Current application of selective decontamination of the digestive tract, perioperative antibiotics and mechanical bowel preparation in surgical departments in the Netherlands.

OBJECTIVE: To study the current application of selective decontamination of the digestive tract (SDD), the use of preoperative antibiotics and mechanical bowel preparation (MBP) in elective gastrointestinal (GI) surgery in surgical departments in the Netherlands. METHODS: A point prevalence survey was carried out and an online questionnaire was sent to GI surgeons of 86 different hospitals. RESULTS: The response rate was 74%. Only 4/64 (6.3%) of the Dutch surgical wards are currently using perioperative SDD as a prophylactic strategy to prevent postoperative infectious complications. The 4 hospitals using SDD on their surgical wards also use it on their ICUs. All hospitals make use of perioperative intravenous antibiotic prophylaxis in elective GI surgery. In most hospitals, a cephalosporin and metronidazole are applied (81.3 and 76.6%). MBP was used in 58 hospitals (90.6%) mainly in left colonic surgery. CONCLUSIONS: Perioperative SDD is rarely used in elective GI surgery in the Netherlands. Perioperative intravenous antibiotic prophylaxis is given in all Dutch hospitals, conforming to guidelines. Although the recent literature does not recommend MBP before surgery, it is still selectively used in 90.6% of the Dutch surgical departments, mainly in open or laparoscopic left colonic surgery (including sigmoid resections).

Randomized clinical trial of perioperative selective decontamination of the digestive tract versus placebo in elective gastrointestinal surgery.

BACKGROUND: This randomized clinical trial analysed the effect of perioperative selective decontamination of the digestive tract (SDD) in elective gastrointestinal surgery on postoperative infectious complications and leakage. METHODS: All patients undergoing elective gastrointestinal surgery during a 5-year period were evaluated for inclusion. Randomized patients received either SDD (polymyxin B sulphate, tobramycin and amphotericin) or placebo in addition to standard antibiotic prophylaxis. The primary endpoint was postoperative infectious complications and anastomotic leakage during the hospital stay or 30 days after surgery. RESULTS: A total of 289 patients were randomized to either SDD (143) or placebo (146). Most patients (190, 65·7 per cent) underwent colonic surgery. There were 28 patients (19·6 per cent) with infectious complications in the SDD group compared with 45 (30·8 per cent) in the placebo group (P = 0·028). The incidence of anastomotic leakage in the SDD group was 6·3 per cent versus 15·1 per cent in the placebo group (P = 0·016). Hospital stay and mortality did not differ between groups. CONCLUSION: Perioperative SDD in elective gastrointestinal surgery combined with standard intravenous antibiotics reduced the rate of postoperative infectious complications and anastomotic leakage compared with standard intravenous antibiotics alone. Perioperative SD.D should be considered for patients undergoing gastrointestinal surgery. REGISTRATION NUMBER: P02.1187L (Dutch Central Committee on Research Involving Human Subjects).

[Abdominal pain and rectal blood loss]. / Buikpijn en rectaal bloedverlies.

The medical history of a 46-year-old man recorded osteomas in the maxillary bone 18 years before, haemorrhoids, and kidney stones. He presented with pain in the right lower abdomen and rectal blood loss. His complaints were diagnosed as familial adenomatous polyposis, culminating in sigmoid carcinoma. Due to the extent of the polyps and, consequently, the great cancer relapse risk, a surgical treatment was indicated. A symptom ofa familial adenomatous polyposis variant, Gardner's syndrome, is osteomas in the orofacial region. Dentists and oral surgeons should be aware of this rare syndrome in a patient with orofacial osteomas, especially if the patient has a familial risk of adenomatous polyposis.

Health-related quality of life after gastric banding.

BACKGROUND: Bariatric surgery ameliorates obesity-associated diseases, resulting in psychological and social benefits. Long-term studies of its effects on quality of life (QOL) assessed with well established instruments are lacking. This prospective study investigated the long-term effects of gastric banding on health-related QOL using an obesity-specific validated measure. METHODS: The Health Related Quality of Life (HRQL) questionnaire was completed by 50 severely obese patients before surgery and at 1, 2.5 and 5 years after gastric banding. Ninety-eight subjects with normal weight, matched for age, sex and education, also completed the HRQL questionnaire as controls. RESULTS: Surgery was successful in all patients. Mean excess weight loss after 1, 2.5 and 5 years was 42.1, 42.2 and 41.6 per cent respectively. General wellbeing, health distress, depression, perceived attractiveness and self-worth improved significantly over the 5 years and, except for general wellbeing, were still improving after 5 years. There were increases in physical activity and work productivity. Successful weight loss was the main determinant of general wellbeing and health distress, and these were adversely affected by band-related complications. In subjects with a body mass index below 30 kg/m(2), scores improved to values for subjects of normal weight. CONCLUSION: Bariatric surgery resulted in sustained improvement in health-related QOL even though not all excess weight was lost. Normalization of health-related QOL may necessitate greater weight losses.

Readmissions after pancreatoduodenectomy.

BACKGROUND: Readmission after pancreatoduodenectomy because of tumour recurrence or surgery-related complications can adversely affect patient outcome. METHODS: From October 1992 to June 1999, 283 consecutive resections were performed (243 for malignant disease and 40 for benign disease). The hospital mortality rate was 1 per cent (three of 283). All readmissions were analysed with regard to indication, treatment and outcome. RESULTS: One hundred and six patients (38 per cent) were readmitted, 64 (60 per cent) because of tumour recurrence and indications such as gastrointestinal obstruction (n = 19), biliary obstruction (n = 15) and pain (n = 21), of whom 30 patients (47 per cent) were in a preterminal condition. Median hospital stay and hospital-free survival after discharge were 14 and 51 days respectively. Median survival after surgical treatment (n = 14) was 58 days, and ascites was significantly associated with poor survival. Forty-seven (44 per cent) of the patients were readmitted for surgical complications such as abscess (n = 11), fistula (n = 8) and gastrointestinal obstruction (n = 8). Median hospital stay was 15 days and median hospital-free survival after discharge was 1035 days. CONCLUSION: Readmission after pancreatoduodenectomy was common (38 per cent), 60 per cent for tumour recurrence and 44 per cent for surgery-related complications. Survival after surgical bypass procedures for tumour recurrence was limited, particularly when ascites was present. Patients readmitted for complications of surgery had a good prognosis.

Survival after pancreaticoduodenectomy for periampullary adenocarcinoma: an update.

AIM: Survival after pancreaticoduodenectomy for periampullary tumours is limited. Over the last decade peri-operative management has improved and morbidity and mortality decreased. The aim of the study was to analyse recent survival data after pancreaticoduodenectomy and to determine factors that influence survival. METHODS: From October 1992 to September 1998, 204 patients with a ductal adenocarcinoma in the pancreatic head (108), distal bile duct (32), and ampulla (64) who underwent standard pancreaticoduodenectomy, were analysed with regard to histology and tumour status. Survival was calculated by using the Kaplan-Meier method. Risk factors were identified in a univariate and multivariate analysis. RESULTS: Median survival after resection for carcinoma of the pancreatic head, distal bile duct, and ampulla were 16, 25 and 24 months, respectively (P=0.008). In the univariate analysis vein resection, blood transfusion of more than four packed red cells, the presence of tumour positive resection margins, lymph-node metastases and poor tumour differentiation significantly decreased survival. In the multivariate analysis positive resection margins, lymph-node metastases, and poor tumour differentiation independently influenced survival. CONCLUSIONS: Resection margins, lymph-node status and tumour differentiation are independent prognostic factors. Survival after standard pancreaticoduodenectomy for periampullary tumours has not improved.

Palliative treatment in patients with unresectable hilar cholangiocarcinoma: results of endoscopic drainage in patients with type III and IV hilar cholangiocarcinoma.

OBJECTIVE: To find out how patients fared after palliative endoscopic biliary drainage for inoperable hilar cholangiocarcinoma. DESIGN: Retrospective study. SETTING: University hospital, the Netherlands. SUBJECTS: Between 1992 and 1999, 41 patients who were referred for resection had tumours that were considered unresectable after additional investigations, including an exploratory laparotomy in 16 patients. In all patients, biliary drainage was established by endoscopic retrograde cholangiography (ERCP) and insertion of endoprostheses. Twelve patients also had percutaneous transhepatic biliary drainage (PTBD). RESULTS: The patients who did not have an exploratory laparotomy had fewer complications (1/25) than those who had explorations (4/16). All patients in both groups had one or more long-term complications during follow-up, of which cholangitis, jaundice, and abdominal pain were the most often recorded. In 32 patients, endoprostheses had to be replaced, a mean of 4 times. Median survival was 9 months, with no significant difference between the groups (8 and 11 months). Adjuvant radiotherapy had no influence on survival. CONCLUSION: The patients in this series had relatively long survival times, during which they had a substantial number of complications predominantly related to biliary drainage. Because biliary-enteric bypass operations result in effective relief of symptoms and excellent palliation, we suggest that when an exploration is done for patients with type III and IV tumours, a bypass should be made.

Hand-assisted laparoscopic donor nephrectomy. Ascending the learning curve.

BACKGROUND: The hand-assisted approach to laparoscopic donor nephrectomy (LDN) might minimize the learning curve and shorten both the operation and the warm ischemia time. Our initial results from hand-assisted LDN are presented and compared with data from the literature. METHODS: From January to September 2000, ten hand-assisted LDNs of the right kidney were performed. RESULTS: The median operation time was 140 min (range, 120-400 min), and the warm ischemia time was 2.5 min (range, 1-4 min). There were no conversions. Postoperative morbidity included one urinary tract infection. All but one patient returned to a normal diet within 48 h. Opiates were needed a maximum of 48 h. One recipient experienced initial loss of graft function as a result of unknown causes. CONCLUSIONS: Even at the beginning of the learning curve, operation time and warm ischemia time are significantly reduced by the hand-assisted approach, as compared with conventional LDN.

Analysis of the quality and efficiency in learning laparoscopic skills.

OBJECTIVES: This study demonstrates the application of time-action analysis to the evaluation of task performance of diagnostic laparoscopy with laparoscopic ultrasonography. METHODS: The first 25 diagnostic laparoscopies with laparoscopic ultrasonography performed by a surgical resident were analyzed and compared with the outcomes of these procedures performed by an experienced surgeon. The time, actions, and correctness of task performance were evaluated. Furthermore, outcome correctness and postoperative complications were assessed. RESULTS: No postoperative complications occurred. The resident made one wrong diagnosis, for which the cause was detected by peroperative analysis. Additionally, 1% of the subtasks were performed only partially, 4% not at all, and 2% using the wrong technique. The efficiency for most diagnostic tasks remained significantly lower than that of the experienced surgeon (p < 0.001). CONCLUSIONS: Time-action analysis can be used to provide detailed insight into the quality and efficiency of learning surgical skills. It enables objective measurement of correctness in task performance as well as time and action efficiency.

Segmental resection and wedge excision of the portal or superior mesenteric vein during pancreatoduodenectomy.

BACKGROUND: Resection of the portal/superior mesenteric vein (PV/SMV) during pancreatoduodenectomy (PD) is disputed. Although morbidity and mortality are acceptable, survival is limited after PV/SMV resection. In this study, we evaluate the effect of PV/SMV resection. METHODS: Between 1992 and 1998, there were 215 consecutive patients who underwent PD for malignant disease. Thirty-four patients underwent a PV/SMV resection. Resection was only performed when minimal venous ingrowth was found perioperatively. Surgical techniques, perioperative parameters, and survival were analyzed. RESULTS: The percentage of PV/SMV resections was 16%. Extensive (segment) resections were performed in 6 patients. The median blood loss was 1.8 L and resection margins were microscopically tumor free in 41% of the patients. The median hospital stay was 15 days, and mortality was 0%. Median survival after PV/SMV resection for pancreatic adenocarcinoma was 14 months. CONCLUSIONS: Limited PV/SMV resection for perioperatively encountered minimal venous ingrowth during PD can be performed safely without increased morbidity and mortality but also results in a high frequency of tumor-positive resection margins.

Fracture of the pancreas in two patients after a go-kart accident.

BACKGROUND: After blunt abdominal trauma, an isolated injury to the pancreatic duct is uncommon. Physical signs and laboratory parameters are often inaccurate, and missing this diagnosis can cause serious clinical problems. CASE OUTLINES: Two young women (aged 18 and 20 years) are reported who sustained isolated trauma to the pancreatic duct in go-kart accidents. Each patient sustained a fracture of the pancreas.This injury was diagnosed only after a period of clinical observation with repeated laboratory parameters, ultrasound and CT scan. Pancreatic tissue was conserved by performing a pancreaticojejunostomy. DISCUSSION: After any episode of blunt abdominal trauma, isolated injury to the pancreatic duct should be considered. Serum analysis, ultrasonography and CT scanning can be helpful in early diagnosis. Preservation of pancreatic tissue can be achieved with a good clinical outcome.

Laparoscopy and laparoscopic ultrasonography in staging carcinoma of the gastric cardia.

OBJECTIVE: To investigate the role of diagnostic laparoscopy and laparoscopic ultrasonography in the staging of carcinoma of the gastric cardia that is involving the distal oesophagus. DESIGN: Retrospective consecutive case series. SETTING: Tertiary care centre, The Netherlands. SUBJECTS: 48 patients (34 men and 14 women, median age 63 years, range 39-84) who presented with tumours of the gastric cardia that involved the distal oesophagus and in whom non-invasive staging had not shown unresectable locoregional disease or distant metastases. INTERVENTIONS: In addition to laparoscopy and laparoscopic ultrasonography, biopsy of all suspected lesions outside the area of potential resection. MAIN OUTCOME MEASURES: Number of patients in whom the findings obviated the need for exploratory laparotomy. RESULTS: There were no complications related to the laparoscopy. The investigation showed distant metastases (which were histologically verified) in 11 patients (23%, 95% confidence interval (CI) 16 to 30). These patients had non-operative palliation. Seven were identified by laparoscopy, and laparoscopic ultrasonography showed the other four. In three patients whose distant metastases had already been identified by laparoscopy, ultrasonography was omitted. Three additional patients had suspect lesions, but these were not confirmed histologically. However, these lesions were shown to be cancerous at laparotomy. One additional patient had an intra-abdominal metastasis which was missed by laparoscopy with ultrasonography. CONCLUSIONS: Laparoscopy with ultrasonography safely detected metastases that had not been shown by conventional staging investigations in 23% of 48 patients with carcinoma of the gastric cardia. The investigation should therefore be added to the standard staging procedures in patients with carcinoma of the gastric cardia that is involving the distal oesophagus.

Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume.

OBJECTIVE: To perform a two-part study of pancreaticoduodenectomy in the Netherlands, focusing on the effects of risk factors on outcomes in a single high-volume hospital and the effect of hospital volume on outcomes. SUMMARY BACKGROUND DATA: Hospital volume and surgeon caseload can be related to the rates of complications and death, and the influence of risk factors can be volume-dependent. Provision of regionalized care should take this into account. METHODS: In part A, a single-institution database on 300 consecutive patients undergoing pancreaticoduodenectomy was divided into two periods with similar numbers of patients. Overall complications, deaths, hospital stay, and risk factors were analyzed in the two periods and compared with an historical reference group. In part B, Netherlands medical registry data on age and postoperative death of patients who underwent partial pancreaticoduodenectomy from 1994 to 1998 were analyzed for the influence of hospital volume on death. RESULTS: Between the time periods, the institutional death rate decreased from 4.9% to 0.7%, the complication rate from 60% to 41%. Median hospital stay decreased from 24 to 15 days. The death rate was not related to patient age and did not differ between surgeons. Serum creatinine levels, need for blood transfusion, and period of resection were independent risk factors for complications. The death rate after pancreaticoduodenectomy in the Netherlands was 12.6% in 1994 and 10.1% in 1998; it was greater in patients older than age 65. During the 5-year period, 40% of the procedures were performed in hospitals performing fewer than five resections per year, and the death rate was greater than in hospitals performing more than 25 resections per year. CONCLUSIONS: The overall death rate after pancreaticoduodenectomy did not decrease significantly during the period, and it was greater in low-volume hospitals and older patients. The lower death and complication rates in high-volume hospitals, including the single-center outcomes, were similar to those reported in other countries and may be due to better prevention and management of complications. Pancreaticoduodenectomy should be performed in centers with sufficient experience and resources for support.

Prevention of implantation metastases after resection of proximal bile duct tumours with pre-operative low dose radiation therapy.

AIMS: Pre-operative endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage is associated with a greater risk of implantation metastases after resection of proximal bile duct tumours. In a previous study among patients who had undergone biliary drainage before resection, eight patients (20%) developed implantation metastases, within 1 year following resection. The aim of this analysis was to evaluate the results of pre-operative irradiation with regard to a possible reduction of implantation metastases. METHODS: Twenty-one patients with proximal bile duct tumours who had undergone resection following pre-operative irradiation were retrospectively analysed. Pre-operative radiation therapy consisted of three fractions of 3.5 Gy external beam irradiation of the hilar area. RESULTS: Pre-operative biliary drainage was performed in 19 patients (90%). All patients received pre-operative radiotherapy during which no complications were noted. None of the patients developed implantation metastases within a follow-up time of 2 to 79 months. CONCLUSION: The results of this study suggest that pre-operative radiotherapy in patients with a resectable proximal bile duct tumour who have undergone pre-operative drainage, decreases the risk of implantation metastases. To be certain about the role of pre-operative radiotherapy, a randomized study is required. Until then, we advocate standard low dose radiotherapy preceding resection in all patients with lesions suggestive of a proximal bile duct tumour who have undergone biliary drainage.

Establishment of pneumoperitoneum with a modified blunt trocar.

Veress needle and trocar-related accidents have caused many surgeons to adopt the Hasson technique for establishment of pneumoperitoneum, but this technique also has drawbacks. A modification of the sharp trocar has been developed that overcomes the disadvantages of the Veress needle and Hasson trocar.

Evaluation of morbidity and mortality after resection for hilar cholangiocarcinoma--a single center experience.

BACKGROUND: Hilar resection, especially in combination with liver resection, results in substantial morbidity and mortality, which clearly influences the overall outcome. In the present study, patients who underwent resection of a proximal bile duct tumor were analyzed with the aim of identifying risk factors for morbidity and mortality. METHODS: Between 1983 and 1998, 112 consecutive patients underwent a local resection, which in 32 patients was combined with a hemihepatectomy (11 extended resections). Eighty-four percent of the patients underwent preoperative (endoscopic) drainage. For evaluation of different treatment strategies during the study, the period was divided in three 5-year intervals. RESULTS: Postoperative complications occurred in 65% of the patients. The overall hospital mortality was 15% for local resections and 25% for hemi-hepatectomies. There was a significantly lower morbidity and no mortality after hilar resection during the last 5 years. A higher Bismuth classification showed significant correlation with postoperative morbidity. Extended liver resections and vascular resections and a preoperative albumin level below 35 g/L were found to be significant predictors of increased mortality in univariate analysis. CONCLUSIONS: The overall morbidity and mortality rate in this series is higher than most recently published series. More (extended) liver resections resulted in an increased rate of microscopic tumor-free resections, at the cost of higher hospital morbidity and mortality. Improved preoperative work-ups will result in a selection of patients who might benefit from these extensive resections.

Hand-assisted laparoscopic splenectomy.

Laparoscopic splenectomy is performed routinely in patients with small and moderately enlarged spleens at specialized centers. Large spleens are difficult to handle laparoscopically and hand-assisted laparoscopic splenectomy might facilitate the procedure through enhanced vascular control, easier retraction and manipulation, manual guidance of endostaplers, and clip appliers. A technique of hand-assisted laparoscopic splenectomy is described.

Efficacy of establishment of pneumoperitoneum with the Veress needle, Hasson trocar, and modified blunt trocar (TrocDoc): a randomized study.

PURPOSE: To compare three techniques of establishment of pneumoperitoneum for efficacy: the Veress needle/first trocar, the Hasson trocar, and a newly developed modified blunt trocar, the TrocDoc. PATIENTS AND METHODS: Between June and December 1999, 62 patients eligible for laparoscopic surgery were randomized. The effectiveness of installation of the pneumoperitoneum using the three techniques was assessed by time-motion analysis. Primary efficacy measures were total time and number of actions required to establish the pneumoperitoneum. Secondary efficacy measures were procedure-related complications, wound complications, and occurrence of CO2 leakage. RESULTS: Two patients were withdrawn from inclusion. The three groups were comparable for age and body mass index. Total time was shortest using the TrocDoc rather than the Veress needle/first trocar and the Hasson trocar (respectively, 138 +/- 58 v 237 +/- 56 v 350 +/- 103 seconds), and the number of actions was lowest for the Veress needle/first trocar combination: 22 +/- 7 v 32 +/- 12 (TrocDoc) v 53 +/- 17 (Hasson). There was no morbidity related to the installation of pneumoperitoneum nor trocar wound complications. Gas leakage occurred in five of the Hasson introductions. CONCLUSIONS: Establishment of the pneumoperitoneum is more efficient using the TrocDoc compared with the Veress needle/first trocar and the Hasson trocar. The TrocDoc might replace the two alternatives because of its efficacy and open method of introduction.

Staging laparoscopy and laparoscopic ultrasonography in more than 400 patients with upper gastrointestinal carcinoma.

BACKGROUND: Resection offers the only chance of cure to patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors. Staging is essential to select patients who will benefit from operation because palliation can also be performed nonoperatively. Several studies, including limited numbers of patients, have shown that laparoscopic staging prevents unnecessary laparotomies, but it is doubtful whether general application of this staging method can be advised. The aim of this study was to assess the benefit of diagnostic laparoscopy for staging patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors. STUDY DESIGN: Between June 1992 and December 1996, 420 patients with a resectable tumor after conventional staging underwent diagnostic laparoscopy combined with laparoscopic ultrasonography. Histologic proof of metastases or ingrowth was used to cancel laparotomy. RESULTS: Laparoscopic staging avoided laparotomy in 20% of patients (sensitivity 0.70): 5% with an esophageal tumor, 20% with a gastroesophageal junction tumor, 15% with a periampullary tumor, 40% with a proximal bile duct tumor, 35% with a liver tumor, and 40% with a pancreatic body or tail tumor. Complications and port-site metastases were seen in 4% and 2% of patients, respectively. CONCLUSIONS: Laparoscopic staging is a safe procedure with low morbidity and without mortality in this series. It has shown no benefit in esophageal cancer, but seems beneficial for staging tumors located at the gastroesophageal junction, proximal bile duct tumors, liver tumors, and pancreatic body and tail tumors. The value of laparoscopic staging for patients with periampullary tumors is not as great as stated in previous studies and is still the subject of investigation.