Effectiveness of a Tailored Work-Related Support Intervention for Patients Diagnosed with Gastrointestinal Cancer: A Multicenter Randomized Controlled Trial.

Purpose The aim of this research was to study the effectiveness on return to work (RTW) of an early tailored work-related support intervention in patients diagnosed with curative gastrointestinal cancer. Methods A multicenter randomized controlled trial was undertaken, in which patients were assigned randomly to the intervention or the control group (usual care). The intervention encompassed three psychosocial work-related support meetings, starting before treatment. Five self-reported questionnaires were sent over twelve months of follow-up. Primary outcome was days until RTW (fulltime or partial) and secondary outcomes included work status, quality of life, work ability, and work limitations. Descriptive analysis, Kaplan-Meier analysis, relative risk ratio and linear mixed models were applied. Results Participants (N = 88) had a mean age of 55 years; 67% were male and the most common cancer type was colon cancer (66%). Of the participants, 42 were randomized to the intervention group. The median time from sick leave until RTW was 233 days (range 187-279 days) for the control group, versus 190 days (range 139-240 days) for the intervention group (log-rank p = 0.37). The RTW rate at twelve months after baseline was 83.3% for the intervention group and 73.5% for the control group. Work limitations did statistically differ between the groups over time (p = 0.01), but quality of life and work ability did not. Conclusion Patients in the intervention group seem to take fewer days to RTW, albeit not to a statistically significant extent.Trial registration Trial NL4920 (NTR5022) (Dutch Trial Register https://www.trialregister.nl ).

Randomized clinical trial of intracutaneously versus transcutaneously sutured ileostomy to prevent stoma-related complications (ISI trial).

BACKGROUND: Ileostomy construction is a common procedure but can be associated with morbidity. The stoma is commonly secured to the skin using transcutaneous sutures. It is hypothesized that intracutaneous sutures result in a tighter adherence of the peristomal skin to the stoma plate to prevent faecal leakage. The study aimed to compare the effect of intracutaneous versus transcutaneous suturing of ileostomies on faecal leakage and quality of life. METHODS: This randomized trial was undertaken in 11 hospitals in the Netherlands. Patients scheduled to receive an ileostomy for any reason were randomized to intracutaneous or transcutaneous suturing (IC and TC groups respectively). The primary outcome was faecal leakage. Secondary outcomes were stoma-related quality of life and costs of stoma-related materials and reinterventions. RESULTS: Between April 2011 and February 2016, 339 patients were randomized to the IC (170) or TC (169) group. Leakage rates were higher in the IC than in the TC group (52·4 versus 41·4 per cent respectively; risk difference 11·0 (95 per cent c.i. 0·3 to 21·2) per cent). Skin irritation rates were high (78·2 versus 72·2 per cent), but did not differ significantly between the groups (risk difference 6·1 (95 per cent c.i. -3·2 to 15·10) per cent). There were no significant differences in quality of life or costs between the groups. CONCLUSION: Intracutaneous suturing of an ileostomy is associated with more peristomal leakage than transcutaneous suturing. Overall stoma-related complications did not differ between the two techniques. Registration number: NTR2369 ( http://www.trialregister.nl).

Intensified follow-up in colorectal cancer patients using frequent Carcino-Embryonic Antigen (CEA) measurements and CEA-triggered imaging: Results of the randomized "CEAwatch" trial.

AIM: The value of frequent Carcino-Embryonic Antigen (CEA) measurements and CEA-triggered imaging for detecting recurrent disease in colorectal cancer (CRC) patients was investigated in search for an evidence-based follow-up protocol. METHODS: This is a randomized-controlled multicenter prospective study using a stepped-wedge cluster design. From October 2010 to October 2012, surgically treated non-metastasized CRC patients in follow-up were followed in eleven hospitals. Clusters of hospitals sequentially changed their usual follow-up care into an intensified follow-up schedule consisting of CEA measurements every two months, with imaging in case of two CEA rises. The primary outcome measures were the proportion of recurrences that could be treated with curative intent, recurrences with definitive curative treatment outcome, and the time to detection of recurrent disease. RESULTS: 3223 patients were included; 243 recurrences were detected (7.5%). A higher proportion of recurrences was detected in the intervention protocol compared to the control protocol (OR = 1.80; 95%-CI: 1.33-2.50; p = 0.0004). The proportion of recurrences that could be treated with curative intent was higher in the intervention protocol (OR = 2.84; 95%-CI: 1.38-5.86; p = 0.0048) and the proportion of recurrences with definitive curative treatment outcome was also higher (OR = 3.12, 95%-CI: 1.25-6.02, p-value: 0.0145). The time to detection of recurrent disease was significantly shorter in the intensified follow-up protocol (HR = 1.45; 95%-CI: 1.08-1.95; p = 0.013). CONCLUSION: The CEAwatch protocol detects recurrent disease after colorectal cancer earlier, in a phase that a significantly higher proportion of recurrences can be treated with curative intent.

Decision making for relaparotomy in secondary peritonitis.

BACKGROUND/AIMS: To provide a qualitative ranking of clinical variables by surgeons that influence their decision for reoperation and to evaluate whether these variables are related to positive findings at relaparotomy. METHODS: Importance in decision making for relaparotomy was evaluated for 21 factors using a 10-point visual analogue scale (VAS). Variables with median VAS scores >5.0 were labeled 'important'. Predictive value for positive findings was evaluated by multivariate analysis. RESULTS: The response rate was 64%. For each variable, a wide range of VAS scores was given. Of variables labeled 'important', a diffuse extent of abdominal contamination (odds ratio, OR 1.9; 95% CI 0.99-3.8; p = 0.052), localization of the infectious focus (upper gastrointestinal tract including small bowel: OR 2.6, 95% CI 0.98-7.0, p = 0.055; colon: OR 2.4, 95% CI 0.93-6.0, p = 0.071), and both low (<3 x 10(9)/l: OR 4.6, 95% CI 1.3-17, p = 0.021) and high (>20 x 10(9)/l: OR 2.2, 95% CI 1.0-4.9, p = 0.042) leukocyte counts independently predicted positive relaparotomy. As a set, these variables had only moderate predictive accuracy (c-statistic 0.69). CONCLUSIONS: There was no consensus among surgeons which variables were important in decision making for relaparotomy. Only three out of ten variables labeled as 'important' were indeed independently predictive, but even as a set had only moderate predictive accuracy.

[Pneumatosis intestinalis; no disease, but a symptom]. / Pneumatosis intestinalis; geen ziekte, maar een symptoom.

In three patients, men aged 77, 83 and 69 years, pneumatosis intestinalis was detected during CT for abdominal pain occurring in the first patient after an aortic stent had been placed, and during laparotomy because of ileus in the latter two patients. The first patient underwent removal of an ischaemic intestinal segment but died later due to infection around the prosthesis. The other two patients recovered after conservative therapy. Pneumatosis intestinalis is defined as the presence of gas in the wall of the gastrointestinal tract. Often it is detected by accident during abdominal radiographic examination or laparotomy. Pneumatosis intestinalis is a symptom and has been found in a wide variety of diseases. The clinical condition of the patient and the underlying disease determine the clinical significance of pneumatosis intestinalis and the therapy. The main issue is whether surgical intervention is necessary because of intestinal ischaemia or perforation.

Early versus late surgical drainage for obstructive pancreatitis in an experimental model.

BACKGROUND: Chronic pancreatitis (CP) is characterized by intractable abdominal pain, and pancreatic exocrine and endocrine dysfunction. This study investigated whether early surgical drainage of pancreatic duct obstruction leads to improved recovery of pancreatic function compared with late surgical drainage in an experimental model of chronic obstructive pancreatitis. METHODS: Twenty-one piglets underwent pancreatic duct ligation and subsequent longitudinal pancreaticojejunostomy after 3 weeks (early drainage) or 6 weeks (late drainage), and drainage continued for 6 weeks. In controls with CP pancreatic duct ligation was continued for 12 weeks without a drainage procedure. RESULTS: Histological pancreatitis scores decreased with early drainage (P = 0.005), but not with late drainage. Pancreatic secretion of amylase and lipase was restored after early but not late drainage (P = 0.003 and P = 0.048 respectively). Excretion levels of lipase were restored to near-baseline preligation levels after early drainage. Pancreatic endocrine function (glucose tolerance test) showed no insufficiency in either group. CONCLUSION: In this model of early versus late surgical drainage of obstructive pancreatitis, histology grades and pancreatic exocrine function showed improvement in the early drainage group but no recovery in the late drainage group.

Retroperitoneal haemorrhage caused by a renal angiomyolipoma.

Renal angiomyolipoma (AML) is a benign renal tumour and is nowadays considered a relatively common lesion. When an AML increases in size or becomes symptomatic, embolisation via the renal artery should then be considered, because rupture is an important complication and interventional therapies are required to stop bleeding. We present a 21 year old woman who was seen at the emergency department following a low velocity trauma. After a period of 9 weeks, clinical examination and radiological examination revealed a haemorrhage from a renal AML, which was treated by selective embolisation. A discussion of the relevant literature is also presented.

Surgical therapy attenuates abdominal and extra-abdominal inflammation in experimental peritonitis.

BACKGROUND: This study examines the influence of surgical management (elimination of the infectious focus and abdominal lavage) on survival and the inflammatory response in the various compartments of the body: local (abdomen), systemic (blood) and distant organ (lungs). MATERIALS AND METHODS: Peritonitis was established in mice by cecal ligation and puncture (CLP). After 24 h, a group was made in which the infected cecum was resected and the abdominal cavity was lavaged (RES), and another group that received no surgical resection (NoRES). Survival was examined over a period of 96 h. Mice were sacrificed at 24 (sham and CLP), 48 and 72 h after CLP to measure inflammatory parameters. RESULTS: Survival was significantly lower is NoRES compared to sham and RES (p = 0.006, p = 0.014, respectively). Intraperitoneal parameters were improved in the RES group compared to sham but results were not significantly different between groups. In plasma, levels of interleukin-6 (IL-6) were decreased in RES (p = 0.048). Accordingly, anti-inflammatory IL-10 in plasma was increased in this group (p = 0.031). In the lung, keratinocyte-derived chemokine (KC) and myeloperoxidase (MPO) was reduced indicating decreased granulocytes accumulation in the lung in the RES group (p = 0.012 and p = 0.004, respectively). CONCLUSIONS: In experimental secondary peritonitis surgical management improves survival and attenuates the inflammatory response predominantly in the extra-abdominal compartments. This illustrates the importance of surgery in prevention of multiple organ failure and denotes the compartmentalized character of the inflammatory response. This polymicrobial model with implicated surgical intervention reflects the clinical situation and may be more appropriate to test therapeutic interventions than a model involving only CLP.

[Relaparotomy in secondary peritonitis Planned relaparotomy or relaparotomy on demand?]. / Relaparotomie bei sekundärer Peritonitis. Programmierte Relaparotomie oder Relaparotomie "on demand"?

Secondary peritonitis is associated with serious morbidity and a persistent high mortality in recent decades, this despite improvement in antibiotic, intensive care and surgical treatment. The available literature regarding the surgical treatment of secondary peritonitis was searched through Pubmed (1966- January 2005) as well as a hand search of references of retrieved articles. Definitions, pathophysiology and classification of secondary peritonitis are discussed, as well as the scientific rationale for the surgical treatment in secondary peritonitis. The historical development and the scientific foundation of present-day relaparotomy strategies in secondary peritonitis are evaluated, with an emphasis on two frequently applied surgical treatment strategies: planned relaparotomy and relaparotomy on demand. Criteria for relaparotomy after the initial laparotomy and potential areas for further research to reduce both morbidity and mortality are discussed. Furthermore, the care of patients with secondary peritonitis is evolving from a surgical entity to a more multidisciplinary challenge uniting surgeons, intensivists, radiologists and microbiologists. Research needs to be expanded into novel fields to further decrease morbidity and mortality.

[The aortocaval fistula, a rare complication of an aneurysm of the abdominal aorta]. / De aortocavale fistel, een zeldzame complicatie van een aneurysma van de abdominale aorta.

Four patients, 3 men aged 73, 60 and 81 years with hemodynamic instability and 1 man aged 80 with abdominal symptoms and breathlessness appeared to have an arteriovenous fistula secondary to spontaneous rupture of an atherosclerotic aneurysm: between the aorta and the V. cava inferior or between the A. and the left V. iliaca communis. One patient died, one patient had postoperative decompensatio cordis, one suffered a deep vein thrombosis and the 4th recovered without symptoms. The presence of an aortocaval fistula has to be considered in patients with a symptomatic abdominal aneurysm with a harsh bruit heard over the abdomen, signs of high venous pressure and peripheral hypoperfusion. When no rupture of the aneurysm is found at laparotomy in symptomatic patients, the presence of a fistula is rare, but has to be considered. Furthermore, a fistula can be the underlying cause of therapy-resistant heart failure or acute renal dysfunction. Pre-operative identification can lead to decrease of morbidity and mortality of the phenomenon.

Survey among surgeons on surgical treatment strategies for secondary peritonitis.

BACKGROUND: There is controversy about performing either a planned relaparotomy (PR) or relaparotomy on demand (ROD) in patients with secondary peritonitis. Subjective factors influencing surgeons in decision making for either surgical treatment strategy have never been studied. METHODS: All 858 surgeons of the Association of Surgeons of The Netherlands were sent a survey with 16 case vignettes simulating peritonitis patients and evaluating the preference for PR or ROD. RESULTS: Sixty-two percent of surgeons responded to the survey. Of the returned surveys, 407 were eligible for evaluation. The responding surgeons had a slight overall preference for the ROD strategy, as shown by the mean overall preference score of 5.2 (range 3.54-6.52, with a maximal score of 7). Gastrointestinal surgeons and surgeons working in regional and smaller hospitals were significantly more in favour of a ROD strategy than their counterparts. Factors significantly influencing the preference towards PR were ischaemia as aetiology and performing a primary anastomosis; as for ROD, it was small bowel as focus, local extent of contamination and the question whether abdominal closure was possible. However, there was a considerable variability in treatment decisions by surgeons. CONCLUSION: The majority of responding surgeons would make a choice for a particular treatment strategy based on peritonitis and surgical treatment characteristics. There was a slight overall preference towards the ROD strategy despite the considerable variability per case vignette.

Mortality and morbidity of planned relaparotomy versus relaparotomy on demand for secondary peritonitis.

BACKGROUND: Planned relaparotomy (PR) and relaparotomy on demand (ROD) are both frequently used in the treatment of secondary peritonitis. The aim of this study was to evaluate the mortality, morbidity and long-term outcome associated with PR compared with ROD in patients with secondary peritonitis admitted to a university hospital. METHOD: This retrospective study included 278 consecutive patients who underwent emergency laparotomy for secondary peritonitis between January 1994 and January 2000. Outcome was analysed based on the decision made by the surgeon during the first operation to perform either ROD (197 patients) or PR (81). RESULTS: The Acute Physiology And Chronic Health Evaluation II score was comparable in ROD and PR groups (10.8 versus 11.7; P = 0.222). The in-hospital mortality rate was significantly lower with ROD than PR (21.8 versus 36 per cent; P = 0.016). Two-year survival(s.e.) was 65.8(3.4) per cent in the ROD group and 55.5(5.5) per cent in the PR group (P = 0.031). CONCLUSION: The in-hospital and long-term survival rates were higher in patients with secondary peritonitis treated by ROD than in those with disease of comparable severity treated by PR. Choice of treatment strategy was an independent predictor of survival.

[Pleural fluid in chronic pancreatitis]. / Pleuravocht bij chronische pancreatitis.

In three patients, a 44-year-old schizophrenic woman and two men aged 54 and 42, who presented with dyspnoea, a pancreaticopleural fistula was diagnosed as a complication of pancreatitis, i.e. a fistulous tract between the pancreas and the pleural cavity. In general, these fistulas have a good prognosis; however, delay in finding the correct diagnosis influences the prognosis. This is often due to unfamiliarity with the disease and the non-specific presentation of patients with pleural effusion. The initial presentation usually comprises respiratory (dyspnoea, coughing due to pleural effusion) and occasional abdominal symptoms (epigastric pain). A definitive diagnosis is made when elevated pleural effusion amylase levels are demonstrated. Surgical treatment is only indicated if conservative or endoscopic treatment fails, and consists of resection of the fistula and drainage of the pancreatic duct via a lateral pancreaticojejunostomy or resection of the part of the pancreas where the fistula originates. In the first patient, surgical drainage of the fluid accumulation was applied, but she died of aspiration pneumonia after she had removed the feeding tube and had refused further treatment. Pancreatic resection resulted in recovery in the two men.

[Diagnostic image (144) A man with clubbing of fingers. Hypertrophic osteoarthropathy (Pierre-Marie-Bamberger syndrome)]. / Diagnose in beeld (144). Een man met trommelstokvingers. Hypertrofische osteoartropathie (syndroom van Pierre-Marie-Bamberger).

A 59-year-old man presented with clubbing of fingers and toes, arthralgia and a tumour of the left lung. Pulmonary hypertrophic osteoarthropathy (Pierre-Marie-Bamberger syndrome) was diagnosed. After pneumonectomy of the left lung the clubbing disappeared.

Endovascular treatment of thoracic aortic pathology: feasibility and mid-term results.

OBJECTIVE: to report our experience with 21 consecutive patients treated with a thoracic stent-graft. DESIGN: retrospective analysis. MATERIALS AND METHODS: Between October 1998 and February 2002, 21 patients (12 male), mean age 55.6 years (range 19-86 years), were treated for aorticortic pathology localized to the descending aorta (18 patients), the aortic arch (2 patients) and the ascending aorta (1 patient) and comprising true aneurysms (8 patients), false aneurysms (6 patients), traumatic rupture (4 patients), mycotic aneurysms (2 patients), and ruptured aneurysm (1 patient). Plain chest X-rays and computed tomography was performed at 3, 6 and 12 months postoperatively and then annually. RESULTS: the median (range) operation time was 85min (50-305min), hospital stay 6 days (3-63 days) and follow-up 24 months (5-44 months). Complications occurred in 5 patients and comprised intraoperative migration (1), type I endoleak (1), type II endoleak (1), ischemic myelopathy (1), pneumonia (2), suture granuloma (1) and common femoral artery dissection (1). CONCLUSIONS: stent-grafting can be successfully employed to treat a wide range of thoracic aortic pathologies with a mortality, morbidity and resource utilization that is considerably less than that associated with conventional surgery. However, long term follow-up on safety and efficacy is needed.

Meta-analysis of relaparotomy for secondary peritonitis.

BACKGROUND: Planned relaparotomy and relaparotomy on demand are two frequently employed surgical treatment strategies for patients with abdominal sepsis. METHODS: The available literature was evaluated to compare the efficacy of both surgical treatment strategies. A systematic search for studies comparing planned and on-demand relaparotomy strategies in adult patients with secondary peritonitis was employed. Studies were reviewed independently for design features, inclusion and exclusion criteria, and outcomes. The primary outcome measure was in-hospital mortality. RESULTS: No randomized studies were found; eight observational studies with a total of 1266 patients (planned relaparotomy, 286; relaparotomy on demand, 980) met the inclusion criteria and were included in the meta-analysis. These eight studies were heterogeneous on clinical and statistical grounds (chi2= 40.7, d.f. = 7, P < 0.001). Using a random-effects approach, the combined odds ratio for in-hospital mortality was 0.70 (95 per cent confidence interval 0.27 to 1.80) in favour of the on-demand strategy. CONCLUSION: The combined results of observational studies show a statistically non-significant reduction in mortality for the on-demand relaparotomy strategy compared with the planned relaparotomy strategy when corrected for heterogeneity in a random-effects model. Owing to the non-randomized nature of the studies, the limited number of patients per study, and the heterogeneity between studies, the overall evidence generated by the eight studies was inconclusive.