The impact of the national bowel screening program in the Netherlands on detection and treatment of endoscopically unresectable benign polyps.

BACKGROUND: In January 2014, a national bowel cancer screening program started in the Netherlands. The program is being implemented in phases until 2019. Due to this program, an increase in patients referred for a colorectal resection for benign, but endoscopically unresectable polyps, is expected. So far, most resections are performed according to oncological principles despite no pre-operative histological diagnosis of malignancy. The aim of this study was to analyze the increase in referred patients during the first year of the screening program and to compare pathological results and clinical outcome of resections of patients undergoing resection for benign polyps before and after implementation of screening. METHODS: Patients referred for colorectal resection without biopsy-proven cancer between January 2009 and January December 2014 were identified from a prospectively maintained database. Patients with endoscopically macroscopic features of carcinoma were excluded. RESULTS: Seventy-six patients were included. Forty-seven patients (61.8%) were operated on in the 5 years prior to implementation of the screening program, and 29 patients (38.2%) were operated during the first year of implementation of the screening program. The overall malignancy rate before the introduction of the program was 14.1 and 6.6% after it had started (p = .469). All resections were performed laparoscopically; the conversion rate was 3.9% (n = 3). The overall mortality rate was 2.7% (n = 2), major complications (Clavien-Dindo > 3b) occurred in 11.8% (n = 9) of patients. The anastomotic leakage rate was 3.9% (n = 3). CONCLUSIONS: The number of patients referred for benign polyps tripled after introduction of the screening program. With an overall major morbidity and mortality rate of 11.8%, it seems valid to discuss whether an endoscopic excision with advanced techniques with or without laparoscopic assistance would be preferable in this patient group, accepting a 6.6% reoperation rate for additional oncological resection with lymph node sampling in patients in whom a malignancy is found on histological analysis of the complete polyp.

Colorectal anastomotic leak: delay in reintervention after false-negative computed tomography scan is a reason for concern.

BACKGROUND: Early detection of anastomotic leakage (AL) after colorectal surgery followed by timely reintervention is of crucial importance. The aim of this study was to investigate the accuracy of computed tomography (CT) imaging for AL and the effects of delay in reintervention after a false-negative CT. METHODS: All files from patients who had colorectal surgery with primary anastomoses between 2009 and 2014 were reviewed. The predictive value of CT scanning for AL was determined and correlated with short-term postoperative patient outcomes. In addition, factors predictive of false-negative scans were assessed. RESULTS: Six hundred and twenty-eight patient files were reviewed. In total, a CT scan was performed in 127 patients. Overall, leakage was seen in 49 patients (7.8%). The positive and negative predictive values were 78 and 88%, respectively. Sensitivity was 73% and specificity 91%. In patients with a true-positive CT (n = 24), reintervention followed after a median interval of 0 days (IQR 1), whereas this was 1 day (IQR 2) in the false-negative group (n = 11) (p < 0.05). This was associated with a significantly increased mortality rate (1/24 = 4.2% vs 5/11 = 45.5%) (p < 0.005), an increased length of hospital stay [median 28 days (IQR 26) vs 54 days (IQR 20) (p < 0.05)]. CONCLUSIONS: Delayed reintervention after false-negative CT scanning is associated with a high mortality rate and a significant increase in length of hospital stay.

The effect of a postoperative quality improvement program on outcomes in colorectal surgery in a community hospital.

PURPOSE: The aim of this study was to evaluate whether implementation of a comprehensive quality improvement program was associated with improved outcomes in patients undergoing oncological colorectal surgery in a non-academic, non-referral community hospital. METHODS: The quality improvement program (QIP) was introduced in January 2011 and consisted of the following interventions: (1) avoidance of postoperative nonsteriodal anti-inflammatory drugs; (2) normovolemia was pursued pre- and postoperatively; (3) non-resectional surgery if possible, in patients over 80 with ASA 3 or 4 classification; and (4) a standardized, postoperative surveillance protocol was introduced, with CRP determination day 2 and 4, and if necessary subsequent abdominal CT with rectal contrast to reduce delay in diagnosis of complications. From a prospectively maintained database of 488 patients undergoing colorectal surgery between 2009 and 2014, postoperative outcomes of patients operated before and after implementation of the program were compared. RESULTS: The severe complication rate (Clavien-Dindo >3b) decreased significantly (25.0 vs. 13.7 %; p < .001) after implementation of the QIP program. The mortality rate dropped from 8.7 to 2.6 % (p = .003). The percentage of anastomotic leakage was 9.6% before QIP implementation and 4.2% after (p = .013). Median length of hospital stay decreased from 9 (IQR 5-19) to 7 days (IQR 4-12) (p < .001). Multivariate analyses showed that surgery after implementation of the program was a strong independent predictor for less major complications (OR 0.54, 95 % CI 0.32-0.88). CONCLUSIONS: A significant decrease in major complications and mortality was observed after introduction of a relative simple quality improvement program.

Transinguinal preperitoneal (TIPP) vs endoscopic total extraperitoneal (TEP) procedure in unilateral inguinal hernia repair: a randomized controlled trial.

PURPOSE: The Lichtenstein hernioplasty has long been seen as the gold standard for inguinal hernia repair. Unfortunately, this repair is often associated with chronic pain, up to 10-35%. Therefore, several new techniques have been developed, such as the transinguinal preperitoneal patch (TIPP) and the endoscopic total extraperitoneal (TEP) technique. Several studies showed beneficial results of the TIPP and TEP compared to the Lichtenstein hernioplasty; however, little is published on the outcome when comparing the TIPP and TEP procedures. This study aimed to evaluate outcomes after the TIPP vs the TEP technique for inguinal hernia repair. METHODS: A single-center randomized controlled trial was carried out between 2015 and 2020. A total of 300 patients with unilateral inguinal hernia were enrolled and randomized to the TIPP- or TEP technique. Primary outcome was chronic pain (defined as any pain following the last 3 months) and quality of life, assessed with Carolinas comfort scale (CCS) at 12 months. Secondary outcomes were: wound infection, wound hypoesthesia, recurrence, readmission within 30 days, and reoperation. RESULTS: A total of 300 patients were randomized (150 per group). After a follow-up of 12 months, we observed significantly less postoperative chronic groin pain, chronic pain at exertion, wound hypoesthesia, and wound infections after the TEP when compared to the TIPP procedure. No significant differences in quality of life, reoperations, recurrence rate, and readmission within 30 days were observed. CONCLUSION: We showed that the TEP has a favorable outcome compared to the TIPP procedure, leading to less postoperative pain and wound complications, whereas recurrence rates and reoperations were equal in both the groups.

[A foreign body in the tongue]. / Corpus alienum in de tong.

A 3-year-old boy was referred to the emergency department of a medical centre because of a local swelling of the tongue. Radiographic imaging concluded that it concerned a complete tooth, which had been overlooked during an earlier visit to the same department. The foreign body was removed easily under general anaesthesia. A foreign body in the lip is a feature frequently seen by family physicians and in emergency departments of medical centres. However, a foreign body in the tongue is, by contrast, less often reported. Physical examination is the key factor in diagnostics. When in doubt, a radiograph should be made.

[A colo-colic invagination on the basis of MutYH-associated polyposis in a boy aged 14]. / Een colocolische invaginatie op basis van MutYH-geassocieerde polyposis coli bij een jongen van 14 jaar.

A 14-year-old boy presented with acute abdominal pain, vomiting and diarrhoea. Colo-colic intussusception was diagnosed by means of a colonic contrast X-ray. The intussusception was successfully reduced during this procedure. Hundreds of polyps were seen throughout the entire colon. Genetic research showed a mutation of the MutYH gene. Proctocolectomy with ileoanal pouch anastomosis was carried out. The pathology specimen showed an intramucosal carcinoma and multiple adenomas. MutYH-associated polyposis coli is an autosomal recessive disease that occurs as a result of a mutation in the MutYH gene. This will lead to polyposis coli. An intussusception is a rarely seen symptom. Patients need preventive surgical treatment because of the high risk developing a colorectal carcinoma.

Biliary excretion of platinum in rats after administration of cisplatin and aqua(1,1-bis(aminomethyl)-cyclohexane)sulfatoplatinum(II) (spiroplatin, TNO-6).

Three groups of 6 rats were treated with cisplatin (3 mg/kg, bolus and 3-h infusion) and spiroplatin (3 mg/kg, bolus) by infusion in the right external jugular vein. The mean amounts of platinum +/- c.v. excreted in the bile during the first 6 h after the start of administration were 0.32 +/- 0.19% and 0.39 +/- 0.29% of the dose after bolus injection and 3-h infusion of cisplatin, respectively, and 3.77 +/- 3.32% of the dose after spiroplatin. The values were not significantly different between the 2 cisplatin administration modes (P greater than 0.05), but were between the spiroplatin and cisplatin bolus groups (Wilcoxon two-sided rank test, P less than 0.01). These data are related to pharmacokinetic parameters in man.

Results of pancreaticoduodenectomy for ampullary carcinoma and analysis of prognostic factors for survival.

BACKGROUND: Results of pancreaticoduodenectomy for ampullary carcinoma were evaluated, and prognostic factors for survival were analyzed. METHODS: During the period from 1984 to 1992 67 patients underwent subtotal or total pancreaticoduodenectomy for ampullary carcinoma. All clinicopathologic data and their influence on survival were studied. RESULTS: Subtotal pancreaticoduodenectomy was performed in 62 of 67 patients with a mortality of 6% and a morbidity of 65%; the remaining five patients underwent total pancreaticoduodenectomy. Intraabdominal infection was the most important complication. Resection margins were tumor free in 75% of 67 patients. The overall 5-year survival was 50%. Survival was significantly influenced by the involvement of resection margins. After resection with involved margins 5-year survival was 15% and 60% after resection with free margins (p < 0.001). Tumor size, lymph node involvement, and differentiation grade had limited and not significant influence on survival. CONCLUSIONS: Subtotal pancreaticoduodenectomy is the type of resection of first choice for ampullary carcinoma. Involvement of resection margins was the strongest prognostic factor for survival. Patients with a tumor size larger than 2 cm, with lymph node involvement, or with a poorly differentiated tumor still had a 5-year survival rate greater than 40%. Patients with involved margins might be candidates for studies on adjuvant therapy.

Benign fibrosing disease at the hepatic confluence mimicking Klatskin tumors.

BACKGROUND: Hilar obstructions remain a challenge with regard to diagnosis and treatment. METHODS: In the period from 1984 to 1990, 82 patients underwent resective surgery under the presumptive diagnosis of hilar cholangiocarcinoma (Klatskin tumor). The diagnosis was based on the combined appearances on direct cholangiography and ultrasonography in all cases, with the use of various other imaging modalities in some cases. RESULTS: The perioperative findings from an experienced surgical team were usually thought to be compatible with bile duct carcinoma. However, histologic examination of the resected specimens revealed benign fibrosing or localized sclerosing lesions in 11 patients (13.4%). CONCLUSIONS: The current state of diagnostic imaging fails as yet to discriminate reliably between benign and malignant hilar lesions. Whereas the immediate therapeutic consequences may be equal (resection followed by hepaticojejunostomy), the late consequences differ in a major way because benign disease has a much better prognosis. In the presence of suspicious hilar obstruction, operable lesions should not be treated by "palliative" intubational techniques and radiation therapy without a firm diagnosis of malignancy. However, overtreatment (extended liver resection, vascular reconstruction, and liver transplantation) should be avoided as well when a benign lesion has not been ruled out.

Does additive radiotherapy after hilar resection improve survival of cholangiocarcinoma? An analysis in sixty-four patients.

Between September 1983 and January 1990, 64 patients with Klatskin tumors were treated with resective therapy in the Academic Medical Centre Amsterdam. Twenty-nine patients received postoperative adjuvant radiotherapy, 22 patients were treated with resective therapy only and there were 13 postoperative deaths. The longterm results in the patients treated with or without adjuvant radiotherapy were retrospectively assessed. Three patients had a curative resection. Comparison of both therapeutic modalities demonstrated a statistically significant difference in survival (P less than 0.001) in favour of the patients who were treated with additive radiotherapy. The radiotherapy was generally well tolerated.

[Abdominal pain due to nerve compression]. / Buikpijn door beklemde zenuwen.

Persistent abdominal pain in a 15-year-old girl was diagnosed after examination by the GP, the pediatrician, the gynaecologist and finally, the surgeon as rib-tip syndrome. The patient could be treated sufficiently by the injection of local anaesthetics and corticosteroids. In the rib-tip syndrome hypermobility of the lower ribs irritates the intercostal nerves causing pain along the lower edge of the chest. The condition can be established objectively with the aid of fluoroscopy and electrostimulation, electromyography or magnetic stimulation.

The value of a bulk-tank milk ELISA and individual serological and faecal examination for diagnosing (sub)clinical Dictyocaulus viviparus infection in dairy cows.

To test the value of a recently developed bulk-tank milk (BTM) ELISA for diagnosing (sub)clinical Dictyocaulus viviparus infection in lactating dairy herds under field conditions, bulk milk samples were collected from farms with or without clinical symptoms suspected to be caused by lungworm infection. Results of the BTM ELISA were compared against individual examinations for lungworm larvae in faeces and lungworm antibodies in serum from up to 20 heifers (parity 1) and up to 20 cows (parity ≥ 2) on the same farms. This also allowed, for the first time, to examine the value of individual faecal and serological examinations in the diagnosis of (sub)clinical lungworm infections. In total, 33 farms participated. Of these, 16 reported clinical symptoms possibly related to lungworm infection (defined as a suspected positive clinical status or CS(+)) and 17 reported having no such symptoms (CS(-)). In total, 503 heifers and 649 cows were sampled. Of all faeces samples positive for lungworm larvae, 94 were from heifers (18.9% of all heifers) and 75 from cows (11.7% of all cows) (P<0.001). Of all sera positive for lungworm antibodies, 130 were from heifers (26.1% of all heifers) and 113 from cows (17.5% of all cows) (P<0.001). Of the CS(-) farms 41% had at least one heifer or cow shedding larvae and 71% had at least one seropositive heifer or cow. Of the CS(+) farms this was 81% and 94%, respectively. There were only 4 farms, all CS(-), where none of the animals were found shedding larvae and all animals tested seronegative. This implies that on 76% of the CS(-) farms lungworm infection circulated unnoticed. On all CS(+) farms the suspicion that lungworm caused the respiratory symptoms was confirmed by the individual faecal and serological examinations, whereas the BTM ELISA confirmed presence of lungworm on half of the CS(+) farms. The latter in particular occurred on farms with the more severe outbreaks. Overall, of 32 available BTM samples 10 tested positive (8 of 15 CS(+) and 2 of 17 CS(-) farms). For diagnosing suspected lungworm disease it was concluded that testing a BTM sample might suffice in case of moderate to severe outbreaks. However, in case of a mild outbreak with just a few animals coughing, examining individual animals has to be preferred over testing a BTM sample. The likelihood to detect lungworm infection is higher if heifers are sampled compared to cows. Sensitivity of the BTM ELISA was 35.7% if the presence of at least one seropositive and/or one larvae shedding animal in the herd was used to define lungworm positive farms. On average, at least 30% of the herd had to be seropositive before the BTM ELISA was found positive for lungworm antibodies. Results indicate that the BTM ELISA in its current form does not appear to be suitable for surveys on the prevalence of lungworm presence on farms. However, this BTM ELISA might be used in large-scale surveys to detect, for instance, annual changes in percentage positive farms, as long as it is recognized that positivity is more closely related to incidence of lungworm disease than to prevalence of lungworm infection.

The value of various forms of regional administration of cisplatin in the treatment of liver metastases in the rat.

Tumour growth was induced exclusively in the livers of 40 F1 WagRij/BN rats (eight groups of five rats each) by intraportal inoculation of a squamous cell carcinoma. Four groups were treated by infusion of cisplatin (to which the tumour was sensitive) for a total of three doses of 3 mg/kg body weight at 5-day intervals and one group served as control. Treatment was given systemically, via the hepatic artery, via the portal vein and the hepatic artery simultaneously, and via the portal vein. The untreated animals had a mean survival time of 119 days, as opposed to 211, 249, 192 and 239 days for the treated animals. The animals treated via the hepatic artery lived significantly longer on average (P = 0.035) than those treated systemically or via the portal vein. The combination of intraportal and intra-arterial infusion had no advantage over infusion via the hepatic artery alone. The route of administration does not appear to influence the general toxicity of cisplatin.

Clinical significance of implantation metastases after surgical treatment of cholangiocarcinoma.

Cytologic examination of bile obtained during surgery from intrahepatic bile ducts in patients with malignant proximal bile duct obstruction has shown a high incidence of tumor cells. Spill of bile occurs frequently during these operations and postoperative bile leakage often occurs. Typical implantation metastases were detected in three patients who underwent resective surgery for bile duct cancer. In addition, peritoneal spread of bile duct carcinoma was found on postmortem examination in seven of ten patients who died 6 to 27 months after resection of the hilar tumor. A relation between tumor-positive bile cytologic findings, tumor spill, and seeding during surgery is likely to exist. It is recommended that during surgery the utmost care should be taken to prevent spill of bile.

A double or bilobar gallbladder as a cause of severe complications after (laparoscopic) cholecystectomy.

A double or bilobar gallbladder is a rare congenital anomaly. If not recognized during preoperative evaluation or operation, it can cause severe complications. We describe two cases in which a second operation had to be performed because of the presence of a second or bilobar gallbladder that was not recognized in the preoperative evaluation and during (laparoscopic) cholecystectomy. The types of anomalies, the concomitant pathology, and treatment are discussed.

Technical considerations for the management of primary cholangiocarcinoma of the porta hepatis.

Surgical management of primary hilar cholangio-carcinoma remains challenging and controversial. Our policy in dealing with the disease includes local resection of the tumor with the bifurcation of the common hepatic duct, or combined tumor and liver resection with or without resection of the regional vascular structures. The various technical options regarding these alternatives have been described in detail in this article.

Endosonography in diagnosing and staging duodenal villous adenoma.

Endosonography was carried out in a patient with an extensive juxtapapillary tumour. Radiology and endoscopy were unable to distinguish a villous adenoma from an invasive carcinoma. Endosonography revealed a mucosal hypoechoic tumour without penetration into the submucosa and muscularis propria. The common bile duct, pancreatic duct, and pancreas were normal. Lymph node abnormalities were not found. Based on the endosonography findings, local surgical tumour resection was undertaken instead of a Whipple procedure. The histology of the resected specimen confirmed the endosonography diagnosis.

"Split" pancreaticojejunostomy in the surgical treatment of chronic pancreatitis.

"Split" pancreaticojejunostomy is a procedure consisting of vertical transection of the pancreas and anastomosis of both sides of the cut pancreatic duct with an interposed, Roux-en-Y jejunal loop. In this paper we report the long term results of this procedure in the treatment of eight patients with chronic pancreatitis (CP).

Portal vein resection in patients undergoing pancreatoduodenectomy for carcinoma of the pancreatic head.

Of 176 patients with carcinoma of the pancreatic head region 156 underwent standard pancreatoduodenectomy (group 2) and 20 with macroscopic suspicion of invasion of the portal vein or superior mesenteric vein (SMV) underwent pancreatoduodenectomy with partial resection of the portal vein or SMV (group 1). In 16 patients in group 1 end-to-end anastomosis was used for reconstruction of the vein. The morbidity rate in groups 1 and 2 was similar (55 versus 63 per cent). The hospital mortality rate was 15 per cent in group 1 and 7 per cent in group 2 (P = 0.22). Histological examination confirmed tumour invasion of the portal vein or SMV in ten patients in group 1. Invasion of the portal vein or SMV was significantly more frequent in patients with pancreatic cancer than in those with distal bile duct or ampullary carcinoma. Of the 20 patients in group 1 only three underwent curative resection with tumour-free margins. The median survival time after resection of the portal vein or SMV was 8 months; the 2-year survival rate was 19 per cent. Comparison of survival in group 1 with survival in subgroups of patients undergoing standard pancreatoduodenectomy, matched for all histological parameters, showed no significant difference. It is concluded that partial resection of the portal vein or SMV in patients undergoing pancreatoduodenectomy who are suspected of having tumour invasion of the portal vein or SMV does not improve either the rate of curative resection or survival.