The role of plain radiographs in patients with acute abdominal pain at the ED.

OBJECTIVE: 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). METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Spontaneous splenic rupture during Pringle maneuver in liver surgery.

During liver resection clamping of the hepato-duodenal ligament (the Pringle maneuver) is performed to reduce intraoperative blood-loss. During this maneuver acute portal hypertension may lead to spontaneous splenic rupture requiring rapid splenectomy in order to control blood loss. We present 2 case of patients with hemorrhage from the spleen during clamping for liver surgery. A review of the literature with an emphasis on the pathophysiology of splenic hemorrhage is presented.

Immunogenicity of dendritic cells pulsed with CEA peptide or transfected with CEA mRNA for vaccination of colorectal cancer patients.

BACKGROUND: Dendritic cells (DCs) are the professional antigen-presenting cells of the immune system. We have demonstrated that vaccination of autologous ex vivo cultured DCs results in the induction of tumor-specific immune responses in cancer patients, which correlates with clinical response. Optimization of antigen loading is one of the possibilities for further improving the efficacy of DC vaccination. Theoretically, transfection of DCs with RNA encoding a tumor-specific antigen may induce a broader immune response as compared to the most widely used technique of peptide pulsing. PATIENTS AND METHODS: In this clinical study, RNA transfection was compared with peptide pulsing as an antigen loading strategy for DC vaccination. Patients with resectable liver metastases of colorectal cancer were vaccinated intravenously and intradermally 3 times weekly with either carcinoembryogenic antigen (CEA)-derived HLA-A2 binding peptide-loaded or CEA mRNA electroporated DCs prior to surgical resection of the metastases. All DCs were loaded with keyhole limpet hemocyanin (KLH) as a control protein. Evaluation of vaccine-induced immune reactivity consisted of T-cell proliferative responses and B-cell antibody responses against KLH in peripheral blood. CEA reactivity was determined in T-cell cultures of biopsies of post-treatment delayed type hypersensitivity skin tests. RESULTS: Sixteen patients were included. All patients showed T-cell responses against KLH upon vaccination. CEA peptide-specific T-cells were detected in 8 out of 11 patients in the peptide group, but in none of the 5 patients in the RNA group. CONCLUSION: In our study, DC CEA mRNA transfection was not superior to DC CEA peptide pulsing in the induction of a tumor-specific immune response in colorectal cancer patients.

Preoperative biliary drainage for periampullary tumors causing obstructive jaundice; DRainage vs. (direct) OPeration (DROP-trial).

BACKGROUND: Surgery in patients with obstructive jaundice caused by a periampullary (pancreas, papilla, distal bile duct) tumor is associated with a higher risk of postoperative complications than in non-jaundiced patients. Preoperative biliary drainage was introduced in an attempt to improve the general condition and thus reduce postoperative morbidity and mortality. Early studies showed a reduction in morbidity. However, more recently the focus has shifted towards the negative effects of drainage, such as an increase of infectious complications. Whether biliary drainage should always be performed in jaundiced patients remains controversial. The randomized controlled multicenter DROP-trial (DRainage vs. Operation) was conceived to compare the outcome of a 'preoperative biliary drainage strategy' (standard strategy) with that of an 'early-surgery' strategy, with respect to the incidence of severe complications (primary-outcome measure), hospital stay, number of invasive diagnostic tests, costs, and quality of life. METHODS/DESIGN: Patients with obstructive jaundice due to a periampullary tumor, eligible for exploration after staging with CT scan, and scheduled to undergo a "curative" resection, will be randomized to either "early surgical treatment" (within one week) or "preoperative biliary drainage" (for 4 weeks) and subsequent surgical treatment (standard treatment). Primary outcome measure is the percentage of severe complications up to 90 days after surgery. The sample size calculation is based on the equivalence design for the primary outcome measure. If equivalence is found, the comparison of the secondary outcomes will be essential in selecting the preferred strategy. Based on a 40% complication rate for early surgical treatment and 48% for preoperative drainage, equivalence is taken to be demonstrated if the percentage of severe complications with early surgical treatment is not more than 10% higher compared to standard treatment: preoperative biliary drainage. Accounting for a 10% dropout, 105 patients are needed in each arm resulting in a study population of 210 (alpha = 0.95, beta = 0.8). DISCUSSION: The DROP-trial is a randomized controlled multicenter trial that will provide evidence whether or not preoperative biliary drainage is to be performed in patients with obstructive jaundice due to a periampullary tumor.