National implementation of an optimal standardised technique for right-sided colon cancer:protocol of an interventional sequential cohort study (Right study)

Purpose: Minimally invasive right hemicolectomy (MIRH) is the cornerstone of treatment for patients with right-sided colon cancer. This operation has evolved during recent decades, with many innovations and improvements but this has also resulted in high variability of uptake with subsequent substantial variableness. The aim of this ongoing study is to identify current surgical variations, determine the most optimal and standardised MIRH and nationally train and implement that technique to improve short-term clinical and long-term oncological outcomes. Methods: The Right study is a national multicentre prospective interventional sequential cohort study. Firstly, current local practice was evaluated. Subsequently, a standardised surgical technique for right-sided colon cancer was determined using the Delphi consensus method, and this procedure was trained during hands-on courses. The standardised MIRH will be implemented with proctoring (implementation cohort), after which the performance will be monitored (consolidation cohort). Patients who will receive a minimally invasive (extended) right hemicolectomy for cT1-3N0-2M0 colon cancer will be included. The primary outcome is patient safety reflected in the 90-day overall complication rate according to the Clavien–Dindo classification. Secondary outcomes will include intraoperative complications, 90-day mortality rate, number of resected tumour-positive lymph nodes, completeness of mesocolic excision, surgical quality score, locoregional and distant recurrence and 5-year overall survival. A total number of 1095 patients (365 per cohort) will be included. Discussion: The Right study is designed to safely implement the best surgical practice concerning patients with right-sided colon cancer aiming to standardise and improve the surgical quality of MIRH at a national level. Trial registration: ClinicalTrials.gov: NCT04889456, May 2021.</p

Perianale fistels en abcessen bij kinderen: denk aan de ziekte van Crohn

While perianal fistulae and abscesses in infants usually occur as an isolated phenomenon, in older children Crohn's disease might be the underlying etiologic factor. We present four children of different ages with recurrent perianal fistulae and abscesses. Only after the diagnosis Crohn's disease was established and adequate treatment was initiated, the perianal lesions disappeared without further surgical treatment. Perianal fistulae and abscesses in older children should raise the suspicion of Crohn's disease, in which case therapy is indicated to induce and maintain remission of the underlying disease instead of surgical interventio

Patients’ preferences for information in bariatric surgery

Background: The decision to undergo bariatric surgery is multifactorial and made both by patient and doctor. Information is of the utmost importance for this decision. Objective: To investigate the bariatric surgery patient's preferences regarding information provision in bariatric surgery. Setting: A teaching hospital, bariatric center of excellence in Amsterdam, the Netherlands. Methods: All patients who underwent a primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between September 2013 and September 2014 were approached by mail to participate. A questionnaire was used to elicit patient preferences for the content and format of information. Sociodemographic characteristics, clinicopathologic factors, and psychologic factors were explored as predictors for specific preferences. Results: Of the 356 eligible patients, 112 (31.5%) participated. The mean age was 49.2 (±10.7) years, and 91 (81.3%) patients were female. Patients deemed the opportunity to ask questions (96.4%) the most important feature of the consult, followed by a realistic view on expectations—for example, results of the procedure (95.5%) and information concerning the consequences of surgery for daily life (89.1%). Information about the risk of complications on the order of 10% was desired by 93% of patients; 48% desired information about lower risks (.1%). Only 25 patients (22.3%) desired detailed information concerning their weight loss after surgery. Conclusion: Bariatric patients wished for information about the consequences of surgery on daily life, whereas the importance of information concerning complications decreased when their incidence lessened

Routine Postoperative Monitoring after Bariatric Surgery in Morbidly Obese Patients with Severe Obstructive Sleep Apnea: ICU Admission is not Necessary

Obstructive sleep apnea (OSA) occurs in 70-80% of bariatric surgery patients. Patients with severe OSA (apnea/hypopnea index (AHI) >30/h) are postoperatively admitted to an intensive care unit (ICU) for continuous monitoring, to prevent complications. The aim of this study was to assess the necessity of routine postoperative monitoring at an ICU of severe OSA patients after bariatric surgery, attempting to prevent and detect cardiorespiratory complications. Patients undergoing bariatric surgery from November 2010 to July 2013 were entered into a database. Minimal follow-up was 1 month. Poly(somno)graphy (P(S)G) was routinely performed. Patients with severe OSA were admitted to the ICU for the first postoperative night. Oxygen saturation was continuously measured. The database was reviewed regarding patient characteristics, CPAP use, re-intubations, desaturations (saturation <90% and severe <85%), and complications. Severe OSA was present in 151 of the 794 patients, and all 151 were admitted to the ICU. Thirty who underwent revisional surgery were excluded. Forty-seven percent was male, median age was 51 years (27.0-68.0), and median body mass index (BMI) was 46.6 (kg/m(2)) (34.0-77.6). No deaths, re-intubations, or cardiopulmonary complications occurred. Eighty-two (67.8%) patients used continuous positive airway pressure (CPAP). Twenty-one (17.4%) patients experienced desaturations with a median of 2.0 (1-8). Six patients (5.0%) had one episode of severe desaturation. Patients with severe OSA and adequate CPAP use are at low risk of cardiopulmonary complications after (laparoscopic) bariatric surgery. Routine admission to an ICU might be superfluous. However, continuous digital oximetry remains essentia

Morphologic, cytogenetic and molecular characteristics of patients with WBC≥100 G/l.

<p>Hyperleukocytotic patients commonly had AML FAB types M4/M5 or ELN favorable or intermediate-I risk.</p><p>Abbreviations: FAB, French-American-British classification of AML; ELN, European Leukemia Net classification of AML; <i>FLT</i>3-ITD, internal tandem duplication of the <i>FLT</i>3 gene; <i>FLT</i>3-TKD, point mutation at D835 in the <i>FLT</i>3-tyrosine kinase domain of the <i>FLT</i>3 gene; <i>MLL</i>-PTD, partial tandem duplication of the <i>MLL</i> gene; n, number; <i>NPM</i>1, nucleophosmin1.</p

Unexplained abdominal pain in morbidly obese patients after bariatric surgery

Background There is an overall complication rate of 6.3%–10% after bariatric surgery. After ruling out anatomic/physical causes, there is a substantial group of patients who develop unexplained postsurgical abdominal pain. Objectives To inventory the prevalence of unexplained abdominal pain after laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy and to determine predictive factors for unexplained abdominal pain. Setting Obesity Center Amsterdam, Amsterdam, the Netherlands. Methods A retrospective study in a prospective database was performed. Baseline characteristics and postoperative course were evaluated. Results A total of 1788 patients underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between November 2007 and April 2015. The average follow-up consisted of 33.5 months, without loss to follow-up. Abdominal pain was presented in 387 patients (21.6%). The study population consisted of 337 women (87.1%) and 50 men (12.9%); the mean age was 43.3 years (standard deviation 10.1) and the median preoperative body mass index was 43.7 kg/m². An explanation for abdominal pain was found in 246 of 387 patients (63.6%), whereas no explanation was found in 133 patients (34.4%). Revisional surgery was a significant predictor for unexplained pain (odds ratio 1.7; confidence interval 1.0–2.8; P = 0.037). Conclusion A total of 133 patients (7.4%) experienced unexplained abdominal pain after laparoscopic bariatric surgery. Revisional surgery was found to be a significant predictive factor for this outcome. Present study results suggest that postoperative unexplained abdominal pain is a significant morbidity and should be part of the informed consent. More research is needed regarding further diagnosis and management and treatment

The influence of prophylactic proton pump inhibitor treatment on the development of symptomatic marginal ulceration in Roux-en-Y gastric bypass patients: a historic cohort study

Marginal ulceration at the gastrojejunostomy is a serious complication after laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) and occurs in 1%-16% of patients. Proton pump inhibitors (PPIs) might lower the occurrence of these ulcers. The aim of the present study was to evaluate the effect of 6 months prophylactic usage of PPIs on the development of marginal ulceration and compare this with a historic patient control group. A single institution cohort at a bariatric center of excellence, The Sint Lucas Andreas Zienkenhuis, Amsterdam A consecutive database of patients who underwent LRYGB from November 2007 to September 2012 in a single institution was retrospectively reviewed. From August 2011, patients received a standard dose of pantozol 40 mg once daily directly postoperatively for 6 months. No standard PPI prophylaxis was administered before August 2011, and the patients not using PPIs in this historic cohort served as the control group. A total of 610 patients underwent LRYGB, of which 128 patients (21.0%) underwent revisional surgery. Postoperative PPIs were administered in the intervention group of 337 patients, compared with the historic control group consisting of 273 patients. Six patients (1.2%) who received postoperative PPIs versus 20 patients (7.3 %) in the historic control group developed marginal ulceration (P = .001). Patients using proton pump inhibitors developed fewer gastrointestinal complaints postoperatively (P <.001). Routine usage of PPIs reduced the occurrence of marginal ulceration after LRYG

Predicting postoperative complications after bariatric surgery: the Bariatric Surgery Index for Complications, BASIC

textabstractBackground: Around 20% of bariatric surgery patients develop a short- or long-term complication. Objective: Aim of this study was to develop a risk model predicting complications: the Bariatric Surgery Index for Complications (BASIC). Setting: The Obesity Center Amsterdam, located in a large teaching hospital, in Amsterdam, The Netherlands. Methods: A prospective consecutive database including patients operated between November 2007 and February 2015 was used. For the BASIC, analysis according to the TRIPOD statement was performed to identify risk factors for complications. Class I included patients with zero to one risk factor, class II patients with two risk factors, and class III patients with three or more risk factors. Results: Of 1709 analyzed patients, mean age was 45 years (±SD 10.7), 1393 (81.5%) were female; mean body mass index was 44.5 kg/m2 (6.8). Overall, 271 (15.9%) patients developed a complication of which 197 (72.5%) occurred within 30 days. Predictors in multivariable analysis were use of anticoagulants (odd’s ratio (OR) 1.5); chronic obstructive pulmonary disease (OR 2.3); dyslipidemia (OR 1.4); gender (OR 1.4); psychiatric history (OR 1.3); and revisional surgery (OR 1.5). In class I, 13.5% (181 out of 1338) experienced complications, in class II 58 (21.6%) of the 269 patients and in class III 32 (31.4%) of the 102 patients, respectively. There was a significant difference (p < 0.001) in both overall and 30 day complications. Conclusion: The BASIC uses six preoperative variables to classify patients in a low-, intermediate-, or high-risk group for postoperative complications after bariatric surgery