Validation of a Scoring System to Distinguish Uncomplicated From Complicated Appendicitis.

BACKGROUND: Studies have shown that uncomplicated appendicitis can be treated conservatively with antibiotics. It is important to select only those patients with uncomplicated appendicitis when considering conservative management. Recently, a scoring system based on clinical evaluation and ultrasound was developed to improve this selection and aid in shared decision making when considering an antibiotics-first strategy. The aim of this study was to externally validate the scoring system. MATERIALS AND METHODS: A retrospective cohort study of all adult patients presenting to the emergency department between January 2014 and January 2017 with suspected acute appendicitis based on clinical evaluation and ultrasound was performed. For every patient, a score was calculated using the previously described scoring system. A final diagnosis, subdivided into complicated appendicitis, uncomplicated appendicitis, complicated alternative disease, and uncomplicated alternative disease, was assigned to every patient based on operative findings. RESULTS: A total of 678 patients with suspected acute appendicitis based on clinical and ultrasonography findings were identified, of whom 175 (25.8%) had complicated appendicitis, 491 (72.4%) had uncomplicated appendicitis, and 12 (1.8%) had an alternative disease. Of the 678 patients, 272 had a score of five points or less, of whom 17 (6.2%) had complicated appendicitis, giving a negative predictive value of 93.8%. CONCLUSIONS: With the scoring system based on clinical and ultrasonography features, 93.8% of patients predicted to have uncomplicated appendicitis were correctly identified. The scoring system could help identify patients suitable for conservative management in future studies.

Long-Term Effects of Omitting Antibiotics in Uncomplicated Acute Diverticulitis.

BACKGROUND: Traditionally uncomplicated acute diverticulitis was routinely treated with antibiotics, although evidence for this strategy was lacking. Recently, two randomized clinical trials (AVOD trial and DIABOLO trial) published short-term results of omitting antibiotics compared to routine antibiotic treatment. Both showed no significant differences regarding recovery from the initial episode, as well as rates of complicated or recurrent diverticulitis and sigmoid resection. However, both studies showed a trend of higher rates of sigmoid resection in the observational groups. Here, the long-term effects of omitting antibiotics in first episode uncomplicated acute diverticulitis were assessed. METHODS: A total of 528 patients with CT-proven, primary, left-sided, uncomplicated acute diverticulitis were randomized to either an observational or an antibiotic treatment strategy (DIABOLO trial). Outcome measures were complicated diverticulitis, recurrent diverticulitis and sigmoid resection at 24 months' follow up. Differences between the groups were explored and risk factors were identified using multivariable logistic regression. RESULTS: Complete case analyses showed no difference in rates of recurrent diverticulitis (15.4% in the observational group versus 14.9% in the antibiotic group; p = 0.885), complicated diverticulitis (4.8% versus 3.3%; p = 0.403) and sigmoid resection (9.0% versus. 5.0%; p = 0.085). Young patients (<50 years) and patients with a pain score at presentation of 8 or higher on a visual analogue pain scale were at risk for complicated or recurrent diverticulitis. In this multivariable analysis, treatment type (with or without antibiotics) was not an independent predictor for complicated or recurrent diverticulitis. CONCLUSION: Omitting antibiotics in the treatment of uncomplicated acute diverticulitis did not result in more complicated diverticulitis, recurrent diverticulitis or sigmoid resections at long-term follow up. As the DIABOLO trial was not powered for these secondary outcome measures, some uncertainty remains whether (small) non-significant differences could be true associations.

[Fibroepithelial tumours of the breast: not always a simple fibroadenoma]. / Fibro-epitheliale tumoren van de borst.

Fibroepithelial tumours are the most common type of solid breast tumours. They include the common fibroadenomas and the rare phyllodes tumours. Fibroadenomas usually present in younger patients and are smaller than phyllodes tumours. They are benign and do not require any treatment or follow-up. Further examination (usually ultrasound-guided thick-needle biopsy) is recommended if in doubt about the diagnosis. Phyllodes tumours can be divided into benign, borderline and malignant tumours and are primarily treated with surgery, breast-conserving surgery if possible. In this article, we present three cases and an overview of characteristics, diagnosis, and treatment of fibroepithelial breast tumours.

[A preschooler with abdominal pain in the right lower quadrant]. / Een kleuter met pijn rechts onderin de buik.

A 5-year-old boy with acute abdominal pain in the right lower quadrant and fever underwent open appendectomy following clinical observation and serial equivocal ultrasound. During exploration we encountered a normal-looking appendix but multiple enlarged mesenteric lymph nodes, suggestive of mesenteric lymphadenitis. The boy had an uneventful postoperative course and recovered completely.

Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis.

BACKGROUND: Antibiotics are advised in most guidelines on acute diverticulitis, despite a lack of evidence to support their routine use. This trial compared the effectiveness of a strategy with or without antibiotics for a first episode of uncomplicated acute diverticulitis. METHODS: Patients with CT-proven, primary, left-sided, uncomplicated, acute diverticulitis were included at 22 clinical sites in the Netherlands, and assigned randomly to an observational or antibiotic treatment strategy. The primary endpoint was time to recovery during 6 months of follow-up. Main secondary endpoints were readmission rate, complicated, ongoing and recurrent diverticulitis, sigmoid resection and mortality. Intention-to-treat and per-protocol analyses were done. RESULTS: A total of 528 patients were included. Median time to recovery was 14 (i.q.r. 6-35) days for the observational and 12 (7-30) days for the antibiotic treatment strategy, with a hazard ratio for recovery of 0·91 (lower limit of 1-sided 95 per cent c.i. 0·78; P = 0·151). No significant differences between the observation and antibiotic treatment groups were found for secondary endpoints: complicated diverticulitis (3·8 versus 2·6 per cent respectively; P = 0·377), ongoing diverticulitis (7·3 versus 4·1 per cent; P = 0·183), recurrent diverticulitis (3·4 versus 3·0 per cent; P = 0·494), sigmoid resection (3·8 versus 2·3 per cent; P = 0·323), readmission (17·6 versus 12·0 per cent; P = 0·148), adverse events (48·5 versus 54·5 per cent; P = 0·221) and mortality (1·1 versus 0·4 per cent; P = 0·432). Hospital stay was significantly shorter in the observation group (2 versus 3 days; P = 0·006). Per-protocol analyses were concordant with the intention-to-treat analyses. CONCLUSION: Observational treatment without antibiotics did not prolong recovery and can be considered appropriate in patients with uncomplicated diverticulitis. Registration number: NCT01111253 (http://www.clinicaltrials.gov).

Do Complications Alter Postoperative Weight Loss 1 Year After Primary and Revisional Roux-en-Y Gastric Bypass?

BACKGROUND: Around 10 % of the bariatric surgery patients experience postoperative complications (<30 days). It could be hypothesized that complications influence postoperative weight loss, which is one of the most important endpoints of bariatric surgery. Therefore, this study inventoried the effect of complications on postoperative weight loss. METHODS: A consecutive database including patients who were operated from November 2007 onwards was retrospectively reviewed. All short-term complications were classified according to the Clavien-Dindo classification. Weight loss was assessed at 6 and 12 months postoperatively. RESULTS: A total of 1130 patients underwent either primary (n = 907, 80.3 %) or revisional (n = 233, 19.7 %) surgery till October 2013. Short-term complications occurred in 115 (10.2 %) patients, of whom 48 (41.7 %) had a severe (Clavien-Dindo ≥ 3) complication. One year post surgery, 184 patients (16.3 %) were lost to follow-up. Patients with a short-term complication had a higher percentage of excess weight loss (%EWL) at 6 months (58.6 (SD 16.6) versus 52.9 (SD 17.6), p = 0.003) and 1 year (71.9 (SD 22.3) versus 65.9 (SD 21.3), p = 0.017) of follow-up. Although a trend was seen toward higher BMI loss and total weight loss (TWL) after 6 months, no effect was seen 1 year postoperatively. In multivariable linear regression analysis, complications were not a significant predictor for 1-year %EWL. CONCLUSIONS: Although short-term complications alter 1-year %EWL, no effect was seen on BMI loss and TWL. In addition, complications were not a predictor in a multivariable linear regression model for 1-year %EWL. It can be concluded that short-term complications do not impair weight loss after Roux-en-Y gastric bypass.

Migrant breast cancer patients and their participation in genetic counseling: results from a registry-based study.

Certain ethnic groups seem to have less access to cancer genetic counseling. Our study was to investigate the participation in cancer genetic counseling among migrant breast cancer patients of Turkish and Moroccan origin. Hospital medical records of Turkish and Moroccan and of a comparative group of non-Turkish/Moroccan newly diagnosed breast cancer patients were studied. All women were diagnosed between 2007 and 2012. Eligibility for genetic counseling was assessed with a checklist. A total of 156 Turkish/Moroccan patients were identified, and 321 patients were assigned to the comparative group. About one third (35%) of the Turkish/Moroccan patients fulfilled criteria for breast cancer genetic counseling, compared to 21% of the comparative group (P = 0.001); this was largely due to a relatively young age at diagnosis in the migrant group (26% <40 years vs 5% in the comparative group, P = 0.0001). Uptake of genetic counseling among eligible patients was 47% in the migrant group and 56% in the comparative group; differences in uptake were seen among the patients diagnosed before 40 years of age (48% in the migrant group vs 81% in the comparative group; P = 0.021). When adjusted for age at diagnosis, ethnicity was associated with discussing referral to genetic counseling and its actual uptake. The Turkish/Moroccan ethnicity appears to be associated with a lower uptake of genetic counseling, mainly caused by the lower uptake in the young age-group. The major barrier to participation in genetic counseling seems to lie within the referral process.

Treatment strategies in elderly breast cancer patients: Is there a need for surgery?

BACKGROUND: The aim of this study was to determine the role of surgery in elderly patients with breast cancer. METHODS: Between 1999 and 2009, 153 consecutive women, ≥80 years old with breast cancer were treated at our hospital. Surgically and non-surgically treated patients were compared with respect to characteristics and survival. RESULTS: Treatment was surgical in 102 patients (67%). The non-surgically treated patients were older than surgically treated patients, had more co-morbidity and were more often diagnosed with a clinically T3/T4 tumour and distant metastasis. Patients not receiving surgery, had an 11% overall survival rate at 5-year versus 48% in surgically treated patients (P < 0.001). Independent factors for survival were clinical N0 status, M0 status at presentation and surgery. CONCLUSION: One in three patients of 80 years and older did not have surgical treatment for breast cancer. Patient not treated surgically are older, have more severe co-morbidity and are diagnosed with more advanced disease than patients who underwent surgery.The selection of patients, who have a poor prognosis, is made on clinical grounds not measurable with a common co-morbidity survey. Better and evidence-based selection criteria for surgical and non-surgical treatment in these patients are needed.

The value of pre-operative computed tomography scanning for the assessment of lymph node status in patients with colon cancer.

AIM: Our aim was to determine the value of a pre-operative computed tomography (CT) scan for the assessment of lymph node status in patients diagnosed with colon cancer by comparing radiological N-stage to histopathological N-stage. PATIENTS AND METHODS: We performed a retrospective cohort study at the Sint Lucas Andreas Hospital in Amsterdam, the Netherlands. Between 2008 and 2010, two radiologists independently reviewed all pre-operative CT scans of patients diagnosed with colon cancer. The scans were examined for signs of regional lymphatic spread (N+), defined as lymph nodes exceeding 1 cm, clusters of ≥ 3 lymph nodes or a combination of the two. The results were compared with the histopathological N-stage. Inter-observer agreement, positive predictive value (PVV), negative predictive value (NPV), sensitivity, specificity, and accuracy were calculated. RESULTS: We included 106 patients in our study. PVV, NPV, sensitivity, specificity, and accuracy of detecting regional lymph nodes metastases were 47%, 66%, 71%, 41% and 54%, respectively. Inter-observer agreement was 74.5% (к = 0.48). CONCLUSION: Although our study group was relatively large and newer techniques were used in comparison to previous studies, our results demonstrated that the value of a pre-operative CT scan for the assessment of regional lymph nodes remained poor and unreliable. Therefore we question if a radiologist should assess regional lymph nodes on a pre-operative CT scan in colon cancer. Before treatment decisions are made on the appearance of lymph nodes in colon cancer patients, its diagnostic accuracy needs strong improvement.

A systematic review of complicated diverticulitis in post-transplant patients.

BACKGROUND: Immunosuppression could increase the complication rate in patients with acute diverticulitis. This would justify a low threshold for elective sigmoid resection in these patients after an episode of diverticulitis. Well-documented groups of immunocompromised patients are transplant patients, in which many prospective studies have been conducted. OBJECTIVES: The aim of this systematic review is to assess the incidence of complicated diverticulitis in post-transplant patients. DATA SOURCE: We searched MEDLINE, EMBASE, CINAHL, and Cochrane databases for papers published between January 1966 and January 2014. STUDY SELECTION AND INTERVENTION: Publications dealing with post-transplant patients and left-sided diverticulitis were eligible for inclusion. The following exclusion criteria were used for study selection: abstracts, case-series and non-English articles. MAIN OUTCOME MEASURES: Primary outcome measure was the incidence of complicated diverticulitis. Secondary outcome was the incidence of acute diverticulitis and the proportion of complicated diverticulitis. Pooling of data was only performed when more than five reported on the outcome of interest with comparable cohorts. Only studies describing proportion of complicated diverticulitis and renal transplant studies were eligible for pooling data. RESULTS: Seventeen articles met the inclusion criteria. Nine renal transplant cohorts, four mixed lung-heart-heart lung transplant cohorts, two heart transplant cohorts, and two lung cohorts. A total of 11,966 post-transplant patients were included in the present review. Overall incidence of complicated diverticulitis in all transplantation studies ranged from 0.1 to 3.5%. Nine studies only included renal transplant patients. Pooled incidence of complicated diverticulitis in these patients was 1.0% (95% CI 0.6 to 1.5%). Ten studies provided proportion of complicated diverticulitis. Pooled incidence of acute diverticulitis in these studies was 1.7% (95% CI 1.0 to 2.7%). Pooled proportion of complicated diverticulitis among these patients was 40.1% (95% CI 32.2 to 49.7%). All studies were of moderate quality using the MINORS scoring scale. CONCLUSION: The incidence of complicated diverticulitis is about one in 100 transplant patients. Additionally when a transplant patient develops an episode of acute diverticulitis, a high proportion of patients have a complicated disease course.

Mediastinal lymphangioma in an adult.

Lymphangiomas are rare benign neoplasms derived from portions of lymph sacs. They most often occur in children in the cervical region and 90% have manifested by the end of the second year of life. An isolated mediastinal lymphangioma in an adult is an uncommon disease entity. We report the case of a mediastinal lymphangioma in a 29-year-old man presenting as a suprasternal lump, which was resected through a partial sternotomy/hemiclamshell thoracotomy.

Impact of rapid genetic counselling and testing on the decision to undergo immediate or delayed prophylactic mastectomy in newly diagnosed breast cancer patients: findings from a randomised controlled trial.

BACKGROUND: Female breast cancer patients with a BRCA1/2 mutation have an increased risk of contralateral breast cancer. We investigated the effect of rapid genetic counselling and testing (RGCT) on choice of surgery. METHODS: Newly diagnosed breast cancer patients with at least a 10% risk of a BRCA1/2 mutation were randomised to an intervention group (offer of RGCT) or a control group (usual care; ratio 2 : 1). Primary study outcomes were uptake of direct bilateral mastectomy (BLM) and delayed contralateral prophylactic mastectomy (CPM). RESULTS: Between 2008 and 2010, we recruited 265 women. On the basis of intention-to-treat analyses, no significant group differences were observed in percentage of patients opting for a direct BLM (14.6% for the RGCT group vs 9.2% for the control group; odds ratio (OR) 2.31; confidence interval (CI) 0.92-5.81; P=0.08) or for a delayed CPM (4.5% for the RGCT group vs 5.7% for the control group; OR 0.89; CI 0.27-2.90; P=0.84). Per-protocol analysis indicated that patients who received DNA test results before surgery (59 out of 178 women in the RGCT group) opted for direct BLM significantly more often than patients who received usual care (22% vs 9.2%; OR 3.09, CI 1.15-8.31, P=0.03). INTERPRETATION: Although the large majority of patients in the intervention group underwent rapid genetic counselling, only a minority received DNA test results before surgery. This may explain why offering RGCT yielded only marginally significant differences in uptake of BLM. As patients who received DNA test results before surgery were more likely to undergo BLM, we hypothesise that when DNA test results are made routinely available pre-surgery, they will have a more significant role in surgical treatment decisions.

Inter-observer reliability of computed tomographic classifications of diverticulitis.

AIM: The wide use of computed tomography (CT) for diverticulitis has initiated new classifications, but their reliability has not been studied. The aim of the study was to assess the inter-observer agreement of radiologists on the classifications of diverticulitis. METHOD: A set of 100 CT examinations of patients with an episode of diverticulitis was used to assess inter-observer agreement. Cases were derived from two prospective trials and a retrospective cohort to comprise an evenly distributed case mix of patients. The reference standard was the modified Hinchey classification based on all available information. Three blinded radiologists independently read all CT examinations. We calculated the proportion of agreement and kappa values for the Hinchey and Ambrosetti classifications. For the Dharmarajan classification only inter-observer agreement was calculated. RESULTS: The agreement with the reference standard was substantial for both the modified Hinchey and the Ambrosetti classifications (P = 0.68 and P = 0.76). Overall inter-observer agreement for the modified Hinchey classification was substantial (median kappa 0.72), for the Ambrosetti classification almost perfect (median kappa 0.83) and for the Dharmarajan classification substantial (median kappa 0.76). CONCLUSION: The Ambrosetti classification is more reproducible than the modified Hinchey and Dharmarajan classifications. The Ambrosetti and modified Hinchey classifications have a substantial agreement with the reference standard and therefore produce a reliable classification. The Dhamarajan is applicable only in complicated diverticulitis and is an important complementary classification to the other more general classifications of diverticulitis.

Influence of age on clinical outcome of acute diverticulitis.

BACKGROUND: The controversy about the treatment of acute colonic diverticulitis in young patients continues. The discussion is focused on whether younger age is a risk factor for recurrence or a complicated course, thereby subject to different treatment choices. AIM: In this study, we investigated whether an episode of acute diverticulitis at a younger age (≤50 years) has a higher recurrence rate or a more severe outcome. MATERIAL AND METHODS: A retrospective cohort study was conducted in four teaching hospitals using hospital registry codes for diverticulitis. All patients diagnosed with acute diverticulitis between January 2004 and January 2012, confirmed by imaging, were included. RESULTS: A total of 1,441 consecutive patients were identified as having primary acute diverticulitis of the sigmoid colon. Four hundred and sixty-three patients (32.1%) were ≤50 years (group 1) and 978 patients (67.9%) were older than 50 years (group 2). Twenty patients (4.3%) needed emergency surgery, due to perforated diverticulitis, within 72 h at first presentation in group 1 compared to 77 patients (7.8%) in group 2 (p = 0.029). Surgery within 30 days was needed for 29 of 463 patient (6.2%) in group 1 and 104 of 978 patients (10.6%) in group 2 (p = 0.02). Recurrence rate after a median follow-up of 22 months was comparable among groups (25.6% (111 patients) in group 1 versus 23.8% (208 patients) in group 2; p = 0.278). Also, cumulative recurrence was comparable among groups. CONCLUSION: Younger age is neither associated with a more severe presentation of diverticulitis nor with a higher incidence in recurrence.

Lymphoscintigraphy and SPECT/CT in multicentric and multifocal breast cancer: does each tumour have a separate drainage pattern? Results of a Dutch multicentre study (MULTISENT).

PURPOSE: To investigate whether lymphoscintigraphy and SPECT/CT after intralesional injection of radiopharmaceutical into each tumour separately in patients with multiple malignancies in one breast yields additional sentinel nodes compared to intralesional injection of the largest tumour only. METHODS: Patients were included prospectively at four centres in The Netherlands. Lymphatic flow was studied using planar lymphoscintigraphy and SPECT/CT until 4 h after administration of (99m)Tc-nanocolloid in the largest tumour. Subsequently, the smaller tumour(s) was injected intratumorally followed by the same imaging sequence. Sentinel nodes were intraoperatively localized using a gamma ray detection probe and vital blue dye. RESULTS: Included in the study were 50 patients. Additional lymphatic drainage was depicted after the second and/or third injection in 32 patients (64%). Comparison of planar images and SPECT/CT images after consecutive injections enabled visualization of the number and location of additional sentinel nodes (32 axillary, 11 internal mammary chain, 2 intramammary, and 1 interpectoral. A sentinel node contained metastases in 17 patients (34%). In five patients with a tumour-positive node in the axilla that was visualized after the first injection, an additional involved axillary node was found after the second injection. In two patients, isolated tumour cells were found in sentinel nodes that were only visualized after the second injection, whilst the sentinel nodes identified after the first injection were tumour-negative. CONCLUSION: Lymphoscintigraphy and SPECT/CT after consecutive intratumoral injections of tracer enable lymphatic mapping of each tumour separately in patients with multiple malignancies within one breast. The high incidence of additional sentinel nodes draining from tumours other than the largest one suggests that separate tumour-related tracer injections may be a more accurate approach to mapping and sampling of sentinel nodes in patients with multicentric or multifocal breast cancer.

Evaluation of the appendicitis inflammatory response score for patients with acute appendicitis.

BACKGROUND: Acute appendicitis is still a difficult diagnosis. Scoring systems are designed to aid in the clinical assessment of patients with acute appendicitis. The Alvarado score is the most well known and best performing in validation studies. The purpose of the present study was to externally validate a recently developed appendicitis inflammatory response (AIR) score and compare it to the Alvarado score. METHODS: The present study selected consecutive patients who presented with suspicion of acute appendicitis between 2006 and 2009. Variables necessary to evaluate the scoring systems were registered. The diagnostic performance of the two scores was compared. RESULTS: The present study included 941 consecutive patients with suspicion of acute appendicitis. There were 410 male patients (44%) and 531 female patients (56%). The area under the receiver operating characteristic curve of the AIR score was 0.96 and significantly better than the area under the curve of 0.82 of the Alvarado score (p < 0.05). The AIR score also outperformed the Alvarado score when analyzing the more difficult patients, including women, children, and the elderly. CONCLUSIONS: This study externally validates the AIR Score for patients with acute appendicitis. The scoring system has a high discriminating power and outperforms the Alvarado score.

Retroperitoneal abscess and extensive subcutaneous emphysema in perforated appendicitis: a case report.

Most of the time, the diagnosis and treatment of appendicitis are straightforward. However, a missed diagnosis can sometimes lead to life-threatening complications. A fatal case of appendicitis in a 76-year-old man who presented with progressive abdominal pain, retroperitoneal abscesses and extensive subcutaneous emphysema, is described. Eventually, laparotomy showed appendicitis perforated into the retroperitoneum without any signs of peritonitis. Despite multiple operations the patient died two months after admission due to multiple organ failure.

Radiological evaluation of colorectal anastomoses.

BACKGROUND AND AIMS: The purpose of this study was to determine the accuracy, interobserver variability, timing and discordance with relaparotomy of postoperative radiological examination of colorectal anastomoses. PATIENT/METHODS: From 2000 to 2005, 429 patients underwent an ileocolonic, colo-colonic, or colorectal anastomosis. Radiological examination of the anastomosis was not performed routinely, but only when there were clinically signs of leakage. Radiological imaging was reviewed by an independent radiologist and medical records were retrospectively analyzed. Clinical anastomotic leakage was the standard of reference and defined as leakage confirmed during relaparotomy, drainage of pus per anum or as an anastomotic defect identified at digital examination. RESULTS: Radiological evaluation of the anastomosis was performed in 91 patients (21%): CT in 27 patients, contrast radiography in 40, and both imaging modalities in 24 patients. The interobserver variability of CT and contrast radiography was 10% and 14%, respectively. The sensitivity and negative predictive value of imaging of the anastomosis was 65% and 73%, respectively. Anastomotic leakage was found in 11 of 21 patients (52%) who underwent relaparotomy despite negative imaging. Three of 36 patients (8%) with a diagnosis of anastomotic leakage based on radiological examination had an intact anastomosis at relaparotomy. CONCLUSION: Radiological imaging of the anastomosis after colorectal surgery should be restrictively applied and interpreted with caution because of the high false-negative rate and the substantial interobserver variability.

Factors determining delay in relaparotomy for anastomotic leakage after colorectal resection.

AIM: To analyze the time interval ('delay') between the first occurrence of clinical parameters associated with anastomotic leakage after colorectal resection and subsequent relaparotomy. METHODS: In 36 out of 289 consecutive patients with colorectal anastomosis, leakage was confirmed at relaparotomy. The medical records of these patients were retrospectively analysed and type and time of appearance of clinical parameters suggestive of anastomotic leakage were recorded. These parameters included heart rate, body temperature, local or generalized peritoneal reaction, leucocytosis, ileus and delayed gastric emptying. Factors influencing delay of relaparotomy and consequences of delayed recognition and treatment were determined. RESULTS: First documentation of at least one of the predefined parameters for anastomotic leakage was after a median interval of 4 +/- 1.7 d after the operation. The median number of days between first parameter(s) associated with leakage and relaparotomy was 3.5 +/- 5.7 d. The time interval between the first signs of leakage and relaparotomy was significantly longer when a weekend was included (4.2 d vs 2.4 d, P = 0.021) or radiological evaluation proved to be false-negative (8.1 d vs 3.5 d, P = 0.007). No significant association between delay and number of additional relaparotomies, hospital stay or mortality could be demonstrated. CONCLUSION: An intervening weekend and negative diagnostic imaging reports may contribute to a delay in diagnosis and relaparotomy for anastomotic leakage. That delay was more than two days in two-thirds of the patients.