Postoperative intensive care unit stay after minimally invasive esophagectomy shows large hospital variation. Results from the Dutch Upper Gastrointestinal Cancer Audit

Introduction: The value of routine intensive care unit (ICU) admission after minimally invasive esophagectomy (MIE) has been questioned. This study aimed to investigate Dutch hospital variation regarding length of direct postoperative ICU stay, and the impact of this hospital variation on short-term surgical outcomes. Materials and methods: Patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) undergoing curative MIE were included. Length of direct postoperative ICU stay was dichotomized around the national median into short ICU stay ( ≤ 1 day) and long ICU stay ( > 1 day). A case-mix corrected funnel plot based on multivariable logistic regression analyses investigated hospital variation. The impact of this hospital variation on short-term surgical outcomes was investigated using multilevel multivariable logistic regression analyses. Results: Between 2017 and 2019, 2110 patients from 16 hospitals were included. Median length of postoperative ICU stay was 1 day [hospital variation: 0–4]. The percentage of short ICU stay ranged from 0 to 91% among hospitals. Corrected for case-mix, 7 hospitals had statistically significantly higher short ICU stay rates and 6 hospitals had lower rates. ICU readmission, in-hospital/30-day mortality, failure to rescue, postoperative pneumonia, cardiac complications and anastomotic leakage were not associated with hospital variation in length of ICU stay. Total length of hospital stay was significantly shorter in hospitals with relatively short ICU stay. Conclusion: This study showed significant hospital variation in postoperative length of ICU stay after MIE. Short ICU stay was associated with shorter overall hospital admission and did not negatively impact short-term surgical outcomes. More selected use of ICU resources could result in a national significant cost reduction

Laparoscopic versus open gastrectomy for gastric cancer, a multicenter prospectively randomized controlled trial (LOGICA-trial)

Background: For gastric cancer patients, surgical resection with en-bloc lymphadenectomy is the cornerstone of curative treatment. Open gastrectomy has long been the preferred surgical approach worldwide. However, this procedure is associated with considerable morbidity. Several meta-analyses have shown an advantage in short-term outcomes of laparoscopic gastrectomy compared to open procedures, with similar oncologic outcomes. However, it remains unclear whether the results of these Asian studies can be extrapolated to the Western population. In this trial from the Netherlands, patients with resectable gastric cancer will be randomized to laparoscopic or open gastrectomy. Methods: The study is a non-blinded, multicenter, prospectively randomized controlled superiority trial. Patients (≥18 years) with histologically proven, surgically resectable (cT1-4a, N0-3b, M0) gastric adenocarcinoma and European Clinical Oncology Group performance status 0, 1 or 2 are eligible to participate in the study after obtaining informed consent. Patients (n = 210) will be included in one of the ten participating Dutch centers and are randomized to either laparoscopic or open gastrectomy. The primary outcome is postoperative hospital stay (days). Secondary outcome parameters include postoperative morbidity and mortality, oncologic outcomes, readmissions, quality of life and cost-effectiveness. Discussion: In this randomized controlled trial laparoscopic and open gastrectomy are compared in patients with resectable gastric cancer. It is expected that laparoscopic gastrectomy will result in a faster recovery of the patient and a shorter hospital stay. Secondly, it is expected that laparoscopic gastrectomy will be associated with a lower postoperative morbidity, less readmissions, higher cost-effectiveness, better postoperative quality of life, but with similar mortality and oncologic outcomes, compared to open gastrectomy. The study started on 1 December 2014. Inclusion and follow-up will take 3 and 5 years respectively. Short-term results will be analyzed and published after discharge of the last randomized patient

Evaluation of PET and laparoscopy in STagIng advanced gastric cancer: A multicenter prospective study (PLASTIC-study)

Background: Initial staging of gastric cancer consists of computed tomography (CT) and gastroscopy. In locally advanced (cT3-4) gastric cancer, fluorodeoxyglucose positron emission tomography with CT (FDG-PET/CT or PET) and staging laparoscopy (SL) may have a role in staging, but evidence is scarce. The aim of this study is to evaluate the impact and cost-effectiveness of PET and SL in addition to initial staging in patients with locally advanced gastric cancer. Methods: This prospective observational cohort study will include all patients with a surgically resectable, advanced gastric adenocarcinoma (cT3-4b, N0-3, M0), that are scheduled for treatment with curative intent after initial staging with gastroscopy and CT. The modalities to be investigated in this study is the addition of PET and SL. The primary outcome of this study is the proportion of patients in whom the PET or SL lead to a change in treatment strategy. Secondary outcome parameters are: diagnostic performance, morbidity and mortality, quality of life, and cost-effectiveness of these additional diagnostic modalities. The study recently started in August 2017 with a duration of 36 months. At least 239 patients need to be included in this study to demonstrate that the diagnostic modalities are break-even. Based on the annual number of gastrectomies in the participating centers, it is estimated that approximately 543 patients are included in this study. Discussion: In this study, it is hypothesized that performing PET and SL for locally advanced gastric adenocarcinomas results in a change of treatment strategy in 27% of patients and an annual cost-reduction in the Netherlands of €916.438 in this patient group by reducing futile treatment. The results of this study may be applicable to all countries with comparable treatment algorithms and health care systems

Teleconsultatie en teleconferencing vanaf de endoscopische operatiekamer

Endoscopische chirurgie maakt bij elke ingreep op elk type operatiekamer al gebruik van een camera die de beelden van de optiek vastlegt en converteert naar een analoog of digitaal signaal dat op een beeldscherm vertoond kan worden. Op de endoscopische operatiekamer is de eigen informatiestroom geïntegreerd met verschillende externe communicatiemedia en informatiebronnen. Hierdoor is het mogelijk om naast de eigen operatiebeelden via het ziekenhuisnetwerk toegang te krijgen tot informatie van het Elektronisch Patiënten Dossier (EPD) of het Picture Archiving and Communications System (PACS)

The role of seminal plasma in the regulation of inflammation and inflammatory pathways in the cervix: potential for cervical cancer progression and HIV transmission in South African women

Includes bibliographical references.Cervical cancer is a chronic inflammatory disease of multifactorial etiology accounting for an annual estimated 266,000 deaths worldwide and usually present in sexually active women. In sub-Saharan Africa, cervical cancer is the most common cancer among women and the leading cause of cancer related deaths in this region. The obvious association of HIV infection and cervical cancer has long been established. High incidence and prevalence rate of HIV infection has been recorded in many areas with high incidence of cervical cancer suggesting that cervical cancer and premalignant cervical lesions may increase transmission and acquisition of HIV infection. Seminal plasma (SP) has been shown to initiate inflammatory response within the female genital tract. Exposure of neoplastic cervical epithelial cells to SP has been shown to promote the growth of cancer cells in vitro and tumors in vivo by activating several proinflammatory pathways. In addition to the regulation of tumor growth, SP-mediated inflammatory responses within the female genital tract have been suggested to contribute to the transmission of HIV and other sexually transmitted infections (STIs). The initial aim of this study was to determine the role of SP in the regulation of proinflammatory pathways in neoplastic cervical epithelial cells. TaqMan 96-well array revealed that SP regulates the activation of eicosanoid, toll-like receptor-NFκB, kallikrien-bradykininbradykinin receptor, cytokine, and chemokine signaling pathways to mediate the expression of inflammatory mediators in cervical cancer cells. These data highlight the potential of SP to exacerbate inflammatory processes within the local cervical cancer microenvironment creating conditions favorable for cervical tumor progression

Algemene ergonomische concepten

De laatste jaren hebben zich veel ontwikkelingen voorgedaan op het gebied van endoscopische chirurgie. Steeds meer operaties, nu al 40.000 tot 50.000 per jaar in Nederland, worden op deze wijze uitgevoerd. Naast voordeel voor de patiënt, brengt de endoscopische chirurgie echter ook nieuwe mentale en fysieke belastingen voor het OK-team met zich mee op het gebied van ergonomie, training en efficiëntie. In dit hoofdstuk gaan we in op de ergonomische aspecten van endoscopische chirurgie

The long-term effects of early oral feeding following minimal invasive esophagectomy

Item does not contain fulltextA nil-by-mouth regime with enteral nutrition via an artificial route is frequently applied following esophagectomy. However, early initiation of oral feeding could potentially improve recovery and has shown to be beneficial in many types of abdominal surgery. Although short-term nutritional safety of oral intake after an esophagectomy has been documented, long-term effects of this feeding regimen are unknown. In this cohort study, data from patients undergoing minimal invasive Ivor-Lewis esophagectomy between 04-2012 and 09-2015 in three centers in Netherlands were collected. Patients in the oral feeding group were retrieved from a previous prospective study and compared with a cohort of patients with early enteral jejunostomy feeding but delayed oral intake. Body mass index (BMI) measurements, complications, and nutritional re-interventions (re- or start of artificial feeding, start of total parenteral nutrition) were gathered over the course of one year after surgery. One year after surgery the median BMI was 22.8 kg/m2 and weight loss was 7.0 kg (9.5%) in 114 patients. Patients in the early oral feeding group lost more weight during the first postoperative month (P = 0.004). However, in the months thereafter this difference was not observed anymore. In the early oral feeding group, 28 patients (56%) required a nutritional re-intervention, compared to 46 patients (72%) in the delayed oral feeding group (P = 0.078). During admission, more re-interventions were performed in the delayed oral feeding group (17 vs. 46 patients P < 0.001). Esophagectomy reduces BMI in the first year after surgery regardless of the feeding regimen. Direct start of oral intake following esophagectomy has no impact on early nutritional re-interventions and long-term weight loss