Reduction of in-hospital mortality following regionalisation of pancreatic surgery in the south-east of the Netherlands.

BACKGROUND: In the late nineties of the former century, surgery for pancreatic and peri-ampullary cancer in the southern part of The Netherlands was performed mainly in low-volume hospitals (<5 resections/year). Results reported by the Comprehensive Cancer Center South (CCCS) in 2005 revealed the clearly disappointing results of this practice. The former stimulated the regionalisation of pancreatic surgery by 3 collaborating surgical units into one non-academic teaching hospital in the eastern part of the CCCS-region starting from July 2005. METHODS: All of the 76 patients in this regional cohort group in whom a resection of a (peri-)pancreatic tumour was performed with curative intent have been followed up prospectively. The results of surgical morbidity and in-hospital mortality were compared with the results of the CCCS cohort group which were reported previously. RESULTS: Ever since the regionalisation the annual number of patients undergoing resection of a pancreatic tumour increased from 10 to 33, resulting in a total number of 76 patients. Post-operative complications, reoperation rate and in-hospital mortality decreased significantly to 34.2%, 18.4% and 2.6% respectively, as compared to 71.9%, 37.8 and 24.4% in the time period before regionalisation (p < 0.01). CONCLUSION: These unique comparative prospective data derived from daily practice in a collaborative surgical region in The Netherlands (CCCS) support the need for centralisation of pancreatic surgery in order to improve standard of care in pancreatic surgery. This can be achieved by collaboration in a large regional hospital.

Minimally invasive femoral nail extraction.

INTRODUCTION: Case report about a minimally invasive technique for removal of a femoral antegrade nail (FAN). Femoral nails are introduced by minimally invasive techniques, but are often removed with more invasive surgery. MATERIALS AND METHODS: Four cases of young patients are described in whom the femoral nail was removed after consolidation by a minimally invasive extraction technique at the trochanteric site. By using a threaded wire for locating the proximal entrance of the femoral nail followed by reaming over the wire, the entrance of the nail in the trochanteric region is freed. Then the extraction bolt can be placed over the wire and the nail can be extracted through the same incision as it was inserted in, without enlarging the incision. DISCUSSION: This case report discusses a technique for minimally invasive femoral nail extraction, not the necessity of removing nails. Leaving out the endcap at the initial operation is the only preoperative condition, since the endcap blocks the entrance of the nail. This operation is done with fluoroscopic guidance. The difficult part is the reaming. The reamer must not be damaged when approaching the nail entrance. This minimally invasive femoral nail extraction technique is applicable for various types of femoral nails. CONCLUSION: Minimally invasive extraction of femoral nails is possible and needs more attention. The level of evidence is a level IV case series.

Granulocyte-colony stimulating factor in the prevention of postoperative infectious complications and sub-optimal recovery from operation in patients with colorectal cancer and increased preoperative risk (ASA 3 and 4). Protocol of a controlled clinical trial developed by consensus of an international study group. Part three: individual patient, complication algorithm and quality manage.

GENERAL DESIGN: Presentation of a new type of a study protocol for evaluation of the effectiveness of an immune modifier (rhG-CSF, filgrastim): prevention of postoperative infectious complications and of sub-optimal recovery from operation in patients with colorectal cancer and increased preoperative risk (ASA 3 and 4). A randomised, placebo controlled, double-blinded, single-centre study is performed at an University Hospital (n = 40 patients for each group). This part presents the course of the individual patient and a complication algorithm for the management of anastomotic leakage and quality management. OBJECTIVE: In part three of the protocol, the three major sections include: The course of the individual patient using a comprehensive graphic display, including the perioperative period, hospital stay and post discharge outcome. A center based clinical practice guideline for the management of the most important postoperative complication--anastomotic leakage--including evidence based support for each step of the algorithm. Data management, ethics and organisational structure. CONCLUSIONS: Future studies with immune modifiers will also fail if not better structured (reduction of variance) to achieve uniform patient management in a complex clinical scenario. This new type of a single-centre trial aims to reduce the gap between animal experiments and clinical trials or--if it fails--at least demonstrates new ways for explaining the failures.

Management of left-sided colonic obstruction by subtotal colectomy and ileocolic anastomosis.

OBJECTIVE: To assess complications and functional results of emergency subtotal colectomy with ileocolic anastomosis for acute left-sided colonic obstruction. DESIGN: Retrospective study. SETTING: University hospital, Netherlands. SUBJECTS: 37 patients with acute left-sided colonic obstruction. INTERVENTIONS: Emergency subtotal colectomy with immediate anastomosis (n = 20), Hartmann's procedure (n = 13) or double-loop transverse colostomy (n = 4). MAIN OUTCOME MEASURES: Mortality, morbidity, duration of hospital stay, frequency of defecation, and continence. RESULTS: Morbidity after subtotal colectomy was 10% (n = 2) and mortality 0. There was one anastomotic dehiscence that required a temporary ileostomy. Mean hospital stay was 15 days (range 10-31). All had adequate continence. After 6 weeks mean frequency of defecation was 3/24 hrs (range 2-6). 9 patients died within 2 years of metastatic disease. CONCLUSIONS: Subtotal colectomy with ileocolic anastomosis is a suitable procedure for treating left-sided colonic obstruction provided that pelvic floor function is adequate and a skilled surgeon is available.

SIRS, MODS and tertiary peritonitis.

Some patients with peritonitis develop a septic response without a detectable infective focus. It is suggested that an immunological dysfunction is responsible for this so called tertiary peritonitis. The role of the gastrointestinal tract in the development of multiple organ dysfunction syndrome (MODS) is discussed. In patients with tertiary peritonitis treatment should be directed towards restoration of the immunological balance, which is probably more important than the elimination of microorganisms with antibiotics.

Metastatic malignant melanoma to the gastrointestinal tract.

Two cases of gastrointestinal metastasis of malignant melanoma are reported. We describe diagnosis and treatment of these metastases.

Training in general surgery in The Netherlands.

Training in surgery has been for ages a matter of master-fellow relation between a qualified surgeon and a young physician who wishes to become a surgeon. Nowadays, however it has become a well-structured system of selection, education, training and registration, all under the responsibility of the Association of Surgeons of The Netherlands.