J.A. Wegdam

Toward an evidence-based step-up approach in diagnosing diverticulitis.

Abstract Background. The lack of pathognomonic findings and the chance of complicated disease have resulted in the widespread use of additional imaging to diagnose acute colonic diverticulitis (ACD). The added value of additional imaging in the diagnostic workup of patients suspected of ACD is not well defined. Aims. The aim of this study was to systematically review the literature of the accuracy of the clinical evaluation and diagnostic modalities for patients with suspected ACD, to come to an evidence-based approach to diagnose ACD. Methods. A systematic review and meta-analysis of studies that reported diagnostic accuracy of the clinical diagnosis and diagnostic modalities in patients with suspected diverticulitis were performed. Study quality was assessed with the STARD checklist. True-positive, true-negative, false-positive, and false-negative findings were extracted and pooled estimates of sensitivity and specificity per diagnostic test were calculated, if applicable. Results. The overall quality of the studies reporting the diagnostic accuracy of the clinical diagnosis, contrast enema and magnetic resonance imaging (MRI) were moderate to poor and not suitable for meta-analysis. Sensitivity of the clinical diagnosis varied between 64% and 68%. Ultrasound (US) and computed tomography (CT) studies were eligible for meta-analysis. Summary sensitivity estimates for US were 90% (95% CI: 76–98%) versus 95% (95% CI: 91–97%) for CT (p = 0.86). Summary specificity estimates for US were 90% (95% CI: 86–94%) versus 96% (95% CI: 90–100%) for CT (p = 0.04). Sensitivity for MRI was 98% and specificity varied between 70% and 78%. Sensitivity of contrast enema studies varied between 80% and 83%. Conclusion. In two-thirds of the patients, the diagnosis of ACD can be made based on clinical evaluation alone. In one-third of the patients, additional imaging is a necessity to establish the diagnosis. US and CT are comparable in diagnosing diverticulitis and superior to other modalities. CT has the advantage of higher specificity and the ability to identify alternative diagnoses. The role of MRI is not yet clear in diagnosing ACD. Contrast enema is considered an obsolete imaging technique to diagnose ACD based on lower sensitivity and specificity than US and CT. A step-up approach with CT performed after an inconclusive or negative US, seems a logical and safe approach for patients suspected of ACD.

Peritoneal carcinomatosis is less frequently diagnosed during laparoscopic surgery compared to open surgery in patients with colorectal cancer

BACKGROUND During resection of a colorectal tumor a careful inspection of the abdomen should be performed to detect metastases. The aim of the current study was to compare the proportions of patients diagnosed with peritoneal carcinomatosis (PC) during laparoscopic resection (LR) and open resection (OR). METHODS All patients who underwent resection for colorectal cancer in the Eindhoven Cancer Registry area between 2008 and 2012 were included. Proportions of patients with PC were compared between surgical techniques. Multivariate logistic regression analysis was performed. RESULTS 6687 Patients underwent resection for colorectal cancer, of whom 1631 patients (24%) underwent LR, 4665 patients (70%) underwent OR. Conversion took place in 391 patients (19% of laparoscopic treated patients). PC was diagnosed in 1.4% of patients undergoing LR, in 5.0% of patients undergoing OR, and in 3.3% of patients in whom LR was converted to OR (p < 0.001). After adjustment for patient and tumor characteristics (e.g., T- and N-stage), patients who were treated by LR had a lower chance to be diagnosed with PC during surgery than patients undergoing OR (odds ratio = 0.42, p < 0.001). CONCLUSIONS Patients undergoing surgery for colorectal cancer are less frequently diagnosed with PC during LR in comparison to OR. Since effective treatment is currently available for selected patients with PC, a thorough inspection of the peritoneum during surgery is of paramount importance to offer these patients a chance for long-term survival and even cure.

The effects of stimulation of the autonomic nervous system via perioperative nutrition on postoperative ileus and anastomotic leakage following colorectal surgery (SANICS II trial): a study protocol for a double-blind randomized controlled trial

BackgroundPostoperative ileus and anastomotic leakage are important complications following colorectal surgery associated with short-term morbidity and mortality. Previous experimental and preclinical studies have shown that a short intervention with enriched enteral nutrition dampens inflammation via stimulation of the autonomic nervous system and thereby reduces postoperative ileus. Furthermore, early administration of enteral nutrition reduced anastomotic leakage. This study will investigate the effect of nutritional stimulation of the autonomic nervous system just before, during and early after colorectal surgery on inflammation, postoperative ileus and anastomotic leakage.Methods/DesignThis multicenter, prospective, double-blind, randomized controlled trial will include 280 patients undergoing colorectal surgery. All patients will receive a selfmigrating nasojejunal tube that will be connected to a specially designed blinded tubing system. Patients will be allocated either to the intervention group, receiving perioperative nutrition, or to the control group, receiving no nutrition. The primary endpoint is postoperative ileus. Secondary endpoints include anastomotic leakage, local and systemic inflammation, (aspiration) pneumonia, surgical complications classified according to Clavien-Dindo, quality of life, gut barrier integrity and time until functional recovery. Furthermore, a cost-effectiveness analysis will be performed.DiscussionActivation of the autonomic nervous system via perioperative enteral feeding is expected to dampen the local and systemic inflammatory response. Consequently, postoperative ileus will be reduced as well as anastomotic leakage. The present study is the first to investigate the effects of enriched nutrition given shortly before, during and after surgery in a clinical setting.Trial registrationClinicalTrials.gov: NCT02175979 - date of registration: 25 June 2014.Dutch Trial Registry: NTR4670 - date of registration: 1 August 2014.

Perioperative lipid-enriched enteral nutrition versus standard care in patients undergoing elective colorectal surgery (SANICS II): a multicentre, double-blind, randomised controlled trial

BACKGROUND Postoperative ileus and anastomotic leakage severely impair recovery after colorectal resection. We investigated the effect of perioperative lipid-enriched enteral nutrition versus standard care on the risk of postoperative ileus, anastomotic leakage, and other clinical outcomes. METHODS We did an international, multicentre, double-blind, randomised, controlled trial of patients (≥18 years) undergoing elective colorectal surgery with primary anastomosis at six clinical centres in the Netherlands and Denmark. Patients were randomly assigned (1:1), stratified by location (colonic and rectal) and type of surgery (laparoscopic and open), via online randomisation software, with block sizes of six, to receive either continuous lipid-enriched enteral tube feeding from 3 h before until 6 h after surgery (intervention) or no perioperative nutrition (control). Surgeons, patients, and researchers were masked to treatment allocation for the entire study period. The primary outcome was postoperative ileus. Secondary outcomes included anastomotic leakage, pneumonia, preoperative gastric volumes, time to functional recovery, length of hospital stay, the need for additional interventions, intensive care unit admission, postoperative inflammatory response, and surgical complications. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT02175979, and trialregister.nl, number NTR4670. FINDINGS Between July 28, 2014, and February 20, 2017, 280 patients were randomly assigned, 15 of whom were excluded after random allocation because they fulfilled one or more exclusion criteria. 265 patients received perioperative nutrition (n=132) or standard care (n=133) and were included in the analyses. A postoperative ileus occurred in 37 (28%) patients in the intervention group versus 29 (22%) in the control group (risk ratio [RR] 1·09, 95% CI 0·95-1·25; p=0·24). Anastomotic leakage occurred in 12 (9%) patients in the intervention group versus 11 (8%) in the control group (RR 1·01, 95% CI 0·94-1·09; p=0·81). Pneumonia occurred in ten (8%) patients in the intervention group versus three (2%) in the control group (RR 1·06, 95% CI 1·00-1·12; p=0·051). All other secondary outcomes were similar between groups (all p>0·05). INTERPRETATION Perioperative lipid-enriched enteral nutrition in patients undergoing elective colorectal surgery has no advantage over standard care in terms of postoperative complications. FUNDING Netherlands Organisation for Health Research and Development (ZonMW), Fonds NutsOhra, and Danone Research.

Disease Course of Right- and Left-sided Diverticulitis in a Western Population

Aim: To evaluate the similarities and differences in disease courses between right- and left-sided diverticulitis in a Western population. Methods: All consecutive patients admitted in a Dutch regional hospital between 2004 and 2008 for conservative or operative management of clinically and radiologically confirmed acute right- and left-sided diverticulitis were analyzed retrospectively. Diverticulitis was clinically suspect if the patient presented with lower abdominal pain combined with at least one elevated inflammatory parameter (temperature, WBC, CRP or ESR). Diverticulitis was radiologically confirmed if at least US or CT demonstrated signs of acute right- or left-sided diverticulitis. Differences in incidence, patient characteristics, clinical presentation and disease course between the two diagnoses were analyzed. Results: The hospital system yielded 425 patients with a diverticulosis/diverticulitis discharge coding. 57% was excluded because these patients had another diagnosis demonstrated by imaging, besides diverticulosis (19%), had no imaging at all (16%), were elective or referred (7%), were not admitted (4%) or had other reasons (11%). A total of 183 admitted patients with both clinical and radiological confirmed acute colonic diverticulitis were included. The incidence of right-sided diverticulitis was 8%. Patients with right-sided diverticulitis were predominantly female (86% compared to 47% in leftsided diverticulitis, P = 0.05). Median CRP at presentation was lower in right sided diverticulitis, 30 compared to 71 mg/L (P = 0.001). No other differences in clinical presentation, like the severity of diverticulitis, and disease course, like the need for acute surgery, were found between right and left-sided diverticulitis. Conclusions: Disease course of acute right-sided diverticulitis in Caucasians is comparable to left-sided diverticulitis. Left-sided diverticulitis treatment guidelines may also apply for the right-sided diverticulitis in Caucasians.

Complex Ventral Situation

Introduction: Estimating the risk of postoperative complications of large ventral hernia repair remains challenging. Usually only general risk factors such as age, Body Mass Index (BMI), and smoking are used to estimate the postoperative risk of complications. It has been hypothesized that the hernia volume is directly related to postoperative complications because the volume of the hernia sac is reduced into the abdominal cavity, creating tension on the abdominal wall and the diaphragm, thus increasing the risk for wound and pulmonary complications. The primary aim of this study was to analyze the relationship between hernia volume and postoperative complications, the secondary aim was to validate a mathematical formula for calculating hernia volume.