Pancreatitis of biliary origin, optimal timing of cholecystectomy (PONCHO trial):Study protocol for a randomized controlled trial

Background: After an initial attack of biliary pancreatitis, cholecystectomy minimizes the risk of recurrent biliary pancreatitis and other gallstone-related complications. Guidelines advocate performing cholecystectomy within 2 to 4 weeks after discharge for mild biliary pancreatitis. During this waiting period, the patient is at risk of recurrent biliary events. In current clinical practice, surgeons usually postpone cholecystectomy for 6 weeks due to a perceived risk of a more difficult dissection in the early days following pancreatitis and for logistical reasons. We hypothesize that early laparoscopic cholecystectomy minimizes the risk of recurrent biliary pancreatitis or other complications of gallstone disease in patients with mild biliary pancreatitis without increasing the difficulty of dissection and the surgical complication rate compared with interval laparoscopic cholecystectomy.Methods/Design: PONCHO is a randomized controlled, parallel-group, assessor-blinded, superiority multicenter trial. Patients are randomly allocated to undergo early laparoscopic cholecystectomy, within 72 hours after randomization, or interval laparoscopic cholecystectomy, 25 to 30 days after randomization. During a 30-month period, 266 patients will be enrolled from 18 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite endpoint of mortality and acute re-admissions for biliary events (that is, recurrent biliary pancreatitis, acute cholecystitis, symptomatic/obstructive choledocholithiasis requiring endoscopic retrograde cholangiopancreaticography including cholangitis (with/without endoscopic sphincterotomy), and uncomplicated biliary colics) occurring within 6 months following randomization. Secondary endpoints include the individual endpoints of the composite endpoint, surgical and other complications, technical difficulty of cholecystectomy and costs.Discussion: The PONCHO trial is designed to show that early laparoscopic cholecystectomy (within 72 hours) reduces the combined endpoint of mortality and re-admissions for biliary events as compared with interval laparoscopic cholecystectomy (between 25 and 30 days) after recovery of a first episode of mild biliary pancreatitis.</p

Multicentre study of non-surgical management of diverticulitis with abscess formation

Background: Treatment strategies for diverticulitis with abscess formation have shifted from (emergency) surgical treatment to non-surgical management (antibiotics with or without percutaneous drainage (PCD)). The aim was to assess outcomes of non-surgical treatment and to identify risk factors for adverse outcomes. Methods: Patients with a first episode of CT-diagnosed diverticular abscess (modified Hinchey Ib or II) between January 2008 and January 2015 were included retrospectively, if initially treated non-surgically. Baseline characteristics, short-term (within 30 days) and long-term treatment outcomes were recorded. Treatment failure was a composite outcome of complications (perforation, colonic obstruction and fistula formation), readmissions, persistent diverticulitis, emergency surgery, death, or need for PCD in the no-PCD group. Regression analyses were used to analyse risk factors for treatment failure, recurrences and surgery. Results: Overall, 447 patients from ten hospitals were included (Hinchey Ib 215; Hinchey II 232), with a median follow-up of 72 (i.q.r. 55–93) months. Most patients were treated without PCD (332 of 447, 74⋅3 per cent). Univariable analyses, stratified by Hinchey grade, showed no differences between no PCD and PCD in short-term treatment failure (Hinchey I: 22⋅3 versus 33 per cent, P = 0⋅359; Hinchey II: 25⋅9 versus 36 per cent, P = 0⋅149) or emergency surgery (Hinchey I: 5⋅1 versus 6 per

Volume–outcome relationship of liver surgery: a nationwide analysis

Background: Evidence for an association between hospital volume and outcomes for liver surgery is abundant. The current Dutch guideline requires a minimum volume of 20 annual procedures per centre. The aim of this study was to investigate the association between hospital volume and postoperative outcomes using data from the nationwide Dutch Hepato Biliary Audit. Methods: This was a nationwide study in the Netherlands. All liver resections reported in the Dutch Hepato Biliary Audit between 2014 and 2017 were included. Annual centre volume was calculated and classified in categories of 20 procedures per year. Main outcomes were major morbidity (Clavien–Dindo grade IIIA or higher) and 30-day or in-hospital mortality. Results: A total of 5590 liver resections were done across 34 centres with a median annual centre volume of 35 (i.q.r. 20–69) procedures. Overall major morbidity and mortality rates were 11·2 and 2·0 per cent respectively. The mortality rate was 1·9 per cent after resection for colorectal liver metastases (CRLMs), 1·2 per cent for non-CRLMs, 0·4 per cent for benign tumours, 4·9 per cent for hepatocellular carcinoma and 10·3 per cent for biliary tumours. Higher-volume centres performed more major liver resections, and more resections for hepatocellular carcinoma and biliary cancer. There was no association between hospital volume and either major morbidity or mortality in multivariable analysis, after adjustment for known risk factors for adverse events. Conclusion: Hospital volume and postoperative outcomes were not associated

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon

Aim: The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons. Methods: The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements. Results: This guideline contains 38 evidence based consensus statements on the management of diverticular disease. Conclusion: This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients

Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): Study protocol for a randomized controlled trial

Background: Acute appendicitis is one of the most common indications for emergency surgery. In patients with a complex appendicitis, prolonged antibiotic prophylaxis is recommended after appendectomy. There is no consensus regarding the optimum duration of antibiotics. Guidelines propose 3 to 7 days of treatment, but shorter courses may be as effective in the prevention of infectious complications. At the same time, the global issue of increasing antimicrobial resistance urges for optimization of antibiotic strategies. The aim of this study is to determine whether a short course (48 h) of postoperative antibiotics is non-inferior to current standard practice of 5 days. Methods: Patients of 8 years and older undergoing appendectomy for acute complex appendicitis - defined as a gangrenous and/or perforated appendicitis or appendicitis in presence of an abscess - are eligible for inclusion. Immunocompromised or pregnant patients are excluded, as well as patients with a contraindication to the study antibiotics. In total, 1066 patients will be randomly allocated in a 1:1 ratio to the experimental treatment arm (48 h of postoperative intravenously administered (IV) antibiotics) or the control arm (5 days of postoperative IV antibiotics). After discharge from the hospital, patients participate in a productivity-cost-questionnaire at 4 weeks and a standardized telephone follow-up at 90 days after appendectomy. The primary outcome is a composite endpoint of infectious complications, including intra-abdominal abscess (IAA) and surgical site infection (SSI), and mortality within 90 days after appendectomy. Secondary outcomes include IAA, SSI, restart of antibiotics, length of hospital stay (LOS), reoperation, percutaneous drainage, readmission rate, and cost-effectiveness. The non-inferiority margin for the difference in the primary endpoint rate is set at 7.5% (one-sided test at α 0.025). Both per-protocol and intention-to-treat analyses will be performed. Discussion: This trial will provide evidence on whether 48 h of postoperative antibiotics is non-inferior to a standard course of 5 days of antibiotics. If non-inferiority is established, longer intravenous administration following appendectomy for complex appendicitis can be abandoned, and guidelines need to be adjusted accordingly

A Population-Based Analysis of Three Treatment Modalities for Malignant Obstruction of the Proximal Colon: Acute Resection Versus Stent or Stoma as a Bridge to Surgery

Contains fulltext : 172022.pdf (publisher's version ) (Open Access)BACKGROUND: Malignant obstruction of the proximal colon (MOPC) traditionally has been treated with acute resection. However, morbidity and mortality rates following these emergency surgeries are high. Initial bowel decompression by stent placement or stoma construction has been used for distal obstructions as an alternative approach. This study evaluated whether these alternative treatment strategies could be beneficial for patients with a MOPC as well. METHODS: All patients undergoing a colonic resection for a MOPC between January 2009 and December 2013 and who were registered in the Dutch Surgical Colorectal Audit were analyzed. RESULTS: From the 49,013 patients registered in the DSCA, 1860 (3.8 %) were selected for further analysis. Acute resection was performed in 1774 patients (95.4 %), 44 patients (2.4 %) were treated with initial decompression using stent placement and resection, and 42 patients (2.3 %) with stoma construction followed by resection. Thirty-day mortality was 8.8, 2.4, and 2.4 %, respectively. Mortality was significantly lower after a bridging strategy (stent or stoma) compared with acute resection (p = 0.04). Complications following the resection occurred in 39.6% in the acute resection group and in 27.3 and 31.7% in the stent and stoma group, respectively (p = 0.167). CONCLUSIONS: Acute resection was performed in the vast majority of patients with obstructive proximal colon cancer and resulted in a 40 % morbidity and 9 % mortality rate. A bridging strategy may be a valid alternative in some of these patients, because a significantly lower postoperative mortality rate was seen in a subgroup of patients initially treated with a stent or stoma

Emergency resection versus bridge to surgery with stenting in patients with acute right-sided colonic obstruction: a systematic review focusing on mortality and morbidity rates

Contains fulltext : 152183.pdf (publisher's version ) (Closed access)PURPOSE: No consensus exists on the optimal treatment of acute malignant right-sided colonic obstruction (RSCO). This systematic review aims to compare procedure-related mortality and morbidity rates between primary resection and stent placement as a bridge to surgery followed by elective resection for patients with acute RSCO. METHODS: PubMed, Embase and Cochrane library were searched for all relevant literature. Primary endpoints were procedure-related mortality and morbidity. Methodological quality of the included studies was assessed using the MINORS criteria. RESULTS: Fourteen cohort studies were eligible for analysis. A total of 2873 patients were included in the acute resection group and 155 patients in the stent group. Mean mortality rate for patients who underwent acute resection with primary anastomosis was 10.8% (8.1-18.5%). Overall mortality for patients initially treated with a colonic stent followed with elective resection was 0%. Major morbidity was 23.9% (9.3-35.6%) and 0.8% (0-4.8%), respectively. Both mortality and major morbidity were significantly different. In addition, stent placement shows lower rates of anastomotic leakages (0 vs 9.1%) and fewer permanent ileostomies (0 vs 1.0%). CONCLUSION: Primary resection for patients with acute RSCO seems to be associated with higher mortality and major morbidity rates than stent placement and elective resection. In addition, stent placement resulted in fewer anastomotic leakages and permanent ileostomies. However, as no high-level studies are available on the optimal treatment of RSCO and proximal stenting is considered technically challenging, future comparative studies are warranted for the development of an evidence-based clinical decision guideline.16 februari 201

Self-expandable metal stent placement versus emergency resection for malignant proximal colon obstructions

Contains fulltext : 182659.pdf (publisher's version ) (Closed access)BACKGROUND: Traditionally, all patients with a malignant obstruction of the proximal colon (MOPC) are treated with emergency resection. However, recent data suggest that Self-expandable metallic stent (SEMS) placement could lower mortality and morbidity rates. This study therefore aimed to compare SEMS placement with emergency resection as treatment options for MOPC. METHODS: All consecutive patients that underwent SEMS placement for MOPC in the period 2004-2015 at our institution were identified. SEMS placement was the standard of care for colonic obstructions at our institution in that period. All included SEMS patients were matched (1:4) on age (+/-5 years), gender, ASA-score, tumor location, surgical approach and pTNM-stage with patients treated by emergency resection. Controls were selected from a national database that prospectively registers all patients undergoing surgery for colorectal cancer in the Netherlands. RESULTS: In total, 41 patients received SEMS placement for MOPC. In 19 patients SEMS served as a definite palliative measure and in 22 as bridge to surgery. Technical and clinical success rates of SEMS placement were 92.7% and 90.2%, respectively. No significant differences between the SEMS and emergency resection group were found regarding morbidity and mortality rates, the number of radical resections and the number of primary anastomoses. Patients treated with SEMS were, however, less likely to have a temporary stoma constructed (p = 0.04). No SEMS-related complications occurred in patients in whom SEMS was placed as bridge to surgery, whereas one stent-related perforation, three stent migrations, and five stent re-obstructions were observed in the palliative group. Three re-obstructions could be treated with re-stenting, but all other SEMS-related complications required surgical intervention. In the palliative group, SEMS complications necessitating surgery occurred in 31.6% of the patients (6/19). CONCLUSION: SEMS placement for MOPC appears to be a relatively feasible and safe alternative for emergency resection in both the curative and palliative setting

Acute resection versus bridge to surgery with diverting colostomy for patients with acute malignant left sided colonic obstruction: Systematic review and meta-analysis

Item does not contain fulltextBACKGROUND: Currently, no consensus exists on the best treatment strategy for acute malignant left-sided colonic obstruction. This systematic review and meta-analysis aims to compare the outcomes following the two surgical treatment options; primary resection versus colostomy creation as bridge to surgery. METHODS: This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to minimize risk of bias. Pubmed, Embase and Cochrane Library were searched for all relevant literature. Methodological quality of included studies was assessed using the MINORS criteria. Pooled odds ratios with 95% confidence intervals (95%CI) were calculated using random effects models. RESULTS: Eight comparative studies were included, reporting on 2424 patients; 1973 patients were treated with primary resection and 451 patients with colostomy construction followed by elective resection. Meta-analysis showed no significant differences between both treatment groups regarding 30-day mortality and morbidity (OR = 0.77, 95%CI 0.3-1.96 and OR = 0.76, 95%CI 0.51-1.13, respectively). However, patients treated with a colostomy followed by elective resection had significantly more primary anastomoses constructed and were less likely to be left with a permanent colostomy (OR = 0.17, 95%CI 0.11-0.26 and OR = 0.22, 95%CI 0.11-0.46, respectively). CONCLUSION: This systematic review provides an overview of all available literature on primary resection versus colostomy creation as bridge to surgery in patients with acute LSCO. Keeping the limitations of this study in mind, we conclude that a diverting colostomy as bridge to surgery is a safe and valid alternative for primary resection