Peter W. de Graaf

Costs of relaparotomy on-demand versus planned relaparotomy in patients with severe peritonitis: an economic evaluation within a randomized controlled trial

IntroductionResults of the first randomized trial comparing on-demand versus planned-relaparotomy strategy in patients with severe peritonitis (RELAP trial) indicated no clear differences in primary outcomes. We now report the full economic evaluation for this trial, including detailed methods, nonmedical costs, further differentiated cost calculations, and robustness of different assumptions in sensitivity analyses.MethodsAn economic evaluation was conducted from a societal perspective alongside a randomized controlled trial in 229 patients with severe secondary peritonitis and an acute physiology and chronic health evaluation (APACHE)-II score ≥11 from two academic and five regional teaching hospitals in the Netherlands. After the index laparotomy, patients were randomly allocated to an on-demand or a planned-relaparotomy strategy. Primary resource-utilization data were used to estimate mean total costs per patient during the index admission and after discharge until 1 year after the index operation. Overall differences in costs between the on-demand relaparotomy strategy and the planned strategy, as well as relative differences across several clinical subgroups, were evaluated.ResultsCosts were substantially lower in the on-demand group (mean, €65,768 versus €83,450 per patient in the planned group; mean absolute difference, €17,682; 95% CI, €5,062 to €29,004). Relative differences in mean total costs per patient (approximately 21%) were robust to various alternative assumptions. Planned relaparotomy consistently generated more costs across the whole range of different courses of disease (quick recovery and few resources used on one end of the spectrum; slow recovery and many resources used on the other end). This difference in costs between the two surgical strategies also did not vary significantly across several clinical subgroups.ConclusionsThe reduction in societal costs renders the on-demand strategy a more-efficient relaparotomy strategy in patients with severe peritonitis. These differences were found across the full range of healthcare resources as well as across patients with different courses of disease.Trial RegistrationISRCTN51729393

Malignant breast tumor phospholipid profiles using 31P magnetic resonance

Biochemical markers improve the classification and staging of breast cancer and may refine management decisions if it can be shown that they correlate with accepted prognostic factors or patient outcome. Using phosphorus-31 magnetic resonance spectroscopy ((31)P MRS), we determined the phospholipid content of 43 malignant breast tumors, correlating the profiles with specific histopathologic and clinical features and hormone receptor status. Among the 14 phospholipids identified, the mean mole percentage of sphingomyelin, phosphatidylcholine, phosphatidylserine, phosphatidic acid, phosphatidylglycerol, and alkylacylphosphatidylcholine predicted cellular infiltration, infiltration type, elastosis, lymphatic invasion, perineural invasion, necrosis, and estrogen receptor positivity. (31)P MRS phospholipid profile data provide statistical correlations among histologic features and molecules known to play important roles in cellular communication, regulation, and processes unique to malignant tissues.

Advantages of magnetic resonance imaging in breast surgery treatment planning

Preoperative magnetic resonance imaging (MRI) was performed in 40 patients with malignant and benign breast tumors. Images were qualitatively evaluated to determine features of MRI that would benefit breast surgery treatment planning. MRI was found to be exceptional in demonstrating the relationship of tumors with respect to structures such as the chest wall, nipple, and skin. Tumor size was estimated by MRI, mammography, and gross pathological measurement in the 32 patients confirmed to have a malignant tumor of the breast. MRI estimated the tumor size to be larger than mammography in 71% of the cases and larger than pathological measurement in 84% of the cases. Compared with the standard method for determining tumor size (pathological measurement), MRI would have upstaged 22% of the evaluated cases from T1 to T2 and 10% of the cases from T2 to T3. MRI may prove useful in selecting patients for breast conserving therapy.

Healing of the cervical esophagogastrostomy.

Reconstruction of the upper digestive tract with the stomach or gastric tube after esophageal resection has proven to be a safe surgical procedure. But dehiscence, leakage, and stricture of the esophagogastrostomy are prevalent and have been reported in 0% to 4%, 5% to 44%, and 7% to 50% of patients respectively. These complication rates exclude esophageal resection for benign diseases and cast doubt in the case of palliation. Many surgeons prefer to resect the esophagus transhiatally with a cervical anastomosis, which circumvents the transthoracic route and avoids possibility of leakage of an intrathoracic anastomosis and its severe consequences, with mortality rates up to 58%. Anastomotic complications occur more frequently, however, after cervical anastomosis compared with the intrathoracic position when the stomach is used as a substitute for the esophagus. Currently, a narrow gastric tube as a neoesophagus is often preferred because of improved gastric emptying in comparison with wide gastric tubes and gastric pull-up. The extra length can be helpful in reaching the neck because a narrow gastric tube makes widening of the upper thorax aperture unnecessary. Despite these advantages, healing of the cervical esophagogastrostomy is often impaired, leading to nonfatal complications such as leakage and stricture formation. Among the factors that might affect anastomotic healing are: surgical technique and material, vascularization of the gastric tube at the level of the anastomosis, diameter of the gastric tube, position of the anastomosis, and reflux of the gastrointestinal contents.

Breast disease evaluation with fat-suppressed magnetic resonance imaging

Thirty patients with a variety of pathologically confirmed malignant and benign pathologic lesions of the breast were evaluated with a spectrally selective fat suppression imaging technique to obtain fat-suppressed images of the breast. The technique, a selective partial inversion-recovery (SPIR) method, demonstrated the architectural relationship of malignant and benign tumors with respect to the normal water-containing elements of the breast. These relationships included signs of advanced malignant disease such as tissue retraction, invasive growth, and multicentricity, which appeared on the fat-suppressed images. Fat-suppressed imaging provided useful information for assessing the breasts of both pre- and postmenopausal women, especially in the latter group, where fatty involution of the breast is common. Microcysts, which are normally not visualized by conventional methods, were demonstrated and associated with patients having confirmed fibrocystic disease of the breast. As expected, the SPIR technique did not improve the ability to distinguish between tissues having similar T1 and T2 relaxation time values, such as malignant tumors and normal breast parenchymal tissues. The technique was able to demonstrate that the intense lipid signal, known to be responsible for obscuring the borders of water-fat interfaces and small tumors, could be eliminated in a variety of pathological settings.

Health related quality of life six months following surgical treatment for secondary peritonitis – using the EQ-5D questionnaire

BackgroundTo compare health related quality of life (HR-QoL) in patients surgically treated for secondary peritonitis to that of a healthy population. And to prospectively identify factors associated with poorer (lower) HR-QoL.DesignA prospective cohort of secondary peritonitis patients was mailed the EQ-5D and EQ-VAS 6-months following initial laparotomy.SettingMulticenter study in two academic and seven regional teaching hospitals.Patients130 of the 155 eligible patients (84%) responded to the HR-QoL questionnaires.ResultsHR-QoL was significantly worse on all dimensions in peritonitis patients than in a healthy reference population. Peritonitis characteristics at initial presentation were not associated with HR-QoL at six months. A more complicated course of the disease leading to longer hospitalization times and patients with an enterostomy had a negative impact on the mobility (p = 0.02), self-care (p < 0.001) and daily activities: (p = 0.01). In a multivariate analysis for the EQ-VAS every doubling of hospital stay decreases the EQ-VAS by 3.8 points (p = 0.015). Morbidity during the six-month follow-up was not found to be predictive for the EQ-5D or EQ-VAS.ConclusionSix months following initial surgery, patients with secondary peritonitis report more problems in HR-QoL than a healthy reference population. Unfavorable disease characteristics at initial presentation were not predictive for poorer HR-QoL, but a more complicated course of the disease was most predictive of HR-QoL at 6 months.

Fibroadenoma of the breast: in vivo magnetic resonance characterization

Fibroadenoma is a common benign tumor of the breast which is well characterized mammographically [ 11, sonographically [2] and by physical examination. In spite of being well characterized, its presence as a tumor provokes surgical evaluation. Even though the presence of a libroadenoma is not associated with any increased risk for the development of a primary malignant tumor of the breast [3], most surgical textbooks state that excision is mandatory [4,5]. The removal of these lesions results in deformity, morbidity and expenditure of resources; nevertheless, any perceived risk of malignancy by the patient and a conservative clinical attitude are responsible for a large number of surgical procedures for this benign condition [6]. Except in cases where a fibroadenoma causes the patient physical or psychological discomfort by its presence, if a technique were developed to characterize libroadenomas more specifically in vivo, unnecessary surgery could possibly be avoided, especially in young women. Early studies using magnetic resonance imaging (MRI) attempted to characterize fibroadenomas in vivo on the basis of characteristic morphology, signal intensity, T, and T, relaxation times and enhancement with paramagnetic contrast [7-171. While the findings of these studies did improve the MR image characteri-

MRI appearance of multiple papilloma of the breast

SummaryMagnetic resonance imaging (MRI) is capable of providing a different diagnostic perspective in the evaluation of breast lesions. Its application in a single patient with multiple papilloma of the breast is described. MRI convincingly demonstrated the multicentric nature of the disease and helped to select a proper treatment plan. This report makes it clear that MRI could serve as an adjunct to mammography and sonography in selected cases.