[Pectus excavatum: not just a cosmetic problem]. / Trechterborst: niet alleen een cosmetisch probleem.

Pectus excavatum is the most common deformity of the anterior chest wall. Nevertheless, awareness amongst physicians is lacking and consequences of the diagnosis are often underestimated. Symptoms include cardiopulmonary symptoms such as palpitations, fatigue and exercise intolerance. Moreover, patients often have psychosocial problems and suffer from poor body image and lower quality of life. A multidisciplinary approach is recommended for diagnostic work-up and treatment, involving dedicated paediatricians, cardiologists and surgeons. Treatment can be non-surgical or surgical. Conservative options include physiotherapy and vacuum bell therapy. In symptomatic patients, surgical treatment is warranted from the age of 12-14 years. Minimally invasive repair with the Nuss bar technique is considered the gold standard for adolescents. Patients who are unsuitable for minimally invasive repair can be treated with open surgical correction, for example, via a modified Ravitch procedure. Early referral to a specialised centre is recommended.

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. TRIAL REGISTRATION: NCT03208621 . This trial was registered prospectively on June 30, 2017.

Relation between postoperative ileus and anastomotic leakage after colorectal resection: a post hoc analysis of a prospective randomized controlled trial.

AIM: Anastomotic leakage (AL) following abdominal surgery is a critical determinant of postoperative recovery, of which the aetiology is largely unknown. Interestingly, interventions aimed at reducing the inflammatory response and postoperative ileus (POI) have an unexpected effect on AL. The aim of this study was to investigate the relation of POI with inflammation and AL after colorectal resection. METHOD: A post hoc analysis of a prospective randomized controlled trial in which patients underwent a colorectal resection was performed. Patients undergoing a colorectal resection were stratified into having or not having POI. The incidence of AL and other clinical parameters was registered prospectively. Intestinal fatty acid binding protein (I-FABP, a marker for tissue damage) and the inflammatory response in plasma and colon tissue were determined. RESULTS: AL was present in nine of 43 patients in the POI group, and in one of 65 in the group without POI (P < 0.001). There was a significant association between POI and AL (OR 12.57, 95% CI: 2.73-120.65; P = 0.0005). Patients with POI had significantly higher plasma levels of soluble tumour necrosis factor receptor 1 (TNFRSF1A) at 4 h postoperatively (0.89 ng/l, interquartile range 0.56) than patients without POI (0.80 ng/l, interquartile range 0.37; P = 0.04) and higher plasma levels of C-reactive protein on the second day postoperatively (234 ± 77 vs 163 ± 86 mg/l; P = 0.001). Patients who developed AL had significantly higher plasma levels of I-FABP compared with patients without AL at 24 h after onset of surgery. CONCLUSION: POI is associated with a higher prevalence of AL and an increased inflammatory response.

Randomized clinical trial of the effect of gum chewing on postoperative ileus and inflammation in colorectal surgery.

BACKGROUND: Postoperative ileus (POI) is a common complication following colorectal surgery that delays recovery and increases length of hospital stay. Gum chewing may reduce POI and therefore enhance recovery after surgery. The aim of the study was to evaluate the effect of gum chewing on POI, length of hospital stay and inflammatory parameters. METHODS: Patients undergoing elective colorectal surgery in one of two centres were randomized to either chewing gum or a dermal patch (control). Chewing gum was started before surgery and stopped when oral intake was resumed. Primary endpoints were POI and length of stay. Secondary endpoints were systemic and local inflammation, and surgical complications. Gastric emptying was measured by ultrasonography. Soluble tumour necrosis factor receptor 1 (TNFRSF1A) and interleukin (IL) 8 levels were measured by enzyme-linked immunosorbent assay. RESULTS: Between May 2009 and September 2012, 120 patients were randomized to chewing gum (58) or dermal patch (control group; 62). Mean(s.d.) length of hospital stay was shorter in the chewing gum group than in controls, but this difference was not significant: 9·5(4·9) versus 14·0(14·5) days respectively. Some 14 (27 per cent) of 52 analysed patients allocated to chewing gum developed POI compared with 29 (48 per cent) of 60 patients in the control group (P = 0·020). More patients in the chewing gum group first defaecated within 4 days of surgery (85 versus 57 per cent; P = 0·006) and passed first flatus within 48 h (65 versus 50 per cent; P = 0·044). The decrease in antral area measured by ultrasonography following a standard meal was significantly greater among patients who chewed gum: median 25 (range -36 to 54) per cent compared with 10 (range -152 to 54) per cent in controls (P = 0·004). Levels of IL-8 (133 versus 288 pg/ml; P = 0·045) and TNFRSF1A (0·74 versus 0·92 ng/ml; P = 0·043) were lower among patients in the chewing gum group. Fewer patients in this group developed a grade IIIb complication (2 of 58 versus 10 of 62; P = 0·031). CONCLUSION: Gum chewing is a safe and simple treatment to reduce POI, and is associated with a reduction in systemic inflammatory markers and complications. REGISTRATION NUMBER: NTR2867 (http://www.trialregister.nl).

Value of geriatric frailty and nutritional status assessment in predicting postoperative mortality in gastric cancer surgery.

OBJECTIVES: This study seeks to evaluate assessment of geriatric frailty and nutritional status in predicting postoperative mortality in gastric cancer surgery. METHODS: Preoperatively, patients operated for gastric adenocarcinoma underwent assessment of Groningen Frailty Indicator (GFI) and Short Nutritional Assessment Questionnaire (SNAQ). We studied retrospectively whether these scores were associated with in-hospital mortality. RESULTS: From 2005 to September 2012 180 patients underwent surgery with an overall mortality of 8.3%. Patients with a GFI ≥ 3 (n = 30, 24%) had a mortality rate of 23.3% versus 5.2% in the lower GFI group (OR 4.0, 95%CI 1.1-14.1, P = 0.03). For patients who underwent surgery with curative intent (n = 125), this was 27.3% for patients with GFI ≥ 3 (n = 22, 18%) versus 5.7% with GFI < 3 (OR 4.6, 95% CI 1.0-20.9, P = 0.05). SNAQ ≥ 1 (n = 98, 61%) was associated with a mortality rate of 13.3% versus 3.2% in patients with SNAQ =0 (OR 5.1, 95% CI 1.1-23.8, P = 0.04). Given odds ratios are corrected in multivariate analyses for age, neoadjuvant chemotherapy, type of surgery, tumor stage and ASA classification. CONCLUSIONS: This study shows a significant relationship between gastric cancer surgical mortality and geriatric frailty as well as nutritional status using a simple questionnaire. This may have implications in preoperative decision making in selecting patients who optimally benefit from surgery.

Radionuclide-guided biopsy of bone lesions in cancer patients; a reliable, well-tolerated technique.

OBJECTIVES: In follow up or primary analysis of malignant disease, use of nuclear medicine imaging techniques is increasing. The lesions, detected by these modalities, do not always present with a matching radiological abnormality suitable for radiological biopsy. A method to confirm, or rule out, metastatic disease in these cases is radionuclide-guided surgical biopsy. PATIENTS AND METHODS: The technique consists of injecting a Technetium-99m labelled diphosphonate, performing a bone scan and marking the lesion; under general anaesthetic a surgical biopsy is taken through a small incision guided by a gamma-probe. We evaluated the combined experience of two teaching hospitals, by conducting retrospective chart review, over a period of 5.5 years. Sixty-nine procedures with 79 biopsies were performed. The patients previously had breast cancer in 42%, lung cancer in 32%, both gastrointestinal and urological malignancies in 13%, miscellaneous or unknown origin were reported in 9%. In 68% a rib biopsy was taken, in 15% a pelvis biopsy and in 11% a sternum or clavicle biopsy. RESULTS: In 46.8% metastatic disease was confirmed and in 2.6% a new malignancy (M Kahler) was identified. During a median clinical follow up period of 31 months (1-70), 1 initially negative biopsy site was found to contain a metastasis. Apart from local pain in 3% of cases, no complications were mentioned. CONCLUSION: In conclusion we can state that, in this retrospective series, radionuclide-guided bone biopsy is a reliable, well-tolerated technique to determine the diagnosis of these lesions with a sensitivity of 97% and specificity of 100%.

Risk of anastomotic leakage with non-steroidal anti-inflammatory drugs in colorectal surgery.

BACKGROUND: With the implementation of multimodal analgesia regimens in fast-track surgery programmes, non-steroidal anti-inflammatory drugs (NSAIDs) are being prescribed routinely. However, doubts have been raised concerning the safety of NSAIDs in terms of anastomotic healing. METHODS: Data on patients who had undergone primary colorectal anastomosis at two teaching hospitals between January 2008 and December 2010 were analysed retrospectively. Exact use of NSAIDs was recorded. Rates of anastomotic leakage were compared between groups and corrected for known risk factors in both univariable and multivariable analyses. RESULTS: A total of 795 patients were divided into four groups according to NSAID use: no NSAIDs (471 patients), use of non-selective NSAIDs (201), use of selective cyclo-oxygenase (COX) 2 inhibitors (79), and use of both selective and non-selective NSAIDs (44). The overall leak rate was 9.9 per cent (10.0 per cent for right colonic, 8.7 per cent for left colonic and 12.4 per cent for rectal anastomoses). Known risk factors such as smoking and use of steroids were not significantly associated with anastomotic leakage. Stapled anastomosis was identified as an independent predictor of leakage in multivariable analysis (odds ratio (OR) 2.22, 95 per cent confidence interval 1.30 to 3.80; P = 0.003). Patients on NSAIDs had higher anastomotic leakage rates than those not on NSAIDs (13.2 versus 7.6 per cent; OR 1.84, 1.13 to 2.98; P = 0.010). This effect was mainly due to non-selective NSAIDs (14.5 per cent; OR 2.13, 1.24 to 3.65; P = 0.006), not selective COX-2 inhibitors (9 per cent; OR 1.16, 0.49 to 2.75; P = 0.741). The overall mortality rate was 4.2 per cent, with no significant difference between groups (P = 0.438). CONCLUSION: Non-selective NSAIDs may be associated with anastomotic leakage.

Timing and necessity of a flexible sigmoidoscopy in patients with symptoms suggestive of haemorrhoids.

OBJECTIVE: This study was performed to determine the probability of finding additional pathology, requiring treatment or follow-up, in patients referred with symptoms suggestive of haemorrhoids. Secondly, to determine, at what age a flexible sigmoidoscopy should be performed in these patients. METHOD: All patients referred for the treatment of haemorrhoids over a period of 5 years were prospectively included in a database. Data included patient characteristics, clinical information, histopathological analysis and the sigmoidoscopy results. RESULTS: Haemorrhoids were present in 961 (95.6%) of 1005 patients. Of these patients, 692 (72.0%) patients were free from any additional pathology, 161 (16%) patients had diverticulosis, in 15 (1.5%) patients the sigmoidoscopy showed signs of colitis, 116 (11.5%) patients had polyps and a malignancy was present in eight (0.8%) patients. In the age group between 30-40 and 40-50, the presence of additional pathology increased significantly (P < 0.05). No malignancies were found under the age of 40. CONCLUSIONS: The vast majority of patients referred for the treatment and analysis of haemorrhoids were free from any additional pathology. But, over the age of 40, the incidence of additional pathology increased significantly. Therefore, we suggest that a flexible sigmoidoscopy should be performed in all patients over the age of 40, with clinical signs of haemorrhoids.

Results of tailored treatment for breast cancer patients with internal mammary lymph node metastases.

Although the internal mammary (IM) lymph node status is a major prognostic factor in breast cancer, IM nodal staging is not common practice. In order to improve nodal staging, we have routinely performed IM sentinel node (SN) biopsy and have adjusted adjuvant treatment accordingly. We reviewed the outcome of these patients. Data from 764 patients were available for follow-up. A total of 406 patients had no lymph node metastases (group 1), 330 patients had axillary metastases (group 2), 7 patients had IM metastases only (group 3) and 21 patients had both axillary and IM metastases (group 4). Mean follow-up was 46 months. Prognosis did not appear to be worse for patients with IM metastases compared to those with axillary metastases only, which might indicate that they benefit from improved staging and tailored adjuvant treatment algorithms. However, long-term follow-up data, preferably in larger series, are needed to support our findings.

Incidence of axillary recurrence in 344 sentinel node negative breast cancer patients after intermediate follow-up. A prospective study into the accuracy of sentinel node biopsy in breast cancer patients.

Sentinel lymph node biopsy (SLNB) has been validated in the treatment of breast carcinoma and is considered to stage the axilla adequately in this disease. However, long-term follow-up data are scarce. We evaluated the results of SLNB with respect to loco-regional failures in the axilla in SN-negative patients with invasive breast carcinoma and analysed their causal factors. Between 1997 and May 2004, 656 patients without clinically palpable lymph nodes were included in our study. Data with regard to demographics, diagnostics, therapy and follow up were gathered prospectively from all patients. Patients treated after May 2004 were excluded from this study to permit at least one year of follow-up. Out of the 656 patients, 344 patients with a negative sentinel lymph node biopsy did not undergo axillary dissection and were followed up clinically. Median follow up was 43 months. In 3 patients (0.9%) axillary recurrences developed. All three patients subsequently underwent a completion axillary dissection, chemotherapy and radiotherapy. The low rate of clinical axillary recurrence after an intermediate follow up period suggests that a negative SN biopsy accurately reflects the nodal stage in patients with breast cancer.

Incidence of axillary recurrence in 344 sentinel node negative breast cancer patients after intermediate follow-up. A prospective study into the accuracy of sentinel node biopsy in breast cancer patients.

Sentinel lymph node biopsy (SLNB) has been validated in the treatment of breast carcinoma and is considered to stage the axilla adequately in this disease. However, long-term follow-up data are scarce. We evaluated the results of SLNB with respect to loco-regional failures in the axilla in SN-negative patients with invasive breast carcinoma and analysed their causal factors. Between 1997 and May 2004, 656 patients without clinically palpable lymph nodes were included in our study. Data with regard to demographics, diagnostics, therapy and follow up were gathered prospectively from all patients. Patients treated after May 2004 were excluded from this study to permit at least one year of follow-up. Out of the 656 patients, 344 patients with a negative sentinel lymph node biopsy did not undergo axillary dissection and were followed up clinically. Median follow up was 43 months. In 3 patients (0.9%) axillary recurrences developed. All three patients subsequently underwent a completion axillary dissection, chemotherapy and radiotherapy. The low rate of clinical axillary recurrence after an intermediate follow up period suggests that a negative SN biopsy accurately reflects the nodal stage in patients with breast cancer.

Results of sentinel node biopsy not affected by previous excisional biopsy.

AIMS: Sentinel lymph node (SN) biopsy has been validated in the treatment of breast carcinoma. Patients with previous excisional biopsy are regarded as ineligible for SN biopsy. We evaluated the results of SN biopsy for this group of patients based on confirmatory axillary lymph node dissection. PATIENTS AND METHODS: From April 1997 all 88 patients with stage T(1-3) breast cancer who had previously undergone diagnostic excisional biopsy followed by complete axillary lymph node dissection, were enrolled into a prospective study to determine the validity of the sentinel node procedure. RESULTS: Lymphoscintigraphy visualized one or more axillary hot spots in 84/88 patients. A successful SN biopsy was performed in 87 patients. Complete axillary lymph-node dissection showed no false-negative SN biopsy among the 87 SN procedures. CONCLUSION: SN biopsy is a reliable and safe method following excisional biopsy as is confirmed by completion axillary lymph node dissection. Therefore, patients with previous excisional biopsy are eligible for sentinel node procedure and can be spared unnecessary axillary lymph node dissection.

Traumatic abdominal wall hernia: delayed presentation in two cases and a review of the literature.

Blunt and penetrating abdominal traumas are an important source of morbidity and mortality in the western world, especially in the young populations. Although most attention during the (primary) diagnostic process is directed toward the detection of internal injuries of the abdomen, blunt or penetrating trauma to the abdomen may result in defects of the abdominal wall. The diagnosis of traumatic abdominal wall hernia (TAWH) is rarely made. Morbidity due to TAWH, however, may be significant. In this article we report the delayed diagnosis of a TAWH in two patients after abdominal wall trauma and present a review of the literature concerning the diagnostic workup and treatment.

[The acute compartment syndrome of the arm]. / Het acute compartimentsyndroom van de arm.

Two 37-year-old men, both drug addicts, and a 32-year-old homeless woman presented themselves with a painful arm. Except for the first patient, there was a delay in diagnosing the compartment syndrome of the arm. In the first patient emergency fasciotomy led to a good functional recovery, however kidney function was lost despite proper treatment, possibly due to combined heroine use and muscle breakdown. In the second patient prolonged immobility and altered consciousness by drug use should have increased clinical suspicion. Poor arm function remained even after fasciotomy. In the third patient inadequate clinical examination delayed surgery. Major early symptoms of compartment syndrome are progressive disproportional pain and sensory loss, not relieved by analgesia. If left untreated, the ischaemic tissue damage is potentially limb and even life threatening. The acute compartment syndrome is a clinical diagnosis and a low threshold for surgical exploration and fasciotomy is advocated.