The first results of the "bevolkingsonderzoek" in the Zaanstreek region in The Netherlands.

This short communication describes the results with respect to stage of colorectal cancer in people detected via screening and patients with clinical complaints.

Long-term follow-up and development of diverticulitis in patients diagnosed with diverticulosis of the colon.

INTRODUCTION: Diverticulosis of the colon is the most occurring abnormality in the digestive tract. Little is known on the risk of developing diverticulitis. AIM: The study aims to assess the risk of diverticulitis. PATIENTS AND METHODS: All patients undergoing colonoscopy in the years 1998, 1999, and 2000 were studied. Patients with cancer, inflammatory bowel disease, anastomoses, and prior diverticulitis were excluded. In the summer of 2015, all hospital records, endoscopy reports, and reports from the department of radiology were studied. Diverticulitis had to be confirmed by the clinical presentation but also via ultrasound or CT scan. In order to obtain enough follow-up years, patients above the age of 75 years were excluded. RESULTS: After exclusions, a study group of 433 patients remained. There was no difference is gender between patients developing diverticulitis and those who did not. There was no difference in age at time of the index colonoscopy. The sum of follow-up years was 6191. Range of follow-up was 0 to 17 years. The mean follow-up was 14.1 years per patient. Thirty cases of diverticulitis (7 %) could be identified; this is 4.8 cases per 1000 years. The mean time to development of diverticulitis was 5.9 years. Diverticulitis had a mild presentation in 19 patients and a severe presentation needing surgical intervention in 11. CONCLUSION: The risk of developing diverticulitis is low. This contradicts the belief that diverticulosis has a high rate of progression. These results can help inform patients with diverticulosis about their risk of developing acute diverticulitis.

Endoscopic follow-up after surgery for colorectal cancer.

OBJECTIVE: Follow-up surgery for colorectal cancer is recommended. The yield of endoscopy is unknown and was therefore studied. METHODS: Patients with colorectal cancer in the years 2003, 2004 and 2005 were included. Evaluation was done in July 2014. RESULTS: Cancer was diagnosed in 267 patients. These were divided into three groups: group 1-still alive (n = 88), group 2-died within 1 year after diagnosis (n = 67), and group 3-died more than 1 year after diagnosis (n = 112). Patients in group 3 showed a trend towards non-cancer-related death (p = 0.06). Endoscopic follow-up was done in 101 patients (37.6 %). Patients still alive underwent more often follow-up colonoscopy (p < 0.001). Patients still alive had more often synchronous polyps detected during index endoscopy compared with patients of groups 2 and 3 (p = 0.03). Follow-up revealed more often new polyp(s) (p = 0.006). If no polyps were seen during the time of diagnosing cancer, follow-up endoscopy detected polyp(s) in 26 % of cases. Two newly developed cancers in group 1 and three in group 3 were diagnosed. CONCLUSION: Endoscopic follow-up after curative surgery for colorectal cancer has a high diagnostic yield. Whether detection and removal of polyps increases survival is not yet clear.

Individual polyp detection rate in routine daily endoscopy practice depends on case-mix.

INTRODUCTION: The adenoma detection rate (ADR), a marker of endoscopic quality, is confounded by selection bias. It is not known what the ADR is in normal daily practice. AIM: To study the polyp detection rate (PDR) in different endoscopists in the course of years. PATIENTS AND METHODS: All consecutive endoscopies of the colon done in 11 years were included. Endoscopies in the regular surveillance programme after polyp removal and after surgery because of colorectal cancer or diverticular disease were scored separately. The number of yearly procedures per endoscopist and presence of polyps, anastomoses, surveillance and cancer were noted. RESULTS: In the period of 11 years, 14,908 consecutive endoscopies of colon and rectum were done by four endoscopists. Two endoscopists had a significantly lower PDR than the other two (p < 0.001), these two had the longest careers in endoscopy. The two younger endoscopists did significantly less often procedures in patients with anastomoses and because of surveillance (p < 0.001, respectively). One endoscopist detected significantly less colorectal cancers than the other three endoscopists (p < 0.001). CONCLUSION: This study presents the PDR in normal routine daily endoscopy practice. It can be concluded that the PDR, implicating the ADR, in unselected patients can be lower in individual endoscopists than recommended in the literature. This highly depends on the case-mix of patients presented for endoscopy. This result debates the use of the ADR as quality indicator for individual endoscopists.

Incidence and causes of colonoscopic perforations: a single-center case series.

Perforations are known to occur after colonoscopy. In a consecutive study the localization of the perforation was determined, and the etiology of the perforation was classified as: therapeutic, barotraumatic or mechanical. A colonic perforation occurred in 26 of 19,135 patients (0.14%). In 13 cases (50.0%) the cause of perforation was mechanical, in nine (34.6%) the cause was a barotrauma (cecal blow-out), and in three cases (11.5%) it was due to a therapeutic procedure (coagulation or polypectomy). In one case (3.8%) data were not available. Cecal blow-out occurred significantly more often as a result of barotrauma, whereas perforation of the sigmoid occurred more often as a result of direct mechanical trauma. The risk of perforation after colonoscopy is rather low. Barotrauma due to insufflated air occurs more often than therapeutic perforation due to polypectomy or coagulation. Patients with a higher risk of perforation are those with diverticula in the sigmoid.

Rectal bleeding in patients with haemorrhoids. Coincidental findings in colon and rectum.

INTRODUCTION: Rectal bleeding is a very common clinical sign. It is often caused by haemorrhoids. However, it can be a symptom of other pathology in the rectum or colon. There are little data coincidental pathology in patients with haemorrhoids and rectal bleeding. OBJECTIVE: To examine coincidental pathology in patients with rectal bleeding and haemorrhoids, especially with respect to age. METHODS: Prospectively, 290 consecutive patients presenting with bleeding and haemorrhoids were analysed. All patients had an endoscopic examination. All significant endoscopic findings (diverticuli, polyps, cancer, angiodysplasia and varices or colitis) were recorded. RESULTS: The patients were divided into two groups. Group 1 consisted of patients with only haemorrhoids (n = 129, % male: 41.1, mean age: 53.6 +/- 12.7 years). Group 2 consisted of patients with haemorrhoids and coincidental pathology (n = 161, % male: 46.6, mean age: 67.3 +/- 13.7 years). There was no difference in gender or in the type of endoscopy. However, patients in Group 2 were significantly older. CONCLUSION: It can be concluded that in cases of rectal bleeding and haemorrhoids, coincidental pathology occurs in a large proportion of patients, especially the elderly. Omitting endoscopy in these patients can lead to major doctors delay.

The completion rate of colonoscopy in normal daily practice: factors associated with failure.

BACKGROUND: Colonoscopy is an important diagnostic procedure for screening as well as for patients presenting with complaints. The completion of a colonoscopy is defined as cecal intubation. A large single center study was done in order to evaluate the completion rate of colonoscopy and identify reasons for failure. PATIENTS AND METHODS: We reviewed all consecutive endoscopies of the lower digestive tract done over a period of 15 years by 2 endoscopists. The main outcome measure was a successful cecal intubation. RESULTS: 14,139 consecutive colonoscopies were done. Overall cecal intubation was successful in 11,787 procedures (83.3%). Three hundred and sixty-one of the non-successful procedures were due to insufficient colon cleansing, and no significant abnormalities were seen in 362 procedures. In the remaining 1,629 endoscopies, significant diagnoses were made. The presence of colorectal cancer, diverticula and inflammatory bowel disease were significant findings in non-successful procedures. CONCLUSION: In normal daily practice, colonoscopy is completed in 83.3% of the procedures. Reasons for failure are obstructing tumors, diverticula and insufficient colon cleansing.

Colorectal adenomas in patients presenting with inflammatory bowel disease.

BACKGROUND: Adenoma is the precursor of colorectal carcinoma (CRC). Patients with longstanding active ulcerative colitis (UC) are at risk of developing CRC. Every patient with UC can also develop adenomas, which is an extra risk factor. AIM: A large retrospective cross-sectional study was conducted to identify patients with UC and polyps. MATERIAL AND METHODS: All consecutive lower intestinal endoscopies carried out in a period of 16 years were searched for the presence of inflammation and concomitant polyps. RESULTS: Inflammatory bowel disease was diagnosed in 1029 patients. Forty-seven (4.5%) patients had concomitant polyps. The patients with polyps were divided in two groups: group 1 consisted of 34 patients in whom active inflammation was seen with coinciding polyp(s), and group 2 consisted of 12 patients in remission, in whom polyps were detected. One patient had had adenomas in the past and presented with active inflammation and a new adenoma. In group 1, four patients had a history of active inflammation, and adenomas were seen in 29 patients, while seven patients showed hyperplastic polyps. Two patients had adenomas as well as hyperplastic polyps. In group 2 nine patients had adenomas and three had hyperplastic polyps. CONCLUSION: Patients with different phenotypic expressions of inflammatory bowel disease can have concomitant adenomas in the colon. Hence, it is plausible to assume that these patients have an increased risk of developing CRC because of adenomas.

Removal of Common Bile Ducts Stones via Percutaneous Access with a Flexible Ureteroscope and Laser Assistance.

Two patients are described with large stones in the common bile duct. Standard ERCP was not possible. Both patients were successfully treated with percutaneous access and use of the ureteroscope with the holmium laser.

Ascending Cholangitis due to Heavy Lifting.

Gallstone disease is the most common risk factor for cholangitis. In an anatomically normal bile duct system, cholangitis does not occur without the presence of stones. Endoscopic retrograde cholangiography with papillotomy and stone extraction is a well-established curative therapy for gallstones in the common bile duct. More important, papillotomy prevents recurrent episodes. The present case report describes a 73-year-old male with recurring cholangitis in a clear bile duct system after previous papillotomy. An etiology of duodenal reflux into the common bile duct due to heavy lifting is proposed.

Subacute Disseminated Intravascular Coagulation in a Patient with Liver Metastases of a Renal Cell Carcinoma.

Disseminated intravascular coagulation (DIC) is a syndrome characterised by simultaneous bleeding and thromboembolic formation. Its acute form is associated with severe bacterial infections and hematological malignancies. It has a fulminant presentation with prolonged bleeding times and diffuse thrombosis. On the other hand, chronic DIC can be asymptomatic for long periods of time and can be seen in patients with disseminated malignancies. This case report describes a patient who developed DIC within one week and bled profusely from venipuncture wounds. An underlying hepatogenic metastasised renal cell carcinoma appeared to be the cause. This is an uncommon and diagnostically challenging presentation.

[A woman with symptoms of an ileus]. / Een vrouw met een ileusbeeld.

An 84-year-old woman was seen with symptoms of an obstructive ileus. CT imaging revealed a volvulus of her intrathoracic stomach. This was successfully treated with gastroscopic detorsion. The patient recovered well.

Extramural Venous Invasion as Prognostic Factor of Recurrence in Stage 1 and 2 Colon Cancer.

AIM: Extramural venous invasion (EMVI) is a prognostic indicator in patients with colorectal cancer. However, its additional value in patients with stage 1 and 2 colorectal cancer is uncertain. In the present study, the incidence of EMVI and the hazard ratio for recurrence in patients with stage 1 and 2 colon cancer were studied. METHODS: 184 patients treated for stage 1 and 2 colon cancer were included with a follow-up of at least 5 years. Chart review was performed and EMVI was assessed by two separate pathologists. EMVI was scored with additional caldesmon staining on the resection specimen. Primary outcomes were recurrence-free survival (RFS) measured through the Cox regression analysis and prevalence of EMVI. RESULTS: There were 10 cases of EMVI and 3 cases of intramural venous invasion (IMVI) all occurring in patients with stage 2 disease corresponding to a prevalence of 9%. Thirty-one percent of the patients with venous invasion experienced recurrence versus 14% in patients without, corresponding with a hazard ratio of 2.39 (p = 0.11). CONCLUSION: The present study demonstrates a trend towards an increased risk of recurrence in patients with stage 2 colon cancer with venous invasion. This warrants consideration of adjuvant chemotherapy despite the lack of lymph node metastases.

The consequences of lost gallstones during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the preferred surgical technique for symptomatic gallstone disease. The technique generally is safe. probably one of the most common intra-operative complications is gallbladder perforation with stones spreading into the peritoneal cavity. In this paper the sequelae of lost gallstones after laparoscopic cholecystectomy and the diagnostic problems facing the clinician are reviewed. Abscesses and fistula formation in the abdominal wall occur. A long delay can be present between the initial operation and the complications of the lost stones. Although rupture of the gallbladder is usually noticed during preparation and retrieval, the surgeon may not be aware of losing stones. due to the long delay, the occurrence of intra-abdominal abscesses and fistula is often not linked to the prior procedure.

Multiple cysts in the liver autosomal dominant polycystic liver disease.

A 45-year-old woman was admitted because of abdominal pain and a feeling of fullness. Ultrasound and CT scan of the abdomen showed a massively enlarged liver with hundreds of cysts and displacement of the right kidney. There were no cysts in the kidneys. Because several members of her family also had multiple cysts in the liver, the diagnosis of autosomal dominant polycystic liver disease (PCLD) was made. Genetic analysis demonstrated a protein kinase C substrate 80 K-H (PR KCSH) gene mutation (1338-2A>G) and confirmed the clinical diagnosis. A brief review of the genetics and possible treatments is given.

Fatal aspiration of polyethylene glycol solution.

Endoscopy of the colon requires adequate cleansing of the entire bowel. Several laxative regimens have been propagated, but bowel preparation with polyethylene glycol (PEG) solution is popular because of the easy application and good cleansing results. Although very safe in daily use, complications of this bowel-cleansing procedure have been reported and aspiration of the PEG solution is a possible and serious hazard. A case report is presented of a patient who aspirated the PEG solution and ultimately died because of respiratory failure.

Reflux esophagitis in patients with partial gastrectomy and Billroth I or II reconstruction.

BACKGROUND: Data on the occurrence of reflux esophagitis and Barrett's esophagus in patients with Billroth I or II resection is sparse. For this reason a cross-sectional study was done in order to assess reflux disease in Billroth resection. METHODS: Consecutive patients were included in the study. Coincidental pathology (hiatus hernia, ulcer, esophagitis, and cancer) was noted. RESULTS: Over a period of 12 years, 370 consecutive patients with a partial gastrectomy were seen (268 Billroth II, 102 Billroth I) and three groups of patients were identified. Group 1 included 64 patients (17%) with a hiatus hernia; group 2, 16 patients (4%) with reflux esophagitis; and group 3, 290 patients (78%) with only a Billroth resection. Reflux disease occurred significantly more often in men than in women (7.5% vs. 2%, p<0.05). There was no difference in type of resection or in the presence of reflux esophagitis. Four patients had an esophageal cancer (only one adenocarcinoma). CONCLUSION: Only a minority of patients with partial gastrectomy has signs of esophagitis in the long term.

Gastro-oesophageal reflux disease--experience in daily practice: symptoms and symptom assessment.

Gastro-oesophageal reflux disease is one of the most common medical problems in daily practice, with many guidelines on diagnosis and treatment available. The prevalence and incidence of reflux disease are rising. In a period of 10 years, the incidence of reflux oesophagitis has almost doubled, as has the number of pills and tablets of acid-suppressive therapy sold. The decreased number of patients with severe reflux oesophagitis is indicative of increased public awareness. Heartburn and regurgitation are the hallmarks of reflux disease. The symptom score in patients with the mild reflux oesophagitis is significantly higher than it is in patients presenting with severe oesophagitis, NERD or Barrett's oesophagus. Patients with mild oesophagitis also suffer from more reflux. Dysphagia is often the only presenting symptom in severe oesophagitis. Patients with reflux oesophagitis have a significantly higher symptom score than patients with Barrett's oesophagus. The scores for heartburn and acid regurgitation are significantly higher in reflux oesophagitis. The primary goal of treatment is complete clinical remission and prevention of long-term complications. In a study with a follow-up of 4.5 to 7.5 years in patients with reflux oesophagitis it was shown that 85% still used acid-suppressive therapy, mostly on a daily basis. However, the majority were never completely free of reflux. Despite the fact that the degree of reflux oesophagitis correlates with the risk of relapse, also patients in whom initially the most severe grade of reflux oesophagitis (grades III and IV) was diagnosed no longer use medication. Treatment of reflux disease with acid suppressants is a major component in national and international drug budgets, and health-care authorities and insurance companies are eager to reduce these budgets. Since diagnosis and treatment are already discussed in many guidelines, cut-backs could be achieved in patients on maintenance therapy. For this reason, more data have to be assessed on therapy outcome in cases of chronic maintenance therapy. Guidelines for maintenance or on-demand therapy are necessary.