Risk Factor Targeted Perioperative Care Reduces Anastomotic Leakage after Colorectal Surgery: The DoubleCheck study.

OBJECTIVE: The DoubleCheck study aimed to introduce pre- and perioperative interventions minimizing exposure to modifiable risk factors and determine its effect on CAL. SUMMARY BACKGROUND DATA: Colorectal anastomotic leakage (CAL) is a severe complication. In order to predict and prevent its occurrence, the LekCheck study identified intraoperative modifiable risk factors for CAL: anemia, hyperglycemia, hypothermia, incorrect timing of antibiotic prophylaxis, administration of vasopressors and epidural analgesia. METHODS: This international open-labelled interventional study was performed between September 2021 and December 2023. An enhanced care bundle consisting of anemia correction, glucose measurement, attaining normothermia, antibiotics administration within 60 to 15 minutes preoperatively, refraining from vasopressors and epidural analgesia was introduced. Primary outcome was the occurrence of intraoperative risk factors just prior to the anastomosis creation. Secondary outcomes were CAL and mortality. Univariate and multivariate regression analysis were performed to establish the relationship between the enhanced care bundle, exposure to the six factors and CAL. RESULTS: The historical LekCheck group consisted of 1572 patients versus 902 in the DoubleCheck. The LekCheck group had a mean of 1.84 risk factors versus 1.63 in DoubleCheck ( P <0.001). In the DoubleCheck significantly less patients had ≥3 risk factors ( P <0.001). CAL was significantly lower in the DoubleCheck group (8.6% vs. 6.2%, P =0.039). The reduction of CAL was associated with the enhanced care bundle in multivariate regression analysis (OR 1.521, 95% CI 1.01-2.29, P =0.045). The mortality rate did not differ significantly (1.3%, vs. 0.8%, P =0.237). CONCLUSIONS: The DoubleCheck study showed that optimization of modifiable risk factors reduced CAL in colorectal surgery.

[A prehabilitation program for patients undergoing elective resection of a colorectal carcinoma: effects on the postoperative hospital stay and complication burden]. / Prehabilitatie bij resectie van colorectaal carcinoom.

OBJECTIVE: To investigate the effect of a prehabilitation program on the postoperative hospital stay and complication burden in patients undergoing elective resection of a colorectal carcinoma. DESIGN: Comparative retrospective cohort study. METHOD: The study population consisted of patients who had undergone elective resection of a colorectal carcinoma between 2017 and 2020 at the Elkerliek hospital in Helmond. Patients in the intervention group had surgery from May 1, 2019 and they followed a three to six-week prehabilitation program, focusing on physical condition, nutritional status and psychosocial well-being. Patients in the control group had surgery until May 1, 2019 and did not follow a prehabilitation program. The primary outcome measures were hospital stay and complication burden according to the Comprehensive Complication Index (CCI). The secondary outcome measures were the number and type of complications up to 90 days postoperatively. RESULTS: The intervention group (n=85) and control group (n=197) were almost comparable in preoperative patient and treatment characteristics. The intervention group had a shorter hospital stay (median 5 versus 6 days, p<0.001) and less often a heavy complication burden (18% versus 36%, p=0.002). The intervention group also contained fewer patients with a complication (25% versus 44%, p=0.002). Specifically, infection (4% vs 13%, p=0.018), pulmonary complication (2% vs 12%, p=0.009) and delirium (1% vs 9%, p=0.019) were less common. CONCLUSION: A prehabilitation program can shorten the postoperative hospital stay and reduce the postoperative complication burden in patients undergoing elective resection for colorectal carcinoma.

The association of potential prognostic determinants to nonadherence to negative pressure wound therapy: An exploratory prospective prognostic study.

BACKGROUND: Up to now it is unclear which determinants influence nonadherence to negative pressure wound therapy. This study aimed to assess the predictive value of prognostic determinants to nonadherence to negative pressure wound therapy. METHODS: A multicenter prospective cohort study on patients with wounds treated with negative pressure wound therapy. Data of 25 potential prognostic determinants of nonadherence were collected using a web-based case record form. Primary outcome was nonadherence to negative pressure wound therapy, defined as premature termination on request of the patient. Logistic regression analyses were used to explore the association between the potential determinants and nonadherence. RESULTS: Nonadherence to negative pressure wound therapy was found in 32 out of 264 patients (12.1%). Univariable analyses identified 6 candidate prognostic determinants: having sensitive skin (odds ratio 2.32, 95% confidence interval 1.10-5.10, P = .03), decision for negative pressure wound therapy made as a shared decision (odds ratio 2.43, 95% confidence interval 1.06-6.30, P = .05), handiness technique (odds ratio 1.80, 95% confidence interval 0.86-3.89, P = .13), alternatives discussed (odds ratio 1.78, 95% confidence interval 0.83-3.75, P = .13), knowledge and understanding negative pressure wound therapy (odds ratio 0.50, 95% confidence interval 0.18-1.20, P = .15), and previous experience with negative pressure wound therapy (odds ratio 0.42, 95% confidence interval 0.10-1.24, P = .17). In the multivariable analysis, only having sensitive skin appeared to be significant (odds ratio 2.20, 95% confidence interval 1.02-4.85, P = .05). CONCLUSION: Patients who have sensitive skin may have an increased risk of premature termination of negative pressure wound therapy. Further research is warranted to determine which strategies are successful to overcome skin irritation problems to avoid nonadherence to negative pressure wound therapy.

Physical Activity Is Associated with Improved Overall Survival among Patients with Metastatic Colorectal Cancer.

Regular physical activity (PA) is associated with improved overall survival (OS) in stage I-III colorectal cancer (CRC) patients. This association is less defined in patients with metastatic CRC (mCRC). We therefore conducted a study in mCRC patients participating in the Prospective Dutch Colorectal Cancer cohort. PA was assessed with the validated SQUASH questionnaire, filled-in within a maximum of 60 days after diagnosis of mCRC. PA was quantified by calculating Metabolic Equivalent Task (MET) hours per week. American College of Sports and Medicine (ACSM) PA guideline adherence, tertiles of moderate to vigorous PA (MVPA), and sport and leisure time MVPA (MVPA-SL) were assessed as well. Vital status was obtained from the municipal population registry. Cox proportional-hazards models were used to study the association between PA determinants and all-cause mortality adjusted for prognostic patient and treatment-related factors. In total, 293 mCRC patients (mean age 62.9 ± 10.6 years, 67% male) were included in the analysis. Compared to low levels, moderate and high levels of MET-hours were significantly associated with longer OS (fully adjusted hazard ratios: 0.491, (95% CI 0.299-0.807, p value = 0.005) and 0.485 (95% CI 0.303-0.778, p value = 0.003), respectively), as were high levels of MVPA (0.476 (95% CI 0.278-0.816, p value = 0.007)) and MVPA-SL (0.389 (95% CI 0.224-0.677, p value < 0.001)), and adherence to ACSM PA guidelines compared to non-adherence (0.629 (95% CI 0.412-0.961, p value = 0.032)). The present study provides evidence that higher PA levels at diagnosis of mCRC are associated with longer OS.

Associations between alcohol consumption and anxiety, depression, and health-related quality of life in colorectal cancer survivors.

PURPOSE: Alcohol consumption is a major risk factor for colorectal cancer (CRC). It is currently poorly understood, however, how alcohol and different alcoholic beverage types are related to psychosocial outcomes in CRC survivors. METHODS: We used data of N = 910 CRC survivors from the pooled EnCoRe and PROCORE cohorts and harmonized them into five time points: at diagnosis and 3, 6, 12, and 24 months post-diagnosis. Generalized estimated equation models were used to examine longitudinal associations of alcohol consumption, including consumption of beer, wine, and liquor, with anxiety, depression, and health-related quality of life (HRQoL), while correcting for sociodemographic, lifestyle, and clinical factors. RESULTS: Survivors were on average 67 years and 37% was female. In the first 2 years post-diagnosis, survivors who consumed more alcoholic drinks/week reported lower anxiety and depressive symptoms and better HRQoL on all domains and symptom scales. This was the case for moderate and heavy amounts of alcohol and mostly for consuming beer and wine, but not for liquor. Associations were more often significant for men and for younger persons (< 67 years at baseline). CONCLUSIONS: Generally, alcohol consumption was observed to be longitudinally related to less anxiety and depression and better HRQoL in CRC survivors. IMPLICATIONS FOR CANCER SURVIVORS: Although alcohol consumption is generally unfavorable due to increased risk of carcinogenesis and worse prognosis after CRC, it seems to be associated with better psychosocial outcomes in the first 2 years after diagnosis and treatment. More research is needed to gain knowledge about reasons for drinking and causality.

LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery.

OBJECTIVE: To assess potentially modifiable perioperative risk factors for anastomotic leakage in adult patients undergoing colorectal surgery. SUMMARY BACKGROUND DATA: Colorectal anastomotic leakage (CAL) is the single most important denominator of postoperative outcome after colorectal surgery. To lower the risk of CAL, the current research focused on the association of potentially modifiable risk factors, both surgical and anesthesiological. METHODS: A consecutive series of adult patients undergoing colorectal surgery with primary anastomosis was enrolled from January 2016 to December 2018. Fourteen hospitals in Europe and Australia prospectively collected perioperative data by carrying out the LekCheck, a short checklist carried out in the operating theater as a time-out procedure just prior to the creation of the anastomosis to check perioperative values on 1) general condition 2) local perfusion and oxygenation, 3) contamination, and 4) surgery related factors. Univariate and multivariate logistic regression analysis were performed to identify perioperative potentially modifiable risk factors for CAL. RESULTS: There were 1562 patients included in this study. CAL was reported in 132 (8.5%) patients. Low preoperative hemoglobin (OR 5.40, P < 0.001), contamination of the operative field (OR 2.98, P < 0.001), hyperglycemia (OR 2.80, P = 0.003), duration of surgery of more than 3 hours (OR 1.86, P = 0.010), administration of vasopressors (OR 1.80, P = 0.010), inadequate timing of preoperative antibiotic prophylaxis (OR 1.62, P = 0.047), and application of epidural analgesia (OR, 1.81, P = 0. 014) were all associated with CAL. CONCLUSIONS: This study identified 7 perioperative potentially modifiable risk factors for CAL. The results enable the development of a multimodal and multidisciplinary strategy to create an optimal perioperative condition to finally lower CAL rates.

Assessing Textbook Outcome After Implementation of Transversus Abdominis Release in a Regional Hospital.

Background: The posterior component separation technique with transversus abdominis release (TAR) was introduced in 2012 as an alternative to the classic anterior component separation technique (Ramirez). This study describes outcome and learning curve of TAR, five years after implementation of this new technique in a regional hospital in the Netherlands. Methods: A standardized work up protocol, based on the Plan-Do-Check-Act cycle, was used to implement the TAR. The TAR technique as described by Novitsky was performed. After each 20 procedures, outcome parameters were evaluated and new quality measurements implemented. Primary outcome measure was Textbook Outcome, the rate of patients with an uneventful clinical postoperative course after TAR. Textbook Outcome is defined by a maximum of 7 days hospitalization without any complication (wound or systemic), reoperation or readmittance, within the first 90 postoperative days, and without a recurrence during follow up. The number of patients with a Textbook Outcome compared to the total number of consecutively performed TARs is depicted as the institutional learning curve. Secondary outcome measures were the details and incidences of the surgical site and systemic complications within 90 days, as well as long-term recurrences. Results: From 2016, sixty-nine consecutive patients underwent a TAR. Textbook Outcome was 35% and the institutional learning curve did not flatten after 69 procedures. Systemic complications occurred in 48%, wound complications in 41%, and recurrences in 4%. Separate analyses of three successive cohorts of each 20 TARs demonstrated that both Textbook Outcome (10%, 30% and 55%, respectively) and the rate of surgical site events (45%, 15%, and 10%) significantly (p < 0.05) improved with more experience. Conclusion: Implementation of the open transversus abdominis release demonstrated that outcome was positively correlated to an increasing number of TARs performed. TAR has a long learning curve, only partially determined by the technical aspects of the operation. Implementation of the TAR requires a solid plan. Building, and maintaining, an adequate setting for patients with complex ventral hernias is the real challenge and driving force to improve outcome.

Longitudinal associations of sociodemographic, lifestyle, and clinical factors with alcohol consumption in colorectal cancer survivors up to 2 years post-diagnosis.

PURPOSE: Alcohol consumption can lead to worse prognosis and mortality among colorectal cancer (CRC) patients. We investigated alcohol consumption of CRC survivors up to 2 years post-diagnosis, and how sociodemographic, lifestyle, and clinical factors were associated longitudinally with these habits. METHODS: We pooled longitudinal data of 910 CRC survivors from the ongoing PROCORE and EnCoRe studies with data collected at diagnosis (baseline) and 3, 6, 12, and 24 months post-diagnosis. Both studies assessed alcohol consumption, including beer, wine, and liquor. Generalized estimated equation models were used to examine changes over time in alcohol consumption and multivariable longitudinal associations of sociodemographic, lifestyle, and clinical factors with alcohol consumption. RESULTS: At baseline, participants were on average 67 years old, 332 (37%) were female, and alcohol was consumed by 79%. Most survivors (68-71%) drank less at all follow-ups. Beer, wine, and liquor were consumed by 51%, 58%, and 25% at baseline, respectively, and these declined over time. Males consumed more alcohol, and higher education, more physical activity, and not having a (permanent) stoma were associated with consuming more alcohol. CONCLUSION: CRC survivors decreased their alcohol consumption in the 2 years post-diagnosis. Future studies should take the significant factors that were associated with alcohol post-diagnosis consumption into account, when they investigate CRC health outcomes or for identifying subgroups for interventions. Males with higher education, more physical activity, and no stoma should be reminded after diagnosis for reducing their alcohol consumption.

Which determinants are considered to be important for adherence to Negative Pressure Wound Therapy: A multimethods study.

AIM: To explore the extent of patients that choose to cease Negative Pressure Wound Therapy (NPWT) prematurely in a clinical setting, and to explore the determinants of nonadherence. METHOD: This study exists out of: (1) a retrospective study to assess the number of patients who ceased NPWT prematurely; (2) a narrative review (NR) to identify determinants of nonadherence; and (3) a survey among wound care specialists to explore specific determinants of nonadherence to NPWT. RESULTS: (1) Based on the retrospective study, 20% ceased NPWT prematurely because of experienced limitations in daily activities. (2) Based on 22 studies, 23 determinants that might influence nonadherence were identified and added as questions in the survey. (3) Twenty-two percent (n = 136) wound care specialists completed the survey. Confidence with the healthcare team, consistency in therapy advices, coping with pain, former negative experiences with NPWT, a normal activity pattern, social support from family or friends, and support from the healthcare team were identified as highly relevant determinants of nonadherence to NPWT. Only religion scored distinctively lower. CONCLUSION: This study is a first step in exploring the determinants of nonadherence to NPWT. In 20% NPWT was prematurely ceased at the request of the patient, this means that this therapy may have not been the best choice of therapy for this particular patient. The identification of potential determinants of nonadherence may help healthcare professionals in their dialogue with patients. The next step should be a prognostic study to assess which determinants best predict adherence to NPWT.

Negative pressure wound therapy for patients with hard-to-heal wounds: a systematic review.

OBJECTIVE: Despite the lack of evidence, negative pressure wound therapy (NPWT) is commonly used in patients with hard-to-heal wounds. In our medical centre, one third of patients with abdominal wounds infected postoperatively end this therapy prematurely due to negative experiences and prefer standard wound care. This study was designed to explore the effects of NPWT on quality of life (QoL). METHOD: A search from 2000 to 2019 in eight databases was performed to identify qualitative studies of patients treated with NPWT. Studies were selected by two independent reviewers, who appraised the methodological quality, extracted and structured the data and performed content analysis. RESULTS: A total of five qualitative studies with good methodological quality, incorporating 51 individual patients, were included. After content analysis, four major themes emerged: reduced freedom of movement caused by an electric device; decreased self-esteem; increased social and professional dependency; and gaining self-control. CONCLUSION: NPWT has major effects on the physical, psychological and social domains of QoL. Knowledge of these effects may lead to improved treatment decisions for patients with hard-to-heal wounds regarding use of NPWT or standard wound care.

Anxiety and depression mediate the association between chemotherapy-induced peripheral neuropathy and fatigue: Results from the population-based PROFILES registry.

OBJECTIVE: Chemotherapy-induced sensory peripheral neuropathy (CIPN) is common among colorectal cancer (CRC) survivors. The aim of this study was to examine whether CIPN is associated with both psychological distress (ie, anxiety and depression) and fatigue and whether the relationship between CIPN and fatigue can (partly) be explained by psychological distress. METHODS: All CRC survivors diagnosed between 2000 and 2009 as registered by the population-based Netherlands Cancer Registry (Eindhoven region) were eligible for participation. Chemotherapy-treated survivors completed questions on CIPN (EORTC QLQ-CIPN20), psychological distress (HADS), and fatigue (FAS) on average 5.6 years after diagnosis. Simple and multiple mediation analyses were performed to examine anxiety and depression as possible mediators in the association between CIPN and fatigue. RESULTS: Survivors with high (ie, upper 30% of scores) CIPN (n = 172) reported more anxiety and depressive symptoms and more fatigue compared with those with low CIPN (n = 299). Furthermore, among survivors with high CIPN, those who were anxious, depressed, or both reported more fatigue compared with those without psychological distress. These differences were clinically relevant. Finally, mediation analyses showed that while CIPN was directly associated with fatigue, the relationship between CIPN and fatigue was also significantly mediated by both anxiety and depression. CONCLUSIONS: CRC survivors with high CIPN report more fatigue, especially those who are also anxious and/or depressed. More research is needed on the direction of the relationship between CIPN, psychological distress, and fatigue. For now, the treatment of fatigue should also focus on addressing psychological distress, as treating fatigue alone might not be sufficient.

Perioperative lipid-enriched enteral nutrition versus standard care in patients undergoing elective colorectal surgery (SANICS II): a multicentre, double-blind, randomised controlled trial.

BACKGROUND: Postoperative ileus and anastomotic leakage severely impair recovery after colorectal resection. We investigated the effect of perioperative lipid-enriched enteral nutrition versus standard care on the risk of postoperative ileus, anastomotic leakage, and other clinical outcomes. METHODS: We did an international, multicentre, double-blind, randomised, controlled trial of patients (≥18 years) undergoing elective colorectal surgery with primary anastomosis at six clinical centres in the Netherlands and Denmark. Patients were randomly assigned (1:1), stratified by location (colonic and rectal) and type of surgery (laparoscopic and open), via online randomisation software, with block sizes of six, to receive either continuous lipid-enriched enteral tube feeding from 3 h before until 6 h after surgery (intervention) or no perioperative nutrition (control). Surgeons, patients, and researchers were masked to treatment allocation for the entire study period. The primary outcome was postoperative ileus. Secondary outcomes included anastomotic leakage, pneumonia, preoperative gastric volumes, time to functional recovery, length of hospital stay, the need for additional interventions, intensive care unit admission, postoperative inflammatory response, and surgical complications. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT02175979, and trialregister.nl, number NTR4670. FINDINGS: Between July 28, 2014, and February 20, 2017, 280 patients were randomly assigned, 15 of whom were excluded after random allocation because they fulfilled one or more exclusion criteria. 265 patients received perioperative nutrition (n=132) or standard care (n=133) and were included in the analyses. A postoperative ileus occurred in 37 (28%) patients in the intervention group versus 29 (22%) in the control group (risk ratio [RR] 1·09, 95% CI 0·95-1·25; p=0·24). Anastomotic leakage occurred in 12 (9%) patients in the intervention group versus 11 (8%) in the control group (RR 1·01, 95% CI 0·94-1·09; p=0·81). Pneumonia occurred in ten (8%) patients in the intervention group versus three (2%) in the control group (RR 1·06, 95% CI 1·00-1·12; p=0·051). All other secondary outcomes were similar between groups (all p>0·05). INTERPRETATION: Perioperative lipid-enriched enteral nutrition in patients undergoing elective colorectal surgery has no advantage over standard care in terms of postoperative complications. FUNDING: Netherlands Organisation for Health Research and Development (ZonMW), Fonds NutsOhra, and Danone Research.

Impact of hernia volume on pulmonary complications following complex hernia repair.

BACKGROUND: Despite a multitude of evidence-based prediction models and risk factors for postoperative complications after ventral hernia repair, estimating a patient's risk of postoperative complications after ventral hernia repair remains challenging. In an attempt to improve the preoperative assessment of complex hernia patients, some studies have examined pulmonary changes after hernia repair hypothesizing that large hernias lead to pulmonary changes and increased pulmonary complication rates. Some studies have described a correlation between hernia volume and pulmonary changes, although none provided compelling evidence to identify hernia volume as a risk factor for pulmonary complications. This study evaluates the relationship between hernia volume and postoperative pulmonary complications using computed tomography (CT)-based volume measurements. MATERIALS AND METHODS: Analysis of a prospectively maintained database of consecutive complex hernia patients from 2011 to 2014 undergoing endoscopic (ECST) or open component separation technique (CST) for a hernia defect with a minimum width of 6 cm and visual protrusion of the hernia sac ventral of the rectus abdominis muscles in supine position was performed. Hernia volume was calculated using multiple plane reconstruction of a standard abdominal CT-scan. Noted endpoints were pulmonary complications. RESULTS: Thirty-five patients underwent ECST (n = 20) or CST (n = 15) with a median defect volume of 474 cm3 (range, 114-2086 cm3). Observed complications were pneumonia (n = 4), pulmonary infiltrate (n = 3), aspiration pneumonia (n = 2), and acute respiratory distress syndrome (n = 1). Univariate and multivariate analyses showed that pulmonary complications were associated with "hernia volume" (P = 0.045; 95% CI: 1.008-1.910). CONCLUSIONS: Hernia volume is a promising risk factor for postoperative pulmonary complications and can be calculated using a standard abdominal CT-scan.

The Course of Neuropathic Symptoms in Relation to Adjuvant Chemotherapy Among Elderly Patients With Stage III Colon Cancer: A Longitudinal Study.

INTRODUCTION: Among the elderly, the impairment of functional capacities due to neuropathy can have a significant impact. The aim of the present study was to investigate the course of neuropathic symptoms among elderly patients with stage III colon cancer treated with CAPOX (capecitabine, oxaliplatin), capecitabine monotherapy, or no adjuvant chemotherapy. MATERIALS AND METHODS: The Netherlands Cancer Registry was used to select patients with stage III colon cancer and aged ≥ 70 years. Questionnaires were sent after resection (T1) and 6 (T2) and 12 months (T3) later. Neuropathy was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Chemotherapy-Induced Peripheral Neuropathy 20. Logistic generalized estimating equations analyses were used to evaluate the effect of chemotherapy on the course of neuropathic symptoms. RESULTS: Of 155 eligible patients, 117 (76%) completed the T1 questionnaire, and 69 and 59 completed the T2 and T3 questionnaires, respectively. The course of the sensory symptoms tingling fingers or hands, tingling toes or feet, numbness in fingers or hands, and numbness in toes or feet was significantly unfavorable for patients treated with adjuvant chemotherapy (CAPOX or capecitabine) compared with that for patients who had not received adjuvant chemotherapy. The course of numbness in toes or feet also differed significantly between patients treated with CAPOX (T1, 7%; T2, 50%; T3, 42%) and patients treated with capecitabine (T1, 17%; T2, 31%; T3, 8%). Additionally, patients treated with capecitabine reported significantly less tingling toes or feet (T1, 6%; T2, 25%; T3, 7%) compared with patients treated with CAPOX (T1, 0%; T2, 50%; T3, 58%). CONCLUSION: The course of several sensory symptoms over time was less favorable for elderly patients with colon cancer treated with chemotherapy. Moreover, CAPOX was associated with more symptoms in toes and feet compared with capecitabine. It is important to inform patients of these risks to enable informed decision-making.

The effects of stimulation of the autonomic nervous system via perioperative nutrition on postoperative ileus and anastomotic leakage following colorectal surgery (SANICS II trial): a study protocol for a double-blind randomized controlled trial.

BACKGROUND: Postoperative ileus and anastomotic leakage are important complications following colorectal surgery associated with short-term morbidity and mortality. Previous experimental and preclinical studies have shown that a short intervention with enriched enteral nutrition dampens inflammation via stimulation of the autonomic nervous system and thereby reduces postoperative ileus. Furthermore, early administration of enteral nutrition reduced anastomotic leakage. This study will investigate the effect of nutritional stimulation of the autonomic nervous system just before, during and early after colorectal surgery on inflammation, postoperative ileus and anastomotic leakage. METHODS/DESIGN: This multicenter, prospective, double-blind, randomized controlled trial will include 280 patients undergoing colorectal surgery. All patients will receive a selfmigrating nasojejunal tube that will be connected to a specially designed blinded tubing system. Patients will be allocated either to the intervention group, receiving perioperative nutrition, or to the control group, receiving no nutrition. The primary endpoint is postoperative ileus. Secondary endpoints include anastomotic leakage, local and systemic inflammation, (aspiration) pneumonia, surgical complications classified according to Clavien-Dindo, quality of life, gut barrier integrity and time until functional recovery. Furthermore, a cost-effectiveness analysis will be performed. DISCUSSION: Activation of the autonomic nervous system via perioperative enteral feeding is expected to dampen the local and systemic inflammatory response. Consequently, postoperative ileus will be reduced as well as anastomotic leakage. The present study is the first to investigate the effects of enriched nutrition given shortly before, during and after surgery in a clinical setting. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02175979 - date of registration: 25 June 2014. Dutch Trial Registry: NTR4670 - date of registration: 1 August 2014.

[Idiopathic myointimal hyperplasia of mesenteric veins: an unusual cause of diarrhoea]. / Idiopathische myo-intimale hyperplasie van de mesenteriale venen: een ongewone oorzaak van diarree.

BACKGROUND: The analysis of diarrhoea can be a diagnostic challenge. We present a patient with chronic diarrhoea, caused by idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV). IMHMV is a rare condition characterized by thickening of the vessel wall due to proliferation of smooth muscle cells in mesenteric veins, eventually causing intestinal ischemia. CASE DESCRIPTION: A 62-year-old man visited the gastroenterologist because of frequent watery diarrhoea. Initial endoscopic evaluation demonstrated venous congestion and erythema of the left-sided colon. Subsequently, he developed bloody diarrhoea, where endoscopy now revealed ischemic characteristics. CT scans and biopsies showed neither an occlusion of large arteries or veins nor histological features of inflammatory bowel disease. Eventually, the patient presented with an acute abdomen. Left hemicolectomy was performed, which resulted in the diagnosis of IMHMV. CONCLUSION: Prolonged diarrhoea, with a remarkable biphasic clinical and endoscopic presentation, without evidence of inflammatory bowel disease or occlusion of large arteries and veins, may be caused by IMHMV.

Toward an evidence-based step-up approach in diagnosing diverticulitis.

BACKGROUND: The lack of pathognomonic findings and the chance of complicated disease have resulted in the widespread use of additional imaging to diagnose acute colonic diverticulitis (ACD). The added value of additional imaging in the diagnostic workup of patients suspected of ACD is not well defined. AIMS: The aim of this study was to systematically review the literature of the accuracy of the clinical evaluation and diagnostic modalities for patients with suspected ACD, to come to an evidence-based approach to diagnose ACD. METHODS: A systematic review and meta-analysis of studies that reported diagnostic accuracy of the clinical diagnosis and diagnostic modalities in patients with suspected diverticulitis were performed. Study quality was assessed with the STARD checklist. True-positive, true-negative, false-positive, and false-negative findings were extracted and pooled estimates of sensitivity and specificity per diagnostic test were calculated, if applicable. RESULTS: The overall quality of the studies reporting the diagnostic accuracy of the clinical diagnosis, contrast enema and magnetic resonance imaging (MRI) were moderate to poor and not suitable for meta-analysis. Sensitivity of the clinical diagnosis varied between 64% and 68%. Ultrasound (US) and computed tomography (CT) studies were eligible for meta-analysis. Summary sensitivity estimates for US were 90% (95% CI: 76-98%) versus 95% (95% CI: 91-97%) for CT (p = 0.86). Summary specificity estimates for US were 90% (95% CI: 86-94%) versus 96% (95% CI: 90-100%) for CT (p = 0.04). Sensitivity for MRI was 98% and specificity varied between 70% and 78%. Sensitivity of contrast enema studies varied between 80% and 83%. CONCLUSION: In two-thirds of the patients, the diagnosis of ACD can be made based on clinical evaluation alone. In one-third of the patients, additional imaging is a necessity to establish the diagnosis. US and CT are comparable in diagnosing diverticulitis and superior to other modalities. CT has the advantage of higher specificity and the ability to identify alternative diagnoses. The role of MRI is not yet clear in diagnosing ACD. Contrast enema is considered an obsolete imaging technique to diagnose ACD based on lower sensitivity and specificity than US and CT. A step-up approach with CT performed after an inconclusive or negative US, seems a logical and safe approach for patients suspected of ACD.

[Intestinal perforation caused by Salmonella typhimurium]. / Darmperforatie door Salmonella typhimurium.

BACKGROUND: In most patients, infection with a non-typhoid Salmonella species usually results in self-limiting gastroenteritis. Severe complications such as bacteraemia and extra-abdominal infections are most often attributed to typhoid subspecies like S. typhi and S. paratyphi. In this article, we present the case of a healthy patient with non-typhoid salmonellosis who nevertheless developed severe complications. CASE DESCRIPTION: A 63-year-old man with an unremarkable medical history presented at the emergency department with abdominal complaints suggestive of gastroenteritis. Cultures of faeces and blood yielded S. typhimurium. The infection was complicated by many intra-abdominal abscesses, abdominal sepsis and an intestinal perforation requiring multiple interventions. The patient has been symptom-free for half a year now. CONCLUSION: Severe complications related to infection with non-typhoid S. typhimurium are rare. The incidence of salmonellosis has risen over the past few years, however; the risk of severe complications has therefore also increased.