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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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Mungroop TH, van der Heijde N, Busch OR, de Hingh IH, Scheepers JJ, Dijkgraaf MG, Groot Koerkamp B, Besselink MG, van Eijck CH. Randomized clinical trial and meta-analysis of the impact of a fibrin sealant patch on pancreatic fistula after distal pancreatectomy: CPR trial. BJS Open 2021; 5:6301536. [PMID: 34137446 PMCID: PMC8262074 DOI: 10.1093/bjsopen/zrab001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 12/06/2020] [Accepted: 12/14/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains the main cause of morbidity in patients after distal pancreatectomy. The objective of this study was to investigate whether an absorbable fibrin sealant patch could prevent POPF after distal pancreatectomy. METHODS A multicentre, patient-blinded, parallel-group randomized superiority trial was performed in seven Dutch hospitals. Allocation was done using a computer-generated randomization list with a 1 : 1 allocation ratio and concealed varying permuted block sizes. Pancreatic stump closure with a fibrin patch was compared with standard treatment in patients undergoing distal pancreatectomy. The primary endpoint was the development of grade B/C POPF. A systematic review and meta-analysis was performed which combined the present findings with all available evidence. RESULTS Between October 2010 and August 2017, 247 patients were enrolled. Fifty-four patients (22.2 per cent) developed a POPF, 25 of 125 patients in the patch group versus 29 of 122 in the control group (20.0 versus 23.8 per cent; P = 0·539). No related adverse effects were observed. In the meta-analysis, no significant difference was seen between the patch and control groups (19.7 versus 22.0 per cent; odds ratio 0.89, 95 per cent c.i. 0.60 to 1.32; P = 0·556). CONCLUSION Application of a fibrin patch to the pancreatic stump does not reduce the incidence of POPF in distal pancreatectomy. Future studies should focus on alternative fistula mitigation strategies, considering pancreatic neck thickness and duct size as risk factors. Trial registration number NL5876 (Netherlands Trial Registry).
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Affiliation(s)
- T H Mungroop
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - N van der Heijde
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - I H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - J J Scheepers
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - M G Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C H van Eijck
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
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Olthof PB, Metman MJH, de Krijger RR, Scheepers JJ, Roos D, Dekker JWT. Routine Pathology and Postoperative Follow-Up are Not Cost-Effective in Cholecystectomy for Benign Gallbladder Disease. World J Surg 2018; 42:3165-3170. [PMID: 29696323 PMCID: PMC6132861 DOI: 10.1007/s00268-018-4619-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 01/04/2023]
Abstract
INTRODUCTION The incidence of gallstone disease is increasing and represents a strain on healthcare systems worldwide. Following cholecystectomy, gallbladder specimens are generally submitted for histopathologic examination and the diagnostic yield of this strategy remains questionable. This study aimed to evaluate the usefulness of routine pathologic examination of the gallbladder specimens and investigate the results of routine postoperative follow-up visits. METHODS All cholecystectomies performed between January 2011 and July 2017 at a single center were evaluated. All gallbladder specimens were routinely pathologically examined. The outcome parameters were the macro- and microscopic gallbladder anomalies at pathology and the reported symptoms during routine follow-up visits 2-6 weeks after surgery. RESULTS In the study period a total of 2763 patients underwent cholecystectomy, of which 2615 had a postoperative visit in the outpatient clinic. Seventy-three patients (3%) complained of persistent abdominal pain, and 29 of these patients were referred for further treatment, resulting in a resolution of symptoms in 97%. Of all gallbladder specimens, 199 (7%) displayed macroscopic anomalies and in four (2%) of these, gallbladder carcinoma was diagnosed. DISCUSSION Selective pathologic examination of gallbladder specimens in case of macroscopic anomalies appears justified. Also routine follow-up after cholecystectomy appears not useful since 97% of patients do not report any symptoms at follow-up. A selective pathology and follow-up strategy could save significant healthcare costs.
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Affiliation(s)
- Pim B Olthof
- Department of Surgery, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands. .,Department of Experimental Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Madelon J H Metman
- Department of Surgery, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands
| | | | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands
| | - Jan Willem T Dekker
- Department of Surgery, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands
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4
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van Rijssen LB, Zwart MJ, van Dieren S, de Rooij T, Bonsing BA, Bosscha K, van Dam RM, van Eijck CH, Gerhards MF, Gerritsen JJ, van der Harst E, de Hingh IH, de Jong KP, Kazemier G, Klaase J, van der Kolk BM, van Laarhoven CJ, Luyer MD, Molenaar IQ, Patijn GA, Rupert CG, Scheepers JJ, van der Schelling GP, Vahrmeijer AL, Busch ORC, van Santvoort HC, Groot Koerkamp B, Besselink MG, Festen S, Karsten TM, Coene PP. Variation in hospital mortality after pancreatoduodenectomy is related to failure to rescue rather than major complications: a nationwide audit. HPB (Oxford) 2018; 20:759-767. [PMID: 29571615 DOI: 10.1016/j.hpb.2018.02.640] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [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] [Received: 10/23/2017] [Revised: 01/22/2018] [Accepted: 02/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND In the mandatory nationwide Dutch Pancreatic Cancer Audit, rates of major complications and Failure to Rescue (FTR) after pancreatoduodenectomy between low- and high-mortality hospitals are compared, and independent predictors for FTR investigated. METHODS Patients undergoing pancreatoduodenectomy in 2014 and 2015 in The Netherlands were included. Hospitals were divided into quartiles based on mortality rates. The rate of major complications (Clavien-Dindo ≥3) and death after a major complication (FTR) were compared between these quartiles. Independent predictors for FTR were identified by multivariable logistic regression analysis. RESULTS Out of 1.342 patients, 391 (29%) developed a major complication and in-hospital mortality was 4.2%. FTR occurred in 56 (14.3%) patients. Mortality was 0.9% in the first hospital quartile (4 hospitals, 327 patients) and 8.1% in the fourth quartile (5 hospitals, 310 patients). The rate of major complications increased by 40% (25.7% vs 35.2%) between the first and fourth hospital quartile, whereas the FTR rate increased by 560% (3.6% vs 22.9%). Independent predictors of FTR were male sex (OR = 2.1, 95%CI 1.2-3.9), age >75 years (OR = 4.3, 1.8-10.2), BMI ≥30 (OR = 2.9, 1.3-6.6), histopathological diagnosis of periampullary cancer (OR = 2.0, 1.1-3.7), and hospital volume <30 (OR = 3.9, 1.6-9.6). CONCLUSIONS Variations in mortality between hospitals after pancreatoduodenectomy were explained mainly by differences in FTR, rather than the incidence of major complications.
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Affiliation(s)
- Lennart B van Rijssen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Maurice J Zwart
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Susan van Dieren
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Koert P de Jong
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Geert Kazemier
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Joost Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | | | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Coen G Rupert
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | | | | | - Olivier R C Busch
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, 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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van Rijssen LB, Koerkamp BG, Zwart MJ, Bonsing BA, Bosscha K, van Dam RM, van Eijck CH, Gerhards MF, van der Harst E, de Hingh IH, de Jong KP, Kazemier G, Klaase J, van Laarhoven CJ, Molenaar IQ, Patijn GA, Rupert CG, van Santvoort HC, Scheepers JJ, van der Schelling GP, Busch OR, Besselink MG, Bruno MJ, van Tienhoven GJ, Norduyn A, Berry DP, Tingstedt B, Tseng JF, Wolfgang CL. Nationwide prospective audit of pancreatic surgery: design, accuracy, and outcomes of the Dutch Pancreatic Cancer Audit. HPB (Oxford) 2017; 19:919-926. [PMID: 28754367 DOI: 10.1016/j.hpb.2017.06.010] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [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: 03/28/2017] [Revised: 05/19/2017] [Accepted: 06/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Auditing is an important tool to identify practice variation and 'best practices'. The Dutch Pancreatic Cancer Audit is mandatory in all 18 Dutch centers for pancreatic surgery. METHODS Performance indicators and case-mix factors were identified by a PubMed search for randomized controlled trials (RCT's) and large series in pancreatic surgery. In addition, data dictionaries of two national audits, three institutional databases, and the Dutch national cancer registry were evaluated. Morbidity, mortality, and length of stay were analyzed of all pancreatic resections registered during the first two audit years. Case ascertainment was cross-checked with the Dutch healthcare inspectorate and key-variables validated in all centers. RESULTS Sixteen RCT's and three large series were found. Sixteen indicators and 20 case-mix factors were included in the audit. During 2014-2015, 1785 pancreatic resections were registered including 1345 pancreatoduodenectomies. Overall in-hospital mortality was 3.6%. Following pancreatoduodenectomy, mortality was 4.1%, Clavien-Dindo grade ≥ III morbidity was 29.9%, median (IQR) length of stay 12 (9-18) days, and readmission rate 16.0%. In total 97.2% of >40,000 variables validated were consistent with the medical charts. CONCLUSIONS The Dutch Pancreatic Cancer Audit, with high quality data, reports good outcomes of pancreatic surgery on a national level.
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Affiliation(s)
- L Bengt van Rijssen
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas G Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maurice J Zwart
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Koert P de Jong
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Geert Kazemier
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Joost Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Coen G Rupert
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | | | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | | | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands.
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7
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de Rooij T, van Hilst J, Vogel JA, van Santvoort HC, de Boer MT, Boerma D, van den Boezem PB, Bonsing BA, Bosscha K, Coene PP, Daams F, van Dam RM, Dijkgraaf MG, van Eijck CH, Festen S, Gerhards MF, Groot Koerkamp B, Hagendoorn J, van der Harst E, de Hingh IH, Dejong CH, Kazemier G, Klaase J, de Kleine RH, van Laarhoven CJ, Lips DJ, Luyer MD, Molenaar IQ, Nieuwenhuijs VB, Patijn GA, Roos D, Scheepers JJ, van der Schelling GP, Steenvoorde P, Swijnenburg RJ, Wijsman JH, Abu Hilal M, Busch OR, Besselink MG. Minimally invasive versus open distal pancreatectomy (LEOPARD): study protocol for a randomized controlled trial. Trials 2017; 18:166. [PMID: 28388963 PMCID: PMC5385082 DOI: 10.1186/s13063-017-1892-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/08/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Observational cohort studies have suggested that minimally invasive distal pancreatectomy (MIDP) is associated with better short-term outcomes compared with open distal pancreatectomy (ODP), such as less intraoperative blood loss, lower morbidity, shorter length of hospital stay, and reduced total costs. Confounding by indication has probably influenced these findings, given that case-matched studies failed to confirm the superiority of MIDP. This accentuates the need for multicenter randomized controlled trials, which are currently lacking. We hypothesize that time to functional recovery is shorter after MIDP compared with ODP even in an enhanced recovery setting. METHODS LEOPARD is a randomized controlled, parallel-group, patient-blinded, multicenter, superiority trial in all 17 centers of the Dutch Pancreatic Cancer Group. A total of 102 patients with symptomatic benign, premalignant or malignant disease will be randomly allocated to undergo MIDP or ODP in an enhanced recovery setting. The primary outcome is time (days) to functional recovery, defined as all of the following: independently mobile at the preoperative level, sufficient pain control with oral medication alone, ability to maintain sufficient (i.e. >50%) daily required caloric intake, no intravenous fluid administration and no signs of infection. Secondary outcomes are operative and postoperative outcomes, including clinically relevant complications, mortality, quality of life and costs. DISCUSSION The LEOPARD trial is designed to investigate whether MIDP reduces the time to functional recovery compared with ODP in an enhanced recovery setting. TRIAL REGISTRATION Dutch Trial Register, NTR5188 . Registered on 9 April 2015.
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Affiliation(s)
- Thijs de Rooij
- Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, AZ 1105, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, AZ 1105, The Netherlands
| | - Jantien A Vogel
- Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, AZ 1105, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, PO Box 2500, Nieuwegein, EM 3430, The Netherlands
| | - Marieke T de Boer
- Department of Surgery, University Medical Center Groningen, PO Box 30 001, Groningen, RB 9700, The Netherlands
| | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, PO Box 2500, Nieuwegein, EM 3430, The Netherlands
| | - Peter B van den Boezem
- Department of Surgery, Radboud University Nijmegen Medical Center, PO Box 9101, Nijmegen, HB 6500, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, PO Box 9600, Leiden, ZA 2333, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, PO Box 90153, Den Bosch, ME 5200, The Netherlands
| | - Peter-Paul Coene
- Department of Surgery, Maasstad Hospital, PO Box 9100, Rotterdam, AC 3007, The Netherlands
| | - Freek Daams
- Department of Surgery, VU University Medical Center, PO Box 7057, Amsterdam, HV 1081, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, PO Box 5800, Maastricht, AZ 6202, The Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, PO Box 22660, Amsterdam, DD 1100, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus University Medical Center, PO Box 2040, Rotterdam, CA 3000, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, PO Box 95500, Amsterdam, HM 1090, The Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, PO Box 95500, Amsterdam, HM 1090, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, PO Box 2040, Rotterdam, CA 3000, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, PO Box 85 500, Utrecht, GA 3508, The Netherlands
| | - Erwin van der Harst
- Department of Surgery, Maasstad Hospital, PO Box 9100, Rotterdam, AC 3007, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, PO Box 1350, Eindhoven, ZA 5602, The Netherlands
| | - Cees H Dejong
- Department of Surgery, Maastricht University Medical Center, PO Box 5800, Maastricht, AZ 6202, The Netherlands.,NUTRIM School for Nutrition and Translational Research in Metabolism, PO Box 5800, Maastricht, AZ 6202, The Netherlands
| | - Geert Kazemier
- Department of Surgery, VU University Medical Center, PO Box 7057, Amsterdam, HV 1081, The Netherlands
| | - Joost Klaase
- Department of Surgery, Medisch Spectrum Twente, PO Box 50 000, Enschede, KA 7500, The Netherlands
| | - Ruben H de Kleine
- Department of Surgery, University Medical Center Groningen, PO Box 30 001, Groningen, RB 9700, The Netherlands
| | - Cornelis J van Laarhoven
- Department of Surgery, Radboud University Nijmegen Medical Center, PO Box 9101, Nijmegen, HB 6500, The Netherlands
| | - Daan J Lips
- Department of Surgery, Jeroen Bosch Hospital, PO Box 90153, Den Bosch, ME 5200, The Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, PO Box 1350, Eindhoven, ZA 5602, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, PO Box 85 500, Utrecht, GA 3508, The Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala Clinics, PO Box 10 400, Zwolle, AB 8025, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graag Gasthuis, PO Box 5011, Delft, GA 2600, The Netherlands
| | - Joris J Scheepers
- Department of Surgery, Reinier de Graag Gasthuis, PO Box 5011, Delft, GA 2600, The Netherlands
| | | | - Pascal Steenvoorde
- Department of Surgery, Medisch Spectrum Twente, PO Box 50 000, Enschede, KA 7500, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Leiden University Medical Center, PO Box 9600, Leiden, ZA 2333, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, PO Box 90 158, Breda, RK 4800, The Netherlands
| | - Moh'd Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, SO166YD, UK
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, DD 1100, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, PO Box 22660, Amsterdam, DD 1100, The Netherlands.
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8
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Marsman EM, de Rooij T, van Eijck CH, Boerma D, Bonsing BA, van Dam RM, van Dieren S, Erdmann JI, Gerhards MF, de Hingh IH, Kazemier G, Klaase J, Molenaar IQ, Patijn GA, Scheepers JJ, Tanis PJ, Busch OR, Besselink MG. Pancreatoduodenectomy with colon resection for cancer: A nationwide retrospective analysis. Surgery 2016; 160:145-152. [DOI: 10.1016/j.surg.2016.02.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/18/2016] [Accepted: 02/21/2016] [Indexed: 01/02/2023]
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9
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de Rooij T, Tol JA, van Eijck CH, Boerma D, Bonsing BA, Bosscha K, van Dam RM, Dijkgraaf MG, Gerhards MF, van Goor H, van der Harst E, de Hingh IH, Kazemier G, Klaase JM, Molenaar IQ, Patijn GA, van Santvoort HC, Scheepers JJ, van der Schelling GP, Sieders E, Busch OR, Besselink MG. Outcomes of Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma in the Netherlands: A Nationwide Retrospective Analysis. Ann Surg Oncol 2016; 23:585-91. [PMID: 26508153 PMCID: PMC4718962 DOI: 10.1245/s10434-015-4930-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Large multicenter series on outcomes and predictors of survival after distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC) are scarce. METHODS Adults who underwent DP for PDAC in 17 Dutch pancreatic centers between January 2005 and September 2013 were analyzed retrospectively. The primary outcome was survival, and predictors of survival were identified using Cox regression analysis. RESULTS In total, 761 consecutive patients after DP were assessed, of whom 620 patients were excluded because of non-PDAC histopathology (n = 616) or a lack of data (n = 4), leaving a total of 141 patients included in the study [45 % (n = 63) male, mean age 64 years (SD = 10)]. Multivisceral resection was performed in 43 patients (30 %) and laparoscopic resection was performed in 7 patients (5 %). A major complication (Clavien-Dindo score of III or higher) occurred in 46 patients (33 %). Mean tumor size was 44 mm (SD 23), and histopathological examination showed 70 R0 resections (50 %), while 30-day and 90-day mortality was 3 and 6 %, respectively. Overall, 63 patients (45 %) received adjuvant chemotherapy. Median survival was 17 months [interquartile range (IQR) 13-21], with a median follow-up of 17 months (IQR 8-29). Cumulative survival at 1, 3 and 5 years was 64, 29, and 22 %, respectively. Independent predictors of worse postoperative survival were R1/R2 resection [hazard ratio (HR) 1.6, 95 % confidence interval (CI) 1.1-2.4], pT3/pT4 stage (HR 1.9, 95 % CI 1.3-2.9), a major complication (HR 1.7, 95 % CI 1.1-2.5), and not receiving adjuvant chemotherapy (HR 1.5, 95 % CI 1.0-2.3). CONCLUSION Survival after DP for PDAC is poor and is related to resection margin, tumor stage, surgical complications, and adjuvant chemotherapy. Further studies should assess to what extent prevention of surgical complications and more extensive use of adjuvant chemotherapy can improve survival.
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Affiliation(s)
- Thijs de Rooij
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Johanna A Tol
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Geert Kazemier
- Department of Surgery, VU Medical Center, Amsterdam, The Netherlands
| | - Joost M Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | | | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | | | - Egbert Sieders
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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van Dijk LJD, Noordman BJ, Scheepers JJ, Hartholt KA. A young woman with a jejuno-jejunal intussusception. BMJ Case Rep 2015; 2015:bcr-2015-212135. [PMID: 26607189 DOI: 10.1136/bcr-2015-212135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 27-year-old woman presented at the emergency department, with pain in the epigastric region. Because physical examination, blood results, urine tests and an X-ray of the thorax showed no abnormalities, she was discharged. Twelve hours later, she presented again at the emergency department, with intense abdominal pain. The blood results, an X-ray and ultrasound of the abdomen were now aberrant. A CT of the abdomen showed an extensive intussusception. During an emergency laparotomy, the intussusception of the proximal jejunum was confirmed. Owing to gangrene of the proximal jejunum, a resection was inevitable. A polyp in the resected part of the jejunum was the lead point of the intussusception. This case report shows the challenges of diagnosing an 'intussusception' and gives a short overview of this condition in adults.
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Affiliation(s)
- Louisa J D van Dijk
- Department of Surgery-Traumatology, Reinier de Graaf Group, Delft, Zuid-Holland, The Netherlands
| | - Bo Jan Noordman
- Department of Surgery-Traumatology, Reinier de Graaf Group, Delft, Zuid-Holland, The Netherlands
| | - Joris J Scheepers
- Department of Surgery-Traumatology, Reinier de Graaf Group, Delft, Zuid-Holland, The Netherlands
| | - Klaas A Hartholt
- Department of Surgery-Traumatology, Reinier de Graaf Group, Delft, Zuid-Holland, The Netherlands
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11
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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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12
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de Rooij T, Jilesen AP, Boerma D, Bonsing BA, Bosscha K, van Dam RM, van Dieren S, Dijkgraaf MG, van Eijck CH, Gerhards MF, van Goor H, van der Harst E, de Hingh IH, Kazemier G, Klaase JM, Molenaar IQ, Nieveen van Dijkum EJ, Patijn GA, van Santvoort HC, Scheepers JJ, van der Schelling GP, Sieders E, Vogel JA, Busch OR, Besselink MG. A nationwide comparison of laparoscopic and open distal pancreatectomy for benign and malignant disease. J Am Coll Surg 2014; 220:263-270.e1. [PMID: 25600974 DOI: 10.1016/j.jamcollsurg.2014.11.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 11/13/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cohort studies from expert centers suggest that laparoscopic distal pancreatectomy (LDP) is superior to open distal pancreatectomy (ODP) regarding postoperative morbidity and length of hospital stay. But the generalizability of these findings is unknown because nationwide data on LDP are lacking. STUDY DESIGN Adults who had undergone distal pancreatectomy in 17 centers between 2005 and 2013 were analyzed retrospectively. First, all LDPs were compared with all ODPs. Second, groups were matched using a propensity score. Third, the attitudes of pancreatic surgeons toward LDP were surveyed. The primary outcome was major complications (Clavien-Dindo grade ≥III). RESULTS Among 633 included patients, 64 patients (10%) had undergone LDP and 569 patients (90%) had undergone ODP. Baseline characteristics were comparable, except for previous abdominal surgery and mean tumor size. In the full cohort, LDP was associated with fewer major complications (16% vs 29%; p = 0.02) and a shorter median [interquartile range, IQR] hospital stay (8 days [7-12 days] vs 10 days [8-14 days]; p = 0.03). Of all LDPs, 33% were converted to ODP. Matching succeeded for 63 LDP patients. After matching, the differences in major complications (9 patients [14%] vs 19 patients [30%]; p = 0.06) and median [IQR] length of hospital stay (8 days [7-12 days] vs 10 days [8-14 days]; p = 0.48) were not statistically significant. The survey demonstrated that 85% of surgeons welcomed LDP training. CONCLUSIONS Despite nationwide underuse and an impact of selection bias, outcomes of LDP seemed to be at least noninferior to ODP. Specific training is welcomed and could improve both the use and outcomes of LDP.
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Affiliation(s)
- Thijs de Rooij
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Anneke P Jilesen
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Susan van Dieren
- Clinical Research Unit, Academic Medical Center, Amsterdam, the Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, Amsterdam, the Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Geert Kazemier
- Department of Surgery, VU Medical Center, Amsterdam, the Netherlands
| | - Joost M Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala Clincs, Zwolle, the Netherlands
| | | | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | | | - Egbert Sieders
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Jantien A Vogel
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands.
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13
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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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14
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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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15
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van Wagensveld BA, van Gulik TM, Gelderblom HC, Scheepers JJ, Bosma A, Endert E, Obertop H, Gouma DJ. Continuous or intermittent vascular clamping during hemihepatectomy in pigs: hyaluronic acid kinetics in the assessment of early microvascular liver damage. Eur J Surg 2000; 166:255-61. [PMID: 10755342 DOI: 10.1080/110241500750009375] [Citation(s) in RCA: 15] [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] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To assess the uptake of hyaluronic acid (HA) as a marker of microvascular damage in a model of hemihepatectomy in pigs having continuous or intermittent vascular inflow occlusion. DESIGN Prospective, animal study. SETTING Laboratory for experimental surgery, University hospital, The Netherlands. INTERVENTIONS Total liver ischaemia was achieved during 90 minutes by continuous (n = 5) or intermittent (n = 5) occlusion of the portal vein and hepatic artery followed by 120 minutes of reperfusion. In a second series of pigs (n = 8) a left hemihepatectomy was added to the protocol. MAIN OUTCOME MEASURES Uptake of exogenous HA was assessed before ischaemia and after 120 minutes of reperfusion, together with the galactose elimination capacity. Plasma activities of aspartate aminotransferase (AST), alanine amino transferase, and lactate dehydrogenase were measured and specimens of liver were obtained for histopathological examination. RESULTS HA uptake was slightly reduced after reperfusion in unresected livers compared with uptake before ischaemia. After hemihepatectomy HA uptake after reperfusion was significantly reduced after both continuous and intermittent occlusion, but more HA was taken up after continuous occlusion (p = 0.02). Release of AST after reperfusion was increased only after hemihepatectomy. CONCLUSIONS Microvascular damage, as assessed by HA uptake capacity, significantly contributed to normothermic ischaemia and reperfusion injury in porcine liver. Vascular inflow occlusion during 90 minutes in combination with hemihepatectomy resulted in less liver damage when vascular occlusion was continuous rather than intermittent.
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Affiliation(s)
- B A van Wagensveld
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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16
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van Wagensveld BA, van Gulik TM, Gelderblom HC, Scheepers JJ, Bosma A, Endert E, Gouma DJ. Prolonged continuous or intermittent vascular inflow occlusion during hemihepatectomy in pigs. Ann Surg 1999; 229:376-84. [PMID: 10077050 PMCID: PMC1191703 DOI: 10.1097/00000658-199903000-00011] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess ischemia and reperfusion (I/R) injury in a hemihepatectomy model in pigs after prolonged continuous or intermittent vascular inflow occlusion in the liver. SUMMARY BACKGROUND DATA Massive intraoperative blood loss during liver resections can be prevented by temporary vascular inflow occlusion, consequently leading to ischemia and reperfusion injury in the remnant liver. Previously, in a pig liver resection model in which only limited I/R injury was induced during brief (90 min) vascular inflow occlusion, the authors demonstrated reduced I/R injury after continuous (CNT) occlusion, compared to intermittent (INT). This liver resection study on pigs was undertaken to assess I/R injury after prolonged (120 min) CNT or INT occlusion. METHODS In pigs (37.0 +/- 1.5 kg), liver ischemia during 2 hours was CNT (n = 6) or INT (n = 6) (eight subsequent periods of 12 min ischemia and 3 min recirculation), followed by 6 hours of reperfusion. A left hemihepatectomy (45.5% +/- 1.4%) was performed within the first 12 minutes of ischemia. No hepatic pedicle clamping or liver resection was performed in control experiments (n = 6). Microvascular damage was assessed by hyaluronic acid (HA) uptake capacity of the liver (parameter of early sinusoidal endothelial cell damage) and restoration of intrahepatic tissue pO2 during reperfusion. Hepatocellular damage was tested by plasma concentrations of aspartate aminotransferase (AST), alanine aminotransferase, and lactate dehydrogenase (LDH). RESULTS Hyaluronic acid uptake after 6 hours of reperfusion, compared to preischemic uptake, was unaltered in the control group, but was significantly reduced in both resection groups. However, more HA was taken up after INT occlusion, compared to CNT (60.4% +/- 5.6% and 39.5% +/- 3.7%, respectively; ANOVA: p = 0.001). Intrahepatic tissue pO2 distribution after 6 hours of reperfusion more closely returned to preischemic configuration in the INT group than in the CNT group, indicating reduced microcirculatory disturbances after INT occlusion. Release of AST and LDH after 6 hours of reperfusion was significantly increased in both CNT and INT groups. Lower AST levels, however, were found after INT occlusion than after CNT occlusion (267.0 +/- 74.7 U/l and 603.3 +/- 132.4 U/l, respectively; p = 0.06). CONCLUSIONS Intermittent hepatic vascular inflow occlusion during prolonged liver ischemia in pigs resulted in less microcirculatory and hepatocellular injury, compared to continuous occlusion. Intermittent clamping is preferable when prolonged periods of vascular inflow occlusion are applied during liver resections.
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Affiliation(s)
- B A van Wagensveld
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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17
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van Wagensveld BA, Scheepers JJ, van Gulik TM, Frederiks WM, Bleeker WK, Obertop H, Gouma DJ. Alpha glutathione S-transferase as novel parameter for hepatocellular damage in the isolated perfused rat liver. Transplant Proc 1997; 29:3449-51. [PMID: 9414786 DOI: 10.1016/s0041-1345(97)00974-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- B A van Wagensveld
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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