Evaluation of CPAP adherence in bariatric patients diagnosed with obstructive sleep apnea: outcomes of a multicenter cohort study.

PURPOSE: Obstructive sleep apnea (OSA) is highly prevalent but mostly undiagnosed in obese patients scheduled for bariatric surgery. To prevent cardiopulmonary complications, many clinics perform preoperative OSA screening. Consequently, adequate adherence to continuous positive airway pressure (CPAP) therapy is essential but challenging. We aimed to evaluate CPAP adherence and its influence on postoperative outcomes. METHODS: In a prospective multicenter cohort study, we compared different perioperative strategies for handling undiagnosed OSA in bariatric patients. In this subgroup analysis, patients newly diagnosed with OSA were compared to those with pre-existing OSA. We assessed inadequate CPAP adherence, defined as < 4 h/night, between the preoperative period and 6 months postoperative. Cardiopulmonary complications and (un)scheduled ICU admissions were also evaluated. RESULTS: In total, 272 patients with newly diagnosed OSA (67.4%) and 132 patients with pre-existing OSA (32.6%) were included. Before surgery, 41 newly diagnosed patients used CPAP inadequately, compared to 5 patients with pre-existing OSA (15% vs. 4%, p = 0.049). Six months after surgery, inadequate CPAP use increased to 73% for newly diagnosed patients and 39% for patients with pre-existing OSA, respectively (p < 0.001). Incidences of cardiopulmonary complications, scheduled, and unscheduled ICU admissions were similar in the two study groups (p = 0.600, p = 0.972, and p = 0.980, respectively). CONCLUSION: Inadequate CPAP adherence is higher in bariatric patients newly diagnosed with OSA when compared to patients with pre-existing OSA. Strategies to increase CPAP adherence may be valuable when considering routine OSA screening and CPAP therapy in patients undergoing bariatric surgery. Further studies are needed to improve current guidelines on perioperative OSA management of obese patients. TRIAL REGISTRATION: POPCORN study, registered at Netherlands Trial Register, https://www.trialregister.nl/trial/6805 . ID no: 6805.

Complications and predictors associated with moderate to severe obstructive sleep apnoea in bariatric surgery: Evaluation of routine obstructive sleep apnoea screening.

PURPOSE: Obstructive sleep apnoea (OSA) is a breathing disorder resulting in blockage of airflow and hypo-oxygenation. The incidence of OSA in patients with class 2 or 3 obesity (Body Mass index, BMI >35) is 60-70%. Unfortunately, most bariatric patients are unaware they suffer from OSA. Untreated OSA can lead to perioperative cardiopulmonary complications. The aim of this study was to identify predictors associated with moderate to severe OSA and asses the incidence of OSA-related complications in a large cohort of patients who underwent OSA-screening and treatment if indicated before bariatric surgery. METHODS: All consecutive patients who underwent primary bariatric surgery between September 2013 and September 2019 were included. Univariable and multivariable logistic regression analysis was performed to identify potential predictors for moderate to severe OSA using sleep studies. RESULTS: A total of 2872 patients who underwent bariatric surgery were included for analysis. Overall, OSA was identified in 62.5% of all patients and moderate to severe OSA (AHI ≥15) in 28.6%. Independent predictors for moderate to severe OSA were male gender (p < 0.001), age (p < 0.001), preoperative BMI (p < 0.001), preoperative waist circumference (p < 0.001), hypertension (p < 0.001), and dyslipidaemia (p = 0.046). The incidence of OSA-related complications was low (0.8%) and not significantly different among the different OSA severity classes. CONCLUSION: This is the largest study to assess OSA presence and OSA-related complications in patients undergoing bariatric surgery. The incidence of potential OSA-related complications was low (0.8%). We believe focus could be shifted towards more cost-efficient strategies where OSA screening is omitted such as perioperative continuous monitoring.

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.

Multicentre randomized controlled trial comparing ferric(III)carboxymaltose infusion with oral iron supplementation in the treatment of preoperative anaemia in colorectal cancer patients.

BACKGROUND: At least a third of patients with a colorectal carcinoma who are candidate for surgery, are anaemic preoperatively. Preoperative anaemia is associated with increased morbidity and mortality. In general practice, little attention is paid to these anaemic patients. Some will have oral iron prescribed others not. The waiting period prior to elective colorectal surgery could be used to optimize a patients' physiological status. The aim of this study is to determine the efficacy of preoperative intravenous iron supplementation in comparison with the standard preoperative oral supplementation in anaemic patients with colorectal cancer. METHODS/DESIGN: In this multicentre randomized controlled trial, patients with an M0-staged colorectal carcinoma who are scheduled for curative resection and with a proven iron deficiency anaemia are eligible for inclusion. Main exclusion criteria are palliative surgery, metastatic disease, neoadjuvant chemoradiotherapy (5 × 5 Gy = no exclusion) and the use of Recombinant Human Erythropoietin within three months before inclusion or a blood transfusion within a month before inclusion. Primary endpoint is the percentage of patients that achieve normalisation of the haemoglobin level between the start of the treatment and the day of admission for surgery. This study is a superiority trial, hypothesizing a greater proportion of patients achieving the primary endpoint in favour of iron infusion compared to oral supplementation. A total of 198 patients will be randomized to either ferric(III)carboxymaltose infusion in the intervention arm or ferrofumarate in the control arm. This study will be performed in ten centres nationwide and one centre in Ireland. DISCUSSION: This is the first randomized controlled trial to determine the efficacy of preoperative iron supplementation in exclusively anaemic patients with a colorectal carcinoma. Our trial hypotheses a more profound haemoglobin increase with intravenous iron which may contribute to a superior optimisation of the patient's condition and possibly a decrease in postoperative morbidity. TRIAL REGISTRATION: ClincalTrials.gov: NCT02243735 .

A novel triazolic naphthofuranquinone induces autophagy in reservosomes and impairment of mitosis in Trypanosoma cruzi.

Chagas' disease, caused by the protozoan Trypanosoma cruzi, represents a serious health problem in Latin America, and the available chemotherapy, which is based on 2 nitro-derivatives, is not satisfactory. In folk medicine, natural products including naphthoquinones have been employed for the treatment of different parasitic diseases. In the pursuit of alternative drugs for Chagas' disease, we investigated the mechanism of action of the triazolic naphthoquinone (TN; 2,2-dimethyl-3-(4-phenyl-1H-1,2,3-triazol-1-yl)-2,3-dihydronaphtho[1,2-b]furan-4,5-dione), which is the most active compound against T. cruzi trypomastigotes among a series of naphthofuranquinones. TN was active against the 3 parasite forms producing a dose-dependent inhibitory effect. In epimastigotes, TN induced reservosome disruption, flagellar blebbing, Golgi disorganization, the presence of cytosolic concentric membrane structures and abnormal multiflagellar parasites. The treatment also led to the appearance of well-developed endoplasmic reticulum profiles surrounding organelles that associated with an increase in monodansylcadaverine labelling, suggesting autophagy as part of the TN mechanism of action. Interestingly, no ultrastructural damage was detected in the mitochondria of naphthoquinone-treated epimastigotes. Flow cytometric analysis demonstrated an impairment of mitosis, an increase in ROS production and the maintenance of mitochondrial membrane potential. TN could be a good starting point in the investigation of a chemotherapeutic approach for the treatment of Chagas' disease.

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.

The trypanocidal activity of amidine compounds does not correlate with their binding affinity to Trypanosoma cruzi kinetoplast DNA.

Due to limited efficacy and considerable toxicity, the therapy for Chagas' disease is far from being ideal, and thus new compounds are desirable. Diamidines and related compounds such as arylimidamides have promising trypanocidal activity against Trypanosoma cruzi. To better understand the mechanism of action of these heterocyclic cations, we investigated the kinetoplast DNA (kDNA) binding properties and trypanocidal efficacy against T. cruzi of 13 compounds. Four diamidines (DB75, DB569, DB1345, and DB829), eight arylimidamides (DB766, DB749, DB889, DB709, DB613, DB1831, DB1852, and DB2002), and one guanylhydrazone (DB1080) were assayed in thermal denaturation (T(m)) and circular dichroism (CD) studies using whole purified T. cruzi kDNA and a conserved synthetic parasite sequence. The overall CD spectra using the whole kDNA were similar to those found for the conserved sequence and were indicative of minor groove binding. Our findings showed that some of the compounds that exhibited the highest trypanocidal activities (e.g., DB766) caused low or no change in the T(m) measurements. However, while some active compounds, such as DB766, induced profound alterations of kDNA topology, others, like DB1831, although effective, did not result in altered T(m) and CD measurements. Our data suggest that the strong affinity of amidines with kDNA per se is not sufficient to generate and trigger their trypanocidal activity. Cell uptake differences and possibly distinct cellular targets need to be considered in the final evaluation of the mechanisms of action of these compounds.

In vitro and in vivo activities of 1,3,4-thiadiazole-2-arylhydrazone derivatives of megazol against Trypanosoma cruzi.

From a series of 1,3,4-thiadiazole-2-arylhydrazone derivatives of megazol screened in vitro against Trypanosoma cruzi, eight (S1 to S8) were selected for in vivo screening by single-dose oral administration (200 mg/kg of body weight) to infected mice at 5 days postinfection (dpi). Based on significant decreases in both parasitemia levels and mortality rates, S2 and S3 were selected for further assays. Despite having no in vivo effect, S1 was included since it was 2-fold more potent against trypomastigotes than megazol in vitro. Trypomastigotes treated with S1, S2, or S3 showed alterations of the flagellar structure and of the nuclear envelope. When assayed on intracellular amastigotes, the selectivity index (SI) for macrophages was in the range of >27 to >63 and for cardiac cells was >32 for S1 and >48 for megazol. In noninfected mice, S1 did not alter the levels of glutamic oxalacetic transaminase (GOT), glutamate pyruvate transaminase (GPT), or urea. S2 led to an increase in GOT, S3 to increases in GOT and GPT, and megazol to an increase in GOT. Infected mice were treated with each derivative at 50 and 100 mg/kg from dpi 6 to 15: S1 did not interfere with the course of infection or reduce the number of inflammatory foci in the cardiac tissue, S2 led to a significant decrease of parasitemia, and S3 decreased mortality. There was no direct correlation between the in vitro effect on trypomastigotes and amastigotes and the results of the treatment in experimental models, as S1 showed a high potency in vitro while, in two different schemes of in vivo treatment, no decrease of parasitemia or mortality was observed.

Immunomagnetic quantification of circulating tumoral cells in patients with prostate cancer: clinical and pathological correlation.

OBJECTIVES: To detect and enumerate circulating prostatic tumor cells (CTC) in the peripheral blood of patients with prostate cancer (PC) and study the relationship between CTCs and clinical-pathological parameters. METHODS: Prospective three-arm study: 26 patients (p) with localised PC (LPC); 24 P with metastatic PC (MPC) and 30 healthy volunteer controls. A single 7.5 ml sample of peripheral blood was retrieved; CTCs were isolated using an immunomagnetic method based on the CellSearch system (Veridex). CTCs were identified as nucleated cells negative for CD45 (leukocytes) and positive for cytokeratins. (8, 18 y 19) The relationship between CTC numbers and PSA levels, Gleason score and TNM classification was studied. RESULTS: Only 10% of the healthy controls had 1 CTC/7.5 mL, none of the patients with localised PC had more than 3 CTCs (88% < or = 2 CTCs), and patients with MPC had significantly higher CTC levels [m: 29 (1-178)] compared with the other two groups (P: 0.000). A positive correlation was demonstrated between the CTC count and PSA levels, tumor size, and presence or absence of enlarged lymph nodes. Gleason score was the only parameter that did not show any correlation with CTC levels, and although the number of CTCs was higher in patients with visceral metastases [m: 297 (0-416)] compared with bone metastases patients [m: 68 (9.5-168)] , these differences were not significant. CONCLUSIONS: Immunomagnetic analysis permits CTCs to be enumerated in peripheral blood and could be a possible way to correctly stage and make a reasonable prognosis of metastatic disease.

Risk Factors Associated with Prolonged Hospital Stay and Readmission in Patients After Primary Bariatric Surgery.

INTRODUCTION: The introduction of enhanced recovery after surgery (ERAS) has resulted in a decrease in length of hospital stay of patients after bariatric surgery. The general length of hospital stay is 1 day. Some bariatric patients stay longer after an uncomplicated procedure or are readmitted for varying reasons. OBJECTIVES: The aim of the present study is to identify risk factors associated with prolonged hospital stay and readmissions. METHODS: A retrospective study of all patients who underwent a primary procedure (i.e. Roux-en-Y gastric bypass or sleeve gastrectomy) between January 2016 and January 2019 was performed. RESULTS: A total of 1669 patients who underwent primary laparoscopic Roux-en-Y gastric bypass (70.7%) or sleeve gastrectomy (29.3%) were included. The median length of stay was 1 day (range 1-69 days). In 138 patients (8.3%), a postoperative complication was diagnosed and 89 patients were readmitted (5.3%) within 30 days after discharge. Overall, 348 patients (20.9%) stayed longer than 1 day. Univariable analysis showed that depression, ASA III, sleeve gastrectomy and a perioperative and/or postoperative complication were significantly (p value < 0.05) associated with a prolonged stay. In the multivariable model depression, sleeve gastrectomy and postoperative complication were independent risk factors for prolonged stay. Univariable analysis of risk factors associated with readmission identified depression and perioperative and postoperative complications. Multivariable analysis for readmission demonstrated only presence of a postoperative complication was an independent risk factor. CONCLUSION: Depression, sleeve gastrectomy and postoperative complications were independent risk factors for prolonged stay. Postoperative complication was an independent risk factor for readmission.

Rapid TB diagnostic service and community action to FIND.TREAT.ALL#EndTB, Maputo, Mozambique, 2013-2018.

Finding and treating all tuberculosis (TB) patients is crucial for ending TB. We investigated whether rapid diagnostic turnaround time (TAT) and patient tracking could increase TB treatment initiation in Maputo, Mozambique. Among 3329 TB patients newly diagnosed by the University Eduardo Mondlane-Anti-Persoonsmijnen Ontmijnende Product Ontwikkeling/Anti-Personnel Landmines Detection Product Development (APOPO) Laboratory between 2013 and 2018, on average 61% were verifiably linked to care. This proportion increased from 54% (first half 2013) to 79% (second half 2018) after introducing a 24-hour TAT in 2015 and patient tracking conducted by a community-based partner, Associação Kenguelekezé, in 2017. Rapid, well-connected TB diagnostic services can reduce pre-treatment loss to follow-up and support the joint initiative of WHO, Stop TB and Global Fund to 'FIND.TREAT.ALL.#EndTB'.

Identifier et traiter tous les patients atteints de tuberculose (TB) est crucial pour mettre fin à la TB. Nous avons vérifié si un délai plus court de diagnostic (TAT) et un système de recherche des patients augmentait la mise en œuvre du traitement de la TB à Maputo, Mozambique. Parmi 3329 patients TB nouvellement diagnostiqués par le laboratoire UEM-APOPO (2013­2018), en moyenne 61% ont été réellement connectés à la prise en charge. Le pourcentage a augmenté de 54% (première moitié de 2013) à 79% (deuxième moitié de 2018) après l'introduction du TAT en 24h en 2015 et la surveillance des patients effectuée par notre partenaire l'association à base communautaire Kenguelekezé en 2017. Notre expérience suggère que des services de diagnostic de TB rapides, bien connectés peuvent réduire les abandons avant le traitement et soutenir les tentatives mondiales « FIND.TREAT.ALL.#EndTB ¼.

La búsqueda y el tratamiento de todos los pacientes con tuberculosis (TB) son primordiales para poner fin a esta enfermedad. Se investigó si con un lapso corto de obtención del diagnóstico y el seguimiento de los pacientes aumentaría el inicio del tratamiento antituberculoso en Maputo, Mozambique. En promedio, en 61% de los 3329 casos nuevos de TB diagnosticados en el laboratorio UEM-APOPO (2013­2018) se confirmó la vinculación de los pacientes con los servicios de atención. El porcentaje aumentó de 54% (primer semestre del 2013) a 79% (segundo semestre del 2018), después de haber introducido un plazo de obtención del diagnóstico de 24 horas en el 2015 y la localización de los pacientes por parte de la asociación comunitaria Kenguelekezé en el 2017. Esta experiencia indica que los servicios diagnósticos de la TB que son rápidos y mantienen vínculos adecuados disminuyen la pérdida durante el seguimiento antes de comenzar el tratamiento y fortalecen los esfuerzos de la iniciativa 'FIND.TREAT.ALL.#EndTB'.

The Influence of Body Contouring Surgery on Weight Control and Comorbidities in Patients After Bariatric Surgery.

INTRODUCTION: A considerable number of patients experience some long-term weight regain after bariatric surgery. Body contouring surgery (BCS) is thought to strengthen post-bariatric surgery patients in their weight control and maintenance of achieved improvements in comorbidities. OBJECTIVES: To examine the impact of BCS on long-term weight control and comorbidities after bariatric surgery. METHODS: We performed a retrospective study in a prospective database. All patients who underwent primary Roux-en-Y gastric bypass (RYGB) and presented for preoperative consultation of BCS in the same hospital were included in the study. Linear and logistic mixed-effect model analyses were used to evaluate the longitudinal relationships between patients who were accepted or rejected for BCS and their weight loss outcomes or changes in comorbidities. RESULTS: Of the 1150 patients who underwent primary RYGB between January 2010 and December 2014, 258 patients (22.4%) presented for preoperative consultation of BCS. Of these patients, 126 patients eventually underwent BCS (48.8%). Patients who were accepted for BCS demonstrated significant better ∆body mass index (BMI) on average over time (- 1.31 kg/m2/year, 95% confidence interval (CI) -2.52 - -0.10, p = 0.034) and percent total weight loss (%TWL) was significantly different at 36 months (5.79, 95%CI 1.22 - 10.37, p = 0.013) and 48 months (6.78, 95%CI 0.93 - 12.63, p = 0.023) after body contouring consultation. Patients who were accepted or rejected did not differ significantly in the maintenance of achieved improvements in comorbidities. CONCLUSION: BCS could not be associated with the maintenance of achieved improvements in comorbidities after bariatric surgery, whereas it could be associated with improved weight loss maintenance at 36 and 48 months after body contouring consultation. This association should be further explored in a large longitudinal study.

Feasibility of Postoperative Home Monitoring Using Video Consultation and Vital Sign Monitoring of Bariatric Patients.

RATIONALE: The length of hospital stay after bariatric surgery has decreased rapidly in recent years to an average of 1 day (one midnight). The transition from a controlled hospital environment to home environment may be a big step for patients. For these patients, home monitoring can be a substitute. METHODS: A pilot study of 84 morbidly obese patients undergoing either laparoscopic Roux-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LGS) was performed. Home monitoring consisted of daily contact via video consultation and measurement of vital signs at home. The primary outcome was feasibility of home monitoring. Secondary outcomes were complications and patient satisfaction measured with a questionnaire (PSQ-18). RESULTS: In 77 of the 84 patients (92%), videoconference was possible on day 1, 74 patients (88%) on day 2 and 76 patients (90%) on day 3. Four patients (5%) were never reached. On day 1, 52 patients (62%) performed all instructed measurements, on day 2, 49 patients (58%) and on day 3, 63 patients (75%). Only 47 out of 84 patients (56%) measured the instructed amount of times on all 3 days. High satisfaction rates were reported in the patients receiving home monitoring. CONCLUSION: Our first experience with home monitoring was disappointing since home monitoring of vital signs had poor compliance and not all patients were able to use the application. Further refinement of the home monitoring tool is needed to increase compliance and utility of the tool.

Validation of a nomogram for predicting survival after resection for adenocarcinoma of the pancreas.

BACKGROUND: Nomograms are statistical tools providing the overall probability of a specific outcome; they have shown better individual discrimination than the tumour node metastasis staging system in several cancers. The pancreatic nomogram, originally developed in the Memorial Sloan-Kettering Cancer Center (MSKCC) in the USA, combines clinicopathological and operative data to predict disease-specific survival at 1, 2 and 3 years from initial resection. METHODS: An external patient cohort from a retrospective pancreatic adenocarcinoma database at the Academic Medical Centre in Amsterdam was used to test the validity of the pancreatic adenocarcinoma nomogram. The cohort included 263 consecutive patients who had surgery between January 1985 and December 2004. RESULTS: Data for all the necessary variables were available for 256 patients (97.3 per cent). At the last follow-up, 35 patients were alive, with a median follow-up of 27 (range 3-114) months. The 1-, 2- and 3-year disease-specific survival rates were 60.8, 30.4 and 16.0 per cent respectively. The nomogram concordance index was 0.61. The calibration analysis of the model showed that the predicted survival did not significantly deviate from the actual survival. CONCLUSION: The MSKCC pancreatic cancer nomogram provided an accurate survival prediction. It may aid in counselling patients and in stratification of patients for clinical trials.

Naphthoimidazoles promote different death phenotypes in Trypanosoma cruzi.

SUMMARY: In a screening of 65 derivatives of natural quinones using bloodstream trypomastigotes of Trypanosoma cruzi, the 3 naphthoimidazoles derived from beta-lapachone - N1, N2 and N3--were selected as the most active. Investigation of their mode of action led to the characterization of mitochondrion, reservosomes and DNA as their main targets, and stimulated further studies on death pathways. Ultrastructural analysis revealed both autophagic (autophagosomes) and apoptotic-like (membrane blebbing) phenotypes. Flow cytometry analysis showed, in N2-treated trypomastigotes, a small increase of phosphatidylserine exposure, and a large increase in the percentage of necrosis, caused by N1 or N2. These death phenotypes were not detected in treated epimastigotes. The strong increase in labelling of monodansyl cadaverine, the inhibition of the death process by wortmannin or 3-methyladenine, the overexpression of ATG genes in treated epimastigotes, together with ultrastructural evidence point to autophagy as the predominant phenotype induced by the naphthoimidazoles. However, there are other pathways occurring concomitantly with variable intensities, justifying the need to detail the molecular features involved.

Evaluation of POSSUM for patients undergoing pancreatoduodenectomy.

BACKGROUND: Comparison of operative morbidity rates after pancreatoduodenectomy between units may be misleading because it does not take into account the physiological variable of the condition of the patients. The aim of the present study was to evaluate the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) for pancreatoduodenectomy patients and to look for risk factors associated with morbidity in a high-volume center. METHODS: Between January 1993 and April 2006, 652 patients underwent a pancreatoduodenectomy, 502 of them for malignant disease. POSSUM performance was evaluated by assessing the "goodness-of-fit" with the linear analysis method. RESULTS: Overall, 332 of the 652 patients (50.9%) had one or more complication after pancreatoduodenectomy, and 9 patients (1.4%) died. POSSUM had a significant lack of fit using goodness-of-fit analysis. In multivariate analysis, one statistically significant factor associated with morbidity and not incorporated in POSSUM (P < 0.05) was identified: ampulla of Vater adenocarcinoma (OR = 1.73, 95% CI: 1.07-2.80). CONCLUSIONS: Overall, there is a lack of calibration of POSSUM among patients who undergo pancreatoduodenectomy.

POSSUM predicts survival in patients with unresectable pancreatic cancer.

BACKGROUND: The aim of this study was to evaluate the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) for patients with unresectable pancreatic cancer and to analyze whether POSSUM can predict the long-term outcome in these patients. Such a scoring system could be useful to aid in the decision between surgical and endoscopic palliation. METHODS: Between January 1993 and December 2004, 241 patients were found to have unresectable pancreatic cancer during exploratory laparotomy and underwent a double bypass procedure consisting of a gastrojejunostomy and a hepaticojejunostomy. RESULTS: Overall, 64 of 240 patients (27%) had one or more complications after bypass surgery and 4 patients (2%) died. POSSUM predicted morbidity in 114 patients (47%). The observed:predicted (O:P) ratio for morbidity was 0.56 and the model had a significant lack of fit (p < 0.001) using a goodness-of-fit analysis. The overall median survival was 7 months. The POSSUM scoring system was, however, an independent predictor of survival in multivariate analysis. CONCLUSIONS: Overall, POSSUM overpredicted morbidity but was an independent predictor of survival.

Pancreas-preserving total duodenectomy versus standard pancreatoduodenectomy for patients with familial adenomatous polyposis and polyps in the duodenum.

BACKGROUND: Pancreas-preserving total duodenectomy (PPTD) was introduced as a replacement for pancreatoduodenectomy (PD) for familial adenomatous polyposis (FAP). This study analysed the results of PPTD in the Netherlands and reviewed the relevant literature. METHODS: All 26 patients who underwent PPTD for FAP in four centres in the Netherlands between January 2000 and January 2007 were compared with a group of 77 patients who had PD for ampulla of Vater adenocarcinoma at one centre during the same interval. RESULTS: Morbidity rates were similar after PPTD for FAP (16 patients, 62 per cent) and PD for ampulla of Vater adenocarcinoma (44 patients, 57 per cent) (P = 0.694). One patient (4 per cent) died after PPTD and two (3 per cent) after PD. A review of the literature, including patients from the present study, found that 71 patients had PPTD, with postoperative morbidity in 36 (51 per cent) and one death (1 per cent). In publications containing a total of 94 patients who underwent PD for FAP, 43 (46 per cent) developed complications and three (3 per cent) died. CONCLUSION: PPTD has similar short-term results to PD in terms of morbidity and mortality.