Colonic stenting as bridge to surgery versus emergency surgery for management of acute left-sided malignant colonic obstruction: a multicenter randomized trial (Stent-in 2 study)

Background

Acute left-sided colonic obstruction is most often caused by malignancy and the surgical treatment is associated with a high mortality and morbidity rate. Moreover, these operated patients end up with a temporary or permanent stoma. Initial insertion of an enteral stent to decompress the obstructed colon, allowing for surgery to be performed electively, is gaining popularity. In uncontrolled studies stent placement before elective surgery has been suggested to decrease mortality, morbidity and number of colostomies. However stent perforation can lead to peritoneal tumor spill, changing a potentially curable disease in an incurable one. Therefore it is of paramount importance to compare the outcomes of colonic stenting followed by elective surgery with emergency surgery for the management of acute left-sided malignant colonic obstruction in a randomized multicenter fashion.

Methods/design

Patients with acute left-sided malignant colonic obstruction eligible for this study will be randomized to either emergency surgery (current standard treatment) or colonic stenting as bridge to elective surgery. Outcome measurements are effectiveness and costs of both strategies. Effectiveness will be evaluated in terms of quality of life, morbidity and mortality. Quality of life will be measured with standardized questionnaires (EORTC QLQ-C30, EORTC QLQ-CR38, EQ-5D and EQ-VAS). Morbidity is defined as every event leading to hospital admission or prolonging hospital stay. Mortality will be analyzed as total mortality as well as procedure-related mortality. The total costs of treatment will be evaluated by counting volumes and calculating unit prices. Including 120 patients on a 1:1 basis will have 80% power to detect an effect size of 0.5 on the EORTC QLQ-C30 global health scale, using a two group t-test with a 0.05 two-sided significance level. Differences in quality of life and morbidity will be analyzed using mixed-models repeated measures analysis of variance. Mortality will be compared using Kaplan-Meier curves and log-rank statistics.

Discussion

The Stent-in 2 study is a randomized controlled multicenter trial that will provide evidence whether or not colonic stenting as bridge to surgery is to be performed in patients with acute left-sided colonic obstruction.

Trial registration

Current Controlled Trials ISRCTN46462267.

Preoperative biliary drainage for periampullary tumors causing obstructive jaundice; DRainage vs. (direct) OPeration (DROP-trial)

Background

Surgery in patients with obstructive jaundice caused by a periampullary (pancreas, papilla, distal bile duct) tumor is associated with a higher risk of postoperative complications than in non-jaundiced patients. Preoperative biliary drainage was introduced in an attempt to improve the general condition and thus reduce postoperative morbidity and mortality. Early studies showed a reduction in morbidity. However, more recently the focus has shifted towards the negative effects of drainage, such as an increase of infectious complications. Whether biliary drainage should always be performed in jaundiced patients remains controversial. The randomized controlled multicenter DROP-trial (DRainage vs. Operation) was conceived to compare the outcome of a 'preoperative biliary drainage strategy' (standard strategy) with that of an 'early-surgery' strategy, with respect to the incidence of severe complications (primary-outcome measure), hospital stay, number of invasive diagnostic tests, costs, and quality of life.

Methods/design

Patients with obstructive jaundice due to a periampullary tumor, eligible for exploration after staging with CT scan, and scheduled to undergo a "curative" resection, will be randomized to either "early surgical treatment" (within one week) or "preoperative biliary drainage" (for 4 weeks) and subsequent surgical treatment (standard treatment). Primary outcome measure is the percentage of severe complications up to 90 days after surgery. The sample size calculation is based on the equivalence design for the primary outcome measure. If equivalence is found, the comparison of the secondary outcomes will be essential in selecting the preferred strategy. Based on a 40% complication rate for early surgical treatment and 48% for preoperative drainage, equivalence is taken to be demonstrated if the percentage of severe complications with early surgical treatment is not more than 10% higher compared to standard treatment: preoperative biliary drainage. Accounting for a 10% dropout, 105 patients are needed in each arm resulting in a study population of 210 (alpha = 0.95, beta = 0.8).

Discussion

The DROP-trial is a randomized controlled multicenter trial that will provide evidence whether or not preoperative biliary drainage is to be performed in patients with obstructive jaundice due to a periampullary tumor.

[Symptoms of cholelithiasis following cholecystectomy; possibly a second gallbladder]

Three patients with cholelithiasis were found to possess a duplicate gallbladder. A 48-year-old woman continued to have symptoms one year after cholecystectomy, a 69-year-old woman had symptoms even though her gallbladder had been removed 40 years before, and in a 29-year-old woman a second gallbladder was found during cholecystectomy. In all three patients, the second gallbladder was removed as well, after which they recovered. The differential diagnosis of persistent symptoms following cholecystectomy should also consider the possible presence of an accessory gallbladder.

The cut-closed-reconnected Roux loop

BACKGROUND

Motility disturbances in the Roux loop can negatively influence the outcome of reflux gastritis; the uncut Roux loop does not have these disadvantages, but is less suitable for clinical application because of staple dehiscence. The reported "cut-closed-reconnected" Roux loop has the same physiological starting points as the uncut Roux loop, but a difference is an extra closure at the site of the seromuscular level.

METHOD

The technique of the cut-closed-reconnected Roux loop is described.

RESULTS

After 1 year, the clinical findings in 8 patients were as follows: 1 patient free of symptoms, 4 with gastric pain, 2 patients vomited (1 bilious), and 1 felt fullness.

CONCLUSION

Dehiscence of the closure could not be demonstrated by endoscopy, barium contrast roentgenography, and HIDA scan.

A molecular epidemiological approach to studying the transmission of tuberculosis in Amsterdam

We conducted a retrospective, population-based study with use of restriction fragment length polymorphism (RFLP) analysis to determine the incidence of and risk factors for clustering of Mycobacterium tuberculosis isolates, indicative of recently transmitted infection, among patients with culture-proven tuberculosis diagnosed between 1 July 1992 and 1 January 1995 in Amsterdam. We found that 214 (47%) of 459 patients were in 53 clusters, probably because of recent transmission of M. tuberculosis among 161 (35%) of these patients. Conventional contact tracing resulted in identification of 5.6% of the 161 patients. Clustering was more frequent among Dutch patients (59.3%) than among foreign ethnic patients (42.1%) (P = .002). The independent risk factor for clustering among Dutch patients was younger age; the independent risk factors among foreign ethnic patients were hard-drug use; alcohol abuse; and country of origin (Surinam or the Netherlands Antilles). These findings suggest the shortcomings of the usual tuberculosis control policies in Amsterdam. We identified several risk factors for clustering, which may guide adjustment of tuberculosis control and contact tracing strategies.

[Sweet's syndrome (acute febrile neutrophilic dermatosis)]

The clinical presentation and the relation with malignancy of acute febrile neutrophilic dermatosis in 7 patients are described. The syndrome is characterised by fever, neutrophilic granulocytosis, painful erythematous plaques and typical histology consisting of a dense dermal infiltrate of mature neutrophils. The idiopathic form (80% of reported patients) usually follows a viral infection. The secondary form (20% of reported patients) is associated with a malignancy, which in the large majority (85%) is a hematologic disorder (this was the case in 3 of the 7 patients); the course of the syndrome may then be serious. The secondary form of the disease may be associated with an exacerbation of a preexistent malignancy, as was seen in 2 of the 3 patients. If the syndrome runs a serious course the treatment consists of corticosteroid administration.

Experience with mass screening for lung carcinoma

The 5-year-survival of 128 primary lung cancer patients was studied between 1970 and 1976. In all patients mediastinoscopy was carried out without any mortality or morbidity. Asymptomatic stage I (TNM classification) patients having a squamous cell carcinoma had the best 5 year survival: 46.3% as against 9.5% and 0% of the stage II and III patients. The resectability rate was 58.6% with a perioperative mortality of 7.5%. This suggests the importance of further evaluation of mass screening for lung carcinoma despite the statistical shortcomings of a retrospective study.