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BackgroundThe role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity.MethodsPatients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity.ResultsIn 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424–4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%.ConclusionsThe stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.

AbstractObjectiveTo assess whether laparoscopic cholecystectomy is superior to percutaneous catheter drainage in high risk patients with acute calculous cholecystitis.DesignMulticentre, randomised controlled, superiority trial.Setting11 hospitals in the Netherlands, February 2011 to January 2016.Participants142 high risk patients with acute calculous cholecystitis were randomly allocated to laparoscopic cholecystectomy (n=66) or to percutaneous catheter drainage (n=68). High risk was defined as an acute physiological assessment and chronic health evaluation II (APACHE II) score of 7 or more.Main outcome measuresThe primary endpoints were death within one year and the occurrence of major complications, defined as infectious and cardiopulmonary complications within one month, need for reintervention (surgical, radiological, or endoscopic that had to be related to acute cholecystitis) within one year, or recurrent biliary disease within one year.ResultsThe trial was concluded early after a planned interim analysis. The rate of death did not differ between the laparoscopic cholecystectomy and percutaneous catheter drainage group (3% v 9%, P=0.27), but major complications occurred in eight of 66 patients (12%) assigned to cholecystectomy and in 44 of 68 patients (65%) assigned to percutaneous drainage (risk ratio 0.19, 95% confidence interval 0.10 to 0.37; P<0.001). In the drainage group 45 patients (66%) required a reintervention compared with eight patients (12%) in the cholecystectomy group (P<0.001). Recurrent biliary disease occurred more often in the percutaneous drainage group (53% v 5%, P<0.001), and the median length of hospital stay was longer (9 days v 5 days, P<0.001).ConclusionLaparoscopic cholecystectomy compared with percutaneous catheter drainage reduced the rate of major complications in high risk patients with acute cholecystitis.Trial registrationDutch Trial Register NTR2666.

Purpose Two non-restorative options for low rectal cancer not invading the sphincter are the low Hartmann’s procedure (LH) or intersphincteric proctectomy (IP). The aim of this study was to compare postoperative morbidity with emphasis on pelvic abscesses after LH and IP. Methods All patients that had LH or IP for low rectal cancer were included in three centres between 2008 and 2014 in this retrospective cohort study. Follow-up was performed for at least 12 months. Results A total of 52 patients were included: 40 LH and 12 IP. Median follow-up was 29 months (IQR 23). There were no differences between groups in gender, age and ASA classification. Seven patients in the LH group (18%) and four patients in the IP group (33%) developed a complication within 30-day postoperative with a Clavien-Dindo classification grade III or higher ( P  = 0.253). Four out of 40 patients (10%) in the LH group and two out of 12 patients (17%) in the IP group developed a pelvic abscess ( P  = 0.612). Reinterventions were performed in 11 (28%) patients in the LH group and five (42%) patients in the IP group ( P  = 0.478), with a total number of reinterventions of 13 and 20, respectively. Six and 15 interventions were related to pelvic abscesses, respectively. Conclusion Pelvic abscesses seem to occur in a similar rate after both LH and IP. Previous reports from the literature suggesting that IP might be associated with less infectious pelvic complications compared to LH are not supported by this study, although numbers are small.

Purpose Intensified treatment for distal rectal cancer has improved oncological outcome, but at the expense of more perineal wound complications in patients undergoing an abdominoperineal resection (APR). The aim of this study was to analyse perineal wound healing after APR with primary perineal wound closure over time. Method All patients undergoing APR for primary rectal cancer with primary wound closure between 2000 and 2013 were included and analysed in three consecutive time periods. Both early (<30 days postoperatively) and late perineal wound complications were determined. Independent risk factors of early perineal wound complications were identified using multivariable analysis. Results A total of 136 patients were identified, of whom 129 patients underwent primary perineal wound closure. The use of neo-adjuvant (chemo)radiotherapy increased from 72 to 91 %, and the use of an extralevator approach increased from 9 to 19 %. The rate of early perineal wound complications increased from 18 to 31 % and was independently associated with an extralevator approach [odds ratio (OR) 3.17; 95 % confidence interval (CI) 1.16–8.66] and intra-operative perforation (OR 3.35; 95 % CI 1.06–10.57). Perineal wound complications had no impact on local recurrence or 3-year overall survival rate. During a median follow-up of 28 months [interquartile range (IQR) 14–56], a persistent presacral sinus was diagnosed in 10 %, and a perineal hernia occurred in 8 % of the patients. Conclusion The increased use of an extralevator APR for rectal cancer significantly increased the risk of perineal wound complications over time. Intra-operative perforation was also independently associated with impaired perineal wound healing.

Background The most appropriate closure for the appendicular stump with either endoloops or an endostapler in laparoscopic appendectomy remains unclear and under debate because of limited and conflicting evidence. Methods In a 2-month prospective, observational, resident-led nationwide cohort study, patients undergoing laparoscopic appendectomy for both uncomplicated and complicated appendicitis were analysed. Logistic regression analyses were performed for identifying the possible effect of stump closure type and other risk factors for infectious complications. Results Laparoscopic appendectomy for acute appendicitis was performed in 1369 patients in 62 hospitals; endoloops were used in 76.7 % and an endostapler in other patients. Median operating time was not different between endoloop and endostapler use (42.0 vs. 44.0 min, P  = 0.243). A superficial surgical site infection was seen in 2.0 % after uncomplicated appendicitis and in 0.8 % after complicated appendicitis. The intra-abdominal abscess rate was 1.9 % after uncomplicated and 11.0 % after complicated appendicitis. No significant effect of stump closure type was observed for any infectious complication (OR 1.05; 95 % CI 0.625–1.766, P  = 0.853) or an intra-abdominal abscess (OR OR 0.96; 95 % CI 0.523–1.768, P  = 0.899). In multivariable analysis, complicated appendicitis was identified as the only independent risk factor for an intra-abdominal abscess (OR 6.26; 95 % CI 3.454–11.341, P  < 0.001). Conclusions The infectious complication rate is not influenced by the type of appendicular stump closure with either endoloops or an endostapler in this study. If technically feasible, closure with endoloops is advised for cost considerations.

IntroductionGrowing evidence is showing that complicated and uncomplicated appendicitis are two different entities that may be treated differently. A correct diagnosis of the type of appendicitis is therefore essential. The Scoring system of Appendicitis Severity (SAS) combines clinical, laboratory and imaging findings. The SAS rules out complicated appendicitis in 95% (negative predictive value, NPV) and detects 95% (sensitivity) of patients with complicated appendicitis in adults suspected of acute appendicitis. However, this scoring system has not yet been validated externally. In this study, we aim to provide a prospective external validation of the SAS in a new cohort of patients with clinical suspicion of appendicitis. We will optimise the score when necessary.Methods and analysisThe SAS will be validated in 795 consecutive adult patients diagnosed with acute appendicitis confirmed by imaging. Data will be collected prospectively in multiple centres. The predicted diagnosis based on the SAS score will be compared with the combined surgical and histological diagnosis. Diagnostic accuracy for ruling out complicated appendicitis will be calculated. If the SAS does not reach a sensitivity and NPV of 95% in its present form, the score will be optimised. After optimisation, a second external validation will be performed in a new group of 328 patients. Furthermore, the diagnostic accuracy of the clinical perspective of the treating physician for differentiation between uncomplicated and complicated appendicitis and the patient’s preferences for different treatment options will be assessed.Ethics and disseminationEthical approval was granted by the Amsterdam UMC Medical Ethics Committee (reference W19_416 # 19.483). Because of the observational nature of this study, the study does not fall under the scope of the Medical Research Involving Human Subjects Act. Results will be presented in peer-reviewed journals. This protocol is submitted for publication before analysis of the results.

Purpose The appendix can be a rare cause for chronic right lower quadrant abdominal pain (RLQAP), even though no objective disorder can be determined to the appendix. This condition can be described as chronic appendicitis or (neurogenic) appendicopathy. After careful selection, elective appendectomy is performed in our centre for this group of patients. Methods All patients that underwent an elective appendectomy between 2006 and 2013 were prospectively analysed. Inclusion criterion was chronic RLQAP without abnormalities seen on imaging. Exclusion criterion was pain after conservative treatment of (complicated) appendicitis or an abnormal appendix on imaging like a mass, mucocoele or faecolith. Primary outcome was the effect on the pain postoperatively. Results In the period of the study, ten patients met the inclusion criteria and underwent an appendectomy for chronic RLQAP. Average preoperative pain score assessed with visual analogue scale (VAS) was 8.6. Preoperative work-up showed no abnormalities. No macroscopic abnormalities were seen during surgery in any of the patients. Histopathological analysis was obtained and showed limited abnormalities in eight of ten patients, mostly suspicion of previous inflammation. Postoperatively, no complications occurred, and at revision after 3 weeks, average VAS was 1.0. Long-term follow-up showed that patients remained free of symptoms; average VAS after a median of 33 months was 1.0. Conclusions A significant reduction of pain was achieved after an appendectomy in all patients suffering from chronic RLQAP in this series. Seven out of ten patients were completely free of pain.

The purpose of this study was to evaluate the added value of plain radiographs on top of clinical assessment in unselected patients presenting with acute abdominal pain at the emergency department (ED). In a multicenter prospective trial, patients with abdominal pain more than 2 hours and less than 5 days presented at the ED were evaluated clinically, and a diagnosis was made by the treating physician. Subsequently, all patients underwent supine abdominal and upright chest radiographs, after which the diagnosis was reassessed by the treating physician. A final (reference) diagnosis was assigned by an expert panel. The number of changes in the primary diagnosis, as well as the accuracy of these changes, was calculated. Changes in the level of confidence were evaluated for unchanged diagnoses. Between March 2005 and November 2006, 1021 patients, 55% female, mean age 47 years (range, 19-94 years), were included. In 117 of 1021 patients, the diagnosis changed after plain radiographs, and this change was correct in 39 patients (22% of changed diagnoses and 4% of total study population). Overall, the clinical diagnosis was correct in 502 (49%) patients. The diagnosis after evaluation of the radiographs was correct in 514 (50%) patients, a nonsignificant difference ( P = .14). In 65% of patients with unchanged diagnosis before and after plain radiography, the level of confidence of that diagnosis did not change either. The added value of plain radiographs is too limited to advocate their routine use in the diagnostic workup of patients with acute abdominal pain, because few diagnoses change and the level of confidence were mostly not affected.

Background: Little is known about patients with appendicitis presenting at nighttime. It is hypothesized that patients presented at night more frequently have a complicated (gangrenous or perforated) appendicitis and therefore develop more postoperative complications. Methods: In this study data were used from the nationwide, prospective SNAPSHOT study appendicitis, including 1975 patients undergoing surgery for suspected appendicitis. This study included only adults. Two primary outcomes were defined: (A) The proportion of patients with complicated appendicitis and (B) the proportion of patients with a complication postoperatively presenting during daytime versus nighttime period. Analysis for both complicated and uncomplicated appendicitis was performed, and a multivariate model was used to correct for baseline characteristics and time to surgery. Results: In total, 1361 adult patients with appendicitis were analyzed. Both at nighttime and at daytime, 34% had complicated appendicitis. In patients presenting in the daytime, 12.1% developed a postoperative complication versus 18.6% for presentation at night (p = 0.008). In a multivariate analysis, the risk for a postoperative complication when presenting at night was significantly increased (adjusted OR 1.74; 95% CI 1.14–2.66, p = 0.01). Surgery within eight hours after presentation does not lower this risk (adjusted OR 1.37; 95% CI 0.97–1.95, p = 0.078). Conclusion: Complicated appendicitis is seen as frequently during the day as at nighttime. For patients who present at nighttime with acute appendicitis, the risk of a postoperative complication is higher compared with a presentation at daytime. In multivariate analysis, nighttime presentation but not surgery within 8 h after presentation is independently associated with postoperative complication risk.

Background It is expected that in 2020 more than 17,000 cases of colorectal cancer will be diagnosed in The Netherlands. To date, patients are included in a surgeon-led follow-up programme whose main focus is recurrence detection. However, patients often experience multiple physical and psychosocial problems. Currently, these problems are not always encountered. More care by a generalist is suggested as a solution. Furthermore, patients prefer to undergo rehabilitation in their own environment and to be more involved in their own health care. eHealth applications might enhance this. Oncokompas 2.0 is an online self-management application which facilitates access to supportive care. This study aims to evaluate primary care follow-up and aftercare in comparison with secondary care follow-up and aftercare for patients with colon cancer. Second, the added value of Oncokompas 2.0 to care will be assessed. Methods/Design This is a multi-centre 2 × 2 factorial randomised controlled trial with a calculated sample size of 300 patients. Patients with stage I, II, or III colon carcinoma are eligible. Patients will be randomly assigned in four groups: (1) usual follow-up visits and aftercare provided in secondary care, (2) usual follow-up visits and aftercare provided in secondary care with additional use of Oncokompas 2.0 , (3) follow-up and aftercare in primary care, and (4) follow-up and aftercare in primary care with additional use of Oncokompas 2.0 . The primary outcome is quality of life. Secondary outcomes include physical outcomes, psychosocial outcomes, number of investigations, referrals and related communication between secondary and primary care, (time of) recurrence detection and protocol adherence, attention to preventive care, self-management of patients, patient satisfaction, and preference of care at the end of the trial. Data collection will be done by questionnaires and extractions from electronic medical records. Discussion The results of this study will provide evidence, which has been scarce to date, on prominent general practitioner involvement in care for colon cancer patients after initial treatment. Also, it evaluates the efficacy of an eHealth application to enhance patient empowerment. Dutch trial register NTR4860 (registered on 2 October 2014)