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Mackay TM, Latenstein AEJ, Augustinus S, van der Geest LG, Bogte A, Bonsing BA, Cirkel GA, Hol L, Busch OR, den Dulk M, van Driel LMJ, Festen S, de Groot DJA, de Groot JWB, Groot Koerkamp B, Haj Mohammad N, Haver JT, van der Harst E, de Hingh IH, Homs MYV, Los M, Luelmo SAC, de Meijer VE, Mekenkamp L, Molenaar IQ, Patijn GA, Quispel R, Römkens TEH, van Santvoort HC, Stommel MW, Venneman NG, Verdonk RC, van Vilsteren FGI, de Vos-Geelen J, van Werkhoven CH, van Hooft JE, van Eijck CHJ, Wilmink JW, van Laarhoven HWM, Besselink MG. Implementation of Best Practices in Pancreatic Cancer Care in the Netherlands: A Stepped-Wedge Randomized Clinical Trial. JAMA Surg 2024; 159:429-437. [PMID: 38353966 PMCID: PMC10867778 DOI: 10.1001/jamasurg.2023.7872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/26/2023] [Indexed: 02/17/2024]
Abstract
Importance Implementation of new cancer treatment strategies as recommended by evidence-based guidelines is often slow and suboptimal. Objective To improve the implementation of guideline-based best practices in the Netherlands in pancreatic cancer care and assess the impact on survival. Design, setting, and participants This multicenter, stepped-wedge cluster randomized trial compared enhanced implementation of best practices with usual care in consecutive patients with all stages of pancreatic cancer. It took place from May 22, 2018 through July 9, 2020. Data were analyzed from April 1, 2022, through February 1, 2023. It included all patients in the Netherlands with pathologically or clinically diagnosed pancreatic ductal adenocarcinoma. This study reports 1-year follow-up (or shorter in case of deceased patients). Intervention The 5 best practices included optimal use of perioperative chemotherapy, palliative chemotherapy, pancreatic enzyme replacement therapy (PERT), referral to a dietician, and use of metal stents in patients with biliary obstruction. A 6-week implementation period was completed, in a randomized order, in all 17 Dutch networks for pancreatic cancer care. Main Outcomes and Measures The primary outcome was 1-year survival. Secondary outcomes included adherence to best practices and quality of life (European Organisation for Research and Treatment of Cancer [EORTC] global health score). Results Overall, 5887 patients with pancreatic cancer (median age, 72.0 [IQR, 64.0-79.0] years; 50% female) were enrolled, 2641 before and 2939 after implementation of best practices (307 during wash-in period). One-year survival was 24% vs 23% (hazard ratio, 0.98, 95% CI, 0.88-1.08). There was no difference in the use of neoadjuvant chemotherapy (11% vs 11%), adjuvant chemotherapy (48% vs 51%), and referral to a dietician (59% vs 63%), while the use of palliative chemotherapy (24% vs 30%; odds ratio [OR], 1.38; 95% CI, 1.10-1.74), PERT (34% vs 45%; OR, 1.64; 95% CI, 1.28-2.11), and metal biliary stents increased (74% vs 83%; OR, 1.78; 95% CI, 1.13-2.80). The EORTC global health score did not improve (area under the curve, 43.9 vs 42.8; median difference, -1.09, 95% CI, -3.05 to 0.94). Conclusions and Relevance In this randomized clinical trial, implementation of 5 best practices in pancreatic cancer care did not improve 1-year survival and quality of life. The finding that most patients received no tumor-directed treatment paired with the poor survival highlights the need for more personalized treatment options. Trial Registration ClinicalTrials.gov Identifier: NCT03513705.
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Affiliation(s)
- Tara M. Mackay
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Anouk E. J. Latenstein
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Simone Augustinus
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Lydia G. van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Auke Bogte
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Geert A. Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Lieke Hol
- Department of Gastroenterology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Olivier R. Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht UMC+, Maastricht, the Netherlands
- NUTRIM-School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Germany, the Netherlands
| | | | | | | | | | | | - Nadia Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Joyce T. Haver
- Cancer Center Amsterdam, the Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of nutrition and dietetics, Amsterdam, the Netherlands
| | | | | | | | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Vincent E. de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands
| | - Leonie Mekenkamp
- Department of Medical Oncology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Rutger Quispel
- Department of Gastroenterology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Tessa E. H. Römkens
- Department of Gastroenterology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Niels G. Venneman
- Department of Gastroenterology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Judith de Vos-Geelen
- Julius Center for Health Sciences and primary care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - C. Henri van Werkhoven
- Julius Center for Health Sciences and primary care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Johanna W. Wilmink
- Cancer Center Amsterdam, the Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands
| | - Hanneke W. M. van Laarhoven
- Cancer Center Amsterdam, the Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands
| | - Marc G. Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
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van Werkhoven CH, Valk AW, Smagge B, de Melker HE, Knol MJ, Hahné SJ, van den Hof S, de Gier B. Early COVID-19 vaccine effectiveness of XBB.1.5 vaccine against hospitalisation and admission to intensive care, the Netherlands, 9 October to 5 December 2023. Euro Surveill 2024; 29:2300703. [PMID: 38179623 PMCID: PMC10905658 DOI: 10.2807/1560-7917.es.2024.29.1.2300703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/03/2024] [Indexed: 01/06/2024] Open
Abstract
We present early vaccine effectiveness (VE) estimates of the 2023 seasonal COVID-19 XBB.1.5 vaccine against COVID-19 hospitalisation and admission to an intensive care unit (ICU) in previously vaccinated adults ≥ 60 years in the Netherlands. We compared vaccination status of 2,050 hospitalisations including 92 ICU admissions with age group-, sex-, region- and date-specific population vaccination coverage between 9 October and 5 December 2023. VE against hospitalisation was 70.7% (95% CI: 66.6-74.3), VE against ICU admission was 73.3% (95% CI: 42.2-87.6).
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Affiliation(s)
- C Henri van Werkhoven
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Anne-Wil Valk
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Bente Smagge
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Hester E de Melker
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Mirjam J Knol
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Susan Jm Hahné
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Susan van den Hof
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Brechje de Gier
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
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Vehreschild MJGT, Biehl LM, Dane A, de Kraker MEA, Timbermont L, van Werkhoven CH. An obituary on DAV-132-authors' viewpoint on the current limits of pivotal trials in clinical microbiome research. J Antimicrob Chemother 2023:7143694. [PMID: 37100455 DOI: 10.1093/jac/dkad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Affiliation(s)
- Maria J G T Vehreschild
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Lena M Biehl
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Aaron Dane
- Danestat Consulting Limited, Macclesfield, UK
| | - Marlieke E A de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Leen Timbermont
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - C Henri van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Hassoun-Kheir N, van Werkhoven CH, Dunning J, Jaenisch T, van Beek J, Bielicki J, Butler CC, Francois B, Harbarth S, Hernandez Padilla AC, Horby P, Koopmans M, Lee J, Rodriguez-Baño J, Tacconelli E, Themistocleous Y, van der Velden AW, Bonten M, Goossens H, de Kraker ME. Perpetual observational studies: new strategies to support efficient implementation of observational studies and randomized trials in infectious diseases. Clin Microbiol Infect 2022; 28:1528-1532. [PMID: 35940566 PMCID: PMC9354481 DOI: 10.1016/j.cmi.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Nasreen Hassoun-Kheir
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva Switzerland
| | - C. Henri van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jake Dunning
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Thomas Jaenisch
- Heidelberg Institute of Global Health (HIGH), Heidelberg University Hospital, Heidelberg, Germany
| | - Janko van Beek
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Julia Bielicki
- Institute for Infection and Immunity, St George's, University of London, London, UK,Infection Prevention and Control, Universitäts-Kinderspital Beider Basel, Basel, Switzerland
| | | | - Bruno Francois
- Medical-Surgical Intensive Care Unit and Inserm CIC 1435 & UMR 1092, CHU Limoges, Limoges, France
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva Switzerland
| | - Ana C. Hernandez Padilla
- Medical-Surgical Intensive Care Unit and Inserm CIC 1435 & UMR 1092, CHU Limoges, Limoges, France
| | - Peter Horby
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Marion Koopmans
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands,Pandemic and Disaster Preparedness Research Centre, Rotterdam, the Netherlands
| | - James Lee
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Jesús Rodriguez-Baño
- Infectious Diseases and Microbiology, Hospital Universitario Virgen Macarena, Department of Medicine, University of Sevilla, Biomedicine Institute of Sevilla (IBiS), CSIC, Sevilla, Spain,Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Marlieke E.A. de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva Switzerland,Corresponding author. Marlieke E.A. de Kraker, Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
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5
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Smits FJ, Henry AC, Besselink MG, Busch OR, van Eijck CH, Arntz M, Bollen TL, van Delden OM, van den Heuvel D, van der Leij C, van Lienden KP, Moelker A, Bonsing BA, Borel Rinkes IH, Bosscha K, van Dam RM, Derksen WJM, den Dulk M, Festen S, Groot Koerkamp B, de Haas RJ, Hagendoorn J, van der Harst E, de Hingh IH, Kazemier G, van der Kolk M, Liem M, Lips DJ, Luyer MD, de Meijer VE, Mieog JS, Nieuwenhuijs VB, Patijn GA, Te Riele WW, Roos D, Schreinemakers JM, Stommel MWJ, Wit F, Zonderhuis BA, Daamen LA, van Werkhoven CH, Molenaar IQ, van Santvoort HC. Algorithm-based care versus usual care for the early recognition and management of complications after pancreatic resection in the Netherlands: an open-label, nationwide, stepped-wedge cluster-randomised trial. Lancet 2022; 399:1867-1875. [PMID: 35490691 DOI: 10.1016/s0140-6736(22)00182-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Early recognition and management of postoperative complications, before they become clinically relevant, can improve postoperative outcomes for patients, especially for high-risk procedures such as pancreatic resection. METHODS We did an open-label, nationwide, stepped-wedge cluster-randomised trial that included all patients having pancreatic resection during a 22-month period in the Netherlands. In this trial design, all 17 centres that did pancreatic surgery were randomly allocated for the timing of the crossover from usual care (the control group) to treatment given in accordance with a multimodal, multidisciplinary algorithm for the early recognition and minimally invasive management of postoperative complications (the intervention group). Randomisation was done by an independent statistician using a computer-generated scheme, stratified to ensure that low-medium-volume centres alternated with high-volume centres. Patients and investigators were not masked to treatment. A smartphone app was designed that incorporated the algorithm and included the daily evaluation of clinical and biochemical markers. The algorithm determined when to do abdominal CT, radiological drainage, start antibiotic treatment, and remove abdominal drains. After crossover, clinicians were trained in how to use the algorithm during a 4-week wash-in period; analyses comparing outcomes between the control group and the intervention group included all patients other than those having pancreatic resection during this wash-in period. The primary outcome was a composite of bleeding that required invasive intervention, organ failure, and 90-day mortality, and was assessed by a masked adjudication committee. This trial was registered in the Netherlands Trial Register, NL6671. FINDINGS From Jan 8, 2018, to Nov 9, 2019, all 1805 patients who had pancreatic resection in the Netherlands were eligible for and included in this study. 57 patients who underwent resection during the wash-in phase were excluded from the primary analysis. 1748 patients (885 receiving usual care and 863 receiving algorithm-centred care) were included. The primary outcome occurred in fewer patients in the algorithm-centred care group than in the usual care group (73 [8%] of 863 patients vs 124 [14%] of 885 patients; adjusted risk ratio [RR] 0·48, 95% CI 0·38-0·61; p<0·0001). Among patients treated according to the algorithm, compared with patients who received usual care there was a decrease in bleeding that required intervention (47 [5%] patients vs 51 [6%] patients; RR 0·65, 0·42-0·99; p=0·046), organ failure (39 [5%] patients vs 92 [10%] patients; 0·35, 0·20-0·60; p=0·0001), and 90-day mortality (23 [3%] patients vs 44 [5%] patients; 0·42, 0·19-0·92; p=0·029). INTERPRETATION The algorithm for the early recognition and minimally invasive management of complications after pancreatic resection considerably improved clinical outcomes compared with usual care. This difference included an approximate 50% reduction in mortality at 90 days. FUNDING The Dutch Cancer Society and UMC Utrecht.
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Affiliation(s)
- F Jasmijn Smits
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Mark Arntz
- Department of Radiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Thomas L Bollen
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Otto M van Delden
- Department of Radiology, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Daniel van den Heuvel
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Krijn P van Lienden
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Inne H Borel Rinkes
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Wouter J M Derksen
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Robbert J de Haas
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven and GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Mike Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven and GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - J Sven Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - Wouter W Te Riele
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Hospital, Delft, Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, Netherlands
| | - Babs A Zonderhuis
- Department of Surgery, Cancer Centre Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - C Henri van Werkhoven
- Julius Centre for Health Sciences and Primary Care, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands.
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6
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Smits FJ, Henry AC, van Eijck CH, Besselink MG, Busch OR, Arntz M, Bollen TL, van Delden OM, van den Heuvel D, van der Leij C, van Lienden KP, Moelker A, Bonsing BA, Borel Rinkes IHM, Bosscha K, van Dam RM, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IH, Kazemier G, Liem M, van der Kolk BM, de Meijer VE, Patijn GA, Roos D, Schreinemakers JM, Wit F, van Werkhoven CH, Molenaar IQ, van Santvoort HC. Care after pancreatic resection according to an algorithm for early detection and minimally invasive management of pancreatic fistula versus current practice (PORSCH-trial): design and rationale of a nationwide stepped-wedge cluster-randomized trial. Trials 2020; 21:389. [PMID: 32381031 PMCID: PMC7206814 DOI: 10.1186/s13063-020-4167-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/12/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pancreatic resection is a major abdominal operation with 50% risk of postoperative complications. A common complication is pancreatic fistula, which may have severe clinical consequences such as postoperative bleeding, organ failure and death. The objective of this study is to investigate whether implementation of an algorithm for early detection and minimally invasive management of pancreatic fistula may improve outcomes after pancreatic resection. METHODS This is a nationwide stepped-wedge, cluster-randomized, superiority trial, designed in adherence to the Consolidated Standards of Reporting Trials (CONSORT) guidelines. During a period of 22 months, all Dutch centers performing pancreatic surgery will cross over in a randomized order from current practice to best practice according to the algorithm. This evidence-based and consensus-based algorithm will provide daily multilevel advice on the management of patients after pancreatic resection (i.e. indication for abdominal imaging, antibiotic treatment, percutaneous drainage and removal of abdominal drains). The algorithm is designed to aid early detection and minimally invasive step-up management of postoperative pancreatic fistula. Outcomes of current practice will be compared with outcomes after implementation of the algorithm. The primary outcome is a composite of major complications (i.e. post-pancreatectomy bleeding, new-onset organ failure and death) and will be measured in a sample size of at least 1600 patients undergoing pancreatic resection. Secondary endpoints include the individual components of the primary endpoint and other clinical outcomes, healthcare resource utilization and costs analysis. Follow up will be up to 90 days after pancreatic resection. DISCUSSION It is hypothesized that a structured nationwide implementation of a dedicated algorithm for early detection and minimally invasive step-up management of postoperative pancreatic fistula will reduce the risk of major complications and death after pancreatic resection, as compared to current practice. TRIAL REGISTRATION Netherlands Trial Register: NL 6671. Registered on 16 December 2017.
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Affiliation(s)
- F. Jasmijn Smits
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
| | - Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
| | | | - Marc G. Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Olivier R. Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark Arntz
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Thomas L. Bollen
- Department of Radiology, St. Antoniusziekenhuis, Nieuwegein, The Netherlands
| | - Otto M. van Delden
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Krijn P. van Lienden
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Inne H. M. Borel Rinkes
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Ziekenhuis, ´s-Hertogenbosch, The Netherlands
| | - R. M. van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - B. Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Mike Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Vincent E. de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Gijs A. Patijn
- Department of Surgery, Isala Ziekenhuis, Zwolle, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | | | - Fennie Wit
- Department of Surgery, Tjongerschans, Heerenveen, The Netherlands
| | - C. Henri van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
| | - for the Dutch Pancreatic Cancer Group
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Radiology, St. Antoniusziekenhuis, Nieuwegein, The Netherlands
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Jeroen Bosch Ziekenhuis, ´s-Hertogenbosch, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
- Department of Surgery, Maasstad Ziekenhuis, Rotterdam, The Netherlands
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU University, Amsterdam, The Netherlands
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
- Department of Surgery, Isala Ziekenhuis, Zwolle, The Netherlands
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
- Department of Surgery, Amphia Ziekenhuis, Breda, The Netherlands
- Department of Surgery, Tjongerschans, Heerenveen, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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