The DULK (Dutch leakage) and modified DULK score compared: actively seek the leak.

AIM: A standardized postoperative score, the DULK (Dutch leakage) score, has been demonstrated to be a useful clinical tool in the diagnosis of anastomotic leakage. It is complicated, however, and a simplification (the modified DULK score) based on fewer parameters derived from multiple logistic regression analyses has been developed. These include clinical condition, abdominal pain not localized at the wound, C-reactive protein level and respiratory rate. The accuracy of each was compared. METHOD: Data of all patients from five Dutch centres operated on between 16 October 2007 and 1 November 2009 with an anastomosis in the colon or rectum were entered into a prospectively maintained database. RESULTS: In total, 782 patients were included of whom 81 (10.4%) had a clinically relevant anastomotic leakage. The DULK score gave an overall sensitivity of 97% for anastomotic leakage, overall specificity of 53%, a positive predictive value (PPV) of 16% and a negative predictive value (NPV) of 99%. The modified DULK score used clinical condition, abdominal pain not localized at the wound, C-reactive protein level and respiratory rate. With at least one parameter present, overall sensitivity was 97%, overall specificity 57%, PPV 17% and NPV 99.5%. With at least two points PPV was 41% and with three points 57%. CONCLUSION: Both the original and modified DULK scores are useful for the early diagnosis of clinically relevant anastomotic leakage. The modified DULK score offers the benefit of fewer parameters and so can easily be used in a clinical environment to estimate the likelihood of anastomotic leakage. However, the early diagnosis of anastomotic leakage remains difficult.

Improved diagnosis and treatment of anastomotic leakage after colorectal surgery.

AIM: This study aimed at testing feasibility of a standardised postoperative surveillance protocol to reduce delay in the diagnosis of anastomotic leakage (AL) and, subsequently, mortality. MATERIAL AND METHODS: Patient files of patients operated between 1996 and 1999 were reviewed and used as historical controls (n=1066). As a result, a protocol for standardised post-operative surveillance was designed using easily accessible, clinical parameters. Between August 2004 and August 2006, all operated patients with a colorectal anastomosis (n=223) were prospectively subjected to this standardised surveillance. RESULTS: AL was diagnosed in 7.0% of patients in the historical control group and 9.4% of patients in the standardised surveillance group. AL mortality decreased from 39% to 24% with standardised surveillance (n.s.). The delay in AL diagnosis was significantly reduced during standardised surveillance (4 versus 1.5 days, p=0.01), which was confirmed in the multivariate analysis. CONCLUSION: With non-standardised postoperative monitoring, AL was associated with a high mortality rate. Patients were subjected to several additional tests, which were not primarily useful to diagnose AL. Standardised postoperative surveillance for AL was introduced successfully and resulted in a shorter delay between the first signs and symptoms to the confirmation of AL.

[Diversity of complaints in manifesting carcinoma of the gallbladder]. / Diversiteit in klachten bij manifestatie van het galblaascarcinoom.

A man of 47 years with hypercholesterolaemia had no complaints but the family doctor suspected cholecystolithiasis because of abnormal results of the haematological study. Ultrasonography of the abdomen revealed a polyp in the gallbladder. The patient underwent laparoscopic cholecystectomy. Pathological examination revealed that the polyp was a carcinoma. No evidence for a recurrence was found during a return visit after 2 years. A woman of 74 years was admitted to the hospital due to persistent rectal bleeding. She had fever, loss of appetite, nausea and weight loss. A bleeding duodenal ulcer was identified during gastroduodenoscopy. Laparotomy was performed due to haemodynamic instability. During the operation an abnormal gallbladder was found with infiltration in and perforation of the duodenum. The gallbladder was resected and the perforation of the duodenum was sutured. Pathological examination revealed carcinoma of the gallbladder. A palliative policy was adhered to; the patient died 1 month later. Carcinoma ofthe gallbladder is an uncommon but highly fatal malignancy. Several risk factors have been identified and treatment is primarily surgical.