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

Patency van een heparine gebonden ePTFE-gecoverde endograft in vergelijking met een niet-heparine gebonden ePTFE-gecoverde endograft bij chronisch obstructief vaatlijden van de arteria femoralis superfialis.

Background: Occlusive vascular disease of the superficial femoral artery (SFA) is often the cause of ischemia of the lower extremity. Revascularization is necessary for wound healing and limb salvage. Minimal invasive revascularization is emerging as an treatment option for chronic occlusive peripheral arterial disease in the femoro-popliteal segment. The purpose of this study was to assess the 2-year patency rates of non-heparin bonded ePTFE-covered endograft (NH-endograft) versus heparin bonded ePTFE-coverd endografts (H-endograft) in the treatment of chronic occlusive disease of the superficial femoral artery (SFA). Materials and methods: All patients who received endovascular revascularization of the femoro-popliteal segment between 2001 and 2012 were included in this retrospective cohort study. Patients received a NH-endograft or a H-endograft. Treatment took place on an operating room or an radiology intervention room. If there was a concomitant stenosis of the Common Femoral Artery (CFA) endarteriectomie was performed in the same session. Results: A total of 327 limbs were treated in 307 patients. 172 patients received a NH-endograft and 155 received a H-endograft. All patients included had clinical symptoms of critical limb ischemia (Fontaine III or IV) (n = 112) or intermittend claudication (Fontaine IIB) (n=215). Patients in the NH-endograft group were significant younger than patients in the H-endograft group (67,3 ± 9,8 versus 70,9 ± 10,2 year, P=0,001). The average ankle brachial index was significant higher in the NH-endograft group versus the H-endograft group (0,67 ± 0,16 versus 0,58 ± 0,15, P=0,000). There was a significant difference between the diameter of the NH-endograft versus the H-endograft: 5 mm 3 versus 19; 6 mm 142 versus 112; 7 mm 26 versus 20, P=0,001. TASC II classification in the NH-endograft group was TASC A/B/C/D: 54/55/32/31 and in the H-endograft group: 22/38/30/65, P=0,000. After 2 years the patency between NH-endograft versus H-endograft were: primary patency 64,5% versus 62,8% (P=0,331); secondary patency 87,1% versus 83,7% (P=0,603). Multivariate Cox regression analyses shows that age (P=0,006), TASC II classification type D (P=0,006) and the diameter of the endograft (P=0,002) have significant influence on the primary patency after 2 years. Patency isn’t influenced by heparin bonding to the stent, P=0,774. Conclusion: Although the baseline characteristics were not equal between both groups, there was no difference in patency ratio between the NH-endograft and the H-endograft. The 2 year patency of DM patients were equal to those of non-DM patients. The 2 year patency in CLI patients were equal to that of claudicants. Multivariate Cox regression analyses shows that TASC-II type D lesions, age and most important the diameter of the endograft influence the primary patency after 2 years. Endovascular revascularization in the femoro-popliteal segment with a NH- or H-endograft is a good minimal invasive treatment option and must be considered for patients with chronic occlusive vascular disease.

Computation of blood flow through collateral circulation of the superficial femoral artery

Objective: Obliteration of collaterals during (endo)vascular treatment of peripheral arterial occlusive disease is considered detrimental. We use a model to calculate maximum collateral bed flow of the superficial femoral artery in order to provide insight in their hemodynamic relevance. Method: A computational model was developed using digital subtraction angiographies in combination with Poiseuille's equation and Ohm's law. Lesions were divided into short and long (15 cm and ≥15 cm, respectively) and into stenosis and occlusions. Data are presented in relation to the calculated maximum healthy superficial femoral artery flow. Results: Stenotic lesions are longer than occlusive lesions (P 0.05) and occlusions had more and larger collaterals (P 0.05). In all four study groups the collateral flow significantly increased the total flow (P 0.05). The maximum collateral system flow in the stenosis and occlusion groups was 5.1% and 20.8% of healthy superficial femoral artery flow, respectively (P 0.05), and there were no significant differences between short and long lesions (11.2% and 6.7% of healthy superficial femoral artery flow, respectively). Conclusion: The maximum collateral system flow of the superficial femoral artery is only a fraction, with a maximum of one fifth, of healthy superficial femoral artery flow. Effects of collateral vessel occlusion during (endo)vascular treatment may therefore be without detrimental consequences

Propensity score-matched analysis of oncological outcome between stent as bridge to surgery and emergency resection in patients with malignant left-sided colonic obstruction

Background: Although self-expandable metal stent (SEMS) placement as bridge to surgery (BTS) in patients with left-sided obstructing colonic cancer has shown promising short-term results, it is used infrequently owing to uncertainty about its oncological safety. This population study compared long-term oncological outcomes between emergency resection and SEMS placement as BTS.Methods: Through a national collaborative research project, long-term outcome data were collected for all patients who underwent resection for left-sided obstructing colonic cancer between 2009 and 2016 in 75 Dutch hospitals. Patients were identified from the Dutch Colorectal Audit database. SEMS as BTS was compared with emergency resection in the curative setting after 1: 2 propensity score matching.Results: Some 222 patients who had a stent placed were matched to 444 who underwent emergency resection. The overall SEMS-related perforation rate was 7.7 per cent (17 of 222). Three-year locoregional recurrence rates after SEMS insertion and emergency resection were 11-4 and 13.6 per cent (P= 0-457), disease-free survival rates were 58-8 and 52.6 per cent (P= 0-175), and overall survival rates were 74-0 and 68-3 per cent (P= 0.231), respectively. SEMS placement resulted in significantly fewer permanent stomas (23.9 versus 45.3 per cent; P < 0-001), especially in elderly patients (29.0 versus 57.9 per cent; P < 0-001). For patients in the SEMS group with or without perforation, 3-year locoregional recurrence rates were 18 and 11.0 per cent (P= 0.432), disease-free survival rates were 49 and 59.6 per cent (P= 0-717), and overall survival rates 61 and 75.1 per cent (P= 0.529), respectively.Conclusion: Overall, SEMS as BTS seems an oncologically safe alternative to emergency resection with fewer permanent stomas. Nevertheless, the risk of SEMS-related perforation, as well as permanent stoma, might influence shared decision-making for individual patients.Research into fetal development and medicin