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Wassenaar NPM, van Schelt AS, Schrauben EM, Kop MPM, Nio CY, Wilmink JW, Besselink MGH, van Laarhoven HWM, Stoker J, Nederveen AJ, Runge JH. MR Elastography of the Pancreas: Bowel Preparation and Repeatability Assessment in Pancreatic Cancer Patients and Healthy Controls. J Magn Reson Imaging 2024; 59:1582-1592. [PMID: 37485870 DOI: 10.1002/jmri.28918] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/05/2023] [Accepted: 07/07/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) stromal viscoelasticity can be measured using MR elastography (MRE). Bowel preparation regimens could affect MRE quality and knowledge on repeatability is crucial for clinical implementation. PURPOSE To assess effects of four bowel preparation regimens on MRE quality and to evaluate repeatability and differentiate patients from healthy controls. STUDY TYPE Prospective. POPULATION 15 controls (41 ± 16 years; 47% female), 16 PDAC patients (one excluded, 66 ± 12 years; 40% female) with 15 age-/sex-matched controls (65 ± 11 years; 40% female). Final sample size was 25 controls and 15 PDAC. FIELD STRENGTH/SEQUENCE 3-T, spin-echo echo-planar-imaging, turbo spin-echo, and fast field echo gradient-echo. ASSESSMENT Four different regimens were used: fasting; scopolaminebutyl; drinking 0.5 L water; combination of 0.5 L water and scopolaminebutyl. MRE signal-to-noise ratio (SNR) was compared between all regimens. MRE repeatability (test-retest) and differences in shear wave speed (SWS) and phase angle (ϕ) were assessed in PDAC and controls. Regions-of-interest were defined for tumor, nontumorous (n = 8) tissue in PDAC, and whole pancreas in controls. Two radiologists delineated tumors twice for evaluation of intraobserver and interobserver variability. STATISTICAL TESTS Repeated measures analysis of variance, coefficients of variation (CoVs), Bland-Altman analysis, (un)paired t-test, Mann-Whitney U-test, and Wilcoxon signed-rank test. P-value<0.05 was considered statistically significant. RESULTS Preparation regimens did not significantly influence MRE-SNR. Therefore, the least burdensome preparation (fasting only) was continued. CoVs for tumor SWS were: intrasession (12.8%) and intersession (21.7%), and intraobserver (7.9%) and interobserver (10.3%) comparisons. For controls, CoVs were intrasession (4.6%) and intersession (6.4%). Average SWS for tumor, nontumor, and healthy tissue were: 1.74 ± 0.58, 1.38 ± 0.27, and 1.18 ± 0.16 m/sec (ϕ: 1.02 ± 0.17, 0.91 ± 0.07, and 0.85 ± 0.08 rad), respectively. Significant differences were found between all groups, except for ϕ between healthy-nontumor (P = 0.094). DATA CONCLUSION The proposed bowel preparation regimens may not influence MRE quality. MRE may be able to differentiate between healthy tissue-tumor and tumor-nontumor. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Nienke P M Wassenaar
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Anne-Sophie van Schelt
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Eric M Schrauben
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marnix P M Kop
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - C Yung Nio
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johanna W Wilmink
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc G H Besselink
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology, Metabolism, Amsterdam, The Netherlands
| | - Hanneke W M van Laarhoven
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology, Metabolism, Amsterdam, The Netherlands
| | - Aart J Nederveen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jurgen H Runge
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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2
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van Dongen JC, Versteijne E, Bonsing BA, Mieog JSD, de Hingh IHJT, Festen S, Patijn GA, van Dam R, van der Harst E, Wijsman JH, Bosscha K, van der Kolk M, de Meijer VE, Liem MSL, Busch OR, Besselink MGH, van Tienhoven G, Groot Koerkamp B, van Eijck CHJ, Suker M. The yield of staging laparoscopy for resectable and borderline resectable pancreatic cancer in the PREOPANC randomized controlled trial. Eur J Surg Oncol 2022; 49:811-817. [PMID: 36585300 DOI: 10.1016/j.ejso.2022.12.011] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 11/27/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND The necessity of the staging laparoscopy in patients with pancreatic cancer is still debated. The objective of this study was to assess the yield of staging laparoscopy for detecting occult metastases in patients with resectable or borderline resectable pancreatic cancer. METHOD This was a post-hoc analysis of the randomized controlled PREOPANC trial in which patients with resectable or borderline resectable pancreatic cancer were randomized between preoperative chemoradiotherapy or immediate surgery. Patients assigned to preoperative treatment underwent a staging laparoscopy prior to preoperative treatment according to protocol, to avoid unnecessary chemoradiotherapy in patients with occult metastatic disease. RESULTS Of the 246 included patients, 7 did not undergo surgery. A staging laparoscopy was performed in 133 patients (55.6%) and explorative laparotomy in 106 patients (44.4%). At staging laparoscopy, occult metastases were detected in 13 patients (9.8%); 12 liver metastases and 1 peritoneal metastasis. At direct explorative laparotomy, occult metastases were found in 9 patients (8.5%); 6 with liver metastases, 1 with peritoneal metastases, and 2 with metastases at multiple sites. One patient had peritoneal metastases at exploration after a negative staging laparoscopy. Patients with occult metastases were more likely to receive palliative chemotherapy if found with staging laparoscopy compared to laparotomy (76.9% vs. 30.0%, p = 0.040). CONCLUSIONS Staging laparoscopy detected occult metastases in about 10% of patients with resectable or borderline resectable pancreatic cancer. These patients were more likely to receive palliative systemic chemotherapy compared to patients in whom occult metastases were detected with laparotomy. A staging laparoscopy is recommended before planned resection.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Gijs A Patijn
- Department of Surgery, Isala Oncology Center, Zwolle, the Netherlands
| | - Ronald van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, the Netherlands
| | | | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | | | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, the Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, the Netherlands
| | - Marc G H Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Mustafa Suker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
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3
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de Graaff MR, Hogenbirk RNM, Janssen YF, Elfrink AKE, Liem RSL, Nienhuijs SW, de Vries JPPM, Elshof JW, Verdaasdonk E, Melenhorst J, van Westreenen HL, Besselink MGH, Ruurda JP, van Berge Henegouwen MI, Klaase JM, den Dulk M, van Heijl M, Hegeman JH, Braun J, Voeten DM, Würdemann FS, Warps ALK, Alberga AJ, Suurmeijer JA, Akpinar EO, Wolfhagen N, van den Boom AL, Bolster-van Eenennaam MJ, van Duijvendijk P, Heineman DJ, Wouters MWJM, Kruijff S, Koningswoud-Terhoeve CL, Belt E, van der Hoeven JAB, Marres GMH, Tozzi F, von Meyenfeldt EM, Coebergh RRJ, van den Braak, Huisman S, Rijken AM, Balm R, Daams F, Dickhoff C, Eshuis WJ, Gisbertz SS, Zandbergen HR, Hartemink KJ, Keessen SA, Kok NFM, Kuhlmann KFD, van Sandick JW, Veenhof AA, Wals A, van Diepen MS, Schoonderwoerd L, Stevens CT, Susa D, Bendermacher BLW, Olofsen N, van Himbeeck M, de Hingh IHJT, Janssen HJB, Luyer MDP, Nieuwenhuijzen GAP, Ramaekers M, Stacie R, Talsma AK, Tissink MW, Dolmans D, Berendsen R, Heisterkamp J, Jansen WA, de Kort-van Oudheusden M, Matthijsen RM, Grünhagen DJ, Lagarde SM, Maat APWM, van der Sluis PC, Waalboer RB, Brehm V, van Brussel JP, Morak M, Ponfoort ED, Sybrandy JEM, Klemm PL, Lastdrager W, Palamba HW, van Aalten SM, Tseng LNL, van der Bogt KEA, de Jong WJ, Oosterhuis JWA, Tummers Q, van der Wilden GM, Ooms S, Pasveer EH, Veger HTC, Molegraafb MJ, Nieuwenhuijs VB, Patijn GA, van der Veldt MEV, Boersma D, van Haelst STW, van Koeverden ID, Rots ML, Bonsing BA, Michiels N, Bijlstra OD, Braun J, Broekhuis D, Brummelaar HW, Hartgrink HH, Metselaar A, Mieog JSD, Schipper IB, de Steur WO, Fioole B, Terlouw EC, Biesmans C, Bosmans JWAM, Bouwense SAW, Clermonts SHEM, Coolsen MME, Mees BME, Schurink GWH, Duijff JW, van Gent T, de Nes LCF, Toonen D, Beverwijk MJ, van den Hoed E, Keizers B, Kelder W, Keller BPJA, Pultrum BB, van Rosum E, Wijma AG, van den Broek F, Leclercq WKG, Loos MJA, Sijmons JML, Vaes RHD, Vancoillie PJ, Consten ECJ, Jongen JMJ, Verheijen PM, van Weel V, Arts CHP, Jonker J, Murrmann-Boonstra G, Pierie JPEN, Swart J, van Duyn EB, Geelkerken RH, de Groot R, Moekotte NL, Stam A, Voshaar A, van Acker GJD, Bulder RMA, Swank DJ, Pereboom ITA, Hoffmann WH, Orsini M, Blok JJ, Lardenoije JHP, Reijne MMPJ, van Schaik P, Smeets L, van Sterkenburg SMM, Harlaar NJ, Mekke S, Verhaakt T, Cancrinus E, van Lammeren GW, Molenaar IQ, van Santvoort HC, Vos AWF, Schouten- van der Velden AP, Woensdregt K, Mooy-Vermaat SP, Scharn DM, Marsman HA, Rassam F, Halfwerk FR, Andela AJ, Buis CI, van Dam GM, ten Duis K, van Etten B, Lases L, Meerdink M, de Meijer VE, Pranger B, Ruiter S, Rurenga M, Wiersma A, Wijsmuller AR, Albers KI, van den Boezem PB, Klarenbeek B, van der Kolk BM, van Laarhoven CJHM, Matthée E, Peters N, Rosman C, Schroen AMA, Stommel MWJ, Verhagen AFTM, van der Vijver R, Warlé MC, de Wilt JHW, van den Berg JW, Bloemert T, de Borst GJ, van Hattum EH, Hazenberg CEVB, van Herwaarden JA, van Hillegerberg R, Kroese TE, Petri BJ, Toorop RJ, Aarts F, Janssen RJL, Janssen-Maessen SHP, Kool M, Verberght H, Moes DE, Smit JW, Wiersema AM, Vierhout BP, de Vos B, den Boer FC, Dekker NAM, Botman JMJ, van Det MJ, Folbert EC, de Jong E, Koenen JC, Kouwenhoven EA, Masselink I, Navis LH, Belgers HJ, Sosef MN, Stoot JHMB. Impact of the COVID-19 pandemic on surgical care in the Netherlands. Br J Surg 2022; 109:1282-1292. [PMID: 36811624 PMCID: PMC10364688 DOI: 10.1093/bjs/znac301] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/14/2022] [Accepted: 07/31/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands. METHODS A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018-2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates. RESULTS Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018-2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001). CONCLUSION The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.
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Affiliation(s)
- Michelle R de Graaff
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands.,Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, Gelre Ziekenhuizen, Apeldoorn, the Netherlands
| | - Rianne N M Hogenbirk
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Yester F Janssen
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Arthur K E Elfrink
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ronald S L Liem
- Department of Surgery, Dutch Obesity Clinic, Gouda, the Netherlands.,Department of Surgery, Groene Hart Hospital, Gouda, the Netherlands
| | - Simon W Nienhuijs
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan-Willem Elshof
- Department of Surgery, VieCuri Medical Centre, Venlo, the Netherlands
| | - Emiel Verdaasdonk
- Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Marc G H Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands.,Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Joost M Klaase
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mark van Heijl
- Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - Johannes H Hegeman
- Department of Surgery, Ziekenhuisgroep Twente Almelo-Hengelo, Almelo, Hengelo, the Netherlands
| | - Jerry Braun
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Daan M Voeten
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Franka S Würdemann
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Anne-Loes K Warps
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Anna J Alberga
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands.,Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Erman O Akpinar
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Nienke Wolfhagen
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | | | | | - David J Heineman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
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4
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Hoek VT, Edomskis PP, Stark PW, Lambrichts DPV, Draaisma WA, Consten ECJ, Lange JF, Bemelman WA, Hop WC, Opmeer BC, Reitsma JB, Scholte RA, Waltmann EWH, Legemate A, Bartelsman JF, Meijer DW, de Brouwer M, van Dalen J, Durbridge M, Geerdink M, Ilbrink GJ, Mehmedovic S, Middelhoek P, Boom MJ, Consten ECJ, van der Bilt JDW, van Olden GDJ, Stam MAW, Verweij MS, Vennix S, Musters GD, Swank HA, Boermeester MA, Busch ORC, Buskens CJ, El-Massoudi Y, Kluit AB, van Rossem CC, Schijven MP, Tanis PJ, Unlu C, van Dieren S, Gerhards MF, Karsten TM, de Nes LC, Rijna H, van Wagensveld BA, Koff eman GI, Steller EP, Tuynman JB, Bruin SC, van der Peet DL, Blanken-Peeters CFJM, Cense HA, Jutte E, Crolla RMPH, van der Schelling GP, van Zeeland M, de Graaf EJR, Groenendijk RPR, Karsten TM, Vermaas M, Schouten O, de Vries MR, Prins HA, Lips DJ, Bosker RJI, van der Hoeven JAB, Diks J, Plaisier PW, Kruyt PM, Sietses C, Stommel MWJ, Nienhuijs SW, de Hingh IHJT, Luyer MDP, van Montfort G, Ponten EH, Smulders JF, van Duyn EB, Klaase JM, Swank DJ, Ottow RT, Stockmann HBAC, Vermeulen J, Vuylsteke RJCLM, Belgers HJ, Fransen S, von Meijenfeldt EM, Sosef MN, van Geloven AAW, Hendriks ER, ter Horst B, Leeuwenburgh MMN, van Ruler O, Vogten JM, Vriens EJC, Westerterp M, Eijsbouts QAJ, Bentohami A, Bijlsma TS, de Korte N, Nio D, Govaert MJPM, Joosten JJA, Tollenaar RAEM, Stassen LPS, Wiezer MJ, Hazebroek EJ, Smits AB, van Westreenen HL, Lange JF, Brandt A, Nijboer WN, Mulder IM, Toorenvliet BR, Weidema WF, Coene PPLO, Mannaerts GHH, den Hartog D, de Vos RJ, Zengerink JF, Hoofwijk AGM, Hulsewé KWE, Melenhorst J, Stoot JHMB, Steup WH, Huijstee PJ, Merkus JWS, Wever JJ, Maring JK, Heisterkamp J, van Grevenstein WMU, Vriens MR, Besselink MGH, Borel Rinkes IHM, Witkamp AJ, Slooter GD, Konsten JLM, Engel AF, Pierik EGJM, Frakking TG, van Geldere D, Patijn GA, D’Hoore BAJL, de Buck AVO, Miserez M, Terrasson I, Wolthuis A, di Saverio S, de Blasiis MG. Laparoscopic peritoneal lavage versus sigmoidectomy for perforated diverticulitis with purulent peritonitis: three-year follow-up of the randomised LOLA trial. Surg Endosc 2022; 36:7764-7774. [PMID: 35606544 PMCID: PMC9485102 DOI: 10.1007/s00464-022-09326-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/01/2022] [Indexed: 10/31/2022]
Abstract
Abstract
Background
This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.
Methods
Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.
Results
Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.
Conclusion
Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.
Graphical abstract
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5
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Kuemmerli C, Fichtinger RS, Moekotte A, Aldrighetti LA, Aroori S, Besselink MGH, D’Hondt M, Díaz-Nieto R, Edwin B, Efanov M, Ettorre GM, Menon KV, Sheen AJ, Soonawalla Z, Sutcliffe R, Troisi RI, White SA, Brandts L, van Breukelen GJP, Sijberden J, Pugh SA, Eminton Z, Primrose JN, van Dam R, Hilal MA. Laparoscopic versus open resections in the posterosuperior liver segments within an enhanced recovery programme (ORANGE Segments): study protocol for a multicentre randomised controlled trial. Trials 2022; 23:206. [PMID: 35264216 PMCID: PMC8908665 DOI: 10.1186/s13063-022-06112-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 02/15/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND A shift towards parenchymal-sparing liver resections in open and laparoscopic surgery emerged in the last few years. Laparoscopic liver resection is technically feasible and safe, and consensus guidelines acknowledge the laparoscopic approach in the posterosuperior segments. Lesions situated in these segments are considered the most challenging for the laparoscopic approach. The aim of this trial is to compare the postoperative time to functional recovery, complications, oncological safety, quality of life, survival and costs after laparoscopic versus open parenchymal-sparing liver resections in the posterosuperior liver segments within an enhanced recovery setting. METHODS The ORANGE Segments trial is an international multicentre randomised controlled superiority trial conducted in centres experienced in laparoscopic liver resection. Eligible patients for minor resections in the posterosuperior segments will be randomised in a 1:1 ratio to undergo laparoscopic or open resections in an enhanced recovery setting. Patients and ward personnel are blinded to the treatment allocation until postoperative day 4 using a large abdominal dressing. The primary endpoint is time to functional recovery. Secondary endpoints include intraoperative outcomes, length of stay, resection margin, postoperative complications, 90-day mortality, time to adjuvant chemotherapy initiation, quality of life and overall survival. Laparoscopic liver surgery of the posterosuperior segments is hypothesised to reduce time to functional recovery by 2 days in comparison with open surgery. With a power of 80% and alpha of 0.04 to adjust for interim analysis halfway the trial, a total of 250 patients are required to be randomised. DISCUSSION The ORANGE Segments trial is the first multicentre international randomised controlled study to compare short- and long-term surgical and oncological outcomes of laparoscopic and open resections in the posterosuperior segments within an enhanced recovery programme. TRIAL REGISTRATION ClinicalTrials.gov NCT03270917 . Registered on September 1, 2017. Before start of inclusion. PROTOCOL VERSION version 12, May 9, 2017.
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Affiliation(s)
- Christoph Kuemmerli
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
| | - Robert S. Fichtinger
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Alma Moekotte
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
| | | | - Somaiah Aroori
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Marc G. H. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Rafael Díaz-Nieto
- Hepatobiliary Surgery Unit, Aintree University Hospital, Liverpool, UK
| | - Bjørn Edwin
- Department of HPB Surgery, Oslo University Hospital, Oslo, Norway
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
| | - Giuseppe M. Ettorre
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | | | - Aali J. Sheen
- Department of Surgery, Manchester University Foundation Trust, Manchester, UK
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Robert Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Roberto I. Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Steven A. White
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Lloyd Brandts
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
| | - Gerard J. P. van Breukelen
- Department of Methodology and Statistics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jasper Sijberden
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Siân A. Pugh
- Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK
| | - Zina Eminton
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - John N. Primrose
- Department of Surgery, University of Southampton, Southampton, UK
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW – School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Mohammed Abu Hilal
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
| | - on behalf of the ORANGE trials collaborative
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
- Hepatobiliary Surgery Unit, Aintree University Hospital, Liverpool, UK
- Department of HPB Surgery, Oslo University Hospital, Oslo, Norway
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
- Institute of Liver Studies, Kings College Hospital, London, UK
- Department of Surgery, Manchester University Foundation Trust, Manchester, UK
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
- Department of Methodology and Statistics, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
- Department of Surgery, University of Southampton, Southampton, UK
- GROW – School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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6
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Vugts JJA, Gaspersz MP, Roos E, Franken LC, Olthof PB, Coelen RJS, van Vugt JLA, Labeur TA, Brouwer L, Besselink MGH, IJzermans JNM, Murad SD, van Gulik TM, de Jonge J, Polak WG, Busch ORC, Erdmann JL, Koerkamp BG, Buettner S. Correction to: Eligibility for Liver Transplantation in Patients with Perihilar Cholangiocarcinoma. Ann Surg Oncol 2021; 28:880. [PMID: 34018088 DOI: 10.1245/s10434-021-10171-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jaynee J A Vugts
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marcia P Gaspersz
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Eva Roos
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lotte C Franken
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pim B Olthof
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert J S Coelen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen L A van Vugt
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Tim A Labeur
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lieke Brouwer
- Department of Gastroenterology, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan N M IJzermans
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen de Jonge
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Olivier R C Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris L Erdmann
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Stefan Buettner
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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7
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Scheijmans JCG, Borgstein ABJ, Puylaert CAJ, Bom WJ, Bachiri S, van Bodegraven EA, Brandsma ATA, Ter Brugge FM, de Castro SMM, Couvreur R, Franken LC, Gaspersz MP, de Graaff MR, Groenen H, Kleipool SC, Kuypers TJL, Martens MH, Mens DM, Orsini RG, Reneerkens NJMM, Schok T, Sedee WJA, Tavakoli Rad S, Volders JH, Weeder PD, Prins JM, Gietema HA, Stoker J, Gisbertz SS, Besselink MGH, Boermeester MA. Impact of the COVID-19 pandemic on incidence and severity of acute appendicitis: a comparison between 2019 and 2020. BMC Emerg Med 2021; 21:61. [PMID: 33980150 PMCID: PMC8114672 DOI: 10.1186/s12873-021-00454-y] [Citation(s) in RCA: 16] [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: 02/15/2021] [Accepted: 04/23/2021] [Indexed: 01/03/2023] Open
Abstract
Background During the COVID-19 pandemic, a decrease in the number of patients presenting with acute appendicitis was observed. It is unclear whether this caused a shift towards more complicated cases of acute appendicitis. We compared a cohort of patients diagnosed with acute appendicitis during the 2020 COVID-19 pandemic with a 2019 control cohort. Methods We retrospectively included consecutive adult patients in 21 hospitals presenting with acute appendicitis in a COVID-19 pandemic cohort (March 15 – April 30, 2020) and a control cohort (March 15 – April 30, 2019). Primary outcome was the proportion of complicated appendicitis. Secondary outcomes included prehospital delay, appendicitis severity, and postoperative complication rates. Results The COVID-19 pandemic cohort comprised 607 patients vs. 642 patients in the control cohort. During the COVID-19 pandemic, a higher proportion of complicated appendicitis was seen (46.9% vs. 38.5%; p = 0.003). More patients had symptoms exceeding 24 h (61.1% vs. 56.2%, respectively, p = 0.048). After correction for prehospital delay, presentation during the first wave of the COVID-19 pandemic was still associated with a higher rate of complicated appendicitis. Patients presenting > 24 h after onset of symptoms during the COVID-19 pandemic were older (median 45 vs. 37 years; p = 0.001) and had more postoperative complications (15.3% vs. 6.7%; p = 0.002). Conclusions Although the incidence of acute appendicitis was slightly lower during the first wave of the 2020 COVID-19 pandemic, more patients presented with a delay and with complicated appendicitis than in a corresponding period in 2019. Spontaneous resolution of mild appendicitis may have contributed to the increased proportion of patients with complicated appendicitis. Late presenting patients were older and experienced more postoperative complications compared to the control cohort. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00454-y.
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Affiliation(s)
- Jochem C G Scheijmans
- Department of Surgery, Amsterdam UMC, location AMC, Amstserdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Alexander B J Borgstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Carl A J Puylaert
- Department of Radiology and Nuclear Medicine, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Wouter J Bom
- Department of Surgery, Amsterdam UMC, location AMC, Amstserdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Said Bachiri
- Department of Surgery, Noordwest Hospital Group, Alkmaar, the Netherlands
| | | | | | | | | | - Roy Couvreur
- Department of Surgery, Haaglanden Medical Center, The Hague, the Netherlands
| | - Lotte C Franken
- Departement of Surgery, Flevo Hospital, Almere, the Netherlands
| | - Marcia P Gaspersz
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Hannah Groenen
- Department of Surgery, Tergooi Hospitals, Hilversum, the Netherlands
| | | | - Toon J L Kuypers
- Department of Surgery, Elisabeth - Tweesteden Hospital, Tilburg, the Netherlands
| | - Milou H Martens
- Department of Surgery, Zuyderland Medical Center, Sittard-Geleen/Heerlen, the Netherlands
| | - David M Mens
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Ricardo G Orsini
- Department of Surgery, Maastricht UMC+, Maastricht, the Netherlands
| | | | - Thomas Schok
- Department of Surgery, VieCuri Medisch Centrum for Noord-Limburg, Venlo, the Netherlands
| | - Wouter J A Sedee
- Department of Emergency Medicine, St Jansdal Hospital, Harderwijk, the Netherlands
| | | | - José H Volders
- Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Pepijn D Weeder
- Department of Surgery, Spaarne Gasthuis, Haarlem, and Hoofddorp, the Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity (AI&II), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hester A Gietema
- Department of Radiology and Nuclear Medicine, Maastricht UMC+, Maastricht, the Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G H Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam UMC, location AMC, Amstserdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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8
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Vugts JJA, Gaspersz MP, Roos E, Franken LC, Olthof PB, Coelen RJS, van Vugt JLA, Labeur TA, Brouwer L, Besselink MGH, IJzermans JNM, Darwish Murad S, van Gulik TM, de Jonge J, Polak WG, Busch ORC, Erdmann JL, Groot Koerkamp B, Buettner S. Eligibility for Liver Transplantation in Patients with Perihilar Cholangiocarcinoma. Ann Surg Oncol 2020; 28:1483-1492. [PMID: 32901308 PMCID: PMC7892510 DOI: 10.1245/s10434-020-09001-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 03/18/2020] [Accepted: 07/22/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Liver transplantation (LT) has been performed in a select group of patients presenting with unresectable or primary sclerosing cholangitis (PSC)-associated perihilar cholangiocarcinoma (pCCA) in the Mayo Clinic with a reported 5-year overall survival (OS) of 53% on intention-to-treat analysis. The objective of this study was to estimate eligibility for LT in a cohort of pCCA patients in two tertiary referral centers. METHODS Patients diagnosed with pCCA between 2002 and 2014 were included from two tertiary referral centers in the Netherlands. The selection criteria used by the Mayo Clinic were retrospectively applied to determine the proportion of patients that would have been eligible for LT. RESULTS A total of 732 consecutive patients with pCCA were identified, of whom 24 (4%) had PSC-associated pCCA. Overall, 154 patients had resectable disease on imaging and 335 patients were ineligible for LT because of lymph node or distant metastases. An age limit of 70 years led to the exclusion of 50 patients who would otherwise be eligible for LT. After applying the Mayo Clinic criteria, only 34 patients (5%) were potentially eligible for LT. Median survival from diagnosis for these 34 patients was 13 months (95% CI 3-23). CONCLUSION Only 5% of all patients presenting with pCCA were potentially eligible for LT under the Mayo criteria. Without transplantation, a median OS of about 1 year was observed.
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Affiliation(s)
- Jaynee J A Vugts
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marcia P Gaspersz
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Eva Roos
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lotte C Franken
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pim B Olthof
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert J S Coelen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen L A van Vugt
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Tim A Labeur
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lieke Brouwer
- Department of Gastroenterology, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan N M IJzermans
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen de Jonge
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Olivier R C Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris L Erdmann
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Stefan Buettner
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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9
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Balakrishnan A, Lesurtel M, Siriwardena AK, Heinrich S, Serrablo A, Besselink MGH, Erkan M, Andersson B, Polak WG, Laurenzi A, Olde Damink SWM, Berrevoet F, Frigerio I, Ramia JM, Gallagher TK, Warner S, Shrikhande SV, Adam R, Smith MD, Conlon KC. Delivery of hepato-pancreato-biliary surgery during the COVID-19 pandemic: an European-African Hepato-Pancreato-Biliary Association (E-AHPBA) cross-sectional survey. HPB (Oxford) 2020; 22:1128-1134. [PMID: 32565039 PMCID: PMC7284265 DOI: 10.1016/j.hpb.2020.05.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 05/20/2020] [Accepted: 05/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The extent of the COVID-19 pandemic and the resulting response has varied globally. The European and African Hepato-Pancreato-Biliary Association (E-AHPBA), the premier representative body for practicing HPB surgeons in Europe and Africa, conducted this survey to assess the impact of COVID-19 on HPB surgery. METHODS An online survey was disseminated to all E-AHPBA members to assess the effects of the pandemic on unit capacity, management of HPB cancers, use of COVID-19 screening and other aspects of service delivery. RESULTS Overall, 145 (25%) members responded. Most units, particularly in COVID-high countries (>100,000 cases) reported insufficient critical care capacity and reduced HPB operating sessions compared to COVID-low countries. Delayed access to cancer surgery necessitated alternatives including increased neoadjuvant chemotherapy for pancreatic cancer and colorectal liver metastases, and locoregional treatments for hepatocellular carcinoma. Other aspects of service delivery including COVID-19 screening and personal protective equipment varied between units and countries. CONCLUSION This study demonstrates that the COVID-19 pandemic has had a profound adverse impact on the delivery of HPB cancer care across the continents of Europe and Africa. The findings illustrate the need for safe resumption of cancer surgery in a "new" normal world with screening of patients and staff for COVID-19.
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Affiliation(s)
- Anita Balakrishnan
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, United Kingdom.
| | - Mickael Lesurtel
- Department of Digestive Surgery and Liver Transplantation, University Hospital Croix Rousse, Hospices Civils de Lyon, University of Lyon 1, 69317, Lyon, France
| | - Ajith K Siriwardena
- Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, United Kingdom
| | - Stefan Heinrich
- Department of General, Visceral and Transplant Surgery, Universitätsmedizin Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Paseo Isabel la Catolica, 50009, Zaragoza, Spain
| | - Marc G H Besselink
- Department of Surgery, Amsterdam UMC, G4.146-1, Meibergdreef 9, 1105, Amsterdam, the Netherlands
| | - Mert Erkan
- Department of Surgery, Koc University School of Medicine and Research Center for Translational Medicine, Davutpasa Caddesi No:4, 34010, Instanbul, Turkey
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skane University Hospital, 22100, Lund, Sweden
| | - Wojciech G Polak
- Department of Surgery, Erasmus MC University Medical Center, Dr. Molewaterplein 40, 3016 GD, Rotterdam, the Netherlands
| | - Andrea Laurenzi
- Division of General Surgery and Transplantation, S. Orsola-Malpighi Hospital, University of Bologna, via G Masserenti 9, 40138, Bologna, Italy
| | - Stefan W M Olde Damink
- Department of Surgery, Maastricht University Medical Center and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastrict University, 6200 MD, Maastricht, the Netherlands; Department of General Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, University Hospital Gent, Corneel Heymanslaan 10, 9000, Gent, Belgium
| | - Isabella Frigerio
- Department of General and Vascular Surgery, Pederzoli Hospital, Via Monte Baldo 24, 37019, Peschiera del Garda, Verona, Italy
| | - Jose M Ramia
- Department of Surgery, Hospital Universitario de Guadalajara, 19002, Guadalajara, Spain
| | - Thomas K Gallagher
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Susanne Warner
- Department of Surgery, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Centre, Ernest Borges Marg, Parel, Mumbai, 400012, India
| | - Rene Adam
- APHP Hopital Universitaire Paul Brousse, Universite Paris-Saclay, F-94804, Villejuif, France
| | - Martin D Smith
- Department of Surgery, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Braamfontein, 2000, Johannesburg, South Africa
| | - Kevin C Conlon
- Department of Surgery, Trinity College Dublin, Ireland and St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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10
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Buisman FE, Homs MYV, Grünhagen DJ, Filipe WF, Bennink RJ, Besselink MGH, Borel Rinkes IHM, Bruijnen RCG, Cercek A, D'Angelica MI, van Delden OM, Donswijk ML, van Doorn L, Doornebosch PG, Emmering J, Erdmann JI, IJzerman NS, Grootscholten C, Hagendoorn J, Kemeny NE, Kingham TP, Klompenhouwer EG, Kok NFM, Koolen S, Kuhlmann KFD, Kuiper MC, Lam MGE, Mathijssen RHJ, Moelker A, Oomen-de Hoop E, Punt CJA, Te Riele WW, Roodhart JML, Swijnenburg RJ, Prevoo W, Tanis PJ, Vermaas M, Versleijen MWJ, Veuger FP, Weterman MJ, Verhoef C, Groot Koerkamp B. Adjuvant hepatic arterial infusion pump chemotherapy and resection versus resection alone in patients with low-risk resectable colorectal liver metastases - the multicenter randomized controlled PUMP trial. BMC Cancer 2019; 19:327. [PMID: 30953467 PMCID: PMC6451273 DOI: 10.1186/s12885-019-5515-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 02/14/2019] [Accepted: 03/25/2019] [Indexed: 02/07/2023] Open
Abstract
Background Recurrences are reported in 70% of all patients after resection of colorectal liver metastases (CRLM), in which half are confined to the liver. Adjuvant hepatic arterial infusion pump (HAIP) chemotherapy aims to reduce the risk of intrahepatic recurrence. A large retrospective propensity score analysis demonstrated that HAIP chemotherapy is particularly effective in patients with low-risk oncological features. The aim of this randomized controlled trial (RCT) --the PUMP trial-- is to investigate the efficacy of adjuvant HAIP chemotherapy in low-risk patients with resectable CRLM. Methods This is an open label multicenter RCT. A total of 230 patients with resectable CRLM without extrahepatic disease will be included. Only patients with a clinical risk score (CRS) of 0 to 2 are eligible, meaning: patients are allowed to have no more than two out of five poor prognostic factors (disease-free interval less than 12 months, node-positive colorectal cancer, more than 1 CRLM, largest CRLM more than 5 cm in diameter, serum Carcinoembryonic Antigen above 200 μg/L). Patients randomized to arm A undergo complete resection of CRLM without any adjuvant treatment, which is the standard of care in the Netherlands. Patients in arm B receive an implantable pump at the time of CRLM resection and start adjuvant HAIP chemotherapy 4–12 weeks after surgery, with 6 cycles of floxuridine scheduled. The primary endpoint is progression-free survival (PFS). Secondary endpoints include overall survival, hepatic PFS, safety, quality of life, and cost-effectiveness. Pharmacokinetics of intra-arterial administration of floxuridine will be investigated as well as predictive biomarkers for the efficacy of HAIP chemotherapy. In a side study, the accuracy of CT angiography will be compared to radionuclide scintigraphy to detect extrahepatic perfusion. We hypothesize that adjuvant HAIP chemotherapy leads to improved survival, improved quality of life, and a reduction of costs, compared to resection alone. Discussion If this PUMP trial demonstrates that adjuvant HAIP chemotherapy improves survival in low-risk patients, this treatment approach may be implemented in the standard of care of patients with resected CRLM since adjuvant systemic chemotherapy alone has not improved survival. Trial registration The PUMP trial is registered in the Netherlands Trial Register (NTR), number: 7493. Date of registration September 23, 2018.
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Affiliation(s)
- F E Buisman
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands.
| | - M Y V Homs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, The Netherlands
| | - D J Grünhagen
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - W F Filipe
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - R J Bennink
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Rotterdam, The Netherlands
| | - M G H Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - I H M Borel Rinkes
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R C G Bruijnen
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A Cercek
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M I D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - O M van Delden
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Rotterdam, The Netherlands
| | - M L Donswijk
- Department of Nuclear Medicine, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - L van Doorn
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, The Netherlands
| | - P G Doornebosch
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - J Emmering
- Department of Radiology and Nuclear Medicine, Erasmus MC, Erasmus University, Rotterdam, The Netherlands
| | - J I Erdmann
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - N S IJzerman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, The Netherlands.,Department of Medical Oncology, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - C Grootscholten
- Department of Medical Oncology, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - J Hagendoorn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N E Kemeny
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - T P Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - E G Klompenhouwer
- Department of Radiology, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - N F M Kok
- Department of Surgery, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - S Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, The Netherlands
| | - K F D Kuhlmann
- Department of Surgery, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - M C Kuiper
- Department of Medical Oncology, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - M G E Lam
- Department of Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, The Netherlands
| | - A Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC, Erasmus University, Rotterdam, The Netherlands
| | - E Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, The Netherlands
| | - C J A Punt
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W W Te Riele
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J M L Roodhart
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R J Swijnenburg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W Prevoo
- Department of Radiology, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Vermaas
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - M W J Versleijen
- Department of Nuclear Medicine, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - F P Veuger
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M J Weterman
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - C Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
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11
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Smeets XJNM, Litjens G, da Costa DW, Kievit W, van Santvoort HC, Besselink MGH, Fockens P, Bruno MJ, Kolkman JJ, Drenth JPH, Bollen TL, van Geenen EJM. The association between portal system vein diameters and outcomes in acute pancreatitis. Pancreatology 2018; 18:494-499. [PMID: 29784597 DOI: 10.1016/j.pan.2018.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/20/2018] [Accepted: 05/14/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Acute pancreatitis (AP) progresses to necrotizing pancreatitis in 15% of cases. An important pathophysiological mechanism in AP is third spacing of fluids, which leads to intravascular volume depletion. This results in a reduced splanchnic circulation and reduced venous return. Non-visualisation of the portal and splenic vein on early computed tomography (CT) scan, which might be the result of smaller vein diameter due to decreased venous flow, is associated with infected necrosis and mortality in AP. This observation led us to hypothesize that smaller diameters of portal system veins (portal, splenic and superior mesenteric) are associated with increased severity of AP. METHODS We conducted a post-hoc analysis of data from two randomized controlled trials that included patients with predicted severe and mild AP. The primary endpoint was AP-related mortality. The secondary endpoints were (infected) necrotizing pancreatitis and (persistent) organ failure. We performed additional CT measurements of portal system vein diameters and calculated their prognostic value through univariate and multivariate Poisson regression. RESULTS Multivariate regression showed a significant inverse association between splenic vein diameter and mortality (RR 0.75 (0.59-0.97)). Furthermore, there was a significant inverse association between splenic and superior mesenteric vein diameter and (infected) necrosis. Diameters of all veins were inversely associated with organ failure and persistent organ failure. CONCLUSIONS We observed an inverse relationship between portal system vein diameter and morbidity and an inverse relationship between splenic vein diameter and mortality in AP. Further research is needed to test whether these results can be implemented in predictive scoring systems.
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Affiliation(s)
- X J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - G Litjens
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - D W da Costa
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - W Kievit
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - T L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
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12
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Smeets XJNM, da Costa DW, Fockens P, Mulder CJJ, Timmer R, Kievit W, Zegers M, Bruno MJ, Besselink MGH, Vleggaar FP, van der Hulst RWM, Poen AC, Heine GDN, Venneman NG, Kolkman JJ, Baak LC, Römkens TEH, van Dijk SM, Hallensleben NDL, van de Vrie W, Seerden TCJ, Tan ACITL, Voorburg AMCJ, Poley JW, Witteman BJ, Bhalla A, Hadithi M, Thijs WJ, Schwartz MP, Vrolijk JM, Verdonk RC, van Delft F, Keulemans Y, van Goor H, Drenth JPH, van Geenen EJM. Fluid hydration to prevent post-ERCP pancreatitis in average- to high-risk patients receiving prophylactic rectal NSAIDs (FLUYT trial): study protocol for a randomized controlled trial. Trials 2018; 19:207. [PMID: 29606135 PMCID: PMC5879873 DOI: 10.1186/s13063-018-2583-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 03/06/2018] [Indexed: 12/19/2022] Open
Abstract
Background Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common complication of ERCP and may run a severe course. Evidence suggests that vigorous periprocedural hydration can prevent PEP, but studies to date have significant methodological drawbacks. Importantly, evidence for its added value in patients already receiving prophylactic rectal non-steroidal anti-inflammatory drugs (NSAIDs) is lacking and the cost-effectiveness of the approach has not been investigated. We hypothesize that combination therapy of rectal NSAIDs and periprocedural hydration would significantly lower the incidence of post-ERCP pancreatitis compared to rectal NSAIDs alone in moderate- to high-risk patients undergoing ERCP. Methods The FLUYT trial is a multicenter, parallel group, open label, superiority randomized controlled trial. A total of 826 moderate- to high-risk patients undergoing ERCP that receive prophylactic rectal NSAIDs will be randomized to a control group (no fluids or normal saline with a maximum of 1.5 mL/kg/h and 3 L/24 h) or intervention group (lactated Ringer’s solution with 20 mL/kg over 60 min at start of ERCP, followed by 3 mL/kg/h for 8 h thereafter). The primary endpoint is the incidence of post-ERCP pancreatitis. Secondary endpoints include PEP severity, hydration-related complications, and cost-effectiveness. Discussion The FLUYT trial design, including hydration schedule, fluid type, and sample size, maximize its power of identifying a potential difference in post-ERCP pancreatitis incidence in patients receiving prophylactic rectal NSAIDs. Trial registration EudraCT: 2015-000829-37. Registered on 18 February 2015. ISRCTN: 13659155. Registered on 18 May 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2583-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xavier J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands.
| | - David W da Costa
- Department of Radiology, St Antonius Hospital, PO 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, PO 22660, 1100 DD, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Centre Amsterdam, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, PO 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Wietske Kievit
- Department of Health Evidence, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marieke Zegers
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Centre, PO 22660, 1100 DD, Amsterdam, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, PO 85500, 3508 GA, Utrecht, The Netherlands
| | - Rene W M van der Hulst
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, PO 417, 2000 AK, Haarlem, The Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Klinieken, PO 10400, 8000 GK, Zwolle, The Netherlands
| | - Gerbrand D N Heine
- Department of Gastroenterology and Hepatology, Noord-West Hospital, PO 501, 1800 AM, Alkmaar, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO 50000, 7500 KA, Enschede, The Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO 50000, 7500 KA, Enschede, The Netherlands
| | - Lubbertus C Baak
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Postbus 95500, 1090 HM, Amsterdam, The Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, PO 90153, 5200 ME, s'Hertogenbosch, The Netherlands
| | - Sven M van Dijk
- Department of Surgery, Academic Medical Centre, PO 22660, 1100 DD, Amsterdam, The Netherlands
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, PO 444, 3300 AK, Dordrecht, The Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, PO 90158, 4800 RK, Breda, The Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina Hospital, PO 9015, 6500 GS, Nijmegen, The Netherlands
| | - Annet M C J Voorburg
- Department of Gastroenterology and Hepatology, Diakonessenhuis, PO 80250, 3508 TG, Utrecht, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, PO 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, PO 9025, 6710 HN, Ede, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HAGA Hospital, PO 40551, 2504 LN, The Hague, The Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, PO 9100, 3007 AC, Rotterdam, The Netherlands
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, PO 30033, 9700 RM, Groningen, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, PO 1502, 3800 BM, Amersfoort, The Netherlands
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, PO 9555, 6800 TA, Arnhem, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, PO 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, VU University Medical Centre Amsterdam, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Yolande Keulemans
- Department of Gastroenterology and Hepatology, Zuyderland, PO 5500, 6130 MB, Sittard-Geleen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO 9101, 6500 HB, Nijmegen, The Netherlands
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13
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van der Horst A, Versteijne E, Besselink MGH, Daams JG, Bulle EB, Bijlsma MF, Wilmink JW, van Delden OM, van Hooft JE, Franken NAP, van Laarhoven HWM, Crezee J, van Tienhoven G. The clinical benefit of hyperthermia in pancreatic cancer: a systematic review. Int J Hyperthermia 2017; 34:969-979. [PMID: 29168401 DOI: 10.1080/02656736.2017.1401126] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE In pancreatic cancer, which is therapy resistant due to its hypoxic microenvironment, hyperthermia may enhance the effect of radio(chemo)therapy. The aim of this systematic review is to investigate the validity of the hypothesis that hyperthermia added to radiotherapy and/or chemotherapy improves treatment outcome for pancreatic cancer patients. METHODS AND MATERIALS We searched MEDLINE and Embase, supplemented by handsearching, for clinical studies involving hyperthermia in pancreatic cancer patients. The quality of studies was evaluated using the Oxford Centre for Evidence-Based Medicine levels of evidence. Primary outcome was treatment efficacy; we calculated overall response rate and the weighted estimate of the population median overall survival (mp) and compared these between hyperthermia and control cohorts. RESULTS Overall, 14 studies were included, with 395 patients with locally advanced and/or metastatic pancreatic cancer of whom 248 received hyperthermia. Patients were treated with regional (n = 189), intraoperative (n = 39) or whole-body hyperthermia (n = 20), combined with chemotherapy, radiotherapy or both. Quality of the studies was low, with level of evidence 3 (five studies) and 4. The six studies including a control group showed a longer mp in the hyperthermia groups than in the control groups (11.7 vs. 5.6 months). Overall response rate, reported in three studies with a control group, was also better for the hyperthermia groups (43.9% vs. 35.3%). CONCLUSIONS Hyperthermia, when added to chemotherapy and/or radiotherapy, may positively affect treatment outcome for patients with pancreatic cancer. However, the quality of the reviewed studies was limited and future randomised controlled trials are needed to establish efficacy.
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Affiliation(s)
- Astrid van der Horst
- a Department of Radiation Oncology and Hyperthermia , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Eva Versteijne
- a Department of Radiation Oncology and Hyperthermia , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Marc G H Besselink
- b Department of Surgery , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Joost G Daams
- c Medical Library , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Esther B Bulle
- a Department of Radiation Oncology and Hyperthermia , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Maarten F Bijlsma
- d Laboratory for Experimental Oncology and Radiobiology (LEXOR) , Center for Experimental and Molecular Medicine (CEMM), Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Johanna W Wilmink
- e Department of Medical Oncology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Otto M van Delden
- f Department of Radiology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Jeanin E van Hooft
- g Department of Gastroenterology and Hepatology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Nicolaas A P Franken
- d Laboratory for Experimental Oncology and Radiobiology (LEXOR) , Center for Experimental and Molecular Medicine (CEMM), Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Hanneke W M van Laarhoven
- e Department of Medical Oncology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Johannes Crezee
- a Department of Radiation Oncology and Hyperthermia , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Geertjan van Tienhoven
- a Department of Radiation Oncology and Hyperthermia , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
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14
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van der Geest LGM, Haj Mohammad N, Besselink MGH, Lemmens VEPP, Portielje JEA, van Laarhoven HWM, Wilmink JHW. Nationwide trends in chemotherapy use and survival of elderly patients with metastatic pancreatic cancer. Cancer Med 2017; 6:2840-2849. [PMID: 29035014 PMCID: PMC5727341 DOI: 10.1002/cam4.1240] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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: 05/12/2017] [Revised: 08/22/2017] [Accepted: 09/25/2017] [Indexed: 12/19/2022] Open
Abstract
Despite an aging population and underrepresentation of elderly patients in clinical trials, studies on elderly patients with metastatic pancreatic cancer are scarce. This study investigated the use of chemotherapy and survival in elderly patients with metastatic pancreatic cancer. From the Netherlands Cancer Registry, all 9407 patients diagnosed with primary metastatic pancreatic adenocarcinoma in 2005–2013 were selected to investigate chemotherapy use and overall survival (OS), using Kaplan–Meier and Cox proportional hazard regression analyses. Over time, chemotherapy use increased in all age groups (<70 years: from 26 to 43%, 70–74 years: 14 to 25%, 75–79 years: 5 to 13%, all P < 0.001, and ≥80 years: 2 to 3% P = 0.56). Median age of 2,180 patients who received chemotherapy was 63 years (range 21–86 years, 1.6% was ≥80 years). In chemotherapy‐treated patients, with rising age (<70, 70–74, 75–79, ≥80 years), microscopic tumor verification occurred less frequently (91‐88‐87‐77%, respectively, P = 0.009) and OS diminished (median 25‐26‐19‐16 weeks, P = 0.003). After adjustment for confounding factors, worse survival of treated patients ≥75 years persisted. Despite limited chemotherapy use in elderly age, suggestive of strong selection, elderly patients (≥75 years) who received chemotherapy for metastatic pancreatic cancer exhibited a worse survival compared to younger patients receiving chemotherapy.
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Affiliation(s)
- Lydia G M van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Valery E P P Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johanneke E A Portielje
- Department of Internal Medicine and Medical Oncology, Haga Hospital, The Hague, The Netherlands.,Foundation of Geriatric Oncology Netherlands (GeriOnNe), Eindhoven, The Netherlands
| | | | - J Hanneke W Wilmink
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
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15
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Coelen RJS, Olthof PB, van Dieren S, Besselink MGH, Busch ORC, van Gulik TM. External Validation of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) Risk Model to Predict Operative Risk in Perihilar Cholangiocarcinoma. JAMA Surg 2017; 151:1132-1138. [PMID: 27579510 DOI: 10.1001/jamasurg.2016.2305] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Resection of perihilar cholangiocarcinoma (PHC) is high-risk surgery, with reported operative mortality up to 17%. Therefore, preoperative risk assessment is needed to identify high-risk patients and anticipate postoperative adverse outcomes. Objective To provide external validation of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) risk model in a Western PHC cohort. Design, Setting, and Participants The E-PASS variables were obtained from a database that included 156 consecutive patients who underwent resection for suspected PHC between January 1, 2000, and December 31, 2015, at the Academic Medical Center, Amsterdam, the Netherlands. The accuracy of E-PASS using intraoperative variables and its modified form that can be used before surgery (mE-PASS) in predicting mortality was assessed by area under the curve analysis (discrimination) and by the Hosmer-Lemeshow goodness-of-fit test (calibration). Main Outcomes and Measures In-hospital mortality, severe morbidity (Clavien-Dindo grade≥III), and a high Comprehensive Complication Index. Results Among 156 patients included in the study, the median age was 63 years, and 62.8% (n = 98) were male. Of them, 85.3% (n = 133) underwent major liver resection. Severe morbidity occurred in 51.3% (n = 80), and in-hospital mortality was 13.5% (n = 21). Both E-PASS and mE-PASS had adequate discriminative performance, with areas under the curve of 0.78 (95% CI, 0.67-0.88) and 0.79 (95% CI, 0.70-0.89), respectively, while E-PASS showed better calibration (P = .33 vs P = .02, Hosmer-Lemeshow goodness-of-fit test). The ratios of observed to expected mortality were 1.31 for E-PASS and 1.24 for mE-PASS. Both models were able to distinguish groups with low risk, intermediate risk, and high risk, with observed mortality rates of 0.0% to 3.6%, 8.3% to 9.0%, and 25.0% to 28.3%, respectively. Severe morbidity and a high Comprehensive Complication Index were more frequently observed among high-risk patients. Conclusions and Relevance Both E-PASS models accurately identify patients at high risk of postoperative in-hospital mortality after resection for PHC. The mE-PASS model can be used before surgery in outpatient settings and allows for risk assessment and shared decision making.
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Affiliation(s)
- Robert J S Coelen
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Pim B Olthof
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Susan van Dieren
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
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16
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van Rosmalen BV, Alldinger I, Cieslak KP, Wennink R, Clarke M, Ali UA, Besselink MGH. Worldwide trends in volume and quality of published protocols of randomized controlled trials. PLoS One 2017; 12:e0173042. [PMID: 28296925 PMCID: PMC5351864 DOI: 10.1371/journal.pone.0173042] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 10/10/2016] [Accepted: 02/14/2017] [Indexed: 01/30/2023] Open
Abstract
Introduction Publishing protocols of randomized controlled trials (RCT) facilitates a more detailed description of study rational, design, and related ethical and safety issues, which should promote transparency. Little is known about how the practice of publishing protocols developed over time. Therefore, this study describes the worldwide trends in volume and methodological quality of published RCT protocols. Methods A systematic search was performed in PubMed and EMBASE, identifying RCT protocols published over a decade from 1 September 2001. Data were extracted on quality characteristics of RCT protocols. The primary outcome, methodological quality, was assessed by individual methodological characteristics (adequate generation of allocation, concealment of allocation and intention-to-treat analysis). A comparison was made by publication period (First, September 2001- December 2004; Second, January 2005-May 2008; Third, June 2008-September 2011), geographical region and medical specialty. Results The number of published RCT protocols increased from 69 in the first, to 390 in the third period (p<0.0001). Internal medicine and paediatrics were the most common specialty topics. Whereas most published RCT protocols in the first period originated from North America (n = 30, 44%), in the second and third period this was Europe (respectively, n = 65, 47% and n = 190, 48%, p = 0.02). Quality of RCT protocols was higher in Europe and Australasia, compared to North America (OR = 0.63, CI = 0.40–0.99, p = 0.04). Adequate generation of allocation improved with time (44%, 58%, 67%, p = 0.001), as did concealment of allocation (38%, 53%, 55%, p = 0.03). Surgical protocols had the highest quality among the three specialty topics used in this study (OR = 1.94, CI = 1.09–3.45, p = 0.02). Conclusion Publishing RCT protocols has become popular, with a five-fold increase in the past decade. The quality of published RCT protocols also improved, although variation between geographical regions and across medical specialties was seen. This emphasizes the importance of international standards of comprehensive training in RCT methodology.
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Affiliation(s)
| | - Ingo Alldinger
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Kasia P. Cieslak
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Roos Wennink
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mike Clarke
- Northern Ireland Network for Trials Methodology Research, Queen’s University Belfast, Belfast, Northern Ireland
| | - Usama Ahmed Ali
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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17
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van Hilst J, de Rooij T, Abu Hilal M, Asbun HJ, Barkun J, Boggi U, Busch OR, Conlon KCP, Dijkgraaf MG, Han HS, Hansen PD, Kendrick ML, Montagnini AL, Palanivelu C, Røsok BI, Shrikhande SV, Wakabayashi G, Zeh HJ, Vollmer CM, Kooby DA, Besselink MGH. Worldwide survey on opinions and use of minimally invasive pancreatic resection. HPB (Oxford) 2017; 19:190-204. [PMID: 28215904 DOI: 10.1016/j.hpb.2017.01.011] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 01/05/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The introduction of minimally invasive pancreatic resection (MIPR) into surgical practice has been slow. The worldwide utilization of MIPR and attitude towards future perspectives of MIPR remains unknown. METHODS An anonymous survey on MIPR was sent to the members of six international associations of Hepato-Pancreato-Biliary (HPB) surgery. RESULTS The survey was completed by 435 surgeons from 50 countries, with each surgeon performing a median of 22 (IQR 12-40) pancreatic resections annually. Minimally invasive distal pancreatectomy (MIDP) was performed by 345 (79%) surgeons and minimally invasive pancreatoduodenectomy (MIPD) by 124 (29%). The median total personal experience was 20 (IQR 10-50) MIDPs and 12 (IQR 4-40) MIPDs. Current superiority for MIDP was claimed by 304 (70%) and for MIPD by 44 (10%) surgeons. The most frequently mentioned reason for not performing MIDP (54/90 (60%)) and MIPD (193/311 (62%)) was lack of specific training. Most surgeons (394/435 (90%)) would consider participating in an international registry on MIPR. DISCUSSION This worldwide survey showed that most participating HPB surgeons value MIPR as a useful development, especially for MIDP, but the role and implementation of MIPD requires further assessment. Most HPB surgeons would welcome specific training in MIPR and the establishment of an international registry.
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Affiliation(s)
- Jony van Hilst
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Thijs de Rooij
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Horacio J Asbun
- Department of Surgery, The Mayo Clinic Florida, Jacksonville, FL, USA
| | - Jeffrey Barkun
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Uggo Boggi
- Department of Surgery, University of Pisa, Pisa, Italy
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Kevin C P Conlon
- Department of Surgery, The University of Dublin, Trinity College, Dublin, Ireland
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, SeongNam si, Korea
| | - Paul D Hansen
- Department of Surgery, Portland Providence Cancer Center, Portland, Orlando, USA
| | | | | | - Chinnusamy Palanivelu
- Department of Surgery, GEM Hospital & Research Center, Coimbatore, Tamil Nadu, India
| | - Bård I Røsok
- Department of Surgery, Oslo University Hospital, Oslo, Norway
| | | | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Herbert J Zeh
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles M Vollmer
- Department of Surgery, The University of Pennsylvania, Philadelphia, PA, USA
| | - David A Kooby
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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18
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Scheffer HJ, Vroomen LGPH, de Jong MC, Melenhorst MCAM, Zonderhuis BM, Daams F, Vogel JA, Besselink MGH, van Kuijk C, Witvliet J, de van der Schueren MAE, de Gruijl TD, Stam AGM, van den Tol PMP, van Delft F, Kazemier G, Meijerink MR. Ablation of Locally Advanced Pancreatic Cancer with Percutaneous Irreversible Electroporation: Results of the Phase I/II PANFIRE Study. Radiology 2017; 282:585-597. [DOI: 10.1148/radiol.2016152835] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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19
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Loozen CS, Kortram K, Kornmann VNN, van Ramshorst B, Vlaminckx B, Knibbe CAJ, Kelder JC, Donkervoort SC, Nieuwenhuijzen GAP, Ponten JEH, van Geloven AAW, van Duijvendijk P, Bos WJW, Besselink MGH, Gouma DJ, van Santvoort HC, Boerma D. Randomized clinical trial of extended versus single-dose perioperative antibiotic prophylaxis for acute calculous cholecystitis. Br J Surg 2017; 104:e151-e157. [DOI: 10.1002/bjs.10406] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/12/2016] [Accepted: 09/20/2016] [Indexed: 12/13/2022]
Abstract
Abstract
Background
Many patients who have surgery for acute cholecystitis receive postoperative antibiotic prophylaxis, with the intent to reduce infectious complications. There is, however, no evidence that extending antibiotics beyond a single perioperative dose is advantageous. This study aimed to determine the effect of extended antibiotic prophylaxis on infectious complications in patients with mild acute cholecystitis undergoing cholecystectomy.
Methods
For this randomized controlled non-inferiority trial, adult patients with mild acute calculous cholecystitis undergoing cholecystectomy at six major teaching hospitals in the Netherlands, between April 2012 and September 2014, were assessed for eligibility. Patients were randomized to either a single preoperative dose of cefazolin (2000 mg), or antibiotic prophylaxis for 3 days after surgery (intravenous cefuroxime 750 mg plus metronidazole 500 mg, three times daily), in addition to the single dose. The primary endpoint was rate of infectious complications within 30 days after operation.
Results
In the intention-to-treat analysis, three of 77 patients (4 per cent) in the extended antibiotic group and three of 73 (4 per cent) in the standard prophylaxis group developed postoperative infectious complications (absolute difference 0·2 (95 per cent c.i. –8·2 to 8·9) per cent). Based on a margin of 5 per cent, non-inferiority of standard prophylaxis compared with extended prophylaxis was not proven. Median length of hospital stay was 3 days in the extended antibiotic group and 1 day in the standard prophylaxis group.
Conclusion
Standard single-dose antibiotic prophylaxis did not lead to an increase in postoperative infectious complications in patients with mild acute cholecystitis undergoing cholecystectomy. Registration number: NTR3089 (www.trialregister.nl).
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Affiliation(s)
- C S Loozen
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - K Kortram
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - V N N Kornmann
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - B van Ramshorst
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - B Vlaminckx
- Department of Medical Microbiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - C A J Knibbe
- Department of Clinical Pharmacology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - J C Kelder
- Department of Clinical Epidemiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - S C Donkervoort
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - J E H Ponten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | | | - W J W Bos
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - D J Gouma
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - H C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - D Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
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20
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Tol JAMG, van Hooft JE, Timmer R, Kubben FJGM, van der Harst E, de Hingh IHJT, Vleggaar FP, Molenaar IQ, Keulemans YCA, Boerma D, Bruno MJ, Schoon EJ, van der Gaag NA, Besselink MGH, Fockens P, van Gulik TM, Rauws EAJ, Busch ORC, Gouma DJ. Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer. Gut 2016; 65:1981-1987. [PMID: 26306760 DOI: 10.1136/gutjnl-2014-308762] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In pancreatic cancer, preoperative biliary drainage (PBD) increases complications compared with surgery without PBD, demonstrated by a recent randomised controlled trial (RCT). This outcome might be related to the plastic endoprosthesis used. Metal stents may reduce the PBD-related complications risk. METHODS A prospective multicentre cohort study was performed including patients with obstructive jaundice due to pancreatic cancer, scheduled to undergo PBD before surgery. This cohort was added to the earlier RCT (ISRCTN31939699). The RCT protocol was adhered to, except PBD was performed with a fully covered self-expandable metal stent (FCSEMS). This FCSEMS cohort was compared with the RCT's plastic stent cohort. PBD-related complications were the primary outcome. Three-group comparison of overall complications including early surgery patients was performed. RESULTS 53 patients underwent PBD with FCSEMS compared with 102 patients treated with plastic stents. Patients' characteristics did not differ. PBD-related complication rates were 24% in the FCSEMS group vs 46% in the plastic stent group (relative risk of plastic stent use 1.9, 95% CI 1.1 to 3.2, p=0.011). Stent-related complications (occlusion and exchange) were 6% vs 31%. Surgical complications did not differ, 40% vs 47%. Overall complication rates for the FCSEMS, plastic stent and early surgery groups were 51% vs 74% vs 39%. CONCLUSIONS For PBD in pancreatic cancer, FCSEMS yield a better outcome compared with plastic stents. Although early surgery without PBD remains the treatment of choice, FCSEMS should be preferred over plastic stents whenever PBD is indicated. TRIAL REGISTRATION NUMBER Dutch Trial Registry (NTR3142).
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Affiliation(s)
- J A M G Tol
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - J E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - R Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - F J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - F P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Q Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Y C A Keulemans
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - D Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - N A van der Gaag
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - E A J Rauws
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - D J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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21
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van Rijssen LB, Rombouts SJE, Walma MS, Vogel JA, Tol JA, Molenaar IQ, van Eijck CHJ, Verheij J, van de Vijver MJ, Busch ORC, Besselink MGH. Recent Advances in Pancreatic Cancer Surgery of Relevance to the Practicing Pathologist. Surg Pathol Clin 2016; 9:539-545. [PMID: 27926358 DOI: 10.1016/j.path.2016.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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] [Indexed: 06/06/2023]
Abstract
Recent advances in pancreatic surgery have the potential to improve outcomes for patients with pancreatic cancer. We address 3 new, trending topics in pancreatic surgery that are of relevance to the pathologist. First, increasing awareness of the prognostic impact of intraoperatively detected extraregional and regional lymph node metastases and the international consensus definition on lymph node sampling and reporting. Second, neoadjuvant chemotherapy, which is capable of changing 10% to 20% of initially unresectable, to resectable disease. Third, in patients who remain unresectable following neoadjuvant chemotherapy, local ablative therapies may change indications for treatment and improve outcomes.
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Affiliation(s)
- Lennart B van Rijssen
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Steffi J E Rombouts
- Department of Surgery, University Medical Center, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
| | - Marieke S Walma
- Department of Surgery, University Medical Center, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
| | - Jantien A Vogel
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Johanna A Tol
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, University Medical Center, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, Gravendijkwal 230, Rotterdam 3015 CE, The Netherlands
| | - Joanne Verheij
- Department of Pathology, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Marc J van de Vijver
- Department of Pathology, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands.
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22
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Coelen RJS, Ruys AT, Wiggers JK, Nio CY, Verheij J, Gouma DJ, Besselink MGH, Busch ORC, van Gulik TM. Development of a Risk Score to Predict Detection of Metastasized or Locally Advanced Perihilar Cholangiocarcinoma at Staging Laparoscopy. Ann Surg Oncol 2016; 23:904-910. [PMID: 27586005 PMCID: PMC5149561 DOI: 10.1245/s10434-016-5531-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 03/02/2016] [Indexed: 12/16/2022]
Abstract
Background Nearly half of patients with perihilar cholangiocarcinoma (PHC) have incurable tumors at laparotomy. Staging laparoscopy (SL) potentially detects metastases or locally advanced disease, thereby avoiding unnecessary laparotomy. However, the diagnostic yield of SL has decreased with improved imaging in recent years. Objective The aim of this study was to identify predictors for detecting metastasized or locally advanced PHC at SL and to develop a risk score to select patients who may benefit most from this procedure. Methods Data of patients with potentially resectable PHC who underwent SL between 2000 and 2015 in our center were retrospectively analyzed. Multivariable logistic regression analysis was used to identify independent predictors and to develop a preoperative risk score. Results Unresectable PHC was detected in 41 of 273 patients undergoing SL (yield 15 %). Overall sensitivity of SL was 30 %, with highest sensitivity for detecting peritoneal metastases (73 %). Preoperative imaging factors that were independently associated with unresectability at SL were tumor size ≥4.5 cm, bilateral portal vein involvement, suspected lymph node metastases, and suspected (extra)hepatic metastases on imaging without the possibility of diagnosis by percutaneous- or endoscopic ultrasound-guided biopsy. The derived preoperative risk score showed good discrimination to predict unresectability (area under the curve 0.77, 95 % confidence interval 0.68–0.86) and identified three subgroups with a predicted low-risk of 7 % (N = 203 patients), intermediate-risk of 21 % (N = 39), and high-risk of 58 % (N = 31). Conclusions A selective approach for SL in PHC is recommended since the overall yield is low. The proposed preoperative risk score is useful in selecting patients for SL. Electronic supplementary material The online version of this article (doi:10.1245/s10434-016-5531-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert J S Coelen
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - Anthony T Ruys
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jimme K Wiggers
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Chung Y Nio
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Joanne Verheij
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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23
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Haj Mohammad N, Bernards N, Besselink MGH, Busch OR, Wilmink JW, Creemers GJM, De Hingh IHJT, Lemmens VEPP, van Laarhoven HWM. Volume matters in the systemic treatment of metastatic pancreatic cancer: a population-based study in the Netherlands. J Cancer Res Clin Oncol 2016; 142:1353-60. [PMID: 26995276 PMCID: PMC4869755 DOI: 10.1007/s00432-016-2140-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [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: 01/23/2016] [Accepted: 03/02/2016] [Indexed: 01/01/2023]
Abstract
PURPOSE In pancreatic surgery, a relation between surgical volume and postoperative mortality and overall survival (OS) has been recognized, with high-volume centers reporting significantly better survival rates. We aimed to explore the influence of hospital volume on administration of palliative chemotherapy and OS in the Netherlands. METHODS Patients diagnosed between 2007 and 2011 with metastatic pancreatic cancer were identified in the Netherlands Cancer Registry. Three types of high-volume centers were defined: high-volume (1) incidence center, based on the number of patients diagnosed with metastatic pancreatic cancer, (2) treatment center based on number of patients with metastatic pancreatic cancer who started treatment with palliative chemotherapy and (3) surgical center based on the number of resections with curative intent for pancreatic cancer. Independent predictors of administration of palliative chemotherapy were evaluated by means of logistic regression analysis. The multivariable Cox proportional hazard model was used to assess the impact of being diagnosed or treated in high-volume centers on survival. RESULTS A total of 5385 patients presented with metastatic pancreatic cancer of which 24 % received palliative chemotherapy. Being treated with chemotherapy in a high-volume chemotherapy treatment center was associated with improved survival (HR 0.76, 95 % CI 0.67-0.87). Also, in all patients with metastatic pancreatic cancer, being diagnosed in a high-volume surgical center was associated with improved survival (HR 0.74, 95 % CI 0.66-0.83). CONCLUSIONS Hospital volume of palliative chemotherapy for metastatic pancreatic cancer was associated with improved survival, demonstrating that a volume-outcome relationship, as described for pancreatic surgery, may also exist for pancreatic medical oncology.
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Affiliation(s)
- N Haj Mohammad
- Department of Medical Oncology, Academic Medical Center, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands.
| | - N Bernards
- Department of Medical Oncology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.,Department of Research, Comprehensive Cancer Organisation The Netherlands/Netherlands Cancer Registry, Godebaldkwartier 419, 3511 DT, Utrecht, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands
| | - O R Busch
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands
| | - J W Wilmink
- Department of Medical Oncology, Academic Medical Center, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands
| | - G J M Creemers
- Department of Medical Oncology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - I H J T De Hingh
- Department of Surgical Oncology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - V E P P Lemmens
- Department of Research, Comprehensive Cancer Organisation The Netherlands/Netherlands Cancer Registry, Godebaldkwartier 419, 3511 DT, Utrecht, The Netherlands.,Department of Public Health, Erasmus Medical Center, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - H W M van Laarhoven
- Department of Medical Oncology, Academic Medical Center, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands
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Versteijne E, van Eijck CHJ, Punt CJA, Suker M, Zwinderman AH, Dohmen MAC, Groothuis KBC, Busch ORC, Besselink MGH, de Hingh IHJT, Ten Tije AJ, Patijn GA, Bonsing BA, de Vos-Geelen J, Klaase JM, Festen S, Boerma D, Erdmann JI, Molenaar IQ, van der Harst E, van der Kolk MB, Rasch CRN, van Tienhoven G. Preoperative radiochemotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer (PREOPANC trial): study protocol for a multicentre randomized controlled trial. Trials 2016; 17:127. [PMID: 26955809 PMCID: PMC4784417 DOI: 10.1186/s13063-016-1262-z] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [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: 09/15/2015] [Accepted: 02/26/2016] [Indexed: 12/20/2022] Open
Abstract
Background Pancreatic cancer is the fourth largest cause of cancer death in the United States and Europe with over 100,000 deaths per year in Europe alone. The overall 5-year survival ranges from 2–7 % and has hardly improved over the last two decades. Approximately 15 % of all patients have resectable disease at diagnosis, and of those, only a subgroup has a resectable tumour at surgical exploration. Data from cohort studies have suggested that outcome can be improved by preoperative radiochemotherapy, but data from well-designed randomized studies are lacking. Our PREOPANC phase III trial aims to test the hypothesis that median overall survival of patients with resectable or borderline resectable pancreatic cancer can be improved with preoperative radiochemotherapy. Methods/design The PREOPANC trial is a randomized, controlled, multicentric superiority trial, initiated by the Dutch Pancreatic Cancer Group. Patients with (borderline) resectable pancreatic cancer are randomized to A: direct explorative laparotomy or B: after negative diagnostic laparoscopy, preoperative radiochemotherapy, followed by explorative laparotomy. A hypofractionated radiation scheme of 15 fractions of 2.4 gray (Gy) is combined with a course of gemcitabine, 1,000 mg/m2/dose on days 1, 8 and 15, preceded and followed by a modified course of gemcitabine. The target volumes of radiation are delineated on a 4D CT scan, where at least 95 % of the prescribed dose of 36 Gy in 15 fractions should cover 98 % of the planning target volume. Standard adjuvant chemotherapy is administered in both treatment arms after resection (six cycles in arm A and four in arm B). In total, 244 patients will be randomized in 17 hospitals in the Netherlands. The primary endpoint is overall survival by intention to treat. Secondary endpoints are (R0) resection rate, disease-free survival, time to locoregional recurrence or distant metastases and perioperative complications. Secondary endpoints for the experimental arm are toxicity and radiologic and pathologic response. Discussion The PREOPANC trial is designed to investigate whether preoperative radiochemotherapy improves overall survival by means of increased (R0) resection rates in patients with resectable or borderline resectable pancreatic cancer. Trial registration Trial open for accrual: 3 April 2013 The Netherlands National Trial Register – NTR3709 (8 November 2012) EU Clinical Trials Register – 2012-003181-40 (11 December 2012)
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Affiliation(s)
- Eva Versteijne
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Mustafa Suker
- Department of Surgery, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiologic Biostatics, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Miriam A C Dohmen
- Clinical Research Department, Comprehensive Cancer Organisation the Netherlands (IKNL), Postbus 1281, 6501 BG, Nijmegen, The Netherlands.
| | - Karin B C Groothuis
- Clinical Research Department, Comprehensive Cancer Organisation the Netherlands (IKNL), Postbus 1281, 6501 BG, Nijmegen, The Netherlands.
| | - Oliver R C Busch
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Postbus 1350, 5602 ZA, Eindhoven, The Netherlands.
| | - Albert J Ten Tije
- Department of Medical Oncology, Amphia Hospital, Postbus 90158, 4800 RK, Breda, The Netherlands.
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Postbus 10400, 8000 GK, Zwolle, The Netherlands.
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Postbus 9600, 2300 RC, Leiden, The Netherlands.
| | - Judith de Vos-Geelen
- Department of Medical Oncology, Maastricht University Medical Center, Postbus 3035, 6202 NA, Maastricht, The Netherlands.
| | - Joost M Klaase
- Department of Surgery, Medical Spectrum Twente, Postbus 50 000, 7500 KA, Enschede, The Netherlands.
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Postbus 95500, 1090 HM, Amsterdam, The Netherlands.
| | - Djamila Boerma
- Department of Surgery, Sint Antonius Hospital, Postbus 2500, 3430 EM, Nieuwegein, The Netherlands.
| | - Joris I Erdmann
- Department of Surgery, University Medical Center Groningen, Postbus 30.001, 9700 RB, Groningen, The Netherlands.
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Postbus 85500, 3508 GA, Utrecht, The Netherlands.
| | - Erwin van der Harst
- Department of Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands.
| | - Marion B van der Kolk
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Coen R N Rasch
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Groot Koerkamp B, Wiggers JK, Gonen M, Doussot A, Allen PJ, Besselink MGH, Blumgart LH, Busch ORC, D'Angelica MI, DeMatteo RP, Gouma DJ, Kingham TP, van Gulik TM, Jarnagin WR. Survival after resection of perihilar cholangiocarcinoma-development and external validation of a prognostic nomogram. Ann Oncol 2016; 27:753. [PMID: 26920702 DOI: 10.1093/annonc/mdw063] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Coelen RJS, Ruys AT, Besselink MGH, Busch ORC, van Gulik TM. Diagnostic accuracy of staging laparoscopy for detecting metastasized or locally advanced perihilar cholangiocarcinoma: a systematic review and meta-analysis. Surg Endosc 2016; 30:4163-73. [PMID: 26895909 PMCID: PMC5009158 DOI: 10.1007/s00464-016-4788-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 08/04/2015] [Accepted: 01/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite extensive preoperative staging, still almost half of patients with potentially resectable perihilar cholangiocarcinoma (PHC) have locally advanced or metastasized disease upon exploratory laparotomy. The value of routine staging laparoscopy (SL) in these patients remains unclear with varying results reported in the literature. The aim of the present systematic review was to provide an overview of studies on SL in PHC and to define its current role in preoperative staging. METHODS A systematic review and meta-analysis were performed in PubMed and EMBASE regarding studies providing data on the diagnostic accuracy of SL in PHC. Primary outcome measures were the overall yield and sensitivity to detect unresectable disease. Secondary outcomes were the yield and sensitivity for recent studies (after 2010) and large study cohorts (≥100 patients) and specific (metastatic) lesions. Methodological quality of studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool. RESULTS From 173 records, 12 studies including 832 patients met the inclusion criteria. The yield of SL in PHC varied from 6.4 to 45.0 % with a pooled yield of 24.4 % [95 % confidence interval (CI) 16.4-33.4]. Sensitivity to detect unresectable disease ranged from 31.6 to 75 % with a pooled sensitivity of 52.2 % (95 % CI 47.1-57.2). Sensitivity was highest for peritoneal metastases (80.7 %, 95 % CI 70.9-88.3). Subgroup analysis revealed that the yield and sensitivity tended to be lower for studies after 2010. Considerable heterogeneity was detected among the studies. CONCLUSIONS The results of the pooled analyses suggest that one in four patients with potentially resectable PHC benefits from SL. Given considerable heterogeneity, a trend to lower yield in more recent studies and further improvement of preoperative imaging over time, the routine use of SL seems discouraging. Studies that identify predictors of unresectability, that enable selection of patients who will benefit the most from this procedure, are needed.
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Affiliation(s)
- Robert J S Coelen
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Anthony T Ruys
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Scheffer HJ, Vogel JA, van den Bos W, Neal RE, van Lienden KP, Besselink MGH, van Gemert MJC, van der Geld CWM, Meijerink MR, Klaessens JH, Verdaasdonk RM. The Influence of a Metal Stent on the Distribution of Thermal Energy during Irreversible Electroporation. PLoS One 2016; 11:e0148457. [PMID: 26844550 PMCID: PMC4742246 DOI: 10.1371/journal.pone.0148457] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [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: 11/03/2015] [Accepted: 01/18/2016] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Irreversible electroporation (IRE) uses short duration, high-voltage electrical pulses to induce cell death via nanoscale defects resulting from altered transmembrane potential. The technique is gaining interest for ablations in unresectable pancreatic and hepatobiliary cancer. Metal stents are often used for palliative biliary drainage in these patients, but are currently seen as an absolute contraindication for IRE due to the perceived risk of direct heating of the metal and its surroundings. This study investigates the thermal and tissue viability changes due to a metal stent during IRE. METHODS IRE was performed in a homogeneous tissue model (polyacrylamide gel), without and with a metal stent placed perpendicular and parallel to the electrodes, delivering 90 and 270 pulses (15-35 A, 90 μsec, 1.5 cm active tip exposure, 1.5 cm interelectrode distance, 1000-1500 V/cm, 90 pulses/min), and in-vivo in a porcine liver (4 ablations). Temperature changes were measured with an infrared thermal camera and with fiber-optic probes. Tissue viability after in-vivo IRE was investigated macroscopically using 5-triphenyltetrazolium chloride (TTC) vitality staining. RESULTS In the gel, direct stent-heating was not observed. Contrarily, the presence of a stent between the electrodes caused a higher increase in median temperature near the electrodes (23.2 vs 13.3°C [90 pulses]; p = 0.021, and 33.1 vs 24.8°C [270 pulses]; p = 0.242). In-vivo, no temperature difference was observed for ablations with and without a stent. Tissue examination showed white coagulation 1mm around the electrodes only. A rim of vital tissue remained around the stent, whereas ablation without stent resulted in complete tissue avitality. CONCLUSION IRE in the vicinity of a metal stent does not cause notable direct heating of the metal, but results in higher temperatures around the electrodes and remnant viable tissue. Future studies should determine for which clinical indications IRE in the presence of metal stents is safe and effective.
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Affiliation(s)
- Hester J. Scheffer
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Jantien A. Vogel
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Robert E. Neal
- Department of Radiology, The Alfred Hospital, Melbourne, Australia
| | | | | | - Martin J. C. van Gemert
- Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands
| | - Cees W. M. van der Geld
- Department of Mechanical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Martijn R. Meijerink
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - John H. Klaessens
- Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
| | - Rudolf M. Verdaasdonk
- Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
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van der Geest LGM, Besselink MGH, Busch ORC, de Hingh IHJT, van Eijck CHJ, Dejong CHC, Lemmens VEPP. Elderly Patients Strongly Benefit from Centralization of Pancreatic Cancer Surgery: A Population-Based Study. Ann Surg Oncol 2016; 23:2002-9. [DOI: 10.1245/s10434-016-5089-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Indexed: 12/24/2022]
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Schepers NJ, Bakker OJ, Besselink MGH, Bollen TL, Dijkgraaf MGW, van Eijck CHJ, Fockens P, van Geenen EJM, van Grinsven J, Hallensleben NDL, Hansen BE, van Santvoort HC, Timmer R, Anten MPGF, Bolwerk CJM, van Delft F, van Dullemen HM, Erkelens GW, van Hooft JE, Laheij R, van der Hulst RWM, Jansen JM, Kubben FJGM, Kuiken SD, Perk LE, de Ridder RJJ, Rijk MCM, Römkens TEH, Schoon EJ, Schwartz MP, Spanier BWM, Tan ACITL, Thijs WJ, Venneman NG, Vleggaar FP, van de Vrie W, Witteman BJ, Gooszen HG, Bruno MJ. Early biliary decompression versus conservative treatment in acute biliary pancreatitis (APEC trial): study protocol for a randomized controlled trial. Trials 2016; 17:5. [PMID: 26729193 PMCID: PMC4700728 DOI: 10.1186/s13063-015-1132-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 12/17/2015] [Indexed: 01/25/2023] Open
Abstract
Background Acute pancreatitis is mostly caused by gallstones or sludge. Early decompression of the biliary tree by endoscopic retrograde cholangiography (ERC) with sphincterotomy may improve outcome in these patients. Whereas current guidelines recommend early ERC in patients with concomitant cholangitis, early ERC is not recommended in patients with mild biliary pancreatitis. Evidence on the role of routine early ERC with endoscopic sphincterotomy in patients without cholangitis but with biliary pancreatitis at high risk for complications is lacking. We hypothesize that early ERC with sphincterotomy improves outcome in these patients. Methods/Design The APEC trial is a randomized controlled, parallel group, superiority multicenter trial. Within 24 hours after presentation to the emergency department, patients with biliary pancreatitis without cholangitis and at high risk for complications, based on an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 8 or greater, Modified Glasgow score of 3 or greater, or serum C-reactive protein above 150 mg/L, will be randomized. In 27 hospitals of the Dutch Pancreatitis Study Group, 232 patients will be allocated to early ERC with sphincterotomy or to conservative treatment. The primary endpoint is a composite of major complications (that is, organ failure, pancreatic necrosis, pneumonia, bacteremia, cholangitis, pancreatic endocrine, or exocrine insufficiency) or death within 180 days after randomization. Secondary endpoints include ERC-related complications, infected necrotizing pancreatitis, length of hospital stay and an economical evaluation. Discussion The APEC trial investigates whether an early ERC with sphincterotomy reduces the composite endpoint of major complications or death compared with conservative treatment in patients with biliary pancreatitis at high risk of complications. Trial registration Current Controlled Trials ISRCTN97372133 (date registration: 17-12-2012) Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1132-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands. .,Department of Gastroenterology and Hepatology, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, PO 85500, 3508, GA, Utrecht, The Netherlands.
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Marcel G W Dijkgraaf
- Clinical Research Unit, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, HP 690, PO 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Janneke van Grinsven
- Department of Surgery, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands. .,Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands. .,Department of Surgery, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, PO 2500, 3430, EM, Nieuwegein, The Netherlands.
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Gasthuis, PO 10900, 3004, BA, Rotterdam, The Netherlands.
| | - Clemens J M Bolwerk
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Reinier de Graafweg 3-11, 2625, AD, Delft, The Netherlands.
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, VU University Medical Center Amsterdam, PO Box 7057, 1007, MB, Amsterdam, The Netherlands.
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, PO 30001, 9700, RB, Groningen, The Netherlands.
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, PO 9014, 7300, DS, Apeldoorn, The Netherlands.
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center University of Amsterdam, PO 22660, 1100, DD, Amsterdam, The Netherlands.
| | - Robert Laheij
- Department of Gastroenterology and Hepatology, St. Elisabeth Hospital, PO 90151, 5000, LC, Tilburg, The Netherlands.
| | - René W M van der Hulst
- Department of Gastroenterology and Hepatology, Kennemer Gasthuis, PO 417, 2000, AK, Haarlem, The Netherlands.
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Postbus 95500, 1090, HM, Amsterdam, The Netherlands.
| | - Frank J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Maasstadweg 21, 3079, DZ, Rotterdam, The Netherlands.
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, Sint Lucas Andreas Hospital, PO 9243, 1006, AE, Amsterdam, The Netherlands.
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden, PO 432, 2501, CK Den Haag, The Netherlands.
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, PO 5800, 6202, AZ, Maastricht, The Netherlands.
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, PO 90158, 4800, RK, Breda, The Netherlands.
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, PO 90153, 5200, ME 's-Hertogenbosch, The Netherlands.
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, PO 1350, 5602, ZA, Eindhoven, The Netherlands.
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, PO 1502, 3800, BM, Amersfoort, The Netherlands.
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, PO 9555, 6800, TA, Arnhem, The Netherlands.
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina Hospital, PO 9015, 6500, GS, Nijmegen, The Netherlands.
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, PO 30033, 9700, RM, Groningen, The Netherlands.
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO 50000, 7500, KA, Enschede, The Netherlands.
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, PO 85500, 3508, GA, Utrecht, The Netherlands.
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, PO 444, 3300, AK, Dordrecht, The Netherlands.
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei Ede, PO 9025, 6710, HN, Ede, The Netherlands.
| | - Hein G Gooszen
- Department of Operating Rooms - Evidence Based Surgery, Radboud University Nijmegen Medical Centre, HP 690, PO 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, PO 2040, 3000, CA, Rotterdam, The Netherlands.
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van der Geest LGM, Besselink MGH, van Gestel YRBM, Busch ORC, de Hingh IHJT, de Jong KP, Molenaar IQ, Lemmens VEPP. Pancreatic cancer surgery in elderly patients: Balancing between short-term harm and long-term benefit. A population-based study in the Netherlands. Acta Oncol 2015; 55:278-85. [PMID: 26552841 DOI: 10.3109/0284186x.2015.1105381] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/01/2015] [Accepted: 10/04/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND At a national level, it is unknown to what degree elderly patients with pancreatic or periampullary carcinoma benefit from surgical treatment compared to their younger counterparts. We investigated resection rates and outcomes after surgical treatment among elderly patients. METHODS From the Netherlands Cancer Registry, 20 005 patients diagnosed with primary pancreatic or periampullary cancer in 2005-2013 were selected. The associations between age (<70, 70-74, 75-79, ≥80 years) and resection rates were investigated using χ(2) tests, and surgical outcomes (30-, 90-day mortality) were evaluated using logistic regression analysis. Overall survival after resection was investigated by means of Kaplan-Meier and Cox proportional hazard regression analysis. RESULTS During the study period, resection rates increased in all age groups (<70 years: 20-30%, p < 0.001; ≥80 years: 2-8%, p < 0.001). Of 3845 patients who underwent tumour resection for pancreatic or periampullary carcinoma, the proportion of octogenarians increased from 3.5% to 5.5% (p = 0.03), whereas postoperative mortality did not increase (30-day: 6-3%, p = 0.06; 90-day: 9-8%, p = 0.21). With rising age, 30-day postoperative mortality increased (4-5-7-8%, respectively, p < 0.001), while 90-day mortality was 6-10-13-12% (p < 0.001) and three-year overall survival rates after surgery were 35-33-28-31%, respectively (p < 0.001). After adjustment for confounding factors, octogenarians who survived 90 days postoperative exhibited an overall survival close to younger patients [hazard ratio (≥80 vs. <70 years) = 1.21, 95% confidence interval (0.99-1.47), p = 0.07]. CONCLUSION Despite higher short-term mortality, octogenarians who underwent pancreatic resection showed long-term survival similar to younger patients. With careful patient screening and counselling of elderly patients, a further increase of resection rates may be combined with improved outcomes.
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Affiliation(s)
- Lydia G M van der Geest
- a Department of Research , Netherlands Comprehensive Cancer Organisation (IKNL) , Utrecht , The Netherlands
| | - Marc G H Besselink
- b Department of Surgery , Academic Medical Center AMC , Amsterdam , The Netherlands
| | - Yvette R B M van Gestel
- a Department of Research , Netherlands Comprehensive Cancer Organisation (IKNL) , Utrecht , The Netherlands
| | - Olivier R C Busch
- b Department of Surgery , Academic Medical Center AMC , Amsterdam , The Netherlands
| | | | - Koert P de Jong
- d Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation , University Medical Center Groningen , Groningen , The Netherlands
| | - I Quintus Molenaar
- e Department of Surgery , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Valery E P P Lemmens
- a Department of Research , Netherlands Comprehensive Cancer Organisation (IKNL) , Utrecht , The Netherlands
- f Department of Public Health , Erasmus MC University Medical Center , Rotterdam , The Netherlands
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Smits FJ, van Santvoort HC, Besselink MGH, Borel Rinkes IHM, Molenaar IQ. Systematic review on the use of matrix-bound sealants in pancreatic resection. HPB (Oxford) 2015; 17:1033-9. [PMID: 26292846 PMCID: PMC4605343 DOI: 10.1111/hpb.12472] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/04/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic fistula is a potentially life-threatening complication after a pancreatic resection. The aim of this systematic review was to evaluate the role of matrix-bound sealants after a pancreatic resection in terms of preventing or ameliorating the course of a post-operative pancreatic fistula. METHODS A systematic search was performed in the literature from May 2005 to April 2015. Included were clinical studies using matrix-bound sealants after a pancreatic resection, reporting a post-operative pancreatic fistula (POPF) according to the International Study Group on Pancreatic Fistula classification, in which grade B and C fistulae were considered clinically relevant. RESULTS Two were studies on patients undergoing pancreatoduodenectomy (sealants n = 67, controls n = 27) and four studies on a distal pancreatectomy (sealants n = 258, controls n = 178). After a pancreatoduodenectomy, 13% of patients treated with sealants versus 11% of patients without sealants developed a POPF (P = 0.76), of which 4% versus 4% were clinically relevant (P = 0.87). After a distal pancreatectomy, 42% of patients treated with sealants versus 52% of patients without sealants developed a POPF (P = 0.03). Of these, 9% versus 12% were clinically relevant (P = 0.19). CONCLUSIONS The present data do not support the routine use of matrix-bound sealants after a pancreatic resection, as there was no effect on clinically relevant POPF. Larger, well-designed studies are needed to determine the efficacy of sealants in preventing POPF after a pancreatoduodenectomy.
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Affiliation(s)
- F Jasmijn Smits
- Department of Surgery, University Medical Center UtrechtUtrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Center UtrechtUtrecht, The Netherlands,Department of Surgery, Academic Medical CenterAmsterdam, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical CenterAmsterdam, The Netherlands
| | | | - I Quintus Molenaar
- Department of Surgery, University Medical Center UtrechtUtrecht, The Netherlands
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Gerritsen A, Wennink RAW, Busch ORC, Borel Rinkes IHM, Kazemier G, Gouma DJ, Molenaar IQ, Besselink MGH. Feeding patients with preoperative symptoms of gastric outlet obstruction after pancreatoduodenectomy: Early oral or routine nasojejunal tube feeding? Pancreatology 2015; 15:548-553. [PMID: 26235830 DOI: 10.1016/j.pan.2015.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/03/2015] [Accepted: 07/05/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early oral feeding is currently considered the optimal routine feeding strategy after pancreatoduodenectomy (PD). Some have suggested that patients with preoperative symptoms of gastric outlet obstruction (GOO) who undergo PD have such a high risk of developing delayed gastric emptying that these patients should rather receive routine postoperative tube feeding. The aim of this study was to determine whether clinical outcomes after PD in these patients differ between postoperative early oral feeding and routine tube feeding. METHODS We analyzed a consecutive multicenter cohort of patients with preoperative symptoms of GOO undergoing PD (2010-2013). Patients were categorized into two groups based on the applied postoperative feeding strategy (dependent on their center's routine strategy): early oral feeding or routine nasojejunal tube feeding. RESULTS Of 497 patients undergoing PD, 83 (17%) suffered from preoperative symptoms of GOO. 49 patients received early oral feeding and 29 patients received routine tube feeding. Time to resumption of adequate oral intake (primary outcome; 14 vs. 12 days, p = 0.61) did not differ between these two feeding strategies. Furthermore, overall complications and length of stay were similar in both groups. Of the patients receiving early oral feeding, 24 (49%) ultimately required postoperative tube feeding. In patients with an uncomplicated postoperative course, early oral feeding was associated with shorter time to adequate oral intake (8 vs. 12 days, p = 0.008) and shorter hospital stay (9 vs. 13 days, p < 0.001). CONCLUSION Also in patients with preoperative symptoms of GOO, early oral feeding can be considered the routine feeding strategy after PD.
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Affiliation(s)
- Arja Gerritsen
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Roos A W Wennink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Geert Kazemier
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Groot Koerkamp B, Wiggers JK, Gonen M, Doussot A, Allen PJ, Besselink MGH, Blumgart LH, Busch ORC, D'Angelica MI, DeMatteo RP, Gouma DJ, Kingham TP, van Gulik TM, Jarnagin WR. Survival after resection of perihilar cholangiocarcinoma-development and external validation of a prognostic nomogram. Ann Oncol 2015; 26:1930-1935. [PMID: 26133967 DOI: 10.1093/annonc/mdv279] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 06/22/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The objective of this study was to derive and validate a prognostic nomogram to predict disease-specific survival (DSS) after a curative intent resection of perihilar cholangiocarcinoma (PHC). PATIENTS AND METHODS A nomogram was developed from 173 patients treated at Memorial Sloan Kettering Cancer Center (MSKCC), New York, USA. The nomogram was externally validated in 133 patients treated at the Academic Medical Center (AMC), Amsterdam, The Netherlands. Prognostic accuracy was assessed with concordance estimates and calibration, and compared with the American Joint Committee on Cancer (AJCC) staging system. The nomogram will be available as web-based calculator at mskcc.org/nomograms. RESULTS For all 306 patients, the median overall survival (OS) was 40 months and the median DSS 41 months. Median follow-up for patients alive at last follow-up was 48 months. Lymph node involvement, resection margin status, and tumor differentiation were independent prognostic factors in the derivation cohort (MSKCC). A nomogram with these prognostic factors had a concordance index of 0.73 compared with 0.66 for the AJCC staging system. In the validation cohort (AMC), the concordance index was 0.72, compared with 0.60 for the AJCC staging system. Calibration was good in the derivation cohort; in the validation cohort patients had a better median DSS than predicted by the model. CONCLUSIONS The proposed nomogram to predict DSS after curative intent resection of PHC had a better prognostic accuracy than the AJCC staging system. Calibration was suboptimal because DSS differed between the two institutions. The nomogram can inform patients and physicians, guide shared decision making for adjuvant therapy, and stratify patients in future randomized, controlled trials.
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Affiliation(s)
- B Groot Koerkamp
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA; Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam.
| | - J K Wiggers
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA; Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M Gonen
- Department of Statistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A Doussot
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - P J Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - L H Blumgart
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - O R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M I D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - R P DeMatteo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - D J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - T P Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - W R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
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Klaassen R, Bennink RJ, van Tienhoven G, Bijlsma MF, Besselink MGH, van Berge Henegouwen MI, Wilmink JW, Nederveen AJ, Windhorst AD, Hulshof MCCM, van Laarhoven HWM. Feasibility and repeatability of PET with the hypoxia tracer [(18)F]HX4 in oesophageal and pancreatic cancer. Radiother Oncol 2015; 116:94-9. [PMID: 26049919 DOI: 10.1016/j.radonc.2015.05.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 05/11/2015] [Accepted: 05/14/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the feasibility and to determine the repeatability of recurrent [(18)F]HX4 PET scans in patients with oesophageal (EC) and pancreatic (PC) cancer. MATERIALS AND METHODS 32 patients were scanned in total; seven patients (4 EC/3 PC) were scanned 2, 3 and 4h post injection (PI) of [(18)F]HX4 and 25 patients (15 EC/10 PC) were scanned twice 3.5h PI, on two separate days (median 4, range 1-9days). Maximum tumour to background ratio (TBRmax) and the tumour hypoxic volume (HV) (TBR>1.0) were calculated. Repeatability was assessed using Bland-Altman analysis. Agreement in localization was calculated as the distance between the centres of mass in the HVs. RESULTS For EC, the TBRmax in the tumour (mean±SD) was 1.87±0.46 with a coefficient of repeatability (CoR) of 0.53 (28% of mean). The HV ranged from 3.4 to 98.8ml with a CoR of 5.1ml. For PC, the TBRmax was 1.72±0.23 with a CoR of 0.27 (16% of mean). The HV ranged from 4.6 to 104.0ml with a CoR of 7.8ml. The distance between the centres of mass in the HV was 2.2±1.3mm for EC and 2.1±1.5mm for PC. CONCLUSIONS PET scanning with [(18)F]HX4 was feasible in both EC and PC patients. Amount and location of elevated [(18)F]HX4 uptake showed good repeatability, suggesting [(18)F]HX4 PET could be a promising tool for radiation therapy planning and treatment response monitoring in EC and PC patients.
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Affiliation(s)
- Remy Klaassen
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands; LEXOR (Laboratory for Experimental Oncology and Radiobiology), Academic Medical Center, Amsterdam, The Netherlands.
| | - Roelof J Bennink
- Department of Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Maarten F Bijlsma
- LEXOR (Laboratory for Experimental Oncology and Radiobiology), Academic Medical Center, Amsterdam, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Johanna W Wilmink
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Aart J Nederveen
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Albert D Windhorst
- Department of Radiology & Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
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Wicherts DA, Bruntink MM, Demirkiran A, van Santvoort HC, van Lienden KP, Ambarus CA, Besselink MGH, van Gulik TM. Ruptured hepatic artery aneurysm: an unusual presentation of polyarteritis nodosa. BMJ Case Rep 2015; 2015:bcr-2014-208240. [PMID: 25833909 DOI: 10.1136/bcr-2014-208240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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 52-year-old woman presented with severe acute right upper quadrant abdominal pain and signs of intra-abdominal haemorrhage. CT and selective angiography revealed a ruptured right hepatic artery aneurysm and diffuse aneurysmatic disease involving most intra-abdominal organs, suggestive of polyarteritis nodosa. Although treatment with high-dose steroids was initiated, the patient died of progressive bowel ischaemia.
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Affiliation(s)
- D A Wicherts
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M M Bruntink
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | - A Demirkiran
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | - H C van Santvoort
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - K P van Lienden
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - C A Ambarus
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Abu Hilal M, van der Poel MJ, Samim M, Besselink MGH, Flowers D, Stedman B, Pearce NW. Laparoscopic liver resection for lesions adjacent to major vasculature: feasibility, safety and oncological efficiency. J Gastrointest Surg 2015; 19:692-8. [PMID: 25564324 DOI: 10.1007/s11605-014-2739-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [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] [Received: 09/29/2014] [Accepted: 12/19/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVES Laparoscopic liver resection for lesions adjacent to major vasculature can be challenging, and many would consider it a contraindication. Recently, however, laparoscopic liver surgeons have been pushing boundaries and approached some of these lesions laparoscopically. We assessed feasibility, safety and oncological efficiency of this laparoscopic approach for these lesions. METHODS This is a monocenter study (2003-2013) describing technique and outcomes of laparoscopic liver resection for lesions adjacent to major vasculature: <2 cm from the portal vein (main trunk and first division), hepatic arteries or inferior vena cava. RESULTS Thirty-seven patients underwent laparoscopic liver resection (LLR) for a lesion adjacent to major vasculature. Twenty-four (65%) resections were for malignant disease and 92% R0 resections. Conversion occurred in three patients (8%). Mean operative time was 313 min (standard deviation (SD) ± 101) and intraoperative blood loss 400 ml (IQR 213-700). Clavien-Dindo complications > II occurred in two cases (5%), with no mortality. Lesions at <1 cm were larger (7.2 cm (2.7-14) vs. 3 cm (2.5-5), p = 0.03) and operation time was longer (344 ± 94 vs. 262 ± 92 min, p = 0.01) than lesions at 1-2 cm from major vasculature. CONCLUSIONS Lesions <2 cm from major hepatic vasculature do not represent an absolute contraindication for LLR when performed by experienced laparoscopic liver surgeons in selected patients.
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Affiliation(s)
- Mohammad Abu Hilal
- Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 2YD, UK,
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Wiggers JK, Coelen RJS, Rauws EAJ, van Delden OM, van Eijck CHJ, de Jonge J, Porte RJ, Buis CI, Dejong CHC, Molenaar IQ, Besselink MGH, Busch ORC, Dijkgraaf MGW, van Gulik TM. Preoperative endoscopic versus percutaneous transhepatic biliary drainage in potentially resectable perihilar cholangiocarcinoma (DRAINAGE trial): design and rationale of a randomized controlled trial. BMC Gastroenterol 2015; 15:20. [PMID: 25887103 PMCID: PMC4332425 DOI: 10.1186/s12876-015-0251-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [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: 01/29/2015] [Accepted: 02/05/2015] [Indexed: 12/13/2022] Open
Abstract
Background Liver surgery in perihilar cholangiocarcinoma (PHC) is associated with high postoperative morbidity because the tumor typically causes biliary obstruction. Preoperative biliary drainage is used to create a safer environment prior to liver surgery, but biliary drainage may be harmful when severe drainage-related complications deteriorate the patients’ condition or increase the risk of postoperative morbidity. Biliary drainage can cause cholangitis/cholecystitis, pancreatitis, hemorrhage, portal vein thrombosis, bowel wall perforation, or dehydration. Two methods of preoperative biliary drainage are mostly applied: endoscopic biliary drainage, which is currently used in most regional centers before referring patients for surgical treatment, and percutaneous transhepatic biliary drainage. Both methods are associated with severe drainage-related complications, but two small retrospective series found a lower incidence in the number of preoperative complications after percutaneous drainage compared to endoscopic drainage (18-25% versus 38-60%, respectively). The present study randomizes patients with potentially resectable PHC and biliary obstruction between preoperative endoscopic or percutaneous transhepatic biliary drainage. Methods/Design The study is a multi-center trial with an “all-comers” design, randomizing patients between endoscopic or percutaneous transhepatic biliary drainage. All patients selected to potentially undergo a major liver resection for presumed PHC are eligible for inclusion in the study provided that the biliary system in the future liver remnant is obstructed (even if they underwent previous inadequate endoscopic drainage). Primary outcome measure is the total number of severe preoperative complications between randomization and exploratory laparotomy. The study is designed to detect superiority of percutaneous drainage: a provisional sample size of 106 patients is required to detect a relative decrease of 50% in the number of severe preoperative complications (alpha = 0.95; beta = 0.8). Interim analysis after inclusion of 53 patients (50%) will provide the definitive sample size. Secondary outcome measures encompass the success of biliary drainage, quality of life, and postoperative morbidity and mortality. Discussion The DRAINAGE trial is designed to identify a difference in the number of severe drainage-related complications after endoscopic and percutaneous transhepatic biliary drainage in patients selected to undergo a major liver resection for perihilar cholangiocarcinoma. Trial registration Netherlands Trial Register [NTR4243, 11 October 2013]. Electronic supplementary material The online version of this article (doi:10.1186/s12876-015-0251-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jimme K Wiggers
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Room IWO-A1.119, 1105, AZ, Amsterdam, The Netherlands.
| | - Robert J S Coelen
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Room IWO-A1.119, 1105, AZ, Amsterdam, The Netherlands.
| | - Erik A J Rauws
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Otto M van Delden
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands.
| | | | - Jeroen de Jonge
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Robert J Porte
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Carlijn I Buis
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center and NUTRIM School for Translational Research in Metabolism, Maastricht, the Netherlands.
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Room IWO-A1.119, 1105, AZ, Amsterdam, The Netherlands.
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Room IWO-A1.119, 1105, AZ, Amsterdam, The Netherlands.
| | | | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Meibergdreef 9, Room IWO-A1.119, 1105, AZ, Amsterdam, The Netherlands.
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Tol JAMG, Brosens LAA, van Dieren S, van Gulik TM, Busch ORC, Besselink MGH, Gouma DJ. Impact of lymph node ratio on survival in patients with pancreatic and periampullary cancer. Br J Surg 2014; 102:237-45. [DOI: 10.1002/bjs.9709] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 08/18/2014] [Accepted: 10/17/2014] [Indexed: 12/17/2022]
Abstract
Abstract
Background
According to some studies, the number of lymph nodes with metastases in relation to the total number of removed lymph nodes, the lymph node ratio (LNR), is one of the most powerful predictors of survival after resection in patients with pancreatic cancer. However, contradictory results have been reported, and small sample sizes of the cohorts and different definitions of a microscopic positive resection margin (R1) hamper the interpretation of data.
Methods
The predictive value of LNR for 3-year survival was assessed using a Cox proportional hazards model. From 1992 to 2012, all patients with pancreatic and periampullary cancer operated on with pancreatoduodenectomy were selected from a database. Clinicopathological characteristics were analysed. Microscopic positive resection margin was defined as the microscopic presence of tumour cells within 1 mm of the margins. A nomogram was created.
Results
Some 760 patients were included. Predictive factors for death in 350 patients with pancreatic ductal adenocarcinoma included in the nomogram were: R1 resection (hazard ratio (HR) 1·55, 95 per cent c.i. 1·07 to 2·25), poor tumour differentiation (HR 2·78, 1·40 to 5·52), LNR above 0·18 (HR 1·75, 1·13 to 2·70) and no adjuvant therapy (HR 1·54, 1·01 to 2·34). The C statistic was 0·658 (0·632 to 0·698), and calibration was good (Hosmer–Lemeshow χ2 = 5·67, P =0·773). LNR and poor tumour differentiation (HR 4·51 and 3·30 respectively) were also predictive in patients with distal common bile duct (CBD) cancer. LNR, R1 resection and jaundice were predictors of death in patients with ampullary cancer (HR 7·82, 2·68 and 1·93 respectively).
Conclusion
LNR is a common predictor of poor survival in pancreatic, distal CBD and ampullary cancer.
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Affiliation(s)
- J A M G Tol
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - L A A Brosens
- Departments of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - S van Dieren
- Departments of Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - T M van Gulik
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - O R C Busch
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M G H Besselink
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - D J Gouma
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Rombouts SJE, Vogel JA, van Santvoort HC, van Lienden KP, van Hillegersberg R, Busch ORC, Besselink MGH, Molenaar IQ. Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer. Br J Surg 2014; 102:182-93. [PMID: 25524417 DOI: 10.1002/bjs.9716] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 09/14/2014] [Accepted: 10/23/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Locally advanced pancreatic cancer (LAPC) is associated with a very poor prognosis. Current palliative (radio)chemotherapy provides only a marginal survival benefit of 2-3 months. Several innovative local ablative therapies have been explored as new treatment options. This systematic review aims to provide an overview of the clinical outcomes of these ablative therapies. METHODS A systematic search in PubMed, Embase and the Cochrane Library was performed to identify clinical studies, published before 1 June 2014, involving ablative therapies in LAPC. Outcomes of interest were safety, survival, quality of life and pain. RESULTS After screening 1037 articles, 38 clinical studies involving 1164 patients with LAPC, treated with ablative therapies, were included. These studies concerned radiofrequency ablation (RFA) (7 studies), irreversible electroporation (IRE) (4), stereotactic body radiation therapy (SBRT) (16), high-intensity focused ultrasound (HIFU) (5), iodine-125 (2), iodine-125-cryosurgery (2), photodynamic therapy (1) and microwave ablation (1). All strategies appeared to be feasible and safe. Outcomes for postoperative, procedure-related morbidity and mortality were reported only for RFA (4-22 and 0-11 per cent respectively), IRE (9-15 and 0-4 per cent) and SBRT (0-25 and 0 per cent). Median survival of up to 25·6, 20·2, 24·0 and 12·6 months was reported for RFA, IRE, SBRT and HIFU respectively. Pain relief was demonstrated for RFA, IRE, SBRT and HIFU. Quality-of-life outcomes were reported only for SBRT, and showed promising results. CONCLUSION Ablative therapies in patients with LAPC appear to be feasible and safe.
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Affiliation(s)
- S J E Rombouts
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Tol JAMG, Eshuis WJ, Besselink MGH, van Gulik TM, Busch ORC, Gouma DJ. Non-radical resection versus bypass procedure for pancreatic cancer - a consecutive series and systematic review. Eur J Surg Oncol 2014; 41:220-7. [PMID: 25511567 DOI: 10.1016/j.ejso.2014.11.041] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 11/06/2014] [Accepted: 11/16/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Most survival studies comparing non-radical resections to bypass surgery in patients with pancreatic cancer often do not differentiate between an R1 and R2 resection. The aim of this study was to evaluate whether non-radical R1 and R2 resections have better postoperative outcomes and survival compared to a palliative bypass. METHODS A single center cohort study was performed analyzing mortality, morbidity and 1-year survival after R1 (tumor cells within 1 mm from the circumferential margin), R2 and bypass surgery in patients with pancreatic cancer. For the systematic review, studies were identified comparing R1 or R2 resections with bypass, in patients with pancreatic cancer. Postoperative outcomes were compared including the cohort study. RESULTS The cohort study (n=405) showed higher morbidity rates after R1 (n=191) and R2 (n=11) resections compared to bypass (52% and 73% vs. 34%, p < 0.01). In-hospital mortality did not differ (overall 1.7%). 1-year survival rates were 71%, 46% and 32% after R1, R2 resection and bypass (p=0.6 between R2 and bypass). The systematic review identified 8 studies, after including the cohort study 1535 patients were analyzed. Increased morbidity after R1-R2 resection (48%) compared to bypass (30-34%) was found. Median survival was 14-18 months after R1 resection vs. 9-13 months after bypass and 8.5-11.5 months after R2 resection vs. 7.5-10.7 months after bypass. CONCLUSION An R2 resection should be avoided in patients with pancreatic cancer due to its poor prognosis. Survival benefit after an R1 resection, as compared to bypass surgery, justifies a resection despite the increased morbidity rate.
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Affiliation(s)
- J A M G Tol
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - W J Eshuis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - D J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Gerritsen A, Wennink RAW, Besselink MGH, van Santvoort HC, Tseng DSJ, Steenhagen E, Borel Rinkes IHM, Molenaar IQ. Early oral feeding after pancreatoduodenectomy enhances recovery without increasing morbidity. HPB (Oxford) 2014; 16:656-64. [PMID: 24308458 PMCID: PMC4105904 DOI: 10.1111/hpb.12197] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 10/15/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate whether a change in the routine feeding strategy applied after pancreatoduodenectomy (PD) from nasojejunal tube (NJT) feeding to early oral feeding improved clinical outcomes. METHODS An observational cohort study was performed in 102 consecutive patients undergoing PD. In period 1 (n = 51, historical controls), the routine postoperative feeding strategy was NJT feeding. This was changed to a protocol of early oral feeding with on-demand NJT feeding in period 2 (n = 51, consecutive prospective cohort). The primary outcome was time to resumption of adequate oral intake. RESULTS The baseline characteristics of study subjects in both periods were comparable. In period 1, 98% (n = 50) of patients received NJT feeding, whereas in period 2, 53% (n = 27) of patients did so [for delayed gastric empting (DGE) (n = 20) or preoperative malnutrition (n = 7)]. The time to resumption of adequate oral intake significantly decreased from 12 days in period 1 to 9 days in period 2 (P = 0.015), and the length of hospital stay shortened from 18 days in period 1 to 13 days in period 2 (P = 0.015). Overall, there were no differences in the incidences of complications of Clavien-Dindo Grade III or higher, DGE, pancreatic fistula, postoperative haemorrhage and mortality between the two periods. CONCLUSIONS The introduction of an early oral feeding strategy after PD reduced the time to resumption of adequate oral intake and length of hospital stay without negatively impacting postoperative morbidity.
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Affiliation(s)
- Arja Gerritsen
- Department of Surgery, University Medical Centre UtrechtUtrecht, the Netherlands
| | - Roos A W Wennink
- Department of Surgery, University Medical Centre UtrechtUtrecht, the Netherlands
| | - Marc G H Besselink
- Department of Surgery, University Medical Centre UtrechtUtrecht, the Netherlands,Department of Surgery, Academic Medical Centre AmsterdamAmsterdam, the Netherlands
| | | | - Dorine S J Tseng
- Department of Surgery, University Medical Centre UtrechtUtrecht, the Netherlands
| | - Elles Steenhagen
- Department of Dietetics, Division of Internal Medicine and Dermatology, University Medical Centre UtrechtUtrecht, the Netherlands
| | | | - I Quintus Molenaar
- Department of Surgery, University Medical Centre UtrechtUtrecht, the Netherlands
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Nijmeijer RM, van Santvoort HC, Zhernakova A, Teller S, Scheiber JA, de Kovel CG, Besselink MGH, Visser JTJ, Lutgendorff F, Bollen TL, Boermeester MA, Rijkers GT, Weiss FU, Mayerle J, Lerch MM, Gooszen HG, Akkermans LMA, Wijmenga C. Association analysis of genetic variants in the myosin IXB gene in acute pancreatitis. PLoS One 2013; 8:e85870. [PMID: 24386489 PMCID: PMC3875581 DOI: 10.1371/journal.pone.0085870] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 12/08/2013] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Impairment of the mucosal barrier plays an important role in the pathophysiology of acute pancreatitis. The myosin IXB (MYO9B) gene and the two tight-junction adaptor genes, PARD3 and MAGI2, have been linked to gastrointestinal permeability. Common variants of these genes are associated with celiac disease and inflammatory bowel disease, two other conditions in which intestinal permeability plays a role. We investigated genetic variation in MYO9B, PARD3 and MAGI2 for association with acute pancreatitis. METHODS Five single nucleotide polymorphisms (SNPs) in MYO9B, two SNPs in PARD3, and three SNPs in MAGI2 were studied in a Dutch cohort of 387 patients with acute pancreatitis and over 800 controls, and in a German cohort of 235 patients and 250 controls. RESULTS Association to MYO9B and PARD3 was observed in the Dutch cohort, but only one SNP in MYO9B and one in MAGI2 showed association in the German cohort (p < 0.05). Joint analysis of the combined cohorts showed that, after correcting for multiple testing, only two SNPs in MYO9B remained associated (rs7259292, p = 0.0031, odds ratio (OR) 1.94, 95% confidence interval (95% CI) 1.35-2.78; rs1545620, p = 0.0006, OR 1.33, 95% CI 1.16-1.53). SNP rs1545620 is a non-synonymous SNP previously suspected to impact on ulcerative colitis. None of the SNPs showed association to disease severity or etiology. CONCLUSION Variants in MYO9B may be involved in acute pancreatitis, but we found no evidence for involvement of PARD3 or MAGI2.
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Affiliation(s)
- Rian M. Nijmeijer
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- * E-mail:
| | | | - Alexandra Zhernakova
- Complex Genetics Group, Department of Medical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Steffen Teller
- Department of Internal Medicine A, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Jonas A. Scheiber
- Department of Internal Medicine A, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Carolien G. de Kovel
- Complex Genetics Group, Department of Medical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marc G. H. Besselink
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Jeroen T. J. Visser
- Department of Cell Biology, Immunology Section, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Femke Lutgendorff
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Thomas L. Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Ger T. Rijkers
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Operating Room/Evidence Based Surgery, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Frank U. Weiss
- Department of Internal Medicine A, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Julia Mayerle
- Department of Internal Medicine A, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Markus M. Lerch
- Department of Internal Medicine A, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Hein G. Gooszen
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Operating Room/Evidence Based Surgery, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | | | - Cisca Wijmenga
- Complex Genetics Group, Department of Medical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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van Brunschot S, van Grinsven J, Voermans RP, Bakker OJ, Besselink MGH, Boermeester MA, Bollen TL, Bosscha K, Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, Dijkgraaf MGW, van Eijck CH, Erkelens GW, van Goor H, Hadithi M, Haveman JW, Hofker SH, Jansen JJM, Laméris JS, van Lienden KP, Manusama ER, Meijssen MA, Mulder CJ, Nieuwenhuis VB, Poley JW, de Ridder RJ, Rosman C, Schaapherder AF, Scheepers JJ, Schoon EJ, Seerden T, Spanier BWM, Straathof JWA, Timmer R, Venneman NG, Vleggaar FP, Witteman BJ, Gooszen HG, van Santvoort HC, Fockens P. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol 2013; 13:161. [PMID: 24274589 PMCID: PMC4222267 DOI: 10.1186/1471-230x-13-161] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/13/2013] [Indexed: 02/06/2023] Open
Abstract
Background Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes. Methods/Design The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs. Discussion The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.
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Affiliation(s)
- Sandra van Brunschot
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, The Netherlands.
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Bakker OJ, van Santvoort H, Besselink MGH, Boermeester MA, van Eijck C, Dejong K, van Goor H, Hofker S, Ahmed Ali U, Gooszen HG, Bollen TL. Extrapancreatic necrosis without pancreatic parenchymal necrosis: a separate entity in necrotising pancreatitis? Gut 2013; 62:1475-80. [PMID: 22773550 DOI: 10.1136/gutjnl-2012-302870] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [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] [Indexed: 12/22/2022]
Abstract
OBJECTIVE In the revised Atlanta classification of acute pancreatitis, the term necrotising pancreatitis also refers to patients with only extrapancreatic fat necrosis without pancreatic parenchymal necrosis (EXPN), as determined on contrast-enhanced CT (CECT). Patients with EXPN are thought to have a better clinical outcome, although robust data are lacking. METHODS A post hoc analysis was performed of a prospective multicentre database including 639 patients with necrotising pancreatitis on contrast-enhanced CT. All CECT scans were reviewed by a single radiologist blinded to the clinical outcome. Patients with EXPN were compared with patients with pancreatic parenchymal necrosis (with or without extrapancreatic necrosis). Outcomes were persistent organ failure, need for intervention and mortality. A predefined subgroup analysis was performed on patients who developed infected necrosis. RESULTS 315 patients with EXPN were compared with 324 patients with pancreatic parenchymal necrosis. Patients with EXPN less often suffered from complications: persistent organ failure (21% vs 45%, p<0.001), persistent multiple organ failure (15% vs 36%, p<0.001), infected necrosis (16% vs 47%, p<0.001), intervention (18% vs 57%, p<0.001) and mortality (9% vs 20%, p<0.001). When infection of extrapancreatic necrosis developed, outcomes between groups were equal (mortality with infected necrosis: EXPN 28% vs pancreatic necrosis 18%, p=0.16). CONCLUSION EXPN causes fewer complications than pancreatic parenchymal necrosis. It should therefore be considered a separate entity in acute pancreatitis. Outcome in cases of infected necrosis is similar.
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Affiliation(s)
- Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Schepers NJ, Besselink MGH, van Santvoort HC, Bakker OJ, Bruno MJ. Early management of acute pancreatitis. Best Pract Res Clin Gastroenterol 2013; 27:727-43. [PMID: 24160930 DOI: 10.1016/j.bpg.2013.08.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Acute pancreatitis is the most common gastro-intestinal indication for acute hospitalization and its incidence continues to rise. In severe pancreatitis, morbidity and mortality remains high and is mainly driven by organ failure and infectious complications. Early management strategies should aim to prevent or treat organ failure and to reduce infectious complications. This review addresses the management of acute pancreatitis in the first hours to days after onset of symptoms, including fluid therapy, nutrition and endoscopic retrograde cholangiography. This review also discusses the recently revised Atlanta classification which provides new uniform terminology, thereby facilitating communication regarding severity and complications of pancreatitis.
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Affiliation(s)
- Nicolien J Schepers
- Department of Operation Rooms, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.
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Abstract
BACKGROUND Acute pancreatitis remains an unpredictable, potentially lethal disease with significant morbidity and mortality rates. New insights in the pathophysiology of acute pancreatitis have changed management concepts. In the first phase, characterized by a systemic inflammatory response syndrome, organ failure, not related to infection but rather to severe inflammation, dominates the focus of treatment. In the second phase, secondary infectious complications largely determine the clinical outcome. As infection is associated with increased mortality in acute pancreatitis, numerous prophylactic strategies have been explored in the past two decades. PURPOSE This review describes the strategies that have been developed to lower the infection rate, in an attempt to lower mortality. Antibiotic prophylaxis has been the subject of many RCT's without showing convincing evidence of their efficacy. Probiotics, although theoretically capable of lowering the rate of infection, also had no effect on infectious complications, and consequently, no effective strategy to lower the rate of infectious complications is currently available. In the second part of this review, new approaches for necrosectomy that have been designed by different centers around the world are discussed. All the interventional techniques have in common their aim to lower the invasive character, hypothesizing that lowering the surgical trauma will improve survival and lower complication rates. Recent advances include postponing intervention as a strategy to facilitate necrosectomy and improve prognosis and the "step-up approach" in case of infected necrosis. The step-up approach includes percutaneous catheter drainage as the first step, to be followed by necrosectomy, either through a minimally invasive approach or by open necrosectomy, as the next step. CONCLUSIONS All attempts to develop treatment strategies to lower the infection rate in acute pancreatitis have failed. Accumulating evidence is emerging to show that the combination of centralization, the use of catheter drainage as the first step of invasive treatment, and the development of minimally invasive techniques, improve the outlook for patients with infected necrosis. It is uncertain at this point in time as to which of the three effects is dominant in the improvement of prognosis.
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Affiliation(s)
- Hein G Gooszen
- Department of Operating Rooms-Evidence based surgery, Radboud University Nijmegen Medical Centre, PO BOX 9101, 6500, HB Nijmegen, The Netherlands.
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47
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Gerritsen A, Besselink MGH, Gouma DJ, Steenhagen E, Borel Rinkes IHM, Molenaar IQ. Systematic review of five feeding routes after pancreatoduodenectomy. Br J Surg 2013; 100:589-98; discussion 599. [PMID: 23354970 DOI: 10.1002/bjs.9049] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Current European guidelines recommend routine enteral feeding after pancreato-duodenectomy (PD), whereas American guidelines do not. The aim of this study was to determine the optimal feeding route after PD. METHODS A systematic search was performed in PubMed, Embase and the Cochrane Library. Included were studies on feeding routes after PD that reported length of hospital stay (primary outcome). RESULTS Of 442 articles screened, 15 studies with 3474 patients were included. Data on five feeding routes were extracted: oral diet (2210 patients), enteral nutrition via either a nasojejunal tube (NJT, 165), gastrojejunostomy tube (GJT, 52) or jejunostomy tube (JT, 623), and total parenteral nutrition (TPN, 424). Mean(s.d.) length of hospital stay was shortest in the oral diet and GJT groups (15(14) and 15(11) days respectively), followed by 19(12) days in the JT, 20(15) days in the TPN and 25(11) days in the NJT group. Normal oral intake was established most quickly in the oral diet group (mean 6(5) days), followed by 8(9) days in the NJT group. The incidence of delayed gastric emptying varied from 6 per cent (3 of 52 patients) in the GJT group to 23.2 per cent (43 of 185) in the JT group, but definitions varied widely. The overall morbidity rate ranged from 43.8 per cent (81 of 185) in the JT group to 75 per cent (24 of 32) in the GJT group. The overall mortality rate ranged from 1.8 per cent (3 of 165) in the NJT group to 5.4 per cent (23 of 424) in the TPN group. CONCLUSION There is no evidence to support routine enteral or parenteral feeding after PD. An oral diet may be considered as the preferred routine feeding strategy after PD.
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Affiliation(s)
- A Gerritsen
- Department of Surgery, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
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Bossuyt PMM, Besselink MGH. [Is there such a thing as 'fitting evidence'?]. Ned Tijdschr Geneeskd 2013; 157:A6027. [PMID: 23575293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The 'levels of evidence' system, which dates back to the 1980s, ranks studies based on the strength of the corresponding study design. Level sets have been developed for studies of interventions, for test accuracy research, and many other forms of clinical research. For some authors, practicing evidence-based medicine has become identical to assigning levels of evidence. This is unfortunate, because more modern systems to come out of the evidence-based medicine movement, such as GRADE, distinguish between the credibility of evidence (which is not just affected by the selected design), the magnitude of the effect, and the applicability of the findings to the clinical question at hand. A new system - :fitting evidence" - has recently been developed by the Dutch Health Care Insurance Board, to evaluate evidence for reimbursement decisions. That system, with an 18-item checklist, looks at threats to the internal validity of studies as well as to the feasibility of randomized comparisons, to see whether it is "fitting" to design a randomized trial. It is unclear yet how these evaluations can and should be combined in the appraisal of the strength of the existing evidence.
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Affiliation(s)
- Patrick M M Bossuyt
- Academisch Medisch Centrum, Afd. Klinische Epidemiologie, Amsterdam, the Netherlands.
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de Wilde RF, Besselink MGH, van der Tweel I, de Hingh IHJT, van Eijck CHJ, Dejong CHC, Porte RJ, Gouma DJ, Busch ORC, Molenaar IQ. Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg 2012; 99:404-10. [PMID: 22237731 DOI: 10.1002/bjs.8664] [Citation(s) in RCA: 235] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND The impact of nationwide centralization of pancreaticoduodenectomy (PD) on mortality is largely unknown. The aim of this study was to analyse changes in hospital volumes and in-hospital mortality after PD in the Netherlands between 2004 and 2009. METHODS Nationwide data on International Classification of Diseases, ninth revision (ICD-9) code 5-526 (PD, including Whipple), patient age, sex and mortality were retrieved from the independent nationwide KiwaPrismant registry. Based on established cut-off points of annually performed PDs, hospitals were categorized as very low (fewer than 5), low (5-10), medium (11-19) or high (at least 20) volume. A subgroup analysis based on a cut-off age of 70 years was also performed. RESULTS Some 2155 PDs were included. The number of hospitals performing PD decreased from 48 in 2004 to 30 in 2009 (P = 0·011). In these specific years, the proportion of patients undergoing PD in a medium- or high-volume centre increased from 52·9 to 91·2 per cent (P < 0·001). Nationwide mortality rates after PD decreased from 9·8 to 5·1 per cent (P = 0·044). The mortality rate during the 6-year period was 14·7, 9·8, 6·3 and 3·3 per cent in very low-, low-, medium- and high-volume hospitals respectively (P < 0·001). The difference in mortality between medium- and high-volume centres was statistically significant (P = 0·004). The volume-outcome relationship was not influenced by age (P = 0·467). The mortality rate after PD in patients aged at least 70 years was 10·4 per cent compared with 4·4 per cent in younger patients (P < 0·001). CONCLUSION With nationwide centralization of PD, the in-hospital mortality rate after this procedure decreased. Further centralization of PD is likely to decrease mortality further, especially in the elderly.
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Affiliation(s)
- R F de Wilde
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Cieslak KP, Besselink MGH, Rijkers AP, van Leeuwen MS, Vleggaar FP, Bruno M, Biermann K, Borel Rinkes IHM, van Eijck CH, Molenaar IQ. [Pancreatoduodenectomy for suspected malignancy: indications, complications and survival]. Ned Tijdschr Geneeskd 2012; 156:A4449. [PMID: 23114169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate the indications, complications and survival after pancreatoduodenectomy, with special attention for the outcome after extended resection due to tumour extension and in elderly patients. DESIGN Retrospective, partly cross-sectional study. METHOD All 275 consecutive adult patients who underwent explorative laparotomy for a suspected resectable pancreatic head tumour or periampulary tumour in two Dutch tertiary centres between 2007 and 2010 were included. We graded the postoperative complications according to international classifications and collected data on survival. RESULTS In 218/275 patients (79%) the tumour could be resected by pancreatoduodenectomy with or without an extended resection. Malignancy was confirmed in 190/218 patients (87%); in 153/190 patients (81%) a microscopically radical (R0) resection was achieved. Fifteen percent of the patients required a re-intervention (radiological, endoscopic or surgical) because of an intra-abdominal complication. The post-operative 30-day mortality was 4.1%. Eighty-six patients (39%) were ultimately diagnosed with 'pancreatic adenocarcinoma'; they had a 1- and 2-year survival rate of 63% and 34%, respectively. In 27 patients (12%) who underwent an extended resection for oncological reasons, such as partial hepatic portal vein resection, the 30-day mortality was 0% and the survival rates were comparable to patients with a standard resection. The 81 patients (37%) aged 70 or older had a 30-day mortality and survival similar to younger patients. CONCLUSION More than 75% of potentially resectable tumours were resected by a pancreatoduodenectomy with or without an extended resection, with a relatively low postoperative mortality and an adequate survival benefit. After multidisciplinary assessment, both limited tumour extension and a higher age are not necessarily contraindications for a resection, as a comparable survival benefit can be obtained for these groups of patients as for other groups.
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Affiliation(s)
- Kasia P Cieslak
- Universitair Medisch Centrum Utrecht, Afd. Heelkunde, Utrecht, the Netherlands
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