Risk Prediction in Acute Calculous Cholecystitis: A Systematic Review and Meta-analysis of Prognostic Factors and Predictive Models

BACKGROUND: Laparoscopic cholecystectomy is the main treatment of acute cholecystitis. Although considered relatively safe, it carries 6%–9% risk of major complications and 0.1%–1% risk of mortality. There is no consensus regarding the evaluation of the preoperative risks, and the management of patients with acute cholecystitis is usually guided by surgeon's personal preferences. We assessed the best method to identify patients with acute cholecystitis who are at high risk of complications and mortality. METHODS: We performed a systematic review of studies that reported the preoperative prediction of outcomes in people with acute cholecystitis. We searched the Cochrane Library, MEDLINE, EMBASE, WHO ICTRP, ClinicalTrials.gov, and Science Citation Index Expanded until April 27, 2019. We performed a meta-analysis when possible. RESULTS: Six thousand eight hundred twenty-seven people were included in one or more analyses in 12 studies. Tokyo guidelines 2013 (TG13) predicted mortality (two studies; Grade 3 versus Grade 1: odds ratio [OR] 5.08, 95% confidence interval [CI] 2.79–9.26). Gender predicted conversion to open cholecystectomy (two studies; OR 1.59, 95% CI 1.06–2.39). None of the factors reported in at least two studies had significant predictive ability of major or minor complications. CONCLUSION: There is significant uncertainty in the ability of prognostic factors and risk prediction models in predicting outcomes in people with acute calculous cholecystitis. Based on studies of high risk of bias, TG13 Grade 3 severity may be associated with greater mortality than Grade 1. Early referral of such patients to high-volume specialist centers should be considered. Further well-designed prospective studies are necessary

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Safety Measures During Cholecystectomy: Results of a Nationwide Survey

BACKGROUND: This study aimed to identify safety measures practiced by Dutch surgeons during laparoscopic cholecystectomy. METHOD: An electronic questionnaire was sent to all members of the Dutch Society of Surgery with a registered e-mail address. RESULTS: The response rate was 40.4% and 453 responses were analyzed. The distribution of the respondents with regard to type of hospital was similar to that in the general population of Dutch surgeons. The critical view of safety (CVS) technique is used by 97.6% of the surgeons. It is documented by 92.6%, mostly in the operation report (80.0%), but often augmented by photography (42.7%) or video (30.2%). If the CVS is not obtained, 50.9% of surgeons convert to the open approach, 39.1% continue laparoscopically, and 10.0% perform additional imaging studies. Of Dutch surgeons, 53.2% never perform intraoperative cholangiography (IOC), 41.3% perform it incidentally, and only 2.6% perform it routinely. A total of 105 bile duct injuries (BDIs) were reported in 14,387 cholecystectomies (0.73%). The self-reported major BDI rate (involving the common bile duct) was 0.13%, but these figures need to be confirmed in other studies. CONCLUSION: The CVS approach in laparoscopic cholecystectomy is embraced by virtually all Dutch surgeons. The course of action when CVS is not obtained varies. IOC seems to be an endangered skill as over half the Dutch surgeons never perform it and the rest perform it only incidentally

Choledochal malformations in adults in the Netherlands: Results from a nationwide retrospective cohort study

BACKGROUND AND AIMS: Patients with a choledochal malformation, formerly described as cysts, are at increased risk of developing a cholangiocarcinoma and resection is recommended. Given the low incidence of CM in western countries, the incidence in these countries is unclear. Our aim was to assess the incidence of malignancy in CM patients and to assess postoperative outcome. METHODS: In a nationwide, retrospective study, all adult patients, who underwent surgery for CM between 1990 and 2016 were included. Patients were identified through the Dutch Pathology Registry and local patient records and were analysed to determine the incidence of malignancy, as well as postoperative mortality and morbidity. RESULTS: A total of 123 patients with a CM were included in the study (Todani Type I, n=71; Type II, n=10; Type III, n=3; Type IV, n=27; unknown, n=12). Median age was 40 years (range 18-70) and 81% were female. The majority of patients (99/123) underwent extrahepatic bile duct resection, with additional liver parenchyma resections in eight patients, only exploration in two, and a local cyst resection in eight patients. Postoperative 30-day mortality was 2% (2/123) and limited to patients who underwent liver resection. Severe morbidity occurred in 24%. In 14 of the 123 patients (11%) a malignancy was found in the resected specimen. One patient developed a periampullary malignancy 7 years later. CONCLUSIONS: In a large Western series of CM patients 11% were found to have a malignancy. This justifies resection in these patients, despite the risk of morbidity (24%) and mortality (2%)

Long-term survival after hyperthermic intraperitoneal chemotherapy using mitomycin C or oxaliplatin in colorectal cancer patients with synchronous peritoneal metastases:A nationwide comparative study

Objectives: In the Netherlands, limited variability exists in performance of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) among centers treating colorectal peritoneal metastases (PM), except for the intraperitoneal drug administration. This offers a unique opportunity to investigate any disparities in survival between the two most frequently used HIPEC regimens worldwide: mitomycin C (MMC) and oxaliplatin.Methods: This was a comparative, population-based cohort study of all Dutch patients diagnosed with synchronous colorectal PM who underwent CRS-HIPEC between 2014 and 2017. They were retrieved from the Netherlands Cancer Registry. Main outcome was overall survival (OS). The effect of the intraperitoneal drug on OS was investigated using multivariable Cox regression analysis.Results: In total, 297 patients treated between 2014 and 2017 were included. Among them, 177 (59.6%) received MMC and 120 (40.4%) received oxaliplatin. Only primary tumor location was different between the two groups: more left-sided colon in the Oxaliplatin group (47.5% vs. 33.3%, respectively, p=0.048). The 1-, 2- and 3-year OS were 84.6% vs. 85.8%, 61.6% vs. 63.9% and 44.7% vs. 53.5% in patients treated with MMC and oxaliplatin, respectively. Median OS was 30.7 months in the MMC group vs. 46.6 months in the oxaliplatin group (p=0.181). In multivariable analysis, no influence of intraperitoneal drug on survival was observed (adjusted HR 0.77 [0.53-1.13]).Conclusions: Long-term survival between patients treated with either MMC or oxaliplatin during CRS-HIPEC was not significantly different. (C) 2020 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.</p

A randomized controlled trial to compare a restrictive strategy to usual care for the effectiveness of cholecystectomy in patients with symptomatic gallstones (SECURE trial protocol)

BACKGROUND: Five to 22 % of the adult Western population has gallstones. Among them, 13 to 22 % become symptomatic during their lifetime. Cholecystectomy is the preferred treatment for symptomatic cholecystolithiasis. Remarkably, cholecystectomy provides symptom relief in only 60-70 % of patients. The objective of this trial is to compare the effectiveness of usual (operative) care with a restrictive strategy using a standardized work-up with stepwise selection for cholecystectomy in patients with gallstones and abdominal complaints. DESIGN AND METHODS: The SECURE-trial is designed as a multicenter, randomized, parallel-arm, non-inferiority trial in patients with abdominal symptoms and ultrasound proven gallstones or sludge. If patients meet the inclusion criteria they will be randomized to either usual care or the restrictive strategy. Patients in the usual care group will be treated according to the physician's knowledge and preference. Patients in the restrictive care group will be treated with interval evaluation and stepwise selection for laparoscopic cholecystectomy. In this stepwise selection, patients strictly meeting the preselected criteria for symptomatic cholecystolithiasis will be offered a cholecystectomy. Patients not meeting these criteria will be assessed for other diagnoses and re-evaluated at 3-monthly intervals. Follow-up consists of web-based questionnaires at 3, 6, 9 and 12 months. The main end point of this trial is defined as the proportion of patients being pain-free at 12 months follow-up. Pain will be assessed with the Izbicki Pain Score and Gallstone Symptom Score. Secondary endpoints will be the proportion of patients with complications due to gallstones or cholecystectomy, the association between the patients' symptoms and treatment and work performance, and ultimately, cost-effectiveness. DISCUSSION: The SECURE trial is the first randomized controlled trial examining the effectiveness of usual care versus restrictive care in patients with symptomatic gallstones. The outcome of this trial will inform clinicians whether a more restrictive strategy can minimize persistent pain in post-operative patients at least as good as usual care does, but at a lower cholecystectomy rate. (The Netherlands National Trial Register NTR4022, 17th December 2012) TRIAL REGISTRATION: The Netherlands National Trial Register NTR4022 http://www.zonmw.nl/nl/projecten/project-detail/scrutinizing-inefficient-use-of-c holecystectomy-a-randomized-trial-concerning-variation-in-practi/samenvatting/

Effect of intraperitoneal chemotherapy concentration on morbidity and survival

Contains fulltext : 218098.pdf (publisher's version ) (Open Access)BACKGROUND: Selected patients with colorectal peritoneal metastases are treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The concentration of intraperitoneal chemotherapy reflects the administered dose and perfusate volume. The aim of this study was to calculate intraperitoneal chemotherapy concentration during HIPEC and see whether this was related to clinical outcomes. METHODS: An observational multicentre study included consecutive patients with colorectal peritoneal metastases who were treated with CRS-HIPEC between 2010 and 2018 at three Dutch centres. Data were retrieved from prospectively developed databases. Chemotherapy dose and total circulating volumes of carrier solution were used to calculate chemotherapy concentrations. Postoperative complications, disease-free and overall survival were correlated with intraoperative chemotherapy concentrations. Univariable and multivariable logistic regression, Cox regression and survival analyses were performed. RESULTS: Of 320 patients, 220 received intraperitoneal mitomycin C (MMC) and 100 received oxaliplatin. Median perfusate volume for HIPEC was 5.0 (range 0.7-10.0) litres. Median intraperitoneal chemotherapy concentration was 13.3 (range 7.0-76.0) mg/l for MMC and 156.0 (91.9-377.6) mg/l in patients treated with oxaliplatin. Grade III or higher complications occurred in 75 patients (23.4 per cent). Median overall survival was 36.9 (i.q.r. 19.5-62.9) months. Intraperitoneal chemotherapy concentrations were not associated with postoperative complications or survival. CONCLUSION: CRS-HIPEC was performed with a wide variation in intraperitoneal chemotherapy concentrations that were not associated with complications or survival

Digital Platforms in the Global South: Foundations and Research Agenda

Digital platforms have become integral to many of the everyday activities that people across the globe encounter in areas like transportation, commerce and social interactions. Research on the topic has largely concentrated on the general functioning of these platforms in terms of platform governance, business strategies and consumer behaviour. Despite their significant presence in the global South, the developmental implications of digital platforms remain largely understudied. In part, this is because digital platforms are a challenging research object due to their lack of conceptual definition, their spread across different regions and industries, and their intertwined nature with institutions, actors and digital technologies. The aim of this paper is therefore twofold: to provide a conceptual definition of digital platforms, and to identify research strands in international development contexts. To do so, we draw from digital platforms literature, differentiate between transaction and innovation platforms and expose their main characteristics. We the present four strands in the form of research questions, illustrated with concrete examples, that can assist to pursue relevant studies on digital platforms and international development in the future