The QUILT study: quilting sutures in patients undergoing breast cancer surgery: a stepped wedge cluster randomized trial study.

BACKGROUND: Seroma is the most common complication following breast cancer surgery, with reported incidence up to 90%. Seroma causes patient discomfort, is associated with surgical site infections (SSI), often requires treatment and increases healthcare consumption. The quilting suture technique, in which the skin flaps are sutured to the pectoralis muscle, leads to a significant reduction of seroma with a decrease in the number of aspirations and surgical site infections. However, implementation is lagging due to unknown side effects, increase in operation time and cost effectiveness. Main objective of this study is to assess the impact of large scale implementation of the quilting suture technique in patients undergoing mastectomy and/or axillary lymph node dissection (ALND). METHODS: The QUILT study is a stepped wedge design study performed among nine teaching hospitals in the Netherlands. The study consists of nine steps, with each step one hospital will implement the quilting suture technique. Allocation of the order of implementation will be randomization-based. Primary outcome is 'textbook outcome', i.e.no wound complications, no re-admission, re-operation or unscheduled visit to the outpatient clinic and no increased use of postoperative analgesics. A total of 113 patients is required based on a sample size calculation. Secondary outcomes are shoulder function, cosmetic outcome, satisfaction with thoracic wall and health care consumption. Follow-up lasts for 6 months. DISCUSSION: This will be one of the first multicentre prospective studies in which quilting without postoperative wound drain is compared with conventional wound closure. We hypothesize that quilting is a simple technique to increase textbook outcome, enhance patient comfort and reduce health care consumption.

[Late recognition of intestinal malrotation]. / Late herkenning van een intestinale malrotatie.

BACKGROUND: Intestinal malrotation is a congenital intestinal abnormality caused by abnormal intestinal rotation during foetal development. CASE DESCRIPTION: We describe a 20-year-old woman with many years' history of abdominal symptoms and eating disorders that were labelled as psychosomatic following repeated and extensive investigations. The diagnosis of malrotation was only made after an emergency laparotomy, with right hemicolectomy for intestinal necrosis. CONCLUSION: The reason that diagnosis was missed in this patient was probably not only because malrotation is accompanied by non-specific symptoms. The cognitive strategies used by doctors to make a diagnosis on the basis of symptoms may also have led to ignoring details that did not fit, and to clinging to earlier diagnoses. Furthermore, eating disorders and gastrointestinal disorders are sometimes difficult to distinguish and are often linked. Even with extra vigilance a misdiagnosis cannot always be avoided.