Cees J. H. M. van Laarhoven

Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis

BACKGROUNDnRestorative proctocolectomy with ileo pouch anal anastomosis (IPAA) is the main surgical treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). With the advancements of minimal-invasive surgery this demanding operation is increasingly being performed laparoscopically. Therefore, the presumed benefits of the laparoscopic approach need to be systematically evaluated.nnnOBJECTIVESnTo compare the beneficial and harmful effects of laparoscopic versus open IPAA for patients with UC and FAP.nnnSEARCH STRATEGYnWe searched The Cochrane IBD/FBD Group Specialized Trial Register (April 2007), The Cochrane Library (Issue 1, 2007), MEDLINE (1990 to April 2007), EMBASE (1990 to April 2007), ISI Web of Knowledge (1990 to April 2007) and the web casts of the American Society of Colon and Rectal Surgeons (ASCRS) (up to 2006) for all trials comparing open versus laparoscopic IPAA.nnnSELECTION CRITERIAnAll trials in patients with UC or FAP comparing any kind of laparoscopic IPAA versus open IPAA. No language limitations were applied.nnnDATA COLLECTION AND ANALYSISnTwo authors independently performed selection of trials and data extraction. The methodological quality of all included trials was evaluated to assess bias risk. Analysis of RCTs and non-RCTs was performed separately. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate.nnnMAIN RESULTSnEleven trials included 607 patients of whom 253 (41%) in the laparoscopic IPAA group. Only one of the included trials was a randomised controlled trial. There were no significant differences in mortality or complications between the two groups. Reoperation and readmission rates were not significantly different. Operative time was significantly longer in the laparoscopic group both in the RCT and meta-analysis of non-RCTs (weighted mean difference (WMD) 91 minutes; 95% Confidence Interval (CI) 53 to 130). There were no significant differences between the two groups regarding postoperative recovery parameters. Total incision length was significantly shorter in the laparoscopic group, while two trials evaluating cosmesis found significantly higher cosmesis scores in the laparoscopic group. Other long-term outcomes were poorly reported.nnnAUTHORS CONCLUSIONSnThe laparoscopic IPAA is a feasible and safe procedure. Short-term advantages of the laparoscopic approach seem to be limited and their clinical significance is arguable. Large high-quality trials focusing on differences regarding specific postoperative complications, cosmesis, quality of life and costs are needed.

A methodological systematic review on surgical site infections following spinal surgery: part 1: risk factors.

Study Design. A methodological systematic review. Objective. To critically appraise the validity of risk factors for surgical site infection (SSI) after spinal surgery. Summary of Background Data. SSIs lead to higher morbidity, mortality, and increased health care costs. Understanding which factors lead to an increased risk of SSI is important for the development of prophylactic protocols to counter this risk. To date, however, no review appraising the methodological quality of studies evaluating risk factors for spinal SSIs has been published. Methods. Contemporary studies identifying risk factors for SSI after spinal surgery were searched through the Medline and EMBASE databases (January 2001 to December 2010). References were retrieved and bias-prone study features were abstracted individually and independently by 2 authors. Results. Twenty-four eligible studies were identified, including 9 (nested) case-control studies and 15 case series. Included studies covered wide variations of indications and surgical procedures. A total of 73 different types of factors were evaluated for the risk of an SSI of which 34 (47%) were reported to be significantly related to at least 1 study. Only the following risk factors—diabetes mellitus, obesity, and previous SSI—were confirmed more often (n = 11, 8, and 3, respectively) as a significant risk factor for an SSI than they were disproved (n = 7, 6, and 1, respectively). Various sources of heterogeneity were observed, including patient selection, selection and analysis of putative risk factors, and definitions of SSI outcomes. Conclusion. There is an abundance of conflicting data on risk factors for SSI after spinal surgery. Given various sources of heterogeneity observed in observational literature, there is a paucity of solid evidence for the proof of robust risk factors. The authors recommend the introduction, validation, and use of a standardized set of strongly justified eligibility criteria and well-defined candidate risk factors and spinal SSI outcomes.

The Presentation, Incidence, Etiology, and Treatment of Surgical Site Infections After Spinal Surgery

Study Design. Descriptive, retrospective cohort analysis. Objective. To evaluate the presentation, etiology, and treatment of surgical site infections (SSI) after spinal surgery. Summary of Background Data. SSI after spine surgery is frequently seen. Small case control studies have been published reporting the results of treatment options of SSI. We performed this study to indentify the most common clinical and laboratory presentation of a SSI, the most frequently seen infective organism, and evaluate the effectiveness of current treatment. Methods. All patients who underwent spinal surgery at our institution for diagnosis other than infection between June 1996 and December 2005 (N = 3174) were reviewed. All cases of SSI were identified. Patient and operative characteristics were reviewed. Infection type (deep or superficial), treatment course, laboratory and culture results were abstracted. Results. A total of 132 cases of SSI (84 deep and 48 superficial) were identified. About 72.7% of the SSI were detected as outpatients an average 28.7 days (deep, 29.9; superficial, 25.2) after the index procedure. Wound drainage was the most common complaint (68.2%). C-reactive protein level was elevated in 98.0%, erythrocyte sedimentation rate was elevated in 94.4%, but only 48.6% had elevated white blood cell count. Staphylococcus aureus was isolated in 72.6% of deep and 85.7% of superficial positive cultures. Seventy-six percent of deep SSI could be treated with a single debridement to clear the SSI. Instrumentation was retained or primarily exchanged if loose in all cases. Around 72.9% of superficial SSI were treated without formal debridement in the operating room. Antibiotic treatment was longer in deep SSI (40.8 vs. 19.6 days). Conclusion. Deep SSI following spinal surgery was effectively treated with single stage debridement and intravenous antibiotics. Superficial SSI could be treated effectively with local wound care and oral antibiotic therapy.

Effectiveness and Safety of Sleeve Gastrectomy, Gastric Bypass, and Adjustable Gastric Banding in Morbidly Obese Patients: a Multicenter, Retrospective, Matched Cohort Study

BackgroundLaparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the most performed procedures worldwide (92xa0%) nowadays. However, comparative clinical trials are scarce in literature. The objective of this study was to compare the effectiveness and safety of the three most performed bariatric procedures.MethodsA multicenter, retrospective, matched cohort study was conducted. Patients were eligible for analysis when a primary procedure was performed between 2007 and 2010 in one of the two specialized bariatric centers. Primary outcome was weight loss, expressed in the percentage excess weight loss (%EWL). Secondary outcome parameters are hospital stay, complication rate, and revisional surgery.ResultsIn total, 735 patients, 245 in each group, were included for analysis. The groups were comparable for age and gender after matching. Mean postoperative follow-up was 3.1u2009±u20091.2xa0years. LAGB patients showed less %EWL compared to LSG and LRYGB at all postoperative follow-up visits. LRYGB showed a %EWL of 71u2009±u200920xa0% compared to LSG (76u2009±u200923xa0%; pu2009=u20090.008) after 1-year follow-up; thereafter, no significant difference was observed. After 3xa0years of follow-up, LAGB showed a higher complication rate compared to LSG and LRYGB (pu2009<u20090.05). Revisional surgery after LAGB was needed in 21xa0%, while 9xa0% of the LSG underwent conversion to RYGB.ConclusionsLRYGB is a safe and effective treatment in morbid obese patients with good long-term outcomes. LSG seems to be an appropriate alternative as a definitive procedure, in terms of weight reduction and complication rate. LAGB is inferior to both LRYGB and LSG.

Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care

BackgroundDue to the increased incidence of morbid obesity, the demand for bariatric surgery is increasing. Therefore, the methods for optimising perioperative care for the improvement of surgical outcome and to increase efficacy are necessary. The aim of this prospective matched cohort study is to objectify the effect of the fast-track surgery (FTS) programme in patients undergoing primary Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery compared to conventional perioperative care (CPC).MethodsThis study compared the perioperative outcome data of two groups of 75 consecutive morbid obese patients who underwent a primary LRYGB according to international guidelines in the periods January 2011–April 2011 (CPC group) and April 2012–June 2012 (FTS group). The two groups were matched for age and sex. Primary endpoints were surgery and hospitalisation time, while secondary endpoints were intraoperative medication use and complication rates.ResultsBaseline patient characteristics for age, sex, weight and ASA classification were similar (pu2009>u20090.05) for CPC and FTS patients. BMI and waist circumference were significantly lower (pu2009<u20090.05) in the FTS compared to CPC. The total time from arrival at the operating room to the arrival at the recovery was reduced from 119 to 82xa0min (pu2009<u20090.001). Surgery time was reduced from 80 to 56xa0min (pu2009<u20090.001); mean hospital stay was reduced from 65 to 43xa0h (pu2009<u20090.001). Major complications occurred in 3 versus 4xa0% in the FTS and CPC, respectively.ConclusionsThe introduction of a fast-track programme after primary LRYGB improves short-term recovery and may reduces direct hospital-related resources.

Influence of perioperative resuscitation status on postoperative spine surgery complications.

BACKGROUND CONTEXTnRestrictive transfusion criteria have led to decreased morbidity and mortality in critically ill patients. Their use has been extended to other patient groups. In adult spine surgery, ongoing postoperative blood losses and soft-tissue trauma may make these patients not appropriate for restrictive transfusion practices.nnnPURPOSEnThe purpose of this study was to assess the influence of postoperative hemoglobin (HGB) level and use of packed red blood cells (pRBC) or fresh frozen plasma on postoperative patient morbidity, mortality, and hospital length of stay (LOS).nnnSTUDY DESIGN/SETTINGnThis was a retrospective study in a high-volume tertiary hospital.nnnPATIENT SAMPLEnThe sample comprised 300 consecutive patients who underwent spinal surgeries with blood losses of more than 2 L.nnnOUTCOME MEASURESnThe outcome measures were postoperative patient morbidity, mortality, and LOS.nnnMETHODSnThe records of patients who underwent adult spinal surgeries with blood loss of 2 or more L (N=300) were abstracted for patient characteristics, operative characteristics, transfusion, and HGB level over time. Intensive care unit and hospital LOS, discharge location, death, pulmonary embolism, stroke, seizures, surgical site infections (SSI), and myocardial infarctions were noted. Logistic regression analyses (SAS software version 9.2) were used.nnnRESULTSnTwelve (3%) patients had a postoperative HGB level of less than 8 g/dL, 126 (41.3%) had 8 g/dL or more but less than 10 g/dL, and 167 (54.8%) had 10 g/dL or more. There was no significant difference in morbidity or mortality between the two groups with higher HGB levels. Multiple regression analysis revealed that patients with initial postoperative HGB level of less than 8 g/dL were six times more likely to develop SSI (odds ratio 6.37, 95% confidence interval 1.15-35.28). Deep SSI rates were increased with greater postoperative pRBC use (p=.002). Fresh frozen plasma use in the operation room was lower in cases that developed SSI (1.50 vs. 2.69, p=.042). Intensive care unit and ward LOS were longer with increased postoperative blood product use.nnnCONCLUSIONnPatients with high blood loss (more than 2 L) during spine surgery who are under-resuscitated (HGB level less than 8 g/dL) have a significant increased risk of SSI.

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.

An optimized multivitamin supplement lowers the number of vitamin and mineral deficiencies three years after Roux-en-Y gastric bypass: a cohort study

BACKGROUNDnVitamin and mineral deficiencies are common after Roux-en-Y gastric bypass (RYGB) surgery. In particular, inadequate serum concentrations of ferritin and vitamin B12 have been found in 11% and 23% (respectively) of patients using a standard multivitamin supplement (sMVS) 1 year after RYGB.nnnOBJECTIVEnTo evaluate the effectiveness and safety of Weight Loss Surgery (WLS) Forte® (a pharmaceutical-grade, optimized multivitamin supplement) compared with an sMVS and a control group (nonuser) 3 years after RYGB.nnnSETTINGnGeneral hospital specialized in bariatric surgery.nnnMETHODSnA follow-up cohort study of a triple-blind randomized, controlled clinical trial.nnnRESULTSnAt baseline 148 patients were enrolled (74 [50%] in the sMVS group and 74 [50%] in the WLS Forte group). After a mean follow-up of 36 months, 11 (7%) patients were lost to follow-up, of whom 2 were secondary to death. At the end of the study, 11 (17%) patients in the WLS Forte and 17 (24%) in the sMVS group stopped using a supplement. In addition, 64 (47%) patients were using WLS Forte and 45 (33%) patients a sMVS. Patient characteristics and follow-up length were comparable between the groups. Significantly more patients were diagnosed with anemia (16% versus 3% [P = .021]), a ferritin deficiency (14% versus 3% [P = .043]), and a zinc deficiency (8% versus 0% [P = .033]) in the sMVS group compared with WLS Forte. Five patients developed a vitamin B12 deficiency while using WLS Forte, versus 15 of sMVS users (P = .001). No adverse events occurred that were related to supplement use.nnnCONCLUSIONnAt 3 years postoperative of RYGB, an optimized multivitamin supplement (WLS Forte) was more effective in reducing anemia and ferritin, vitamin B12, and zinc deficiencies compared with a standard supplement and control.

Long-term nutritional status in patients following Roux-en-Y gastric bypass surgery

BACKGROUND & AIMSnRoux-en-Y gastric bypass (RYGB) is an effective treatment for obesity. However, it also leads to multiple nutritional deficiencies. Much is known about the short term prevalence, but hardly any long term data is available on deficiencies. The aim of this study was to assess the long term outcome of nutritional status after RYGB.nnnMETHODSnWe performed a retrospective analysis of prospectively collected data obtained from 51 morbidly obese patients who underwent a primary laparoscopic RYGB. Primary outcomes were iron, vitamin B12 and vitamin D deficiencies. Secondary outcomes were deficiencies of other vitamins and minerals and compliance of the patients to multivitamin use.nnnRESULTSnThe mean follow-up was 81xa0±xa027 months. A total of 35%, 16% and 55% of the patients had deficiencies for iron, vitamin B12 and vitamin D respectively. Sixty-nine percent of patients used a (nonspecific) multivitamin supplement on a daily basis. Patients with multivitamin usage had a lower rate of iron deficiency (26% vs. 56%, pxa0=xa00.034), vitamin B12 (11% vs. 25%, pxa0=xa00.46) and vitamin D (46% vs. 75%, pxa0=xa00.07), compared to non-compliant patients.nnnCONCLUSIONSnNutritional deficiencies are common after a RYGB operation. Therefore, strict follow-up by a bariatric surgeon, endocrinologist or general practitioner is required, both short and long term.

Quality of Recovery After Low-Pressure Laparoscopic Donor Nephrectomy Facilitated by Deep Neuromuscular Blockade: A Randomized Controlled Study

AbstractBackgroundThe use of low intra-abdominal pressure (<10xa0mmHg) reduces postoperative pain scores after laparoscopic surgery.nObjectiveTo investigate whether low-pressure pneumoperitoneum with deep neuromuscular blockade improves the quality of recovery after laparoscopic donor nephrectomy (LDN).Design, setting and participantsIn a single-center randomized controlled trial, 64 live kidney donors were randomly assigned to 6 or 12xa0mmHg insufflation pressure. A deep neuromuscular block was used in both groups. Surgical conditions were rated by the five-point Leiden-surgical rating scale (L-SRS), ranging from 5 (optimal) to 1 (extremely poor) conditions. If the L-SRS was insufficient, the pressure was increased stepwise.nMain outcome measureThe primary outcome measure was the overall score on the quality of recovery-40 (QOR-40) questionnaire at postoperative day 1.ResultsThe difference in the QOR-40 scores on day 1 between the low- and standard-pressure group was not significant (pxa0=xa0.06). Also the overall pain scores and analgesic consumption did not differ. Eight procedures (24%), initially started with low pressure, were converted to a standard pressure (≥10xa0mmHg). A L-SRS score of 5 was significantly more prevalent in the standard pressure as compared to the low-pressure group at 30xa0min after insufflation (pxa0<xa0.01).ConclusionsLow-pressure pneumoperitoneum facilitated by deep neuromuscular blockade during LDN does not reduce postoperative pain scores nor improve the quality of recovery in the early postoperative phase. The question whether the use of deep neuromuscular blockade during laparoscopic surgery reduces postoperative pain scores independent of the intra-abdominal pressure should be pursued in future studies.Trial registrationThe trial was registered at clinicaltrial.gov before the start of the trial (NCT02146417).