Cees H. Dejong

Timing and impact of infections in acute pancreatitis

Although infected necrosis is an established cause of death in acute pancreatitis, the impact of bacteraemia and pneumonia is less certain.

Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: A prospective multicenter study

Summary Background Data:The role of early endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) remains controversial. Previous studies have included only a relatively small number of patients with predicted severe ABP. We investigated the clinical effects of early ERCP in these patients. Methods:We performed a prospective, observational multicenter study in 8 university medical centers and 7 major teaching hospitals. One hundred fifty-three patients with predicted severe ABP without cholangitis enrolled in a randomized multicenter trial on probiotic prophylaxis in acute pancreatitis were prospectively followed. Conservative treatment or ERCP within 72 hours after symptom onset (at discretion of the treating physician) were compared for complications and mortality. Patients without and with cholestasis (bilirubin: >2.3 mg/dL [40 &mgr;mol/L] and/or dilated common bile duct) were analyzed separately. Results:Of the 153 patients, 81 (53%) underwent ERCP and 72 (47%) conservative treatment. Groups were highly comparable at baseline. Seventy-eight patients (51%) had cholestasis. In patients with cholestasis, ERCP (52/78 patients: 67%), as compared with conservative treatment, was associated with fewer complications (25% vs. 54%, P = 0.020, multivariate adjusted odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.13–0.99, P= 0.049). This included fewer patients with >30% pancreatic necrosis (8% vs. 31%, P = 0.010). Mortality was nonsignificantly lower after ERCP (6% vs. 15%, P = 0.213, multivariate adjusted OR: 0.44, 95% CI: 0.08–2.28, P = 0.330). In patients without cholestasis, ERCP (29/75 patients: 39%) was not associated with reduced complications (45% vs. 41%, P = 0.814, multivariate adjusted OR: 1.36; 95% CI: 0.49–3.76; P = 0.554) or mortality (14% vs. 17%, P = 0.754, multivariate adjusted OR: 0.78; 95% CI: 0.19–3.12, P = 0.734). Conclusions:Early ERCP is associated with fewer complications in predicted severe ABP if cholestasis is present.

Pancreas-preserving total duodenectomy versus standard pancreatoduodenectomy for patients with familial adenomatous polyposis and polyps in the duodenum†

Pancreas‐preserving total duodenectomy (PPTD) was introduced as a replacement for pancreatoduodenectomy (PD) for familial adenomatous polyposis (FAP). This study analysed the results of PPTD in the Netherlands and reviewed the relevant literature.

The role of routine fine-needle aspiration in the diagnosis of infected necrotizing pancreatitis

BACKGROUNDnDiagnosing infected necrotizing pancreatitis (INP) may be challenging. The aim of this study was to determine the added value of routine fine-needle aspiration (FNA) in addition to clinical and imaging signs of infection in patients who underwent intervention for suspected INP.nnnMETHODSnWe conducted a post hoc analysis of 208 consecutive patients from a prospective, multicenter database who underwent intervention because of suspected INP. In retrospect, 3 groups were constructed based on the patients preoperative characteristics: Clinical, imaging, and FNA. Patients in the clinical group had clinical signs of infection but no gas on preoperative computed tomography (CT) and no FNA performed before intervention. Patients in the imaging group had gas bubbles on the preoperative CT but no was FNA performed, whereas patients in the FNA group had a positive FNA before intervention. The reference standard for infection was the culture taken during the first intervention (either catheter drainage or necrosectomy).nnnRESULTSnThe initial intervention for INP was performed a median of 27 days (interquartile range, 20-39) after admission without difference between the 3 groups (P = .15). Infection was confirmed in 80% of 92 patients of the clinical group, in 94% of 88 patients of the imaging group, and in 86% of 28 patients of the FNA group (P = .07). Mortality was 19% and was not different between groups (P = .39).nnnCONCLUSIONnINP can generally be diagnosed based on clinical or imaging signs of infection. FNA may be useful in patients with unclear clinical signs and no imaging signs of INP.

A prospective cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track multimodal management, for surgical patients with colon carcinomas (TAPAS study)

BackgroundThe present developments in colon surgery are characterized by two innovations: the introduction of the laparoscopic operation technique and fast recovery programs such as the Enhanced Recovery After Surgery (ERAS) recovery program. The Tapas-study was conceived to determine which of the three treatment programs: open conventional surgery, open ERAS surgery or laparoscopic ERAS surgery for patients with colon carcinomas is most cost minimizing?Method/designThe Tapas-study is a three-arm multicenter prospective cohort study.All patients with colon carcinoma, eligible for surgical treatment within the study period in four general teaching hospitals and one university hospital will be included. This design produces three cohorts: Conventional open surgery is the control exposure (cohort 1). Open surgery with ERAS recovery (cohort 2) and laparoscopic surgery with ERAS recovery (cohort 3) are the alternative exposures. Three separate time periods are used in order to prevent attrition bias.Primary outcome parameters are the two main cost factors: direct medical costs (real cost price calculation) and the indirect non medical costs (friction method). Secondary outcome parameters are mortality, complications, surgical-oncological resection margins, hospital stay, readmission rates, time back to work/recovery, health status and quality of life.Based on an estimated difference in direct medical costs (highest cost factor) of 38% between open and laparoscopic surgery (alfa = 0.01, beta = 0.05), a group size of 3×40 = 120 patients is calculated.DiscussionThe Tapas-study is three-arm multicenter cohort study that will provide a cost evaluation of three treatment programs for patients with colon carcinoma, which may serve as a guideline for choice of treatment and investment strategies in hospitals.Trial registrationISRCTN44649165.

Elderly Patients Strongly Benefit from Centralization of Pancreatic Cancer Surgery: A Population-Based Study

AbstractBackgroundSeries from expert centers suggest that pancreas cancer surgery is safe for elderly patients but nationwide data, taking hospital volume into account, are lacking.MethodsFrom the Netherlands Cancer Registry, all 3420 patients who underwent pancreatoduodenectomy (PD) for primary pancreatic or periampullary carcinoma in 2005–2013 were selected. Associations between age (<75, ≥75xa0years), hospital volume (tertiles), and postoperative mortality (30, 90xa0day) were evaluated by χ2 tests and logistic regression analyses. Overall survival was investigated by means of Kaplan–Meier and Cox proportional hazard regression analyses.ResultsThe proportion of elderly patients (≥75xa0years) undergoing PD increased from 15xa0% in 2005–2007 to 20xa0% in 2011–2013 (pxa0=xa00.009). In low (<15xa0per year), medium (15–28xa0per year), and high (>28 per year) hospital volume tertiles, the proportion of elderly patients was 16, 20, and 17xa0%, respectively (pxa0=xa00.10). With increasing hospital volume, 30-day postoperative mortality was 6.0–4.5–2.9xa0% (pxa0=xa00.002) and 90-day mortality 9.3–8.0–5.3xa0% (pxa0=xa00.001), respectively. Within each volume tertile, adjusted 30- and 90-day mortality of elderly patients was 1.6–2.5 times higher compared to outcomes of younger patients. Adjusted 30-day mortality in elderly patients was higher in low-volume hospitals (odds ratioxa0=xa02.87, 95xa0% confidence interval 1.15–7.17) compared to high-volume hospitals. Similarly, elderly patients had a worse overall survival in low-volume hospitals (hazard ratioxa0=xa01.28, 95xa0% confidence interval 1.01–1.63). Postoperative mortality of elderly patients in high-volume hospitals was similar to mortality of younger patients in low- and medium-volume hospitals.ConclusionsnElderly patients benefit from centralization by undergoing PD in high-volume hospitals, both with respect to postoperative mortality and survival. It would seem reasonable to place elderly patients into a high-risk category; they should only undergo surgery in the highest-tertile-volume hospitals.

Minimally invasive versus open distal pancreatectomy (LEOPARD): study protocol for a randomized controlled trial

BackgroundObservational cohort studies have suggested that minimally invasive distal pancreatectomy (MIDP) is associated with better short-term outcomes compared with open distal pancreatectomy (ODP), such as less intraoperative blood loss, lower morbidity, shorter length of hospital stay, and reduced total costs. Confounding by indication has probably influenced these findings, given that case-matched studies failed to confirm the superiority of MIDP. This accentuates the need for multicenter randomized controlled trials, which are currently lacking. We hypothesize that time to functional recovery is shorter after MIDP compared with ODP even in an enhanced recovery setting.MethodsLEOPARD is a randomized controlled, parallel-group, patient-blinded, multicenter, superiority trial in all 17 centers of the Dutch Pancreatic Cancer Group. A total of 102 patients with symptomatic benign, premalignant or malignant disease will be randomly allocated to undergo MIDP or ODP in an enhanced recovery setting. The primary outcome is time (days) to functional recovery, defined as all of the following: independently mobile at the preoperative level, sufficient pain control with oral medication alone, ability to maintain sufficient (i.e. >50%) daily required caloric intake, no intravenous fluid administration and no signs of infection. Secondary outcomes are operative and postoperative outcomes, including clinically relevant complications, mortality, quality of life and costs.DiscussionThe LEOPARD trial is designed to investigate whether MIDP reduces the time to functional recovery compared with ODP in an enhanced recovery setting.Trial registrationDutch Trial Register, NTR5188. Registered on 9 April 2015

Minimally invasive approach in acute necrotizing pancreatitis: a strategy for a selected subgroup or a potential benefit for all? Dutch Acute Pancreatitis Study Group

difference in median survival between patients with extracapsular lymph node involvement and patients with intracapsular lymph node involvement (median 12 versus 36 months resp.) (Po0.001). In a multivariate analysis, extracapsular lymph node involvement as well as lymph node ratio were independent prognostic indicators for survival. In conclusion, extracapsular lymph node involvement is a common phenomenon in patients with adenocarcinoma of the distal esophagus or gastroesophageal junction. It is an indicator of advanced disease and poor prognosis. Presently there is no staging modality that can differentiate between intraand extracapsular lymph node involvement preoperatively. To improve long term outcome in patients with extracapsular lymph node involvement, adjuvant radiotherapy could be tested.