Roles of general practitioners in shared decision-making for patients with cancer: A qualitative study.

OBJECTIVE: The shared decision-making (SDM) process for the treatment of pancreatic and oesophageal cancer primarily takes place with healthcare professionals (HCPs) in the hospital setting. This study aims to explore the perspectives of general practitioners (GPs) on their possible roles during this SDM process, their added value and their requirements for involvement in SDM. METHODS: Semi-structured interviews were conducted with 12 GPs about their views on SDM for patients with cancer. The interviews were analysed by two researchers using an inductive open coding approach. RESULTS: Five potential roles in SDM were described by the interviewed GPs, of which the role as 'coach' of the patient was mentioned by all. GPs see their main added value as their long-standing relationship with the patient. To be able to participate optimally in SDM, GPs indicated that they need to be kept up to date during the patient's care process and should receive enough medical information about treatment options and contextual information. CONCLUSION: GPs see different potential roles for themselves when involved in SDM. Hospital HCPs that want to facilitate GP involvement should take the initiative, provide the GPs with enough and timely information and must be easy to consult.

Ileal pouch anal anastomosis with close rectal dissection using automated vessel sealers for ulcerative colitis: a promising alternative.

BACKGROUND: Despite decennia of experience, ileal pouch anal anastomosis for ulcerative colitis is still associated with high complication rates. The development of automatic vessel sealers has resulted in the revival of a promising surgical alternative to the conventional procedure: close rectal dissection. By preserving the mesorectal layer it is hypothesized that nerve-related and other postoperative complications can be reduced. METHODS: All patients with ulcerative colitis with indication for restorative proctocolectomy at our institution during the pilot study underwent the close rectal pouch procedure with temporary diverting ileostomy. Standardized clinical history, anorectal physiology measurements, and endoscopic and histological examination were carried out before and after surgery. RESULTS: The procedure was technically successful in all 10 patients, with a median age of 41 years and a median postoperative follow-up period of 16 months. There were no cases of pelvic sepsis and bladder or sexual dysfunction. The median daytime defecation frequency was 6.0. Endoscopic and histological examination showed no abnormalities. The anorectal physiology supported the good functional results. CONCLUSION: The preliminary results of the close rectal pouch procedure are promising, with good functional results and a low complication rate after 1 year.

Preoperative radiochemotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer (PREOPANC trial): study protocol for a multicentre randomized controlled trial.

BACKGROUND: Pancreatic cancer is the fourth largest cause of cancer death in the United States and Europe with over 100,000 deaths per year in Europe alone. The overall 5-year survival ranges from 2-7 % and has hardly improved over the last two decades. Approximately 15 % of all patients have resectable disease at diagnosis, and of those, only a subgroup has a resectable tumour at surgical exploration. Data from cohort studies have suggested that outcome can be improved by preoperative radiochemotherapy, but data from well-designed randomized studies are lacking. Our PREOPANC phase III trial aims to test the hypothesis that median overall survival of patients with resectable or borderline resectable pancreatic cancer can be improved with preoperative radiochemotherapy. METHODS/DESIGN: The PREOPANC trial is a randomized, controlled, multicentric superiority trial, initiated by the Dutch Pancreatic Cancer Group. Patients with (borderline) resectable pancreatic cancer are randomized to A: direct explorative laparotomy or B: after negative diagnostic laparoscopy, preoperative radiochemotherapy, followed by explorative laparotomy. A hypofractionated radiation scheme of 15 fractions of 2.4 gray (Gy) is combined with a course of gemcitabine, 1,000 mg/m(2)/dose on days 1, 8 and 15, preceded and followed by a modified course of gemcitabine. The target volumes of radiation are delineated on a 4D CT scan, where at least 95 % of the prescribed dose of 36 Gy in 15 fractions should cover 98 % of the planning target volume. Standard adjuvant chemotherapy is administered in both treatment arms after resection (six cycles in arm A and four in arm B). In total, 244 patients will be randomized in 17 hospitals in the Netherlands. The primary endpoint is overall survival by intention to treat. Secondary endpoints are (R0) resection rate, disease-free survival, time to locoregional recurrence or distant metastases and perioperative complications. Secondary endpoints for the experimental arm are toxicity and radiologic and pathologic response. DISCUSSION: The PREOPANC trial is designed to investigate whether preoperative radiochemotherapy improves overall survival by means of increased (R0) resection rates in patients with resectable or borderline resectable pancreatic cancer. TRIAL REGISTRATION: Trial open for accrual: 3 April 2013 The Netherlands National Trial Register - NTR3709 (8 November 2012) EU Clinical Trials Register - 2012-003181-40 (11 December 2012).

Management of acute pancreatitis in the intensive care unit.

Acute pancreatitis is a disease with a variety of symptoms. In patients in whom the disease takes a more severe course, stabilization is mandatory, often in a high dependency unit or intensive care unit. When the pancreatitis is of biliary origin and cholangitis and cholestatic changes are proven or suspected, an endoscopic cholangiopancreaticography is indicated. Aggressive organ support and continuation of the prophylactic antibiotics are the mainstay of treatment. When infected necrosis has been proven by CT-guided fine needle biopsy, surgical necrotectomy and debridement with drainage are necessary. Enteral feeding is superior to parenteral feeding even in situations of severe pancreatitis. Further investigation into the role of selective digestive tract decontamination, by controlled randomized trials, is needed.