Metachronous peritoneal metastases in patients with pT4b colon cancer: An international multicenter analysis of intraperitoneal versus retroperitoneal tumor invasion

BACKGROUND

It was hypothesized that colon cancer with only retroperitoneal invasion is associated with a low risk of peritoneal dissemination. This study aimed to compare the risk of metachronous peritoneal metastases (mPM) between intraperitoneal and retroperitoneal invasion.

METHODS

In this international, multicenter cohort study, patients with pT4bN0-2M0 colon cancer who underwent curative surgery were categorized as having intraperitoneal invasion (e.g. bladder, small bowel, stomach, omentum, liver, abdominal wall) or retroperitoneal invasion only (e.g. ureter, pancreas, psoas muscle, Gerota's fascia). Primary outcome was 5-year mPM cumulative rate, assessed by Kaplan-Meier analysis.

RESULTS

Out of 907 patients with pT4N0-2M0 colon cancer, 198 had a documented pT4b category, comprising 170 patients with intraperitoneal invasion only, 12 with combined intra- and retroperitoneal invasion, and 16 patients with retroperitoneal invasion only. At baseline, only R1 resection rate significantly differed: 4/16 for retroperitoneal invasion only versus 8/172 for intra- +/- retroperitoneal invasion (p = 0.010). Overall, 22 patients developed mPM during a median follow-up of 45 months. Two patients with only retroperitoneal invasion developed mPM, both following R1 resection. The overall 5-year mPM cumulative rate was 13% for any intraperitoneal invasion and 14% for retroperitoneal invasion only (Log Rank, p = 0.878), which was 13% and 0%, respectively, in patients who had an R0 resection (Log Rank, p = 0.235).

CONCLUSION

This study suggests that pT4b colon cancer patients with only retroperitoneal invasion who undergo an R0 resection have a negligible risk of mPM, but this is difficult to prove because of its rarity. This observation might have implications regarding individualized follow-up.

Body Image as a Potential Motivator for Bariatric Surgery: a Case-Control Study

BACKGROUND

Not every eligible person opts for bariatric surgery. Body image concerns might be a reason to choose surgery. This case-control study evaluated differences in body image between a pre-bariatric surgery population and a weight-matched control group from the general population. We hypothesized that the pre-bariatric group would show less satisfaction with appearance, defined as a discrepancy between evaluating one's appearance as less attractive while attaching more importance to appearance.

METHODS

Data from 125 pre-bariatric patients were compared with 125 body weight-matched controls from the general population. The Multidimensional Body-Self Relations Questionnaire-Appearance Scales was used to assess appearance evaluation (AE), appearance orientation (AO), and their discrepancy score. Both groups were compared with norms from the non-body weight-matched general population.

RESULTS

The pre-bariatric group had lower AE scores (mean 2.23 ± 0.65 vs. mean 2.54 ± 1.06) and higher AO scores (mean 3.33 ± 0.69 vs. mean 3.04 ± 0.90) than the control group. The discrepancy between AE and AO was larger in the pre-bariatric group (p < 0.001). Compared with the general population, both groups showed lower AE scores (d = - 1.43 and d = - 1.12, p < 0.001) and lower AO scores (d = - 0.23 and d = - 0.58, p < 0.001).

CONCLUSIONS

People with morbid obesity have on average less body image satisfaction. The results indicate that part of the motivation of people that choose bariatric surgery may be due to relatively low global appearance evaluation combined with considering appearance more important. Knowledge about motivations can be used to communicate realistic expectations regarding treatment outcome.

Treatment of PERItoneal disease in Stomach Cancer with cytOreductive surgery and hyperthermic intraPEritoneal chemotherapy: PERISCOPE I initial results

BACKGROUND

The role of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in gastric cancer is unknown. This non-randomized dose-finding phase I-II study was designed to assess the safety and feasibility of HIPEC, following systemic chemotherapy, in patients with gastric cancer and limited peritoneal dissemination. The maximum tolerated dose of normothermic intraperitoneal docetaxel in combination with a fixed dose of intraperitoneal oxaliplatin was also explored.

METHODS

Patients with resectable cT3-cT4a gastric adenocarcinoma with limited peritoneal metastases and/or tumour-positive peritoneal cytology were included. An open HIPEC technique was used with 460 mg/m² hyperthermic oxaliplatin for 30 min followed by normothermic docetaxel for 90 min in escalating doses (0, 50, 75 mg/m² ).

RESULTS

Between 2014 and 2017, 37 patients were included. Of 25 patients who completed the full study protocol, four were treated at dose level 1 (0 mg/m² docetaxel), six at dose level 2 (50 mg/m² ) and four at dose level 3 (75 mg/m² ). At dose level 3, two dose-limiting toxicities occurred, both associated with postoperative ileus. Thereafter, another 11 patients were treated at dose level 2, with no more dose-limiting toxicities. Based on this, the maximum tolerated dose was 50 mg/m² intraperitoneal docetaxel. Serious adverse events were scored in 17 of 25 patients. The reoperation rate was 16 per cent (4 of 25) and the treatment-related mortality rate was 8 per cent (2 patients, both in dose level 3).

CONCLUSION

Gastrectomy combined with cytoreductive surgery and HIPEC was feasible using 460 mg/m² oxaliplatin and 50 mg/m² normothermic docetaxel.

The impact of radiological retroperitoneal lymphadenopathy on survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases

OBJECTIVES

To investigate the impact of retroperitoneal lymphadenopathy (RPLP) on pre-operative CT scan on overall survival (OS) and disease-free survival (DFS) after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for peritoneal metastases (PM) of colorectal cancer.

BACKGROUND

In patients with PM enlarged retroperitoneal lymph nodes (RPLP) are usually considered extra-regional lymph node metastases and therefore these patients may be excluded from CRS-HIPEC. This is a clinical dilemma since it is often hard to obtain histology from these nodes.

METHODS

In this multicenter, retrospective study all consecutive patients with colorectal PM treated with CRS-HIPEC between 2004 and 2013 were included. The preoperative CT-scan was re-analyzed for the presence of RPLP based on the radiological appearance of enlarged lymph nodes. Outcomes were OS and DFS. Kaplan-Meier methods and Cox regression modeling were used to analyze the impact of RPLP on OS and DFS.

RESULTS

In 25 of 401 patients (6.1%) RPLP was observed on the preoperative CT-scan. Patient, tumor and surgical characteristics did not statistically significantly differ between groups with and without RPLP. After a median follow-up of 46 months, the one-, three- and five-year survival was 80%, 59%, 38% and 90%, 50%, 36% in the group with and without RPLP respectively. Median OS (47 vs. 35 months, logrank: p = 0.70) and median DFS (14 vs. 15 months, logrank: p = 0.81) did not statistically significantly differ between groups. In multivariable analysis, RPLP did not significantly influence survival.

CONCLUSION

Enlarged retroperitoneal lymph nodes on a pre-operative CT-scan should not automatically exclude patients from CRS-HIPEC.

Acute cholecystitis in elderly patients: A case for early cholecystectomy

BACKGROUND

Recent advances in laparoscopic techniques and perioperative care have changed the indications for surgery in elderly patients. Consequently, the willingness to offer early surgery for acute cholecystitis continues to increase. This study aims to assess the perioperative outcome of early cholecystectomy for acute calculous cholecystitis in elderly patients.

PATIENTS AND METHODS

All consecutive patients treated by early cholecystectomy for acute calculous cholecystitis in a major teaching hospital, between January 2002 and November 2016, were retrospectively analyzed. The outcome of elderly patients (≥75 years) was compared to that of all others. Conversion rate, 30 days morbidity, 30 days mortality and length of hospital stay were assessed.

RESULTS

Early cholecystectomy for acute calculous cholecystitis was performed in 703 patients: 121 (17%) aged ≥75 years and 582 (83%) aged <75 years. Significantly more elderly patients had an ASA score ≥3 (37% vs. 8%, P<0.001). Morbidity was higher in the elderly group (17% vs. 8%, P<0.004), mainly attributable to the high incidence of cystic stump leakage in this group; a complication that no longer occurred after changing the technique of ligation of the cystic stump. The cardiopulmonary complication rate (4% vs. 3%, P=0.35) as well as mortality did not significantly differ (3% vs. 1%, P=0.07). The conversion rate was higher in the elderly group (18% vs. 5%, P<0.001) and the median postoperative length of hospital stay was longer (5.0 vs. 3.0 days, P<0.001).

CONCLUSION

Early laparoscopic cholecystectomy is a treatment well suited to elderly patients with mild and moderate acute cholecystitis.

Randomized clinical trial of extended versus single-dose perioperative antibiotic prophylaxis for acute calculous cholecystitis

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).

Semiphysiologically based pharmacokinetic model for midazolam and CYP3A mediated metabolite 1-OH-midazolam in morbidly obese and weight loss surgery patients

This study aimed to describe the pharmacokinetics of midazolam and its cytochrome P450 3A (CYP3A) mediated metabolite 1‐OH‐midazolam in morbidly obese patients receiving oral and i.v. midazolam before (n = 20) and one year after weight loss surgery (n = 18), thereby providing insight into the influence of weight loss surgery on CYP3A activity in the gut wall and liver. In a semiphysiologically based pharmacokinetic (semi‐PBPK) model in which different blood flow scenarios were evaluated, intrinsic hepatic clearance of midazolam (CL_int,H) was 2 (95% CI 1.40–1.64) times higher compared to morbidly obese patients before surgery (P < 0.01). Midazolam gut wall clearance (CL_int,G) was slightly lower in patients after surgery (P > 0.05), with low values for both groups. The results of the semi‐PBPK model suggest that, in patients after weight loss surgery, CYP3A hepatic metabolizing capacity seems to recover compared to morbidly obese patients, whereas CYP3A mediated CL_int,G was low for both populations and showed large interindividual variability.

Cytoreduction and hyperthermic intraperitoneal chemotherapy: The learning curve reassessed

BACKGROUND

CytoReductive Surgery and Hyperthermic IntraPEritoneal Chemotherapy (CRS-HIPEC) is now the preferred treatment of many peritoneal surface malignancies. In this retrospective study we aimed to analyze how several performance indicators changed during the first 100 CRS-HIPEC procedures in hospitals which recently introduced this treatment, and compare those with an experienced institution.

METHODS

The first consecutive 100 CRS-HIPEC procedures of three institutions were compared to those of the pioneer hospital. The training provided by the pioneer hospital consisted of hands-on training during the first ten procedures; hereafter guidance was available on consult basis. Operation characteristics, morbidity and completeness of cytoreduction were evaluated by case sequence. Locally-estimated-scatter-plot smoothing was used to evaluate the learning curve.

RESULTS

From four institutions 372 cases were included. A macroscopic complete cytoreduction was reached in 66% of the cases in the pioneer hospital and in 86% in the new hospitals (p < 0.001). Complete cytoreduction rates were higher at start off in the new institutions compared with the experienced institution and increased significantly in the first 100 procedures. The new hospitals started with lower morbidity than the experienced hospital, which did not significantly decrease during the study period.

CONCLUSION

New institutions that were trained and mentored by an experienced CRS-HIPEC hospital performed better from the beginning with regard to complete cytoreduction and morbidity rate with than the experienced center. An improvement in complete cytoreduction rate during the first 100 procedures was observed in the new institutions.

Comparison of Imaging Strategies with Conditional versus Immediate Contrast-Enhanced Computed Tomography in Patients with Clinical Suspicion of Acute Appendicitis

Objectives

To compare the diagnostic accuracy of conditional computed tomography (CT), i.e. CT when initial ultrasound findings are negative or inconclusive, and immediate CT for patients with suspected appendicitis.

Methods

Data were collected within a prospective diagnostic accuracy study on imaging in adults with acute abdominal pain. All patients underwent ultrasound and CT, read by different observers who were blinded from the other modality. Only patients with clinical suspicion of appendicitis were included. An expert panel assigned a final diagnosis to each patient after 6 months of follow-up (clinical reference standard).

Results

A total of 422 patients were included with final diagnosis appendicitis in 251 (60 %). For 199 patients (47 %), ultrasound findings were inconclusive or negative. Conditional CT imaging correctly identified 241 of 251 (96 %) appendicitis cases (95 %CI, 92 % to 98 %), versus 238 (95 %) with immediate CT (95 %CI, 91 % to 97 %). The specificity of conditional CT imaging was lower: 77 % (95 %CI, 70 % to 83 %) versus 87 % for immediate CT (95 %CI, 81 % to 91 %).

Conclusion

A conditional CT strategy correctly identifies as many patients with appendicitis as an immediate CT strategy, and can halve the number of CTs needed. However, conditional CT imaging results in more false positives.

Key Points

• Conditional CT (CT after negative/inconclusive ultrasound findings) can be used for suspected appendicitis.

• Half the number of CT examinations is needed with a conditional strategy.

• Conditional CT correctly identifies as many patients with appendicitis as immediate CT.

• Conditional imaging results in more false positive appendicitis cases.

Selection of chemotherapy for hyperthermic intraperitoneal use in gastric cancer

PURPOSE

Several studies have shown the potential benefit of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in gastric cancer patients. At present the most effective chemotherapeutic regime in HIPEC for gastric cancer is unknown. The aim of this review was to provide a comprehensive overview of chemotherapeutic agents used for HIPEC in gastric cancer.

METHODS

A literature search was conducted using the PubMed database to identify studies on chemotherapy used for HIPEC in gastric cancer patients.

RESULTS AND CONCLUSION

The chemotherapeutic regime of choice in HIPEC for gastric cancer has yet to be determined. The wide variety in studies and study parameters, such as chemotherapeutic agents, dosage, patient characteristics, temperature of perfusate, duration of perfusion, carrier solutions, intraperitoneal pressure and open or closed perfusion techniques, warrant more experimental and clinical studies to determine the optimal treatment schedule. A combination of drugs probably results in a more effective treatment.

Peritoneal cancer patients not suitable for cytoreductive surgery and HIPEC during explorative surgery: risk factors, treatment options, and prognosis

BACKGROUND

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is currently the only curative option for patients with peritoneal carcinomatosis of colorectal origin. Despite meticulous preoperative assessment, CRS and HIPEC appear to be impossible in a subset of patients at the time of surgery. This study investigated which clinical factors may identify these patients before surgery and reported on factors influencing survival.

METHODS

All patients with PC of colorectal origin between April 2005 and November 2013 who underwent exploratory surgery to determine whether cytoreduction and HIPEC was feasible were included in this study. Details concerning preoperative patient characteristics, perioperative outcomes, treatment and survival were compared.

RESULTS

In total, 350 patients with PC were referred to evaluate the possibility of CRS + HIPEC of which 268 (76.6 %) underwent CRS and HIPEC and 82 (23.4 %) had an open-close procedure. The main reason for discontinuing surgery was widespread peritoneal disease (50 %). A preoperative ostomy and an ASA score of 3 were associated with an increased risk for "open and close" (O&C). Median survival was 11.2 months in patients treated with palliative chemotherapy (75 %) compared with 2.7 months with palliative care only.

CONCLUSIONS

CRS and HIPEC were deemed unsuitable in almost a quarter of all patients undergoing surgery. No strong clinical predictors for O&C were found, stressing the need for better preoperative imaging modalities. Survival in these patients is limited, but the majority could be treated with palliative chemotherapy resulting in survival of almost 1 year.

The predictive value of proteinuria in acute pancreatitis

BACKGROUND/OBJECTIVES

Acute pancreatitis has a highly variable clinical course. Early and reliable predictors for the severity of acute pancreatitis are lacking. Proteinuria appears to be a useful predictor of disease severity and outcome in a variety of clinical conditions. This study aims to investigate the predictive value of proteinuria on admission for the severity of acute pancreatitis compared with other commonly used predictors; the APACHE II score, Modified Glasgow score and C-reactive protein (CRP).

METHODS

This is a post-hoc analysis of 64 patients admitted with acute pancreatitis treated in one teaching hospital, who participated in a previous randomized trial. Proteinuria was defined as a Protein/Creatinine (P/C) ratio >23 mg/mmol. The primary endpoint was severe acute pancreatitis. Secondary endpoints included infectious complications, need for invasive intervention, ICU stay and in-hospital mortality.

RESULTS

Proteinuria was present in 30/64 patients (47%). Eleven patients (17%) had severe acute pancreatitis. There was no difference in incidence of severe acute pancreatitis between patients with and without proteinuria: 6/30 patients (20%) versus 5/34 patients (15%) respectively (p = 0.58). Likewise, the occurrence of infectious complications, need for intervention and ICU stay and mortality did not differ significantly (p = 0.58, p = 0.99, p = 0.33 and p = 0.60 respectively). The diagnostic performance of the P/C ratio for the prediction of severe pancreatitis was inferior to the Modified Glasgow score (p = 0.04) and CRP (p = 0.03).

CONCLUSION

Proteinuria on admission does not seem to be a reliable predictor for disease severity in acute pancreatitis. The diagnostic performance of the P/C ratio is inferior to the Modified Glasgow score and CRP.

Ethnicity influences weight loss 1 year after bariatric surgery: a study in Turkish, Moroccan, South Asian, African and ethnic Dutch patients

Several studies conducted in the USA have demonstrated that the effectiveness of bariatric surgery differs between patients from African and European origin. However, little is known on differences in outcomes after bariatric surgery between individuals from other ethnic backgrounds. In this retrospective study, we found that, in terms of weight loss, gastric bypass surgery is less effective in African, South Asian, Turkish and Moroccan patients than in their ethnic Dutch counterparts. Our results underscore that ethnic differences in the effectiveness of bariatric surgery are not limited to those between patients of African and European origin, but extend to other minority groups as well. Therefore, it is important that prospective studies both determine ethnic differences in weight loss-related improvement of co-morbidities and elucidate the exact reasons for these ethnic disparities.

Routine colonoscopy is not required in uncomplicated diverticulitis: a systematic review

BACKGROUND

It is generally accepted that patients following an episode of diverticulitis should have additional colonoscopy screening to rule out a colorectal malignancy. We aimed to investigate the rate of CRC found by colonoscopy after an attack of uncomplicated diverticulitis.

METHODS

MEDLINE, Embase, and Cochrane databases were searched systematically for clinical trials or observational studies on colonic evaluation by colonoscopy after the initial diagnosis of acute uncomplicated diverticulitis, followed by hand-searching of reference lists.

RESULTS

Nine studies met the inclusion criteria and included a total number of 2,490 patients with uncomplicated diverticulitis. Subsequent colonoscopy after an episode of uncomplicated diverticulitis was performed in 1,468 patients (59%). Seventeen patients were diagnosed with CRC, having a prevalence of 1.16% (95% confidence interval 0.72-1.9% for CRC). Hyperplastic polyps were seen in 156 patients (10.6%), low-grade adenoma in 90 patients (6.1%), and advanced adenoma was reported in 32 patients (2.2%).

CONCLUSION

Unless colonoscopy is regarded for screening in individuals aged 50 years and older, routine colonoscopy in the absence of other clinical signs of CRC is not required.

Peritoneal carcinomatosis in t4 colorectal cancer: occurrence and risk factors

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy improves outcome of patients with peritoneal carcinomatosis (PC) of colorectal carcinoma. Data on the occurrence of PC in T4 colorectal carcinoma are scarce. We investigated the occurrence and risk factors for PC in these patients.

METHODS

This was a retrospective cohort study of patients undergoing a first resection of a T4 colorectal carcinoma in a tertiary hospital between January 2000 and December 2007. Primary outcome was the occurrence of synchronous or metachronous PC. The association with PC and several patient and tumor characteristics was evaluated using logistic regression.

RESULTS

A total of 200 patients underwent resection of a T4 colorectal carcinoma. Median follow-up censored for death was 66 months (18-89 months). Synchronous PC was found in 46 of 200 patients (23 %) and metachronous PC in 33 of 154 patients (21 %). In univariable analysis, factors associated with PC were: age (OR 0.97; 95 % CI 0.94-0.99; P = 0.03), radical resection (OR 0.32; 95 % CI 0.11-0.91; P = 0.03), and N stage (OR 1.63; 95 % CI 1.36-2.34; P = 0.008). In multivariable analysis, only N stage was associated with PC (OR 1.62; 95 % CI 1.12-2.34; P = 0.01). This association was not significant for the 154 patients at risk for metachronous PC.

CONCLUSIONS

Around 1 in 5 patients undergoing resection of a T4 colorectal carcinoma either have PC during primary resection or develop PC during follow-up. N stage was associated with PC in the entire study population. However, none of the clinical or pathological variables were associated with the risk of metachronous PC and therefore cannot be used to develop targeted surveillance strategies.

Totally laparoscopic right hemicolectomy with intracorporeal anastomosis is a technically and oncologically safe procedure

BACKGROUND

During laparoscopic right hemicolectomy, most surgeons perform an extracorporeal anastomosis. A totally laparoscopic procedure with intracorporeal anastomosis may improve cosmesis because midline- or paraumbilical incisions can be avoided. Here, we investigate the safety of an intracorporeal anastomosis from a technical and oncological perspective.

METHODS

All patients who underwent right hemicolectomy with intracorporeal anastomosis between 2003-2011 were retrospectively analyzed. Parameters were duration of surgery, intraoperative blood loss, mortality and morbidity. Adequacy of oncologic resections was scored by resectional margins and number of harvested lymph nodes.

RESULTS

A total of 162 patients were included with a median age of 69 years (IQR60-76). The duration of surgery was 100 minutes (80-120) and intraoperative blood loss was 30 mL (10-100). Hundred-twenty patients (74%) underwent an oncologic resection. Number of harvested lymph nodes was 12 (9-18). RO-resection was achieved in 100%. Four patients died (2.5%). Postoperative complications were: anastomotic leakage (3.1%; n = 5), ileus (4.9%; n = 8), abscesses (2.5% ; n = 4), wound infection (3.1% ; n = 5) and cardiopulmonary complications (10.5% ; n = 17). Duration of oncological follow-up was 2.5 years (1.3-4.6). Local recurrence and overall survival rates at two years were 0.8% and 85.4%, respectively.

CONCLUSION

Right hemicolectomy with intracorporeal anastomosis is a technically and oncologically safe procedure with acceptable operating time and low mortality.

An integrated population pharmacokinetic meta-analysis of propofol in morbidly obese and nonobese adults, adolescents, and children

This study describes a population pharmacokinetic meta-analysis of propofol to characterize the influence of body size measures and age in morbidly obese and nonobese adults, adolescents, and children. Sixty morbidly obese and nonobese adult patients (55-167 kg; 21-79 years) and 34 morbidly obese and nonobese adolescents and children (37-184 kg; 9-20 years) were included. The results show that clearance increased with total body weight in an allometric function while age was found to influence clearance in a bilinear fashion with two distinct slopes, reflecting an initial increase and subsequent decrease as a result of aging. Using these two functions, the influence of both (over)weight and age on propofol clearance was well characterized, which may provide a basis for dosing across this diverse group of patients.CPT: Pharmacometrics & Systems Pharmacology (2013) 2, e73; doi:10.1038/psp.2013.47; advance online publication 11 September 2013.

Hyperthermic intraperitoneal chemotherapy during primary tumour resection limits extent of bowel resection compared to two-stage treatment

AIM

To compare the clinical outcome of a one-stage, primary tumour resection and hyperthermic intraperitoneal chemotherapy (HIPEC) procedure, versus a two-stage procedure of tumour resection and secondary HIPEC in colorectal cancer (CRC) patients with synchronous peritoneal carcinomatosis.

METHODS

A prospective database of all patients treated with HIPEC in the St. Antonius Hospital in the Netherlands between 2005 and 2012 was analysed.

RESULTS

A total of 72 patients with synchronous peritoneal carcinomatosis (PC) from CRC were included. In 20 patients (27.8%) the primary tumour was resected simultaneously with HIPEC (early referral). In the other 52 patients (72.2%) the primary tumour was resected prior to the HIPEC procedure (late referral). During CRS + HIPEC following late referral, 22 (59.5%) of the 37 anastomoses of the earlier operation were resected, revealing malignancy in 12 (54.5%) on histopathological examination. In twenty (27.8%) patients a permanent colostomy was constructed after HIPEC. Ten of these patients had complete bowel continuity after earlier primary resection. The relaparotomy rate was higher in patients after a resection of a previous anastomosis (36.4%) compared to 12% in the rest of the patients (P = 0.02).

CONCLUSIONS

Resection of the primary tumour simultaneously with HIPEC in patients with synchronous PC from CRC may prevent extended bowel resections and permanent colostomy. Our data support early referral of patients with PC from colorectal cancer.

Incidence of bactobilia increases over time after endoscopic sphincterotomy

Patients with choledochocystolithiasis are usually treated by endoscopic retrograde cholangiography with endoscopic sphincterotomy (ES) followed by laparoscopic cholecystectomy (LC). LC after ES is more difficult than in uncomplicated gallstone disease, possibly due to bacterial colonization of the common bile duct. The goal of this study was to evaluate if bactobilia influences the peri- and postoperative outcomes. Data were obtained from a randomized trial on the timing of LC after ES. Ninety-six patients were randomized after ES to LC either within 72 h (early LC [ELC]) or in 6-8 weeks (delayed LC [DLC]). In 64 of 96 patients bile samples were obtained peroperatively. The overall prevalence of bactobilia was 62.5% [40/64; 50% of ELC patients (n = 13) vs. 71.1% in the DLC group (n = 27); p = 0.088]. Age and group (i.e. ELC/DLC) were independent and significant predictors for the presence of bactobilia. The presence of bactobilia did not influence operating time and difficulty or conversion rate. Patients with bactobilia developed more biliary events in the period between ES and LC (44 vs. 28%). After ES for choledochocystolithiasis, 62.5% of patients have bactobilia at the time of surgery. The prevalence of bactobilia increases with age and time. Patients with bactobilia tend to develop more biliary-related complications awaiting surgery.

Maintenance of anesthesia in morbidly obese patients using propofol with continuous BIS-monitoring: a comparison of propofol-remifentanil and propofol-epidural anesthesia

PURPOSE

Aim of this study was to evaluate maintenance of anesthesia using propofol with continuous Bispectral Index (BIS)-monitoring in morbidly obese patients receiving propofol-remifentanil and propofol-epidural anesthesia.

METHODS

In the first group in ten morbidly obese patients receiving remifentanil analgesia, a propofol infusion was started at 10 mg/kg/hr and modified by aiming at BIS values between 40-60 together with predefined hemodynamic parameters. In the second group, the propofol dose resulting from the first group was prospectively evaluated in a matched cohort of six morbidly obese patients receiving propofol-epidural analgesia aiming for the same BIS and hemodynamic parameters. In both groups, propofol concentration and infusion rates, BIS and hemodynamic values were collected.

RESULTS

In the propofol-remifentanil group (Body Mass Index (BMI) 39-60 kg/m2), the mean propofol infusion rate that corresponded to the predefined BIS and hemodynamic parameters was 4.8 mg/kg/hr (SD 1.5). On this basis, a maintenance dose of 5 mg/kg/hr was started in the propofol-epidural group (BMI 38-58 kg/m2). In this second group, the mean propofol infusion rate that corresponded to predefined BIS and hemodynamic parameters was 5.0 mg/kg/hr (SD 0.6). Between the two groups, there was no difference in the propofol concentration-BIS relation.

CONCLUSION

Using both BIS and hemodynamic parameters as an endpoint, a maintenance dose of propofol of 4-6 mg/kg/hr is proposed for maintenance of anesthesia in morbidly obese patients undergoing bariatric surgery either in combination with remifentanil or epidural analgesia. There was no difference in propofol concentration-BIS relation in morbidly obese patients receiving propofol-remifentanil or propofol-epidural anesthesia.

Long-term results of laparoscopic adjustable gastric banding in patients lost to follow-up

BACKGROUND

The aim of the study was to evaluate the results of laparoscopic adjustable gastric banding (LAGB) in patients lost to follow-up.

METHODS

Patients lost to follow-up were identified from a consecutive cohort of 495 patients who underwent LAGB between November 1995 and September 2006. These patients were asked to return to follow-up and their actual weight was assessed.

RESULTS

Of 93 patients lost to follow-up, 73 were motivated to reattend. Of these, 60 per cent (44 patients) had lost less than 25 per cent of excess weight, compared with 16.3 per cent (P < 0.001), 27.0 per cent (P < 0.001) and 42 per cent (P = 0.026) of patients after 2, 4 and 8 years of regular follow-up.

CONCLUSION

Patients lost to follow-up are more likely to have poor weight loss, emphasizing the importance of follow-up after LAGB. Outcome after surgery for morbid obesity should include patients lost to follow-up as a measure of overall success.

Effects of adjustable gastric banding on gastroesophageal reflux and esophageal motility: a systematic review

Controversial opinions exist concerning the effect of laparoscopic adjustable gastric banding on gastroesophageal reflux. MEDLINE and EMBASE databases were searched for relevant studies on patients undergoing adjustable gastric banding. Data are expressed in mean (range). Twenty studies were identified with a total of 3307 patients. The prevalence of reflux symptoms decreased postoperatively from 32.9% (16-57) to 7.7% (0-26.9) and medication use from 27.5% (16-38.5) to 9.5% (3.1-19.2). Newly developed reflux symptoms were found in 15% (6.1-20) of the patients. The percentage of esophagitis decreased postoperatively from 33.3% (19.4-61.6) to 27% (2.3-60.8). Newly developed esophagitis was observed in 22.9% (0-38.4). Pathological reflux was found in 55.8% (34.9-77.4) preoperatively and postoperatively in 29.4% (0-41.7) of the patients. Lower esophageal sphincter pressures increased from 12.9 to 16.9 mmHg (11.3-21.4). Lower esophageal sphincter relaxation decreased from 100% to 79.7% (58-86). The percentage of dysmotility increased from 3.5% (0-10) to 12.6% (0-25). Adjustable gastric banding has anti-reflux properties resulting in resolution or improvement of reflux symptoms, normalized pH monitoring results and a decrease of esophagitis on short term. However, worsening or newly developed reflux symptoms and esophagitis are found in a subset of patients during longer follow-up.

Large gluteal abscesses as a complication of transgluteal drainage of pelvic abscesses: analysis of three cases and a search of the literature

BACKGROUND

The percutaneous transgluteal approach is a well-accepted method for drainage of deep pelvic abscesses. Recently, in 3 patients, transgluteal drainage was complicated by the development of large gluteal abscesses requiring multiple surgical interventions.

METHODS

This report describes these cases as well as a search of the literature.

RESULTS

Three patients with a complicated clinical course after colon resection are described. After CT-guided percutaneous transgluteal drainage of the pelvic abscess, large gluteal abscesses were diagnosed after 2-6 weeks. Subsequent surgical interventions were needed to adequately drain these abscesses. In the literature, transgluteal drainage of pelvic abscesses is well described as a safe and efficient method. However, until now the development of gluteal abscesses has not been mentioned as a complication in the literature.

CONCLUSION

In our own experience, a transrectally (radiologically or surgically performed) drainage route is recommended in patients who develop a deep pelvic abscess after bowel resection and suspicion of an anastomotic leak.

Aneurysm of the Superior Posterior Pancreatic-Duodenal Artery Presenting with Recurrent Syncopes

We present a 61-year-old woman with hypovolemic shock due to a ruptured aneurysm of the superior posterior pancreatic-duodenal artery in whom recurrent syncopes were the first presenting sign of pancreatic-duodenal artery aneurysm (PDAA). PDAA is a rare but life-threatening condition. The widely varying symptomatology may lead to a delay in diagnosis and treatment. Patients with atypical symptoms, such as vague abdominal pain, recurrent dizziness or syncope, may actually suffer from a sentinel bleeding of the vascular malformation. Radiological imaging, especially selective angiography, may provide a diagnostic as well as a therapeutic tool in these patients.

Life and death of the nasogastric tube in elective colonic surgery in the Netherlands

BACKGROUND & AIMS

There is abundant evidence that the routine use of nasogastric decompression following elective abdominal surgery is ineffective in achieving any goals it is intended for. Nevertheless its use is still standard of care. The aim of the present study was to investigate whether it is possible to ban nasogastric decompression after elective colonic surgery.

METHODS

At first baseline measurements concerning elements of perioperative care, including nasogastric tubes, were recorded retrospectively over the year 2004. In 2006-2007 the implementation of a fast-track colonic surgery project was guided by the Dutch Institute for Quality of Healthcare CBO, using Berwick's Breakthrough approach.

RESULTS

A total of 2007 patients were enrolled. The baseline measurement showed that the use of nasogastric drainage is still common practice in the Netherlands. 953 patients (88.3%) had a nasogastric tube postoperatively. That tube was removed after a median of 2.5 days (range 1-3 days). After the implementation of the Perioperative Care Breakthrough project the percentage of patients having a nasogastric tube postoperatively dropped to 9.6% (p<0.0001).

CONCLUSIONS

Our results show using the Breakthrough Methodology it is possible to eradicate the inappropriate routine use of NG tubes.

[Probiotic prophylaxis in patients with predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial]

OBJECTIVE

To evaluate whether enteral prophylaxis with probiotics in patients with predicted severe acute pancreatitis prevents infectious complications.

DESIGN

Multicentre, randomised, double-blind, placebo-controlled trial.

METHOD

A total of 296 patients with predicted severe acute pancreatitis (APACHE II score > or = 8, Imrie score > or = 3 or C-reactive protein concentration > 150 mg/l) were included and randomised to one of two groups. Within 72 hours after symptom onset, patients received a multispecies preparation of probiotics or placebo given twice daily via a jejunal catheter for 28 days. The primary endpoint was the occurrence of one of the following infections during admission and go-day follow-up: infected pancreatic necrosis, bacteraemia, pneumonia, urosepsis or infected ascites. Secondary endpoints were mortality and adverse reactions. The study registration number is ISRCTN38327949.

RESULTS

Treatment groups were similar at baseline with regard to patient characteristics and disease severity. Infections occurred in 30% of patients in the probiotics group (46 of 152 patients) and 28% of those in the placebo group (41 of 144 patients; relative risk (RR): 1.1; 95% CI: 0.8-1.5). The mortality rate was 16% in the probiotics group (24 of 152 patients) and 6% (9 of 144 patients) in the placebo group (RR: 2.5; 95% CI: 1.2-5.3). In the probiotics group, 9 patients developed bowel ischaemia (of whom 8 patients died), compared with none in the placebo group (p = 0.004).

CONCLUSION

In patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients.

[Sigmoid carcinoma as a long-term complication following ureterosigmoidostomy]

A 45-year-old woman, known to have a congenital exstrophy ofthe bladder, for which she underwent a ureterosigmoidostomy in her infancy, presented with fever. This was due to pyelonephritis, from which she recovered with antibiotic therapy. During colonoscopy a carcinoma of the sigmoid was found at the level of the anastomosis of the ureters. Patients with a ureterosigmoidostomy have a one hundred-fold increased risk of colon carcinoma compared to the general population. The development of malignant tumours as a long-term complication of this procedure is linked with the frequent contact between intestinal tissue and urine. Periodical colonoscopy of these patients is advised.

Intense adrenal enhancement in patients with acute pancreatitis and early organ failure

Intense adrenal enhancement has previously been reported in patients with hypovolemic and septic shock. The purpose of this study was to assess whether this computed tomography (CT) finding is also observed in patients presenting with severe acute pancreatitis and early organ failure. A retrospective analysis of a prospectively collected database was performed. Out of 38 consecutive patients with predicted severe acute pancreatitis, 3 patients showed intense bilateral adrenal enhancement on early CT. All patients had early multiple organ failure and subsequently died. In two cases, pathologic correlation was obtained. Intense adrenal enhancement may be a new prognostic indicator in patients with acute pancreatitis, particularly when organ failure is present at the time of CT examination. Further studies are necessary to confirm this observation.

[Sustained weight loss 2 years after laparoscopic adjustable gastric banding for morbid obesity]

OBJECTIVE

To analyse the results of the laparoscopic adjustable gastric banding (LAGB) procedure for morbid obesity. DESIGN. Retrospective, descriptive.

METHOD

From November 1, 1995 to May 31, 2005, laparoscopic adjustable banding surgery was performed in St. Antonius Hospital, Nieuwegein, the Netherlands, in 411 patients. Inclusion criteria were BMI > or = 40 kg/ m(2) or BMI > 35 kg/m(2) and severe comorbidity with > 3 attempts at weight loss in the past. Selection, inclusion and follow-up were performed in a specialised, multidisciplinary setting. Height, weight, and complications were prospectively recorded. In 1995-2000 the perigastric surgical procedure was used and in 2000-2005 the pars-flaccida method.

RESULTS

The study group consisted of 350 (85%) women and 61 (I5%) men with a median age of 38 years (range 17-60). Out of these 411 patients, the median weight was 133.4 kg, the median overweight, 69.6 kg and the median BMI 46.3 kg/m2. Two years after surgery, data was known for 267 patients where 206 (77%) had a weight loss > 30%, and 7 patients (3%) a weight gain. The median BMI difference was then -10.2 kg/m2 (range +4.7--26.4). The median loss of overweight was 46.3% (+10.00--97.8). The weight loss remained stable in the following years. The most commonly seen complications were fundus slippage (13%) and port-a-cath related complications (7%). These occurred more often in patients who had had the perigastric method surgery than in the parsflaccida surgical method.

CONCLUSION

Three quarters of the patients with morbid obesity who received laparoscopic gastric banding surgery had achieved and sustained weight loss at 2 years following surgery. The pars-flaccida method resulted in fewer complications than the perigastric surgical method.

[Gastric reduction in morbidly obese adults in the Netherlands]

Obesity results in several health problems, the most important of these being diabetes mellitus type 2. In patients with morbid obesity (BMI > or = 35 kg/m(2) and comorbidity or BMI > or = 40 kg/m(2)) in particular, prevention or treatment of health problems resulting from the obesity is only possible with considerable and lasting weight loss. Gastric reduction surgery with the adjustable gastric band has been shown to be safe and effective. This is also true for the more invasive techniques such as the gastric bypass and the biliopancreatic diversion. Surgical treatment is the only treatment that can induce substantial and lasting weight loss (> 50% of the excess weight, on average) in this patient group in the long run. Although the availability of surgical treatment is as yet inadequate in the Netherlands, it has recently improved considerably. Reimbursement of the treatment is however still an obscure issue and the reimbursement of the follow-up is uncertain. Possibly, the current experiments with independent treatment centers will be able to put an end to this uncertainty.

Human visceral adipose tissue and the plasminogen activator inhibitor type 1

OBJECTIVE

The objective of this study was to systematically evaluate the molecular basis of the association between visceral fat mass and plasma plasminogen activator inhibitor-1 (PAI-1) levels in man.

DESIGN

A comprehensive approach comprising observational, in vitro, and human intervention studies.

MEASUREMENTS AND RESULTS

We confirmed an exclusive relationship between visceral fat and plasma PAI-1 levels (r=0.79, P<0.001) and corroborated preferential PAI-1 release from adipose tissue explants. Yet, messenger RNA analysis and in vivo measurement of PAI-1 release from visceral fat (AV-differences over the omentum) not only excluded visceral adipose tissue as a relevant source of circulating PAI-1, but also excluded visceral fat as a significant source of proinflammatory mediators such as tumor necrosis factor-alpha, IL-1 or transforming growth factor-beta that could induce PAI-1 expression in tissues other than visceral fat. Short-term interventions with acipimox and growth hormone (GH) as well as statistical evaluation excluded free fatty acids and GH as metabolic links. Further analysis of the metabolic data in a stepwise regression model indicated that plasma PAI-1 levels and visceral fat rather are co-correlates that both relate to impaired lipid handling.

CONCLUSION

Our PAI-1 studies show that visceral fat mass and plasma PAI-1 levels are co-correlated rather than causatively related, with lipid load as common denominator.

Feasibility of minimally invasive approaches in patients with infected necrotizing pancreatitis

Background

Minimally invasive procedures to treat infected necrotizing pancreatitis (INP) are gaining popularity. The proportion of patients suitable for this approach remains unknown.

Methods

Preoperative computed tomography (CT) scans were reviewed from 106 consecutive patients who had surgery for INP between 2000 and 2003 in 11 Dutch hospitals. Collections related to the pancreas were classified according to their distance from the left abdominal wall. Five radiologists judged ‘accessibility’ for drain placement and the likelihood that there was a fluid component that would drain (‘drainability’). Agreement between radiologists was determined.

Results

CT scans of 80 (75 per cent) patients were available (59 men; age range 29–80 years). The median interval between hospital admission and preoperative CT scan was 20 days. In 55 (69 per cent) patients, the lateral border of the collection was less than 5 cm from the left abdominal wall. Placement of a drain was deemed feasible in 67 (84 (range 77–89) per cent) patients; mean(s.d.) kappa 0·428(0·096). In 45 (56 per cent) patients, a drain could be placed through the left retroperitoneum. In 43 (54 (range 49–82) per cent) patients, collections were judged to contain a drainable fluid component. Interobserver agreement on ‘drainability’ was poor, mean(s.d.) kappa 0·289(0·101).

Conclusion

Most peripancreatic collections in INP were considered accessible to a minimally invasive approach.

Videoscopic assisted retroperitoneal debridement in infected necrotizing pancreatitis

Surgical intervention in patients with infected necrotizing pancreatitis generally consists of laparotomy and necrosectomy. This is an invasive procedure that is associated with high morbidity and mortality rates. In this report, we present an alternative minimally invasive technique: videoscopic assisted retroperitoneal debridement (VARD). This technique can be considered a hybrid between endoscopic and open retroperitoneal necrosectomy. A detailed technical description is provided and the advantages over various other minimally invasive retroperitoneal techniques are discussed.

Laparoscopic gastric banding for morbid obesity: outpatient procedure versus overnight stay

BACKGROUND

In western countries, laparoscopic gastric banding is increasingly used in the surgical treatment of morbid obesity. This study aimed to investigate the feasibility, safety, morbidity, and costs of an outpatient procedure (OP) compared with an overnight stay (OS).

METHODS

In a 2-year period, 50 consecutive patients were randomized to an OP group or an OS group.

RESULTS

In the OP group, 76% of the patients were successfully discharged the same day, without readmissions. Four procedures were converted, and one complication occurred. The patients in the OP group seemed to experience more pain (p = 0.009). Satisfaction scores were 8.1 (OP) and 8.8 (OS) (p = 0.06). Half of the OP patients and most of the OS patients preferred a clinical admission. The OP treatment cost 600 euros less than OS.

CONCLUSION

With proper patient selection, laparoscopic gastric banding can be performed safely and at lower cost as an outpatient procedure.

Effect of Laparoscopic Gastric Banding on Esophageal Motility

BACKGROUND

Alterations in esophageal motility may occur after placement of an adjustable gastric band as treatment for morbid obesity, near the gastro-esophageal junction. It causes an outlet obstruction, especially during follow-up after the band is filled.

METHODS

29 morbidly obese patients underwent conventional manometry preoperatively, 6 weeks postoperatively before and after filling the band and at 6 months postoperatively. A questionnaire was used to assess upper gastrointestinal symptoms during follow-up.

RESULTS

After band placement, there was a significant increase in lower esophageal sphincter (LES) end-expiratory pressure at 6 weeks with an empty band: 1.3 (0.9-1.9) kPa (median (interquartile range) (P=0.003), 6 weeks with a filled band: 2.1 (1.5-2.8) kPa (P=0.0001), and at 6 months: 1.5 (1.3-1.9) kPa (P=0.001), compared to the preoperative pressure: 0.8 (0.6-1.3) kPa. Also after band placement, the high pressure zone length increased (preop 5.0 (4.3-6.0) cm vs 6 weeks 6.0 (5.0-6.5) cm (P=0.003). The propagation of peristaltic contractions was not significantly altered after band placement. Heartburn decreased 6 weeks postoperatively (P=0.04) but increased at 6 months. Heartburn at 6 months was correlated with pouch formation (0.667; P<0.01).

CONCLUSION

Adjustable gastric band placement causes an increase in LES pressure and length of the high pressure zone. It decreases reflux symptoms in the short-term, but this effect appears not to be related to an effect on LES pressure or length. Pouch formation increases reflux symptoms without having any relationship to LES pressure and length. Band placement in the short-term does not disturb propagation of esophageal contractions.

[Timing and choice of intervention in necrotising pancreatitis]

Three patients, men aged 49, 62 and 33 years, were admitted with acute abdominal symptoms due to necrotising pancreatitis. They underwent multiple interventions during a hospital stay of several months, but ultimately recovered completely. In case of infected (peri-)pancreatic necrosis, intervention is required. Good clinical judgement in the differentiation between the septic inflammatory-response syndrome, sepsis and infected necrosis as the cause of the clinical condition is important. Because of the different intervention strategies, treatment by a team comprising a radiologist, gastroenterologist, intensive care specialist and gastrointestinal surgeon is required. Randomised studies on intervention in infected pancreatic necrosis are lacking. In 2002, to improve the treatment of patients with acute (necrotising) pancreatitis via a combination of research, consultation and centralisation, the Dutch Acute Pancreatitis Study Group was formed.

Quality of life after laparoscopic adjustable gastric banding for severe obesity: postoperative and retrospective preoperative evaluations

BACKGROUND

The aim of this study was to examine postoperative as well as retrospective preoperative evaluations of multiple dimensions of quality of life of patients with morbid obesity after laparascopic adjustable gastric banding (LAGB).

METHODS

12 to 38 months after LAGB, 74 consecutive patients (64 female, 10 male, mean age 36.6 years, age range 23-56) filled out the RAND-36 Health Survey questionnaire to evaluate their current postoperative as well as their past preoperative quality of life.

RESULTS

Pre- to 1 year postoperative weight reduction (127.5 to 100.7 kg) and change of BMI (45.2 to 35.6 kg/m2) were highly significant (p<0.001). As compared to age reference groups, the preoperative quality of life was evaluated very poor (p<0.002), postoperative psychological and social quality of life were about normal (all p's >0.10), and postoperative physical functioning (p=0.04), vitality (p=0.01) and general health (p=0.03) were below normal. No differences were found between postoperative evaluations of patient groups with varying postoperative follow-up duration, but patients in the second year after surgery evaluated some aspects of their preoperative quality of life as poorer than patients in the third year after surgery.

CONCLUSION

Postoperative psychosocial quality is at a level that may be expected to motivate patients to consolidate the surgically established weight reduction, but attention should be paid to the physical condition. Since the relative gain in quality of life as experienced by patients tends to be evaluated less with a longer duration of the postoperative interval, the risk of relapse may increase with passage of time.

[Complication rate in laparoscopic cholecystectomy not different for residents in training and surgeons]

OBJECTIVE

To assess the difference in safety of laparoscopic cholecystectomy performed by residents and staff surgeons.

SETTING

St. Antonius Hospital, Nieuwegein, the Netherlands.

DESIGN

Retrospective study.

METHOD

Results of 649 laparoscopic cholecystectomies performed by staff surgeons experienced in laparoscopic surgery, by residents under supervision of a staff surgeon, by residents without supervision and by inexperienced surgeons, were compared.

RESULTS

Patients were comparable, except for liver function disorders and raised sedimentation rates, of which there were more in the group operated by the non-supervised residents, compared with the staff surgeons. Average operation time was 57 minutes in all four groups. Non-supervised residents had more retained stones than staff surgeons (19 vs 6%) and reported more bleeding during surgery than staff surgeons (21 vs 8%). Conversion rate was the same (3.9%) in all four groups. Complications occurred in 5.7%; this also was the same in the four groups.

CONCLUSION

Residents following a traditional surgical training without practice on animals, perform laparoscopic cholecystectomy as quickly as and with the same conversion and complication rates as their teachers.

The development of valvular incompetence after deep vein thrombosis: a 7 year follow-up study with duplex scanning

OBJECTIVES

To study the development and progression in time of deep venous valve incompetence with Duplex ultrasonography in combination with distal cuff deflation in patients with a history of deep venous thrombosis (DVT) and to evaluate symptoms of chronic venous insufficiency (CVI).

DESIGN

Prospective cohort study.

MATERIALS AND METHODS

In a long term follow-up study the deep venous system of 24 patients (7 men, 17 women, mean age 51 years) of an initial group of 27 with phlebographically documented deep venous thrombosis were examined with Duplex scanning at two intervals (mean 34 and 86 months) after DVT.

RESULTS

All but one segments recanalised. Deep venous incompetence occurred exclusively in post-DVT segments. At first follow-up 48% of the post-thrombotic segments showed valve incompetence, while at second follow-up this had increased to 60% (p < 0.001). Venous segments of the upper leg mainly contributed to this increase. Our group of 24 patients was too small to find any significant correlation between symptoms, thrombosis and valvular incompetence.

CONCLUSIONS

The development of deep vein valve incompetence after deep vein thrombosis is a progressive process over more than 5 years.

The development of valvular incompetence after deep vein thrombosis: a follow-up study with duplex scanning

PURPOSE

Duplex ultrasonography with distal cuff deflation was used to establish the physiologic reflux duration in different segments of the deep venous system in healthy individuals, and to document the occurrence of deep vein valve incompetence in patients after deep vein thrombosis (DVT).

METHODS

Two hundred fifty-two vein segments in 42 legs of 21 healthy individuals and 160 deep vein segments in 27 patients with phlebographically documented DVT were examined with duplex scanning.

RESULTS

The duration of reflux in healthy subjects was significantly shorter in distal deep vein segments. Ninety-five percent of the values were less than 0.88, 0.8, 0.8, 0.28, 0.2, and 0.12 seconds, respectively, for the common femoral, superficial femoral, deep femoral, popliteal, and posterior tibial vein (at midcalf and ankle level). The 95 percentile for reflux duration in the superficial venous system was 0.5 seconds for all vein segments, regardless of the location. No significant correlation was found between the reflux peak flow velocity and reflux duration (R = 0.6). The reflux peak flow velocity is therefore not useful as a parameter of the degree of reflux. The patient group was examined with an interval of 18 to 51 months (mean 34 months) after DVT. Forty-five percent of the initially affected segments showed valve incompetence at follow-up (n = 54); only three of 40 segments initially free from thrombus showed pathologic reflux at follow-up (p < 0.01). Reflux durations in most of the incompetent vein segments were two or more times the normal value of reflux duration. The highest prevalence of valve incompetence was found in the superficial femoral and popliteal vein segment (p < 0.01). None of the patients showed valve incompetence at all levels of the deep venous system. A significant (p = 0.04) relation was found between the extent of the initial thrombosis and the number of refluxing vein segments at follow-up, but no correlation was found between the extent of initial thrombosis and the late clinical symptoms (p = 0.16); clinical symptoms could not be related to the number of incompetent vein segments.

CONCLUSIONS

Duplex scanning allows a good discrimination between physiologic and abnormal reflux duration and is an important tool in the evaluation of the postthrombotic limb. Early assessment after DVT may have prognostic value in individual patients.

Non-invasive detection of deep venous thrombosis: ultrasonography versus duplex scanning

In a prospective study the diagnostic value of compression ultrasonography (CUS) versus Duplex scanning (DS) in the non-invasive detection of acute femoropopliteal deep venous thrombosis (DVT) was determined. In 114 eligible patients clinically suspected of DVT of the lower extremity, compression ultrasonography and Duplex scanning were performed within 24 hours by different assessors unaware of the outcome of the other test. In 109 patients concordant results of combined compression ultrasonography and Duplex scanning were obtained and considered as a proof of the absence or presence of deep venous thrombosis and no subsequent invasive investigations were performed. In five patients compression ultrasonography and Duplex scanning were discordant and contrast venography was performed. Femoropopliteal thrombosis was present in 47 legs (41%). The sensitivity, specificity and accuracy of compression ultrasonography were 93.6, 97.0 and 95.6%, respectively, and of Duplex scanning 100, 98.5 and 99.1%, respectively. We conclude that compression ultrasonography and Duplex scanning are methods with comparably high accuracy. Because of its availability, accuracy, cost-effectiveness and simplicity we recommend compression ultrasonography as the primary diagnostic test in the detection of deep venous thrombosis.