P < .001). Treatment complications (27% vs 25%), mortality (0% vs 0%), hospital admissions, pancreatic function, and quality of life were not significantly different between early surgery and the endoscopy-first approach. CONCLUSIONS AND RELEVANCE Among patients with chronic pancreatitis, early surgery compared with an endoscopy-first approach resulted in lower pain scores when integrated over 18 months. However, further research is needed to assess persistence of differences over time and to replicate the study findings. TRIAL REGISTRATION ISRCTN Identifier: ISRCTN45877994.
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Affiliation(s)
- Yama Issa
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marinus A. Kempeneers
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology; Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Amsterdam, the Netherlands
| | - Usama Ahmed Ali
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Thomas L. Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Cees H. Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery, Universitätsklinikum Aachen, Aachen, Germany
| | | | - Hendrik M. van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Casper H. van Eijck
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Jan-Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Yolande Keulemans
- Department of Gastroenterology and Hepatology, Zuyderland Hospital, Sittard/Heerlen, the Netherlands
| | | | - Alexander C. Poen
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, the Netherlands
| | - Erik A. Rauws
- Department of Gastroenterology and Hepatology; Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Adriaan C. Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhemina Hospital, Nijmegen, the Netherlands
| | - Willem Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, the Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Ben J. Witteman
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology; Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marcel G. Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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8
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Hollemans RA, Bakker OJ, Boermeester MA, Bollen TL, Bosscha K, Bruno MJ, Buskens E, Dejong CH, van Duijvendijk P, van Eijck CH, Fockens P, van Goor H, van Grevenstein WM, van der Harst E, Heisterkamp J, Hesselink EJ, Hofker S, Houdijk AP, Karsten T, Kruyt PM, van Laarhoven CJ, Laméris JS, van Leeuwen MS, Manusama ER, Molenaar IQ, Nieuwenhuijs VB, van Ramshorst B, Roos D, Rosman C, Schaapherder AF, van der Schelling GP, Timmer R, Verdonk RC, de Wit RJ, Gooszen HG, Besselink MG, van Santvoort HC. Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of Patients With Necrotizing Pancreatitis. Gastroenterology 2019; 156:1016-1026. [PMID: 30391468 DOI: 10.1053/j.gastro.2018.10.045] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [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: 07/18/2018] [Revised: 10/10/2018] [Accepted: 10/27/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS In a 2010 randomized trial (the PANTER trial), a surgical step-up approach for infected necrotizing pancreatitis was found to reduce the composite endpoint of death or major complications compared with open necrosectomy; 35% of patients were successfully treated with simple catheter drainage only. There is concern, however, that minimally invasive treatment increases the need for reinterventions for residual peripancreatic necrotic collections and other complications during the long term. We therefore performed a long-term follow-up study. METHODS We reevaluated all the 73 patients (of the 88 patients randomly assigned to groups) who were still alive after the index admission, at a mean 86 months (±11 months) of follow-up. We collected data on all clinical and health care resource utilization endpoints through this follow-up period. The primary endpoint was death or major complications (the same as for the PANTER trial). We also measured exocrine insufficiency, quality of life (using the Short Form-36 and EuroQol 5 dimensions forms), and Izbicki pain scores. RESULTS From index admission to long-term follow-up, 19 patients (44%) died or had major complications in the step-up group compared with 33 patients (73%) in the open-necrosectomy group (P = .005). Significantly lower proportions of patients in the step-up group had incisional hernias (23% vs 53%; P = .004), pancreatic exocrine insufficiency (29% vs 56%; P = .03), or endocrine insufficiency (40% vs 64%; P = .05). There were no significant differences between groups in proportions of patients requiring additional drainage procedures (11% vs 13%; P = .99) or pancreatic surgery (11% vs 5%; P = .43), or in recurrent acute pancreatitis, chronic pancreatitis, Izbicki pain scores, or medical costs. Quality of life increased during follow-up without a significant difference between groups. CONCLUSIONS In an analysis of long-term outcomes of trial participants, we found the step-up approach for necrotizing pancreatitis to be superior to open necrosectomy, without increased risk of reinterventions.
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Affiliation(s)
- Robbert A Hollemans
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Erik Buskens
- Department of Epidemiology, University Medical Center Groningen, and Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands and Department of Surgery, Universitätsklinikum Aachen, Aachen, Germany
| | | | - Casper H van Eijck
- Deptartment of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - Joos Heisterkamp
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Eric J Hesselink
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | - Sijbrand Hofker
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Tom Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Philip M Kruyt
- Department of Surgery, Hospital Gelderse Vallei, Ede, the Netherlands
| | | | - Johan S Laméris
- Department of Radiology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Maarten S van Leeuwen
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Eric R Manusama
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Bert van Ramshorst
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | | | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Ralph J de Wit
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - Hein G Gooszen
- Department of Operating Rooms-Evidence Based Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands.
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9
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Smeets XJNM, da Costa DW, Fockens P, Mulder CJJ, Timmer R, Kievit W, Zegers M, Bruno MJ, Besselink MGH, Vleggaar FP, van der Hulst RWM, Poen AC, Heine GDN, Venneman NG, Kolkman JJ, Baak LC, Römkens TEH, van Dijk SM, Hallensleben NDL, van de Vrie W, Seerden TCJ, Tan ACITL, Voorburg AMCJ, Poley JW, Witteman BJ, Bhalla A, Hadithi M, Thijs WJ, Schwartz MP, Vrolijk JM, Verdonk RC, van Delft F, Keulemans Y, van Goor H, Drenth JPH, van Geenen EJM. Fluid hydration to prevent post-ERCP pancreatitis in average- to high-risk patients receiving prophylactic rectal NSAIDs (FLUYT trial): study protocol for a randomized controlled trial. Trials 2018; 19:207. [PMID: 29606135 PMCID: PMC5879873 DOI: 10.1186/s13063-018-2583-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 01/02/2018] [Accepted: 03/06/2018] [Indexed: 12/19/2022] Open
Abstract
Background Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common complication of ERCP and may run a severe course. Evidence suggests that vigorous periprocedural hydration can prevent PEP, but studies to date have significant methodological drawbacks. Importantly, evidence for its added value in patients already receiving prophylactic rectal non-steroidal anti-inflammatory drugs (NSAIDs) is lacking and the cost-effectiveness of the approach has not been investigated. We hypothesize that combination therapy of rectal NSAIDs and periprocedural hydration would significantly lower the incidence of post-ERCP pancreatitis compared to rectal NSAIDs alone in moderate- to high-risk patients undergoing ERCP. Methods The FLUYT trial is a multicenter, parallel group, open label, superiority randomized controlled trial. A total of 826 moderate- to high-risk patients undergoing ERCP that receive prophylactic rectal NSAIDs will be randomized to a control group (no fluids or normal saline with a maximum of 1.5 mL/kg/h and 3 L/24 h) or intervention group (lactated Ringer’s solution with 20 mL/kg over 60 min at start of ERCP, followed by 3 mL/kg/h for 8 h thereafter). The primary endpoint is the incidence of post-ERCP pancreatitis. Secondary endpoints include PEP severity, hydration-related complications, and cost-effectiveness. Discussion The FLUYT trial design, including hydration schedule, fluid type, and sample size, maximize its power of identifying a potential difference in post-ERCP pancreatitis incidence in patients receiving prophylactic rectal NSAIDs. Trial registration EudraCT: 2015-000829-37. Registered on 18 February 2015. ISRCTN: 13659155. Registered on 18 May 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2583-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xavier J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands.
| | - David W da Costa
- Department of Radiology, St Antonius Hospital, PO 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, PO 22660, 1100 DD, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Centre Amsterdam, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, PO 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Wietske Kievit
- Department of Health Evidence, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marieke Zegers
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Centre, PO 22660, 1100 DD, Amsterdam, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, PO 85500, 3508 GA, Utrecht, The Netherlands
| | - Rene W M van der Hulst
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, PO 417, 2000 AK, Haarlem, The Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Klinieken, PO 10400, 8000 GK, Zwolle, The Netherlands
| | - Gerbrand D N Heine
- Department of Gastroenterology and Hepatology, Noord-West Hospital, PO 501, 1800 AM, Alkmaar, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO 50000, 7500 KA, Enschede, The Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO 50000, 7500 KA, Enschede, The Netherlands
| | - Lubbertus C Baak
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Postbus 95500, 1090 HM, Amsterdam, The Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, PO 90153, 5200 ME, s'Hertogenbosch, The Netherlands
| | - Sven M van Dijk
- Department of Surgery, Academic Medical Centre, PO 22660, 1100 DD, Amsterdam, The Netherlands
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, PO 444, 3300 AK, Dordrecht, The Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, PO 90158, 4800 RK, Breda, The Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina Hospital, PO 9015, 6500 GS, Nijmegen, The Netherlands
| | - Annet M C J Voorburg
- Department of Gastroenterology and Hepatology, Diakonessenhuis, PO 80250, 3508 TG, Utrecht, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, PO 9025, 6710 HN, Ede, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HAGA Hospital, PO 40551, 2504 LN, The Hague, The Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, PO 9100, 3007 AC, Rotterdam, The Netherlands
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, PO 30033, 9700 RM, Groningen, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, PO 1502, 3800 BM, Amersfoort, The Netherlands
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, PO 9555, 6800 TA, Arnhem, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, PO 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, VU University Medical Centre Amsterdam, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Yolande Keulemans
- Department of Gastroenterology and Hepatology, Zuyderland, PO 5500, 6130 MB, Sittard-Geleen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
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van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, van Eijck CH, Erkelens WG, van Goor H, van Grevenstein WMU, Haveman JW, Hofker SH, Jansen JM, Laméris JS, van Lienden KP, Meijssen MA, Mulder CJ, Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Römkens TE, Scheepers JJ, Schepers NJ, Schwartz MP, Seerden T, Spanier BWM, Straathof JWA, Strijker M, Timmer R, Venneman NG, Vleggaar FP, Voermans RP, Witteman BJ, Gooszen HG, Dijkgraaf MG, Fockens P. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391:51-58. [PMID: 29108721 DOI: 10.1016/s0140-6736(17)32404-2] [Citation(s) in RCA: 395] [Impact Index Per Article: 65.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/19/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes. METHODS In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711. FINDINGS Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio [RR] 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine [18%] patients in the endoscopy group vs six [13%] patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint. INTERPRETATION In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference. FUNDING The Dutch Digestive Disease Foundation, Fonds NutsOhra, and the Netherlands Organization for Health Research and Development.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
| | - Janneke van Grinsven
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands; Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Esther C Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands
| | - Cornelis H Dejong
- Department of Surgery and NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | | | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Jan-Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Sijbrand H Hofker
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Johan S Laméris
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Chris J Mulder
- Department of Gastroenterology, VU Medical Centre, Amsterdam, Netherlands
| | | | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Tessa E Römkens
- Department of Gastroenterology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | | | - Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology, Meander Medical Centre, Amersfoort, Netherlands
| | - Tom Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, Netherlands
| | | | | | - Marin Strijker
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Robin Timmer
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hein G Gooszen
- Department of OR/Evidence Based Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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11
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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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12
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Smeets XJNM, da Costa DW, Besselink MG, Bruno MJ, Fockens P, Mulder CJJ, van der Hulst RW, Vleggaar FP, Timmer R, Drenth JPH, van Geenen EJM. Systematic review: periprocedural hydration in the prevention of post-ERCP pancreatitis. Aliment Pharmacol Ther 2016; 44:541-53. [PMID: 27444408 DOI: 10.1111/apt.13744] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 05/18/2016] [Revised: 06/06/2016] [Accepted: 07/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND With an overall incidence of 3.5%, pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Periprocedural hydration may prevent post-ERCP pancreatitis by maintaining pancreatic microperfusion, thereby inhibiting the pancreatic inflammatory response. However, the evidence for periprocedural hydration as a preventive measure is unclear. AIM To conduct a systematic review to assess the evidence regarding periprocedural hydration as a preventive measure for post-ERCP pancreatitis. METHODS We searched PubMed and EMBASE databases and adhered to the PRISMA guidelines. We included studies addressing periprocedural hydration as a preventive measure to reduce frequency and severity of post-ERCP pancreatitis. Study quality was assessed by using the MINORS and Cochrane Collaboration's tool. RESULTS Six studies with a total of 1102 patients were included. Two randomised controlled trials reported a decreased incidence of post-ERCP pancreatitis after hydration: 0% vs. 17% (P = 0.016) and 5.3% vs. 22.7% (P = 0.002). A third trial and two case-controls studies did not report significant differences. Two retrospective studies found that patients with mild post-ERCP pancreatitis had received significantly more fluids during (mean 940 mL vs. 810 mL; P = 0.031) or after ERCP (median 2834 mL vs. 2044 mL; P < 0.02) compared to patients with moderate/severe disease. Adverse events of periprocedural hydration were not reported in any of the included studies. The different methodologies of the included studies precluded a formal data synthesis. CONCLUSIONS There is some evidence to suggest that hydration affords protection against post-ERCP pancreatitis, but study heterogeneity precludes firm conclusions. Adequately powered randomised trials are needed to evaluate the preventive effect of periprocedural hydration.
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Affiliation(s)
- X J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
| | - D W da Costa
- Department of Radiology, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - M G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, Noord-Holland, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Noord-Holland, The Netherlands
| | - C J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, Noord-Holland, The Netherlands
| | - R W van der Hulst
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - F P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - J P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
| | - E J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Gelderland, The Netherlands
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13
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Schepers NJ, Bakker OJ, Besselink MGH, Bollen TL, Dijkgraaf MGW, van Eijck CHJ, Fockens P, van Geenen EJM, van Grinsven J, Hallensleben NDL, Hansen BE, van Santvoort HC, Timmer R, Anten MPGF, Bolwerk CJM, van Delft F, van Dullemen HM, Erkelens GW, van Hooft JE, Laheij R, van der Hulst RWM, Jansen JM, Kubben FJGM, Kuiken SD, Perk LE, de Ridder RJJ, Rijk MCM, Römkens TEH, Schoon EJ, Schwartz MP, Spanier BWM, Tan ACITL, Thijs WJ, Venneman NG, Vleggaar FP, van de Vrie W, Witteman BJ, Gooszen HG, Bruno MJ. Early biliary decompression versus conservative treatment in acute biliary pancreatitis (APEC trial): study protocol for a randomized controlled trial. Trials 2016; 17:5. [PMID: 26729193 PMCID: PMC4700728 DOI: 10.1186/s13063-015-1132-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 12/17/2015] [Indexed: 01/25/2023] Open
Abstract
Background Acute pancreatitis is mostly caused by gallstones or sludge. Early decompression of the biliary tree by endoscopic retrograde cholangiography (ERC) with sphincterotomy may improve outcome in these patients. Whereas current guidelines recommend early ERC in patients with concomitant cholangitis, early ERC is not recommended in patients with mild biliary pancreatitis. Evidence on the role of routine early ERC with endoscopic sphincterotomy in patients without cholangitis but with biliary pancreatitis at high risk for complications is lacking. We hypothesize that early ERC with sphincterotomy improves outcome in these patients. Methods/Design The APEC trial is a randomized controlled, parallel group, superiority multicenter trial. Within 24 hours after presentation to the emergency department, patients with biliary pancreatitis without cholangitis and at high risk for complications, based on an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 8 or greater, Modified Glasgow score of 3 or greater, or serum C-reactive protein above 150 mg/L, will be randomized. In 27 hospitals of the Dutch Pancreatitis Study Group, 232 patients will be allocated to early ERC with sphincterotomy or to conservative treatment. The primary endpoint is a composite of major complications (that is, organ failure, pancreatic necrosis, pneumonia, bacteremia, cholangitis, pancreatic endocrine, or exocrine insufficiency) or death within 180 days after randomization. Secondary endpoints include ERC-related complications, infected necrotizing pancreatitis, length of hospital stay and an economical evaluation. Discussion The APEC trial investigates whether an early ERC with sphincterotomy reduces the composite endpoint of major complications or death compared with conservative treatment in patients with biliary pancreatitis at high risk of complications. Trial registration Current Controlled Trials ISRCTN97372133 (date registration: 17-12-2012) Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1132-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands. .,Department of Gastroenterology and Hepatology, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, PO 85500, 3508, GA, Utrecht, The Netherlands.
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Marcel G W Dijkgraaf
- Clinical Research Unit, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, HP 690, PO 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Janneke van Grinsven
- Department of Surgery, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands. .,Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands. .,Department of Surgery, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Gasthuis, PO 10900, 3004, BA, Rotterdam, The Netherlands.
| | - Clemens J M Bolwerk
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Reinier de Graafweg 3-11, 2625, AD, Delft, The Netherlands.
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, VU University Medical Center Amsterdam, PO Box 7057, 1007, MB, Amsterdam, The Netherlands.
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, PO 30001, 9700, RB, Groningen, The Netherlands.
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, PO 9014, 7300, DS, Apeldoorn, The Netherlands.
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Robert Laheij
- Department of Gastroenterology and Hepatology, St. Elisabeth Hospital, PO 90151, 5000, LC, Tilburg, The Netherlands.
| | - René W M van der Hulst
- Department of Gastroenterology and Hepatology, Kennemer Gasthuis, PO 417, 2000, AK, Haarlem, The Netherlands.
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Postbus 95500, 1090, HM, Amsterdam, The Netherlands.
| | - Frank J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Maasstadweg 21, 3079, DZ, Rotterdam, The Netherlands.
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, Sint Lucas Andreas Hospital, PO 9243, 1006, AE, Amsterdam, The Netherlands.
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden, PO 432, 2501, CK Den Haag, The Netherlands.
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, PO 5800, 6202, AZ, Maastricht, The Netherlands.
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, PO 90158, 4800, RK, Breda, The Netherlands.
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, PO 90153, 5200, ME 's-Hertogenbosch, The Netherlands.
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, PO 1350, 5602, ZA, Eindhoven, The Netherlands.
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, PO 1502, 3800, BM, Amersfoort, The Netherlands.
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, PO 9555, 6800, TA, Arnhem, The Netherlands.
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina Hospital, PO 9015, 6500, GS, Nijmegen, The Netherlands.
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, PO 30033, 9700, RM, Groningen, The Netherlands.
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO 50000, 7500, KA, Enschede, The Netherlands.
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, PO 85500, 3508, GA, Utrecht, The Netherlands.
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, PO 444, 3300, AK, Dordrecht, The Netherlands.
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei Ede, PO 9025, 6710, HN, Ede, The Netherlands.
| | - Hein G Gooszen
- Department of Operating Rooms - Evidence Based Surgery, Radboud University Nijmegen Medical Centre, HP 690, PO 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
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14
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van Heijningen EMB, Lansdorp-Vogelaar I, Steyerberg EW, Goede SL, Dekker E, Lesterhuis W, ter Borg F, Vecht J, Spoelstra P, Engels L, Bolwerk CJM, Timmer R, Kleibeuker JH, Koornstra JJ, de Koning HJ, Kuipers EJ, van Ballegooijen M. Adherence to surveillance guidelines after removal of colorectal adenomas: a large, community-based study. Gut 2015; 64:1584-92. [PMID: 25586057 PMCID: PMC4602240 DOI: 10.1136/gutjnl-2013-306453] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [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: 11/16/2013] [Revised: 09/29/2014] [Accepted: 10/18/2014] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To determine adherence to recommended surveillance intervals in clinical practice. DESIGN 2997 successive patients with a first adenoma diagnosis (57% male, mean age 59 years) from 10 hospitals, who underwent colonoscopy between 1998 and 2002, were identified via Pathologisch Anatomisch Landelijk Geautomatiseerd Archief: Dutch Pathology Registry. Their medical records were reviewed until 1 December 2008. Time to and findings at first surveillance colonoscopy were assessed. A surveillance colonoscopy occurring within ± 3 months of a 1-year recommended interval and ± 6 months of a recommended interval of 2 years or longer was considered appropriate. The analysis was stratified by period per change in guideline (before 2002: 2-3 years for patients with 1 adenoma, annually otherwise; in 2002: 6 years for 1-2 adenomas, 3 years otherwise). We also assessed differences in adenoma and colorectal cancer recurrence rates by surveillance timing. RESULTS Surveillance was inappropriate in 76% and 89% of patients diagnosed before 2002 and in 2002, respectively. Patients eligible under the pre-2002 guideline mainly received surveillance too late or were absent (57% of cases). For patients eligible under the 2002 guideline surveillance occurred mainly too early (48%). The rate of advanced neoplasia at surveillance was higher in patients with delayed surveillance compared with those with too early or appropriate timed surveillance (8% vs 4-5%, p<0.01). CONCLUSIONS There is much room for improving surveillance practice. Less than 25% of patients with adenoma receive appropriate surveillance. Such practice seriously hampers the effectiveness and efficiency of surveillance, as too early surveillance poses a considerable burden on available resources while delayed surveillance is associated with an increased rate of advanced adenoma and especially colorectal cancer.
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Affiliation(s)
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - S Lucas Goede
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Wilco Lesterhuis
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands Department of Gastroenterology, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | - Frank ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, the Netherlands
| | - Juda Vecht
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Pieter Spoelstra
- Department of Gastroenterology and Hepatology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Leopold Engels
- Department of Gastroenterology and Hepatology, Orbis Medical Centre, Sittard, the Netherlands
| | - Clemens J M Bolwerk
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jan H Kleibeuker
- Department of Gastroenterology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Jan J Koornstra
- Department of Gastroenterology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands Department of Internal Medicine, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
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15
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da Costa DW, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, van Brunschot S, Bakker OJ, Bollen TL, Dejong CH, van Goor H, Boermeester MA, Bruno MJ, van Eijck CH, Timmer R, Weusten BL, Consten EC, Brink MA, Spanier BWM, Bilgen EJS, Nieuwenhuijs VB, Hofker HS, Rosman C, Voorburg AM, Bosscha K, van Duijvendijk P, Gerritsen JJ, Heisterkamp J, de Hingh IH, Witteman BJ, Kruyt PM, Scheepers JJ, Molenaar IQ, Schaapherder AF, Manusama ER, van der Waaij LA, van Unen J, Dijkgraaf MG, van Ramshorst B, Gooszen HG, Boerma D. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet 2015; 386:1261-1268. [PMID: 26460661 DOI: 10.1016/s0140-6736(15)00274-3] [Citation(s) in RCA: 192] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients with mild gallstone pancreatitis, cholecystectomy during the same hospital admission might reduce the risk of recurrent gallstone-related complications, compared with the more commonly used strategy of interval cholecystectomy. However, evidence to support same-admission cholecystectomy is poor, and concerns exist about an increased risk of cholecystectomy-related complications with this approach. In this study, we aimed to compare same-admission and interval cholecystectomy, with the hypothesis that same-admission cholecystectomy would reduce the risk of recurrent gallstone-related complications without increasing the difficulty of surgery. METHODS For this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, inpatients recovering from mild gallstone pancreatitis at 23 hospitals in the Netherlands (with hospital discharge foreseen within 48 h) were assessed for eligibility. Adult patients (aged ≥18 years) were eligible for randomisation if they had a serum C-reactive protein concentration less than 100 mg/L, no need for opioid analgesics, and could tolerate a normal oral diet. Patients with American Society of Anesthesiologists (ASA) class III physical status who were older than 75 years of age, all ASA class IV patients, those with chronic pancreatitis, and those with ongoing alcohol misuse were excluded. A central study coordinator randomly assigned eligible patients (1:1) by computer-based randomisation, with varying block sizes of two and four patients, to cholecystectomy within 3 days of randomisation (same-admission cholecystectomy) or to discharge and cholecystectomy 25-30 days after randomisation (interval cholecystectomy). Randomisation was stratified by centre and by whether or not endoscopic sphincterotomy had been done. Neither investigators nor participants were masked to group assignment. The primary endpoint was a composite of readmission for recurrent gallstone-related complications (pancreatitis, cholangitis, cholecystitis, choledocholithiasis needing endoscopic intervention, or gallstone colic) or mortality within 6 months after randomisation, analysed by intention to treat. The trial was designed to reduce the incidence of the primary endpoint from 8% in the interval group to 1% in the same-admission group. Safety endpoints included bile duct leakage and other complications necessitating re-intervention. This trial is registered with Current Controlled Trials, number ISRCTN72764151, and is complete. FINDINGS Between Dec 22, 2010, and Aug 19, 2013, 266 inpatients from 23 hospitals in the Netherlands were randomly assigned to interval cholecystectomy (n=137) or same-admission cholecystectomy (n=129). One patient from each group was excluded from the final analyses, because of an incorrect diagnosis of pancreatitis in one patient (in the interval group) and discontinued follow-up in the other (in the same-admission group). The primary endpoint occurred in 23 (17%) of 136 patients in the interval group and in six (5%) of 128 patients in the same-admission group (risk ratio 0·28, 95% CI 0·12-0·66; p=0·002). Safety endpoints occurred in four patients: one case of bile duct leakage and one case of postoperative bleeding in each group. All of these were serious adverse events and were judged to be treatment related, but none led to death. INTERPRETATION Compared with interval cholecystectomy, same-admission cholecystectomy reduced the rate of recurrent gallstone-related complications in patients with mild gallstone pancreatitis, with a very low risk of cholecystectomy-related complications. FUNDING Dutch Digestive Disease Foundation.
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Affiliation(s)
- David W da Costa
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Stefan A Bouwense
- Department of Operating Room/Evidence-Based Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicolien J Schepers
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands; Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | | | | | - Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Robin Timmer
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Bas L Weusten
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Esther C Consten
- Department of Surgery, Meander Medical Center, Amersfoort, Netherlands
| | - Menno A Brink
- Department of Gastroenterology, Meander Medical Center, Amersfoort, Netherlands
| | | | | | | | - H Sijbrand Hofker
- Department of Surgery, University Medical Center Groningen, Netherlands
| | - Camiel Rosman
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands
| | - Annet M Voorburg
- Department of Gastroenterology, Diakonessenhuis, Utrecht, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | | | - Jos J Gerritsen
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | | | | | - Ben J Witteman
- Department of Gastroenterology, Gelderse Vallei Hospital, Ede, Netherlands
| | - Philip M Kruyt
- Department of Surgery, Gelderse Vallei Hospital, Ede, Netherlands
| | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Hospital, Delft, Netherlands
| | | | | | - Eric R Manusama
- Department of Surgery, Medical Center Leeuwarden, Netherlands
| | | | - Jacco van Unen
- Department of Surgery, Laurentius Hospital, Roermond, Netherlands
| | | | | | - Hein G Gooszen
- Department of Operating Room/Evidence-Based Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands.
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16
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de Groot N, van Oijen M, Kessels K, Hemmink M, Weusten B, Timmer R, Hazen W, van Lelyveld N, Vermeijden, Curvers W, Baak L, Verburg R, Bosman J, de Wijkerslooth L, de Rooij J, Venneman N, Pennings M, van Hee K, Scheffer R, van Eijk R, Meiland R, Siersema P, Bredenoord A. Prediction scores or gastroenterologists' Gut Feeling for triaging patients that present with acute upper gastrointestinal bleeding. United European Gastroenterol J 2014; 2:197-205. [PMID: 25360303 DOI: 10.1177/2050640614531574] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 03/08/2014] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Several prediction scores for triaging patients with upper gastrointestinal (GI) bleeding have been developed, yet these scores have never been compared to the current gold standard, which is the clinical evaluation by a gastroenterologist. The aim of this study was to assess the added value of prediction scores to gastroenterologists' Gut Feeling in patients with a suspected upper GI bleeding. METHODS WE PROSPECTIVELY EVALUATED GUT FEELING OF SENIOR GASTROENTEROLOGISTS AND ASKED THEM TO ESTIMATE: (1) the risk that a clinical intervention is needed; (2) the risk of rebleeding; and (3) the risk of mortality in patients presenting with suspected upper GI bleeding, subdivided into low, medium, or high risk. The predictive value of the gastroenterologists' Gut Feeling was compared to the Blatchford and Rockall scores for various outcomes. RESULTS We included 974 patients, of which 667 patients (68.8%) underwent a clinical intervention. During the 30-day follow up, 140 patients (14.4%) developed recurrent bleeding and 44 patients (4.5%) died. Gut Feeling was independently associated with all studied outcomes, except for the predicted mortality after endoscopy. Predictive power, based on the AUC of the Blatchford and Rockall prediction scores, was higher than the Gut Feeling of the gastroenterologists. However, combining both the Blatchford and Rockall scores and the Gut Feeling yielded the highest predictive power for the need of an intervention (AUC 0.88), rebleeding (AUC 0.73), and mortality (AUC 0.71 predicted before and 0.77 predicted after endoscopy, respectively). CONCLUSIONS Gut Feeling is an independent predictor for the need of a clinical intervention, rebleeding, and mortality in patients presenting with upper GI bleeding; however, the Blatchford and Rockall scores are stronger predictors for these outcomes. Combining Gut Feeling with the Blatchford and Rockall scores resulted in the most optimal prediction.
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Affiliation(s)
- Nl de Groot
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Mgh van Oijen
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands ; University of California Los Angeles/Veterans Affairs Center for Outcomes Research and Education (CORE), Los Angeles, CA, USA ; Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - K Kessels
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M Hemmink
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands ; Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands
| | - R Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Wl Hazen
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - N van Lelyveld
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Vermeijden
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Wl Curvers
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Lc Baak
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - R Verburg
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden, Den Haag, The Netherlands
| | - Jh Bosman
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Lrh de Wijkerslooth
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - J de Rooij
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Ng Venneman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - M Pennings
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - K van Hee
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Rch Scheffer
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Rl van Eijk
- Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands
| | - R Meiland
- Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands
| | - Pd Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Aj Bredenoord
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands ; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands ; Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands
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17
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Ahmed Ali U, Issa Y, van Goor H, van Eijck CH, Nieuwenhuijs VB, Keulemans Y, Fockens P, Busch OR, Drenth JP, Dejong CH, van Dullemen HM, van Hooft JE, Siersema PD, Spanier BWM, Poley JW, Poen AC, Timmer R, Seerden T, Tan AC, Thijs WJ, Witteman BJM, Romkens TEH, Roeterdink AJ, Gooszen HG, van Santvoort HC, Bruno MJ, Boermeester MA. Dutch Chronic Pancreatitis Registry (CARE): design and rationale of a nationwide prospective evaluation and follow-up. Pancreatology 2014; 15:46-52. [PMID: 25511908 DOI: 10.1016/j.pan.2014.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 10/30/2014] [Accepted: 11/14/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic pancreatitis is a complex disease with many unanswered questions regarding the natural history and therapy. Prospective longitudinal studies with long-term follow-up are warranted. METHODS The Dutch Chronic Pancreatitis Registry (CARE) is a nationwide registry aimed at prospective evaluation and follow-up of patients with chronic pancreatitis. All patients with (suspected) chronic or recurrent pancreatitis are eligible for CARE. Patients are followed-up by yearly questionnaires and review of medical records. Study outcomes are pain, disease complications, quality of life, and pancreatic function. The target sample size was set at 500 for the first year and 1000 patients within 3 years. RESULTS A total of 1218 patients were included from February 2010 until June 2013 by 76 participating surgeons and gastroenterologist from 33 hospitals. Participation rate was 90% of eligible patients. Eight academic centers included 761 (62%) patients, while 25 community hospitals included 457 (38%). Patient centered outcomes were assessed by yearly questionnaires, which had a response rate of 85 and 82% for year 1 and 2, respectively. The median age of patients was 58 years, 814 (67%) were male, and 38% had symptoms for less than 5 years. DISCUSSION The CARE registry has successfully recruited over 1200 patients with chronic and recurrent pancreatitis in about 3 years. The defined inclusion criteria ensure patients are included at an early disease stage. Participation and compliance rates are high. CARE offers a unique opportunity with sufficient power to investigate many clinical questions regarding natural course, complications, and efficacy and timing of treatment strategies.
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Affiliation(s)
- U Ahmed Ali
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands.
| | - Y Issa
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - H van Goor
- Department of Surgery, RadboudUMC, Nijmegen, Netherlands
| | - C H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Y Keulemans
- Department of Gastroenterology, Maastricht University Medical Center, Maastricht, Netherlands
| | - P Fockens
- Department of Gastroenterology, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - O R Busch
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - J P Drenth
- Department of Gastroenterology, RadboudUMC, Nijmegen, Netherlands
| | - C H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - H M van Dullemen
- Department of Gastroenterology, University Medical Center Groningen, Groningen, Netherlands
| | - J E van Hooft
- Department of Gastroenterology, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - P D Siersema
- Department of Gastroenterology, University Medical Center Utrecht, Utrecht, Netherlands
| | - B W M Spanier
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, Netherlands
| | - J W Poley
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, Netherlands
| | - A C Poen
- Department of Gastroenterology, Isala Clinics, Zwolle, Netherlands
| | - R Timmer
- Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - T Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, Netherlands
| | - A C Tan
- Department of Gastroenterology, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands
| | - W J Thijs
- Department of Gastroenterology, Martini Hospital, Groningen, Netherlands
| | - B J M Witteman
- Department of Gastroenterology, Gelderse Vallei Hospital, Ede, Netherlands
| | - T E H Romkens
- Department of Gastroenterology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - A J Roeterdink
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - H G Gooszen
- Department of OR and Evidence Based Surgery, RadboudUMC, Nijmegen, Netherlands
| | - H C van Santvoort
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - M J Bruno
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
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18
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Zuidema MJ, van Santvoort HC, Besselink MG, van Ramshorst B, Boerma D, Timmer R, Bollen TL, Weusten BLAM. The predictive value of proteinuria in acute pancreatitis. Pancreatology 2014; 14:484-9. [PMID: 25287156 DOI: 10.1016/j.pan.2014.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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: 05/04/2014] [Revised: 09/04/2014] [Accepted: 09/07/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Acute pancreatitis has a highly variable clinical course. Early and reliable predictors for the severity of acute pancreatitis are lacking. Proteinuria appears to be a useful predictor of disease severity and outcome in a variety of clinical conditions. This study aims to investigate the predictive value of proteinuria on admission for the severity of acute pancreatitis compared with other commonly used predictors; the APACHE II score, Modified Glasgow score and C-reactive protein (CRP). METHODS This is a post-hoc analysis of 64 patients admitted with acute pancreatitis treated in one teaching hospital, who participated in a previous randomized trial. Proteinuria was defined as a Protein/Creatinine (P/C) ratio >23 mg/mmol. The primary endpoint was severe acute pancreatitis. Secondary endpoints included infectious complications, need for invasive intervention, ICU stay and in-hospital mortality. RESULTS Proteinuria was present in 30/64 patients (47%). Eleven patients (17%) had severe acute pancreatitis. There was no difference in incidence of severe acute pancreatitis between patients with and without proteinuria: 6/30 patients (20%) versus 5/34 patients (15%) respectively (p = 0.58). Likewise, the occurrence of infectious complications, need for intervention and ICU stay and mortality did not differ significantly (p = 0.58, p = 0.99, p = 0.33 and p = 0.60 respectively). The diagnostic performance of the P/C ratio for the prediction of severe pancreatitis was inferior to the Modified Glasgow score (p = 0.04) and CRP (p = 0.03). CONCLUSION Proteinuria on admission does not seem to be a reliable predictor for disease severity in acute pancreatitis. The diagnostic performance of the P/C ratio is inferior to the Modified Glasgow score and CRP.
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Affiliation(s)
- M J Zuidema
- Department of Gastroenterology, St. Antonius Hospital Nieuwegein, The Netherlands.
| | - H C van Santvoort
- Department of Surgery, St. Antonius Hospital Nieuwegein, The Netherlands
| | - M G Besselink
- Department of Surgery, Academic Medical Center Amsterdam, The Netherlands
| | - B van Ramshorst
- Department of Surgery, St. Antonius Hospital Nieuwegein, The Netherlands
| | - D Boerma
- Department of Surgery, St. Antonius Hospital Nieuwegein, The Netherlands
| | - R Timmer
- Department of Gastroenterology, St. Antonius Hospital Nieuwegein, The Netherlands
| | - T L Bollen
- Department of Radiology, St. Antonius Hospital Nieuwegein, The Netherlands
| | - B L A M Weusten
- Department of Gastroenterology, St. Antonius Hospital Nieuwegein, The Netherlands
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Hollemans RA, van Brunschot S, Bakker OJ, Bollen TL, Timmer R, Besselink MGH, van Santvoort HC. Minimally invasive intervention for infected necrosis in acute pancreatitis. Expert Rev Med Devices 2014; 11:637-48. [DOI: 10.1586/17434440.2014.947271] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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20
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Buddingh KT, Koudstaal LG, Leuvenink HG, Ploeg RJ, Nieuwenhuijs VB, van Santvoort HC, Nijmeijer RM, Gooszen H, Besselink MG, Timmer R, Rosman C, van Goor H. Reply: Early Detection of Potentially Severe Acute Pancreatitis. J Am Coll Surg 2014; 218:1075. [DOI: 10.1016/j.jamcollsurg.2014.02.010] [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] [Received: 02/11/2014] [Accepted: 02/14/2014] [Indexed: 10/25/2022]
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21
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de Vries HS, Boerma D, Timmer R, van Ramshorst B, Dieleman LA, van Westreenen HL. Routine colonoscopy is not required in uncomplicated diverticulitis: a systematic review. Surg Endosc 2014; 28:2039-47. [PMID: 24488358 DOI: 10.1007/s00464-014-3447-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/13/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND It is generally accepted that patients following an episode of diverticulitis should have additional colonoscopy screening to rule out a colorectal malignancy. We aimed to investigate the rate of CRC found by colonoscopy after an attack of uncomplicated diverticulitis. METHODS MEDLINE, Embase, and Cochrane databases were searched systematically for clinical trials or observational studies on colonic evaluation by colonoscopy after the initial diagnosis of acute uncomplicated diverticulitis, followed by hand-searching of reference lists. RESULTS Nine studies met the inclusion criteria and included a total number of 2,490 patients with uncomplicated diverticulitis. Subsequent colonoscopy after an episode of uncomplicated diverticulitis was performed in 1,468 patients (59%). Seventeen patients were diagnosed with CRC, having a prevalence of 1.16% (95% confidence interval 0.72-1.9% for CRC). Hyperplastic polyps were seen in 156 patients (10.6%), low-grade adenoma in 90 patients (6.1%), and advanced adenoma was reported in 32 patients (2.2%). CONCLUSION Unless colonoscopy is regarded for screening in individuals aged 50 years and older, routine colonoscopy in the absence of other clinical signs of CRC is not required.
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Affiliation(s)
- H S de Vries
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands,
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van Putten PG, ter Borg F, Adang RP, Koornstra JJ, Romberg-Camps MJ, Timmer R, Poen AC, Kuipers EJ, van Leerdam ME. Reply to Dr. Tursi. Endoscopy 2014; 45:409. [PMID: 23616133 DOI: 10.1055/s-0032-1326424] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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23
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van Putten PG, ter Borg F, Adang RP, Koornstra JJ, Romberg-Camps MJ, Timmer R, Poen AC, van Leerdam ME, Kuipers EJ. Reply to Thoufeeq. Endoscopy 2014; 45:407. [PMID: 23616131 DOI: 10.1055/s-0032-1326396] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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24
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de Groot NL, van Oijen MGH, Kessels K, Hemmink M, Weusten BLAM, Timmer R, Hazen WL, van Lelyveld N, Vermeijden RR, Curvers WL, Baak BC, Verburg R, Bosman JH, de Wijkerslooth LRH, de Rooij J, Venneman NG, Pennings M, van Hee K, Scheffer BCH, van Eijk RL, Meiland R, Siersema PD, Bredenoord AJ. Reassessment of the predictive value of the Forrest classification for peptic ulcer rebleeding and mortality: can classification be simplified? Endoscopy 2014; 46:46-52. [PMID: 24218308 DOI: 10.1055/s-0033-1344884] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [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: 12/22/2022]
Abstract
BACKGROUND AND STUDY AIMS This study aimed to reassess whether the Forrest classification is still useful for the prediction of rebleeding and mortality in peptic ulcer bleedings and, based on this, whether the classification could be simplified. PATIENTS AND METHODS Prospective registry data on peptic ulcer bleedings were collected and categorized according to the Forrest classification. The primary outcomes were 30-day rebleeding and all-cause mortality rates. Receiver operating characteristic curves were used to test whether simplification of the Forrest classification into high risk (Forrest Ia), increased risk (Forrest Ib-IIc), and low risk (Forrest III) classes could be an alternative to the original classification. RESULTS In total, 397 patients were included, with 18 bleedings (4.5%) being classified as Forrest Ia, 73 (18.4%) as Forrest Ib, 86 (21.7%) as Forrest IIa, 32 (8.1%) as Forrest IIb, 59 (14.9%) as Forrest IIc, and 129 (32.5%) as Forrest III. Rebleeding occurred in 74 patients (18.6%). Rebleeding rates were highest in Forrest Ia peptic ulcers (59%). The odds ratios for rebleeding among Forrest Ib-IIc ulcers were similar. In subgroup analysis, predicting rebleeding using the Forrest classification was more reliable for gastric ulcers than for duodenal ulcers. The simplified Forrest classification had similar test characteristics to the original Forrest classification. CONCLUSION The Forrest classification still has predictive value for rebleeding of peptic ulcers, especially for gastric ulcers; however, it does not predict mortality. Based on these results, a simplified Forrest classification is proposed. However, further studies are needed to validate these findings.
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Affiliation(s)
- Nicolette L de Groot
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Martijn G H van Oijen
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Koen Kessels
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Maarten Hemmink
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Niels van Lelyveld
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Reinoud R Vermeijden
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Bert C Baak
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Robert Verburg
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden, Den Haag, The Netherlands
| | - Joukje H Bosman
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | | | - Janne de Rooij
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Marieke Pennings
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Koen van Hee
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Bob C H Scheffer
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Rachel L van Eijk
- Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands
| | - Ruby Meiland
- Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
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van Brunschot S, van Grinsven J, Voermans RP, Bakker OJ, Besselink MGH, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, Dijkgraaf MGW, van Eijck CH, Erkelens GW, van Goor H, Hadithi M, Haveman JW, Hofker SH, Jansen JJM, Laméris JS, van Lienden KP, Manusama ER, Meijssen MA, Mulder CJ, Nieuwenhuis VB, Poley JW, de Ridder RJ, Rosman C, Schaapherder AF, Scheepers JJ, Schoon EJ, Seerden T, Spanier BWM, Straathof JWA, Timmer R, Venneman NG, Vleggaar FP, Witteman BJ, Gooszen HG, van Santvoort HC, Fockens P. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol 2013; 13:161. [PMID: 24274589 PMCID: PMC4222267 DOI: 10.1186/1471-230x-13-161] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/13/2013] [Indexed: 02/06/2023] Open
Abstract
Background Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes. Methods/Design The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs. Discussion The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, The Netherlands.
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Hirdes MMC, van Hooft JE, Koornstra JJ, Timmer R, Leenders M, Weersma RK, Weusten BLAM, van Hillegersberg R, van Berge Henegouwen MI, Plukker JTM, Wiezer R, Bergman JGHM, Vleggaar FP, Fockens P, Siersema PD. Endoscopic corticosteroid injections do not reduce dysphagia after endoscopic dilation therapy in patients with benign esophagogastric anastomotic strictures. Clin Gastroenterol Hepatol 2013; 11:795-801.e1. [PMID: 23376318 DOI: 10.1016/j.cgh.2013.01.016] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [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: 09/13/2012] [Revised: 12/09/2012] [Accepted: 01/11/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Benign anastomotic strictures are often difficult to treat. We assessed the efficacy of adding corticosteroid injections to endoscopic dilation therapy with Savary bougienage. METHODS In a multicenter, double-blind trial, 60 patients (mean age, 63 ± 9 years; 78% male) with an untreated cervical anastomotic stricture after esophagectomy with gastric tube reconstruction and dysphagia for at least solid food were randomly assigned to groups given 4 quadrant injections of 0.5 mL triamcinolone (40 mg/mL, n = 29) or saline (controls, n = 31) into the stricture, followed by Savary dilation to 16 mm. Dysphagia, complications, and quality of life were assessed after 1 and 2 weeks and 1, 3, and 6 months. The primary end point was a dysphagia-free period of 6 months. RESULTS In the corticosteroid group, 45% of the patients remained dysphagia-free for 6 months, compared with 36% of controls (relative risk, 1.26; 95% confidence interval, 0.68-2.36; P = .46). Median time to repeat dilation was 108 days (range, 15-180 days) in the corticosteroid group vs 42 days (range, 17-180 days) for controls (P = .11). A median number of 2 dilations (range, 1-7) was performed in the corticosteroid group vs 3 dilations (range, 1-9) in controls (relative risk, 0.76; 95% confidence interval, 0.42-1.38; P = .36). Two major intervention-related complications occurred, 1 submucosal laceration in the corticosteroid group and 1 hemorrhage in the control group. Four patients in the corticosteroid group, but none of the controls, developed Candida esophagitis (P = .03). CONCLUSIONS Corticosteroid injections do not provide a statistically significant decrease in frequency of repeat dilations or prolongation of the dysphagia-free period in patients with benign anastomotic esophagogastric strictures. Dutch Trial Registration Number 2236.
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Affiliation(s)
- Meike M C Hirdes
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
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van Heijningen EMB, Lansdorp-Vogelaar I, Kuipers EJ, Dekker E, Lesterhuis W, Ter Borg F, Vecht J, De Jonge V, Spoelstra P, Engels L, Bolwerk CJM, Timmer R, Kleibeuker JH, Koornstra JJ, van Ballegooijen M, Steyerberg EW. Features of adenoma and colonoscopy associated with recurrent colorectal neoplasia based on a large community-based study. Gastroenterology 2013; 144:1410-8. [PMID: 23499951 DOI: 10.1053/j.gastro.2013.03.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [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: 05/24/2012] [Revised: 02/26/2013] [Accepted: 03/05/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND & AIMS We investigated adenoma and colonoscopy characteristics that are associated with recurrent colorectal neoplasia based on data from community-based surveillance practice. METHODS We analyzed data of 2990 consecutive patients (55% male; mean age 61 years) newly diagnosed with adenomas from 1988 to 2002 at 10 hospitals throughout The Netherlands. Medical records were reviewed until December 1, 2008. We excluded patients with hereditary colorectal cancer (CRC) syndromes, a history of CRC, inflammatory bowel disease, or without surveillance data. We analyzed associations among adenoma number, size, grade of dysplasia, villous histology, and location with recurrence of advanced adenoma (AA) and nonadvanced adenoma (NAA). We performed a multivariable multinomial logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS During the surveillance period, 203 (7%) patients were diagnosed with AA and 954 (32%) patients with NAA. The remaining 1833 (61%) patients had no adenomas during a median follow-up of 48 months. Factors associated with AA during the surveillance period included baseline number of adenomas (ORs ranging from 1.6 for 2 adenomas; 95% CI: 1.1-2.4 to 3.3 for ≥5 adenomas; 95% CI: 1.7-6.6), adenoma size ≥10 mm (OR = 1.7; 95% CI: 1.2-2.3), villous histology (OR = 2.0; 95% CI: 1.2-3.2), proximal location (OR = 1.6; 95% CI: 1.2-2.3), insufficient bowel preparation (OR = 3.4; 95% CI: 1.6-7.4), and only distal colonoscopy reach (OR = 3.2; 95% CI: 1.2-8.5). Adenoma number had the greatest association with NAA. High-grade dysplasia was not associated with AA or NAA. CONCLUSIONS Large size and number, villous histology, proximal location of adenomas, insufficient bowel preparation, and poor colonoscopy reach were associated with detection of AA during surveillance based on data from community-based practice. These characteristics should be used jointly to develop surveillance policies for adenoma patients.
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Ahmed Ali U, Issa Y, Bruno MJ, van Goor H, van Santvoort H, Busch ORC, Dejong CHC, Nieuwenhuijs VB, van Eijck CH, van Dullemen HM, Fockens P, Siersema PD, Gouma DJ, van Hooft JE, Keulemans Y, Poley JW, Timmer R, Besselink MG, Vleggaar FP, Wilder-Smith OH, Gooszen HG, Dijkgraaf MGW, Boermeester MA. Early surgery versus optimal current step-up practice for chronic pancreatitis (ESCAPE): design and rationale of a randomized trial. BMC Gastroenterol 2013; 13:49. [PMID: 23506415 PMCID: PMC3610165 DOI: 10.1186/1471-230x-13-49] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [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: 02/18/2013] [Accepted: 03/07/2013] [Indexed: 12/11/2022] Open
Abstract
Background In current practice, patients with chronic pancreatitis undergo surgical intervention in a late stage of the disease, when conservative treatment and endoscopic interventions have failed. Recent evidence suggests that surgical intervention early on in the disease benefits patients in terms of better pain control and preservation of pancreatic function. Therefore, we designed a randomized controlled trial to evaluate the benefits, risks and costs of early surgical intervention compared to the current stepwise practice for chronic pancreatitis. Methods/design The ESCAPE trial is a randomized controlled, parallel, superiority multicenter trial. Patients with chronic pancreatitis, a dilated pancreatic duct (≥ 5 mm) and moderate pain and/or frequent flare-ups will be registered and followed monthly as potential candidates for the trial. When a registered patient meets the randomization criteria (i.e. need for opioid analgesics) the patient will be randomized to either early surgical intervention (group A) or optimal current step-up practice (group B). An expert panel of chronic pancreatitis specialists will oversee the assessment of eligibility and ensure that allocation to either treatment arm is possible. Patients in group A will undergo pancreaticojejunostomy or a Frey-procedure in case of an enlarged pancreatic head (≥ 4 cm). Patients in group B will undergo a step-up practice of optimal medical treatment, if needed followed by endoscopic interventions, and if needed followed by surgery, according to predefined criteria. Primary outcome is pain assessed with the Izbicki pain score during a follow-up of 18 months. Secondary outcomes include complications, mortality, total direct and indirect costs, quality of life, pancreatic insufficiency, alternative pain scales, length of hospital admission, number of interventions and pancreatitis flare-ups. For the sample size calculation we defined a minimal clinically relevant difference in the primary endpoint as a difference of at least 15 points on the Izbicki pain score during follow-up. To detect this difference a total of 88 patients will be randomized (alpha 0.05, power 90%, drop-out 10%). Discussion The ESCAPE trial will investigate whether early surgery in chronic pancreatitis is beneficial in terms of pain relief, pancreatic function and quality of life, compared with current step-up practice. Trial registration ISRCTN: ISRCTN45877994
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Affiliation(s)
- Usama Ahmed Ali
- Department of Surgery, Academic Medical Center Amsterdam, PO 22660, 1100 DD, Amsterdam, the Netherlands
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van Putten PG, Ter Borg F, Adang RPR, Koornstra JJ, Romberg-Camps MJL, Timmer R, Poen AC, Kuipers EJ, Van Leerdam ME. Nurse endoscopists perform colonoscopies according to the international standard and with high patient satisfaction. Endoscopy 2012; 44:1127-32. [PMID: 22930175 DOI: 10.1055/s-0032-1310154] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [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: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS Colonoscopy is increasingly performed by nurse endoscopists. We aimed to assess the endoscopic quality and patient experience of these procedures. PATIENTS AND METHODS This prospective multicenter study analyzed 100 consecutive colonoscopies each for 10 trained nurse endoscopists with respect to endoscopic quality and patient experience. Colonoscopies were performed under the supervision of a gastroenterologist, using the techniques and protocols of the participating hospitals. Patient experience was assessed using a questionnaire. RESULTS Most nurse endoscopists were female (90 %; median age 43 [range 35 - 49]). Before the start of the study, they had performed a median of 528 colonoscopies (range 208 - 2103). For the 1000 patients, mean age was 56 ± 15 years; 55 % were women; and 96 % were in class I or II according to the American Society of Anesthesiologists' physical status classification system. Colonoscopies were performed for screening or surveillance in 42 %; for symptomatic indications in 58 % of patients. The unassisted cecal intubation rate was 94 %; the mean withdrawal time was 10 ± 5 minutes. The adenoma detection rate was 26.7 %. In 229 of the colonoscopies (23 %), the nurse endoscopists required assistance from the supervising gastroenterologist. The complication rate was 0.2 %: one perforation and one cardiopulmonary complication. The questionnaire was completed by 734 /1000 patients (73 %) and of these 694 /734 (95 %) were satisfied with the endoscopic procedure. Among the respondents 530 /734 (72 %) had no specific preference for a physician or nurse endoscopist, whereas 113 /734 (15 %) preferred a physician endoscopist, and 91 /734 (12 %) preferred a nurse endoscopist. CONCLUSION The nurse endoscopists performed colonoscopies according to the internationally recognized quality standards and with high patient satisfaction.
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Affiliation(s)
- P G van Putten
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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Bouwense SA, Besselink MG, van Brunschot S, Bakker OJ, van Santvoort HC, Schepers NJ, Boermeester MA, Bollen TL, Bosscha K, Brink MA, Bruno MJ, Consten EC, Dejong CH, van Duijvendijk P, van Eijck CH, Gerritsen JJ, van Goor H, Heisterkamp J, de Hingh IH, Kruyt PM, Molenaar IQ, Nieuwenhuijs VB, Rosman C, Schaapherder AF, Scheepers JJ, Spanier MBW, Timmer R, Weusten BL, Witteman BJ, van Ramshorst B, Gooszen HG, Boerma D. Pancreatitis of biliary origin, optimal timing of cholecystectomy (PONCHO trial): study protocol for a randomized controlled trial. Trials 2012. [PMID: 23181667 PMCID: PMC3517749 DOI: 10.1186/1745-6215-13-225] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [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] [Indexed: 01/21/2023] Open
Abstract
Background After an initial attack of biliary pancreatitis, cholecystectomy minimizes the risk of recurrent biliary pancreatitis and other gallstone-related complications. Guidelines advocate performing cholecystectomy within 2 to 4 weeks after discharge for mild biliary pancreatitis. During this waiting period, the patient is at risk of recurrent biliary events. In current clinical practice, surgeons usually postpone cholecystectomy for 6 weeks due to a perceived risk of a more difficult dissection in the early days following pancreatitis and for logistical reasons. We hypothesize that early laparoscopic cholecystectomy minimizes the risk of recurrent biliary pancreatitis or other complications of gallstone disease in patients with mild biliary pancreatitis without increasing the difficulty of dissection and the surgical complication rate compared with interval laparoscopic cholecystectomy. Methods/Design PONCHO is a randomized controlled, parallel-group, assessor-blinded, superiority multicenter trial. Patients are randomly allocated to undergo early laparoscopic cholecystectomy, within 72 hours after randomization, or interval laparoscopic cholecystectomy, 25 to 30 days after randomization. During a 30-month period, 266 patients will be enrolled from 18 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite endpoint of mortality and acute re-admissions for biliary events (that is, recurrent biliary pancreatitis, acute cholecystitis, symptomatic/obstructive choledocholithiasis requiring endoscopic retrograde cholangiopancreaticography including cholangitis (with/without endoscopic sphincterotomy), and uncomplicated biliary colics) occurring within 6 months following randomization. Secondary endpoints include the individual endpoints of the composite endpoint, surgical and other complications, technical difficulty of cholecystectomy and costs. Discussion The PONCHO trial is designed to show that early laparoscopic cholecystectomy (within 72 hours) reduces the combined endpoint of mortality and re-admissions for biliary events as compared with interval laparoscopic cholecystectomy (between 25 and 30 days) after recovery of a first episode of mild biliary pancreatitis. Trial registration Current Controlled Trials: ISRCTN72764151
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Affiliation(s)
- Stefan A Bouwense
- Department of OR/Evidence Based Surgery, Radboud University Nijmegen Medical Centre, HP 690, PO 9101, Nijmegen HB 6500, the Netherlands
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Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL, van Eijck CH, Fockens P, Hazebroek EJ, Nijmeijer RM, Poley JW, van Ramshorst B, Vleggaar FP, Boermeester MA, Gooszen HG, Weusten BL, Timmer R. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012; 307:1053-61. [PMID: 22416101 DOI: 10.1001/jama.2012.276] [Citation(s) in RCA: 457] [Impact Index Per Article: 38.1] [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: 12/12/2022]
Abstract
CONTEXT Most patients with infected necrotizing pancreatitis require necrosectomy. Surgical necrosectomy induces a proinflammatory response and is associated with a high complication rate. Endoscopic transgastric necrosectomy, a form of natural orifice transluminal endoscopic surgery, may reduce the proinflammatory response and reduce complications. OBJECTIVE To compare the proinflammatory response and clinical outcome of endoscopic transgastric and surgical necrosectomy. DESIGN, SETTING, AND PATIENTS Randomized controlled assessor-blinded clinical trial in 3 academic hospitals and 1 regional teaching hospital in The Netherlands between August 20, 2008, and March 3, 2010. Patients had signs of infected necrotizing pancreatitis and an indication for intervention. INTERVENTIONS Random allocation to endoscopic transgastric or surgical necrosectomy. Endoscopic necrosectomy consisted of transgastric puncture, balloon dilatation, retroperitoneal drainage, and necrosectomy. Surgical necrosectomy consisted of video-assisted retroperitoneal debridement or, if not feasible, laparotomy. MAIN OUTCOME MEASURES The primary end point was the postprocedural proinflammatory response as measured by serum interleukin 6 (IL-6) levels. Secondary clinical end points included a predefined composite end point of major complications (new-onset multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, or pancreatic fistula) or death. RESULTS We randomized 22 patients, 2 of whom did not undergo necrosectomy following percutaneous catheter drainage and could not be analyzed for the primary end point. Endoscopic transgastric necrosectomy reduced the postprocedural IL-6 levels compared with surgical necrosectomy (P = .004). The composite clinical end point occurred less often after endoscopic necrosectomy (20% vs 80%; risk difference [RD], 0.60; 95% CI, 0.16-0.80; P = .03). Endoscopic necrosectomy did not cause new-onset multiple organ failure (0% vs 50%, RD, 0.50; 95% CI, 0.12-0.76; P = .03) and reduced the number of pancreatic fistulas (10% vs 70%; RD, 0.60; 95% CI, 0.17-0.81; P = .02). CONCLUSION In patients with infected necrotizing pancreatitis, endoscopic necrosectomy reduced the proinflammatory response as well as the composite clinical end point compared with surgical necrosectomy. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN07091918.
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Affiliation(s)
- Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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van Boeckel PGA, Dua KS, Weusten BLAM, Schmits RJH, Surapaneni N, Timmer R, Vleggaar FP, Siersema PD. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol 2012; 12:19. [PMID: 22375711 PMCID: PMC3313862 DOI: 10.1186/1471-230x-12-19] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [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: 08/03/2011] [Accepted: 02/29/2012] [Indexed: 12/14/2022] Open
Abstract
Background Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs. Methods Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected Results A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n = 32), iatrogenic rupture (n = 13), Boerhaave's syndrome (n = 4) or other cause (n = 3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n = 8), stent migration (n = 10), ruptured stent cover (all Ultraflex; n = 6), food obstruction (n = 3), severe pain (n = 2), esophageal rupture (n = 2), hemorrhage (n = 2)). One (2%) patient died of a stent-related cause. Conclusions Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).
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Affiliation(s)
- Petra G A van Boeckel
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Room F02,618, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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van Boeckel PGA, Dua KS, Weusten BLAM, Schmits RJH, Surapaneni N, Timmer R, Vleggaar FP, Siersema PD. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol 2012. [PMID: 22375711 DOI: 10.1186/1471-230x-12-19.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs. METHODS Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected RESULTS A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n=32), iatrogenic rupture (n=13), Boerhaave's syndrome (n=4) or other cause (n=3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n=8), stent migration (n=10), ruptured stent cover (all Ultraflex; n=6), food obstruction (n=3), severe pain (n=2), esophageal rupture (n=2), hemorrhage (n=2)). One (2%) patient died of a stent-related cause. CONCLUSIONS Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).
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Affiliation(s)
- Petra G A van Boeckel
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Room F02,618, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Lambeck YK, van Westreenen HLE, Weusten BLAM, Timmer R, Boerma D. [Haematemesis due to splenic vein thrombosis]. Ned Tijdschr Geneeskd 2012; 156:A4992. [PMID: 22914061] [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: 06/01/2023]
Abstract
BACKGROUND Haematemesis due to gastric fundal varices as a result of splenic vein thrombosis is rare. Splenic vein thrombosis may occur after pancreatitis and can lead to left-sided portal hypertension. Venous drainage from the spleen then occurs through the short gastric vessels, resulting in gastric varices. CASE DESCRIPTION Gastroscopy was performed in a 31-year-old man for transgastric drainage of fluid which had accumulated after an episode of acute pancreatitis. A gastric blood clot and fundal varices were observed. Three days later, the patient experienced haematemesis and went into a state of shock. Gastroscopy showed a bleeding fundal varix which was treated by an injection of Lipiodol/Histoacryl. CT confirmed thrombosis of the splenic vein. Six weeks later, splenectomy was performed and no subsequent bleeding occurred. CONCLUSION Haematemesis in patients with a history of chronic or acute pancreatitis can be a life-threatening expression of gastric fundal varices caused by splenic vein thrombosis. In cases of severe haemorrhaging, splenectomy is the treatment of choice.
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Affiliation(s)
- Young-Kon Lambeck
- Sint Antonius Ziekenhuis, Afd. Chirurgie, Nieuwegein, the Netherlands
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Abstract
OBJECTIVE To assess the accuracy of newly developed software for detection of gastro-esophageal reflux episodes in ambulatory 24-h impedance tracings. MATERIAL AND METHODS. 24-h esophageal impedance recordings obtained from 60 consecutive patients with reflux symptoms were used in this study. The impedance tracings of the first 10 consecutive patients were analyzed manually by three investigators. Liquid-containing reflux episodes and their proximal extent were scored. A consensus between the three investigators was used as a gold standard. Computer analysis using dedicated software was performed, and the results were compared with the results of the consensus agreement. In addition, in order to assess the accuracy of symptom association analysis 24-h impedance tracings of all 60 patients were analyzed both manually by one investigator and using computer software. The number of reflux episodes and the results of symptom association analysis obtained by the human and computer analysis software were compared. RESULTS The consensus meeting resulted in a total of 625 reflux episodes. The mean sensitivity and the percentage of true-positives of analysis by individual investigators was 89±1% and 94±1%, respectively. Automated analysis had a sensitivity of 73±4% and a proportion of true-positive reflux episodes of 62±8%. Symptom association analysis performed by the computer and a human observer showed concordant results in 83% of the patients. CONCLUSIONS Although not as good as manual analysis by experts, computer analysis can be a helpful tool to identify reflux episodes and to assess the relationship between reflux episodes and symptoms.
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Affiliation(s)
- Gerrit J M Hemmink
- Department of Gastroenterology, Sint Antonius Hospital, Nieuwegein, The Netherlands.
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van Santvoort HC, Besselink MG, Bakker OJ, Vleggaar FP, Timmer R, Weusten BL, Gooszen HG. Endoscopic necrosectomy in necrotising pancreatitis: indication is the key. Gut 2010; 59:1587. [PMID: 20732915 DOI: 10.1136/gut.2009.192815] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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Voermans RP, van Berge Henegouwen MI, de Cuba E, van den Broek FJC, van Acker G, Timmer R, Fockens P. Randomized, blinded comparison of transgastric, transcolonic, and laparoscopic peritoneoscopy for the detection of peritoneal metastases in a human cadaver model. Gastrointest Endosc 2010; 72:1027-33. [PMID: 20850736 DOI: 10.1016/j.gie.2010.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [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: 03/04/2010] [Accepted: 06/10/2010] [Indexed: 01/27/2023]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery peritoneoscopy may be able to replace laparoscopic peritoneoscopy (LAP) for staging of GI malignancies if it is proven to be equally accurate and safe. OBJECTIVE To compare transgastric peritoneoscopy (TGP) and transcolonic peritoneoscopy (TCP) to LAP, pairwise, in a randomized, blinded (to location and number of beads) human cadaver model with simulated peritoneal metastases. DESIGN Metastases were simulated by 2.5-mm, color-coded beads, which were placed into the peritoneal cavity via an open approach. In previous porcine experiments, LAP resulted in a yield of 95%. By using a noninferiority design with a margin of equivalence of 15%, we needed a sample size of 34 beads for 80% power. Randomization was performed for number and location of beads. Eighteen experiments were performed on 6 fresh-frozen human cadavers. SETTING Experimental surgical laboratory. INTERVENTION LAP, TGP, and TCP were performed in randomized order by one of two surgeons/endoscopists blinded for location and number of beads. MAIN OUTCOME MEASUREMENTS Number of beads detected and touched. RESULTS LAP found and touched 33 beads (yield 97%), TGP 26 beads (76%; difference in yield vs LAP was -20.5 [95% CI, -26.3 to -9.27]), and TCP 29 beads (85%; difference in yield vs LAP was -11.8 [95% CI, -14.6 to 4.98]). Beads that were missed were mostly located at the inferior liver surface: TGP missed 6 of 9 of these beads (67%), TCP 4 of 9 (44%). LIMITATIONS Cadaver model. CONCLUSION In this prospective, blinded, comparative trial in a human cadaver model, TCP was comparable to LAP in detecting simulated metastases. TGP was inferior to LAP. Future development should focus on improved visualization of the inferior surface of the liver.
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Affiliation(s)
- Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, The Netherlands
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van Hooft JE, Dijkgraaf MGW, Timmer R, Siersema PD, Fockens P. Independent predictors of survival in patients with incurable malignant gastric outlet obstruction: a multicenter prospective observational study. Scand J Gastroenterol 2010; 45:1217-22. [PMID: 20459356 DOI: 10.3109/00365521.2010.487916] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Gastric outlet obstruction (GOO) is one of the late complications of a variety of malignancies. Palliation of symptoms of obstruction rather than cure is the primary aim of treatment in affected patients. Thus far prognostic information on life expectancy is lacking in these patients although it can be of importance when deciding upon their optimal treatment. The purpose of this study was to investigate whether baseline data in patients with incurable GOO can independently predict survival. PATIENTS AND METHODS In total, 105 consecutive patients with symptomatic GOO treated with duodenal stent placement were enrolled in this multicenter prospective observational study. Patients were followed until death or till 1 November 2008. The Cox proportional hazard regression model was used for both univariate and multivariate analyses of survival. RESULTS Baseline data of 101 patients were completed. At the time of analysis, 95% of patients had died; median overall survival was 82 days (75% alive at 36 days, 25% alive at 156 days). The final prediction model revealed the dichotomized WHO performance status (HR: 2.63, 95% CI: 1.68-4.12, p < 0.001), prescription of morphines stronger than tramadol (HR: 2.42, 95% CI: 1.38-4.25, p = 0.002) and pain score of the EORTC QLQ-C30 (HR: 1.01, 95% CI: 1.00-1.01, p = 0.035) as independent significant prognostic factors for short survival. CONCLUSIONS This study demonstrates clear predictors of poor outcome for patients presenting with symptomatic malignant GOO. The model may enhance the selection of optimal treatment for individual patients.
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Affiliation(s)
- Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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Reinders JSK, Goud A, Timmer R, Kruyt PM, Witteman BJM, Smakman N, Breumelhof R, Donkervoort SC, Jansen JM, Heisterkamp J, Grubben M, van Ramshorst B, Boerma D, van Ramshorst B, Boerma D. Early laparoscopic cholecystectomy improves outcomes after endoscopic sphincterotomy for choledochocystolithiasis. Gastroenterology 2010; 138:2315-20. [PMID: 20206179 DOI: 10.1053/j.gastro.2010.02.052] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [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: 07/08/2009] [Revised: 02/06/2010] [Accepted: 02/23/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Patients with choledochocystolithiasis generally undergo endoscopic sphincterotomy (ES) followed by laparoscopic cholecystectomy (LC). However, many patients receive this surgery 6-8 weeks after ES. There is a high conversion rate of elective LC after ES, and patients can develop recurrent biliary events during the waiting period. We investigated whether the timing of surgery influences outcome. METHODS We performed a randomized trial of patients with choledochocystolithiasis who underwent successful ES. Patients were randomly assigned to groups that received early LC (within 72 hours after ES, n = 49) or delayed LC (after 6-8 weeks, n = 47), based on an expected difference in conversion rate of 25% vs 5%, respectively. Conversion rate, biliary events during follow-up, duration and difficulty of surgeries, postoperative morbidity, and hospital stay were scored. Intention-to-treat analyses were performed. RESULTS Groups were comparable in age, sex, and comorbidity. There was no difference between groups in conversion rate (4.3% in early vs 8.7% in delayed group) nor were there differences in operating times and/or difficulties or hospital stays. During the waiting period for LC, 17 patients in the delayed group (36.2%) developed recurrent biliary events compared with 1 patient in the early group (P < .001). CONCLUSIONS In a randomized trial to evaluate timing of LC after ES, recurrent biliary events occurred in 36.2% of patients whose LC was delayed for 6-8 weeks. Early LC (within 72 hours) appears to be safe and might prevent the majority of biliary events in this period following sphincterotomy.
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van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, van Goor H, Schaapherder AF, van Eijck CH, Bollen TL, van Ramshorst B, Nieuwenhuijs VB, Timmer R, Laméris JS, Kruyt PM, Manusama ER, van der Harst E, van der Schelling GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, van Leeuwen MS, Buskens E, Gooszen HG. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362:1491-502. [PMID: 20410514 DOI: 10.1056/nejmoa0908821] [Citation(s) in RCA: 924] [Impact Index Per Article: 66.0] [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: 12/12/2022]
Abstract
BACKGROUND Necrotizing pancreatitis with infected necrotic tissue is associated with a high rate of complications and death. Standard treatment is open necrosectomy. The outcome may be improved by a minimally invasive step-up approach. METHODS In this multicenter study, we randomly assigned 88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue to undergo primary open necrosectomy or a step-up approach to treatment. The step-up approach consisted of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy. The primary end point was a composite of major complications (new-onset multiple-organ failure or multiple systemic complications, perforation of a visceral organ or enterocutaneous fistula, or bleeding) or death. RESULTS The primary end point occurred in 31 of 45 patients (69%) assigned to open necrosectomy and in 17 of 43 patients (40%) assigned to the step-up approach (risk ratio with the step-up approach, 0.57; 95% confidence interval, 0.38 to 0.87; P=0.006). Of the patients assigned to the step-up approach, 35% were treated with percutaneous drainage only. New-onset multiple-organ failure occurred less often in patients assigned to the step-up approach than in those assigned to open necrosectomy (12% vs. 40%, P=0.002). The rate of death did not differ significantly between groups (19% vs. 16%, P=0.70). Patients assigned to the step-up approach had a lower rate of incisional hernias (7% vs. 24%, P=0.03) and new-onset diabetes (16% vs. 38%, P=0.02). CONCLUSIONS A minimally invasive step-up approach, as compared with open necrosectomy, reduced the rate of the composite end point of major complications or death among patients with necrotizing pancreatitis and infected necrotic tissue. (Current Controlled Trials number, ISRCTN13975868.)
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Hemmink GJM, Ten Cate L, Bredenoord AJ, Timmer R, Weusten BLAM, Smout AJPM. Speech therapy in patients with excessive supragastric belching--a pilot study. Neurogastroenterol Motil 2010; 22:24-8, e2-3. [PMID: 19650772 DOI: 10.1111/j.1365-2982.2009.01371.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [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
In patients whose main symptom is excessive belching, supragastric belching appears to be the predominant mechanism. This belch pattern is characterized by a rapid influx of air into the oesophagus, immediately followed by rapid air expulsion. The rate at which supragastric belching occurs is influenced by attention and distraction, suggesting a behavioural disorder and speech therapy may be of benefit to these patients. In 17 consecutive patients with excessive belching, concurrent impedance monitoring and high-resolution manometry were performed to ascertain the mechanism of belching. Patients with supragastric belches were referred to a speech therapist, who was familiar with the concept of supragastric belching. Before and after treatment by the speech therapist, patients filled out a VAS scale regarding the severity of their symptoms. In all patients, supragastric belches were identified with impedance monitoring. Eleven patients were referred to a speech therapist, six patients were not able or willing to undergo repetitive treatments. Eleven patients completed treatment by the speech therapist consisting of 10 (8-10) sessions. Overall, the VAS scales showed a significant improvement of the severity of symptoms (P < 0.05). Six of the 11 patients reported a large decrease (>30%) in their symptoms and four patients reported a modest decrease (<30%). In one patient, the VAS scores indicated an increase in symptoms. Speech therapy performed by a well-informed speech pathologist leads to a significant symptom reduction in patients with excessive supragastric belching. This is the first study indicating benefit of a treatment for excessive belching.
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Affiliation(s)
- G J M Hemmink
- Department of Gastroenterology, Sint Antonius Hospital, Nieuwegein, The Netherlands.
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Hemmink GJM, Weusten BLAM, Bredenoord AJ, Timmer R, Smout AJPM. Aerophagia: excessive air swallowing demonstrated by esophageal impedance monitoring. Clin Gastroenterol Hepatol 2009; 7:1127-9. [PMID: 19602452 DOI: 10.1016/j.cgh.2009.06.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Revised: 05/22/2009] [Accepted: 06/28/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with aerophagia suffer from the presence of an excessive volume of intestinal gas, which is thought to result from excessive air ingestion. However, this has not been shown thus far. The aim of this study was therefore to assess swallowing and air swallowing frequencies in patients with suspected aerophagia. METHODS Ambulatory 24-hour pH-impedance monitoring was performed in patients in whom excessive amounts of intestinal gas were visualized on plain abdominal radiograms. All patients had symptoms of bloating, abdominal distention, flatulence, or excessive belching. Reflux parameters and the number of swallows and air swallows were assessed. RESULTS The most common symptoms were bloating, abdominal distention, and constipation. Only 3 patients reported excessive belching and 1 patient reported flatulence as their predominant symptom. During the 24-hour measurement, patients showed high incidences of air swallows (521 +/- 63) and gastric belches (126 +/- 37). Patients had normal swallowing frequency (741 +/- 71). CONCLUSIONS This study presents objective parameters that confirm the existence of excessive air swallowing or aerophagia using esophageal impedance monitoring.
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Affiliation(s)
- Gerrit J M Hemmink
- Department of Gastroenterology, Sint Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein, The Netherlands.
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Abstract
Gastro-oesophageal reflux disease (GORD) patients often report an increase in their reflux symptoms during stressful situations. The aim of this study was to assess the influence of acute psychological stress on oesophageal acid perception. In 15 healthy volunteers and 10 GORD patients with a positive symptom-reflux association an oesophageal acid perfusion test was performed, once with and once without the presence of an acute psychological stressor (IQ test). The order of the measurements was randomized. The time from onset of the acid infusion to first acid perception, discomfort and pain was noted. Blood pressure was measured to assess the effect of the stress task. In healthy volunteers, the time to first perception (control task: 617 +/- 174 s vs stress task: 561 +/- 162 s), discomfort (control task: 969 +/- 158 s vs stress task: 940 +/- 151 s) or pain (control task: 1393 +/- 122 s vs stress task: 1366 +/- 121 s) did not differ significantly between both measurements. In GORD patients, no significant differences between both measurements were found either in time to first perception (control task: 63 +/- 26 s vs stress task: 43 +/- 15 s), discomfort (control task: 153 +/- 44 s vs stress task: 249 +/- 62 s) or pain (control task: 558 +/- 139 s vs stress task: 633 +/- 118 s). Systolic blood pressure rose significantly during the stress task in both the healthy volunteers (6 +/- 1 mmHg) and the GORD patients (9 +/- 2 mmHg). Neither in the healthy volunteers nor in the GORD patients, the acute psychological stress induced by an IQ test increased oesophageal acid perception. The observed increase in systolic blood pressure shows that the experimental stressors were effective.
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Affiliation(s)
- G J M Hemmink
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, The Netherlands.
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44
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Pot GK, Majsak-Newman G, Geelen A, Harvey LJ, Nagengast FM, Witteman BJM, van de Meeberg PC, Timmer R, Tan A, Wahab PJ, Hart AR, Williams MP, Przybylska-Phillips K, Dainty JR, Schaafsma G, Kampman E, Lund EK. Fish consumption and markers of colorectal cancer risk: a multicenter randomized controlled trial. Am J Clin Nutr 2009; 90:354-61. [PMID: 19553301 DOI: 10.3945/ajcn.2009.27630] [Citation(s) in RCA: 30] [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] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Diet is a major factor in the etiology of colorectal cancer, with high fish consumption possibly decreasing colorectal cancer risk, as was shown in several observational studies. To date, no intervention trials have examined the possible beneficial effects of fish intake on colorectal cancer risk. OBJECTIVE The objective was to investigate the effects of a 6-mo intervention with oil-rich or lean fish on apoptosis and mitosis within the colonic crypt. DESIGN In a multicenter, randomized, controlled intervention trial, patients with colorectal polyps, inactive ulcerative colitis, or no macroscopic signs of disease were recruited (n = 242) and randomly allocated to receive dietary advice plus either 300 g oil-rich fish (salmon) per week (n = 82), 300 g lean fish (cod) per week (n = 78), or only dietary advice (DA) (n = 82). Apoptosis and mitosis were measured in colonic biopsy samples collected before and after intervention (n = 213). RESULTS The total number of apoptotic cells per crypt did not increase in the salmon or cod group: -0.10 (95% CI: -0.36, 0.16) and -0.06 (95% CI: -0.32, 0.20), respectively, compared with the DA group. The total number of mitotic cells per crypt decreased nonsignificantly in the salmon group (-0.87; 95% CI: -2.41, 0.68) and in the cod group (-1.04; 95% CI: -2.62, 0.53) compared with the DA group. Furthermore, the distribution of mitosis within the crypt did not significantly change in either group. CONCLUSION An increase in the consumption of either oil-rich or lean fish to 2 portions weekly over 6 mo does not markedly change apoptotic and mitotic rates in the colonic mucosa. This trial was registered at www.clinicaltrials.gov as NCT00145015.
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Affiliation(s)
- Gerda K Pot
- Division of Human Nutrition, Wageningen University, Netherlands
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45
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Vrieling A, Voskuil DW, Bosma A, Majoor DM, van Doorn J, Cats A, Depla ACTM, Timmer R, Witteman BJM, Wesseling J, Kampman E, Van't Veer LJ. Expression of insulin-like growth factor system components in colorectal tissue and its relation with serum IGF levels. Growth Horm IGF Res 2009; 19:126-135. [PMID: 18801683 DOI: 10.1016/j.ghir.2008.08.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [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] [Received: 04/15/2008] [Revised: 07/02/2008] [Accepted: 08/05/2008] [Indexed: 01/07/2023]
Abstract
CONTEXT The insulin-like growth factor (IGF)-system has been implicated in colorectal tumor carcinogenesis. Although both tumor expression levels and serum concentrations of IGF-system components are related to colorectal cancer risk, it is unknown whether IGF levels in tissue and serum are correlated. OBJECTIVE The objective of this study was to determine expression levels of various IGF-system components in different locations of the colorectum, and to investigate whether normal tissue IGF expression levels are correlated with serum IGF-I and IGF-II concentrations. DESIGN Biopsies from macroscopically normal mucosa at four locations in the colorectum (ascending, transverse, sigmoid colon, and rectum) and a fasting serum sample were obtained from 48 asymptomatic patients at increased risk of colorectal cancer. Expression levels of IGF-I, IGF-II, IGF-IR, IGF-IIR, and IGFBP-3 messenger RNA (mRNA) in tissue were quantitatively evaluated using real-time RT-PCR. Expression of IGF-IR protein in the ascending colon and rectum tissue specimens was assessed semi-quantitatively by immunohistochemistry. Serum IGF-I and IGF-II concentrations were determined using immunometric assays. RESULTS With the exception of IGF-IIR, mRNA levels of all the IGF-system components investigated, as well as IGF-IR protein expression, were significantly higher in the rectum compared with the ascending colon (p<or=0.001). Serum IGF-I and IGF-II concentrations did not correlate with any of the parameters studied in colorectal tissues. CONCLUSIONS Our results indicate that in humans IGF-system components are differentially expressed in the colorectum. Moreover, our findings suggest that local and circulating components of the IGF-system are differentially regulated. However, due to large intra-individual variation in mRNA expression, we cannot formally exclude undetected but existing routes of co-regulation.
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Affiliation(s)
- Alina Vrieling
- Division of Experimental Therapy, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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46
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van den Broek FJC, de Graaf EJR, Dijkgraaf MGW, Reitsma JB, Haringsma J, Timmer R, Weusten BLAM, Gerhards MF, Consten ECJ, Schwartz MP, Boom MJ, Derksen EJ, Bijnen AB, Davids PHP, Hoff C, van Dullemen HM, Heine GDN, van der Linde K, Jansen JM, Mallant-Hent RCH, Breumelhof R, Geldof H, Hardwick JCH, Doornebosch PG, Depla ACTM, Ernst MF, van Munster IP, de Hingh IHJT, Schoon EJ, Bemelman WA, Fockens P, Dekker E. Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study). BMC Surg 2009; 9:4. [PMID: 19284647 PMCID: PMC2664790 DOI: 10.1186/1471-2482-9-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [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: 01/27/2009] [Accepted: 03/13/2009] [Indexed: 02/07/2023] Open
Abstract
Background Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications. The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas. Methods/design Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma ≥ 3 cm, located between 1–15 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane in a piecemeal fashion, and patients will be discharged from the hospital. Residual adenoma that is visible during the first surveillance endoscopy at 3 months will be removed endoscopically in both treatment strategies and is considered as part of the primary treatment. Primary outcome measure is the proportion of patients with recurrence after 3 months. Secondary outcome measures are: 2) number of days not spent in hospital from initial treatment until 2 years afterwards; 3) major and minor morbidity; 4) disease specific and general quality of life; 5) anorectal function; 6) health care utilization and costs. A cost-effectiveness and cost-utility analysis of EMR against TEM for large rectal adenomas will be performed from a societal perspective with respectively the costs per recurrence free patient and the cost per quality adjusted life year as outcome measures. Based on comparable recurrence rates for TEM and EMR of 3.3% and considering an upper-limit of 10% for EMR to be non-inferior (beta-error 0.2 and one-sided alpha-error 0.05), 89 patients are needed per group. Discussion The TREND study is the first randomized trial evaluating whether TEM or EMR is more cost-effective for the treatment of large rectal adenomas. Trial registration number (trialregister.nl) NTR1422
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Hemmink GJM, Weusten BLAM, Bredenoord AJ, Timmer R, Smout AJPM. Increased swallowing frequency in GORD is likely to be caused by perception of reflux episodes. Neurogastroenterol Motil 2009; 21:143-8. [PMID: 19019017 DOI: 10.1111/j.1365-2982.2008.01197.x] [Citation(s) in RCA: 12] [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
Patients with gastro-oesophageal reflux disease (GORD) swallow air more frequently and have more gas-containing reflux episodes than healthy controls. One explanation for this phenomenon may be that GORD patients primarily swallow more frequently and, as a consequence, have more swallow- or transient lower oesophageal sphincter relaxation-associated reflux episodes. Another explanation may be that GORD patients swallow more often in response to perception of reflux episodes. The aim of this study was to differentiate between these two possible mechanisms. In 34 patients with typical reflux symptoms oesophageal 24-h pH-impedance monitoring was performed twice, once off and once on proton pump inhibitor (PPI) therapy. The number of reflux episodes and number of swallows and air swallows was evaluated. The symptom association probability (SAP) was used to distinguish patients with a good relationship between symptoms and reflux episodes (SAP+) from those who had not (SAP-). In both the SAP+ (n = 21) as SAP- patients (n = 13), the acid exposure time decreased during PPI therapy. In the SAP+ patients, the number of swallows decreased on PPI (829 +/- 85 off vs 701 +/- 79 on PPI, P < 0.05), whereas in the SAP- patients, the incidence of swallows (802 +/- 93 off vs 814 +/- 69 on PPI, P = NS) was not influenced by the PPI therapy. PPI therapy reduces the number of swallows in patients with a positive SAP, but not in those with a negative SAP. This finding supports the hypothesis that the increased incidence of swallows in GORD is brought about by responses to perceived reflux events.
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Affiliation(s)
- G J M Hemmink
- Department of Gastroenterology, Sint Antonius Hospital, Nieuwegein, The Netherlands.
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48
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Hemmink GJM, Bredenoord AJ, Weusten BLAM, Monkelbaan JF, Timmer R, Smout AJPM. Esophageal pH-impedance monitoring in patients with therapy-resistant reflux symptoms: 'on' or 'off' proton pump inhibitor? Am J Gastroenterol 2008; 103:2446-53. [PMID: 18684197 DOI: 10.1111/j.1572-0241.2008.02033.x] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.2] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND In patients with proton pump inhibitor (PPI)-resistant symptoms, ambulatory 24-h pH-impedance monitoring can be used to assess whether a relationship exists between symptoms and reflux episodes. Until now, it is unclear whether combined pH-impedance monitoring in these patients should be performed on or off PPI. METHODS Thirty patients with symptoms of heartburn, chest pain, and/or regurgitation despite PPI twice daily underwent ambulatory 24-h pH-impedance monitoring twice, once on PPI and once after cessation of the PPI for 7 days. The order of the measurements was randomized. Reflux episodes were identified and classified as acid, weakly acidic, or weakly alkaline reflux. In addition, the symptom association probability (SAP) was calculated for each measurement. RESULTS The total number of reflux episodes and proximal extent were not affected by PPI therapy. On PPI, there were fewer acid reflux episodes (49 +/- 34 off PPI vs 20 +/- 25 on PPI) while more weakly acidic reflux episodes were identified (24 +/- 17 off PPI vs 48 +/- 31 on PPI). Symptom association analysis identified 15 and 11 patients with a positive SAP in the measurement off and on PPI, respectively, the difference in yield of the SAP not being statistically significant. Eight of the 19 patients who had no symptoms or a negative SAP during measurement on PPI had a positive SAP off PPI therapy. In contrast, only 4 patients with a positive SAP on PPI were missed in the measurement off PPI therapy. CONCLUSIONS In order to demonstrate or exclude GERD in patients with PPI-resistant symptoms, ambulatory 24-h pH-impedance monitoring should preferably be performed after cessation of PPI therapy because this approach seems to offer the best chance to assess a relationship between symptoms and reflux episodes.
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Affiliation(s)
- Gerrit J M Hemmink
- Department of Gastroenterology, Sint Antonius Hospital, Nieuwegein, The Netherlands
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49
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Schrover IM, Weusten BLAM, Besselink MGH, Bollen TL, van Ramshorst B, Timmer R. EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis. Pancreatology 2008; 8:271-6. [PMID: 18497540 DOI: 10.1159/000134275] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Accepted: 01/15/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infected pancreatic and peripancreatic necrosis in acute pancreatitis is potentially lethal, with mortality rates up to 35%. Therefore, there is growing interest in minimally invasive treatment options, such as (EUS-guided) endoscopic transgastric necrosectomy. METHODS Retrospective cohort study on EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis. RESULTS 8 patients (age 38-75, mean 50 years) with documented infected peripancreatic or pancreatic necrosis were included. Median time to first intervention was 33 days (range 17-62) after onset of symptoms. At the time of first intervention 2 patients had organ failure. All patients were managed on the patient ward. Initial endoscopic drainage was successful in all patients, a median of 4 (range 2-6) subsequent endoscopic necrosectomies were needed to remove all necrotic tissue. Two patients needed additional surgical intervention because of pneumoperitoneum (n = 1) and insufficient endoscopic drainage (n = 1). Six patients recovered, with 1 mild relapse during follow-up (median 12, range 8-60 months). One patient died. CONCLUSION EUS-guided endoscopic transgastric necrosectomy of infected necrosis in acute pancreatitis appears to be a feasible and relatively safe treatment option in patients who are not critically ill. Further randomized comparison with the current 'gold standard' is warranted to determine the place of this treatment modality.
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Affiliation(s)
- Ilse M Schrover
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, The Netherlands
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50
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van Hooft JE, Fockens P, Marinelli AW, Timmer R, van Berkel AM, Bossuyt PM, Bemelman WA. Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer. Endoscopy 2008; 40:184-91. [PMID: 18322873 DOI: 10.1055/s-2007-995426] [Citation(s) in RCA: 206] [Impact Index Per Article: 12.9] [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
BACKGROUND AND STUDY AIMS The introduction of self-expandable metal stents has offered a promising alternative for palliation of malignant left-sided colonic obstruction. This randomized clinical trial aimed to assess whether a nonsurgical policy, with endoluminal stenting, is superior to surgical treatment in patients with stage IV left-sided colorectal cancer and imminent obstruction. PATIENTS AND METHODS Patients with incurable left-sided colorectal cancer who fulfilled the study criteria were randomly assigned to nonsurgical or surgical treatment. The primary outcome measure was survival in good health out of hospital (World Health Organization performance scores 0 or 1). RESULTS A high number of serious adverse events in the nonsurgical arm led to premature closure of the trial. Ten patients were allocated to surgical treatment and 11 patients to nonsurgical palliation. The median survival in good health out of hospital during the first year was 56 days (interquartile range 7.5 - 338.5 days) in the surgical arm vs. 38 days (interquartile range 5.25 - 288.75 days) in the nonsurgical arm (P = 0.68). Eleven adverse events (six perforations) occurred in the nonsurgical arm vs. one adverse event in the surgical arm (P < 0.001). Of the six perforations, two were stent-related because they occurred at the proximal edge of the stent by erosion through a normal colon wall; one was probably stent-related (it was located in the region of the proximal half of the stent); one was a colon blowout; and two were late tumor perforations in patients on chemotherapy. CONCLUSIONS The unexpected high rate of perforation in the nonsurgical arm might be specifically WallFlex-related or enteral stent-related in patients on chemotherapy and warrants attention.
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Affiliation(s)
- J E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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