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.

Screening for mobility disorders by the Mobility Control subscale of the short version of the Sickness Impact Profile.

OBJECTIVE: To test the usefulness of the Mobility Control subscale (MC scale) of the short version of the Sickness Impact Profile (SIP68) as a simple self-administered questionnaire for screening mobility disorders in a population of independent living elderly. DESIGN: The SIP68-MC scale was compared with the results of one functional test as independent criteria. SUBJECTS AND SETTING: A group of 81 people of 70 years and older was selected from a potential population of over 200 people. All were independent living elderly persons selected from a general practice. INTERVENTIONS: The short version of the Sickness Impact Profile and questions about falling last year were applied. Three functional tests were carried out: walking 10 metres, get up and sit down in a chair five times and a test for standing balance. A trained observer rated all tests. RESULTS: It is shown that the sensitivity of the MC scale (cut-off point: 1) with the total functional score is 91%, with a relative low specificity (59%). The relationship between the SIP-MC score and falling frequency is significant when there is a falling frequency equal to or more than two times a year. CONCLUSION: It is concluded that the MC scale is a useful test for screening mobility disorders in the elderly.

Liver cell proliferation after partial hepatectomy in rats with liver metastases.

OBJECTIVE: To validate proliferating cell nuclear antigen (PCNA) expression and flow cytometry as proliferation markers in regenerating rat liver containing metastases. STUDY DESIGN: Rats containing colorectal liver metastases were killed at various days after 70% partial hepatectomy or a sham operation. [3H]thymidine and 5-bromo-2'deoxyuridine (BrdU) incorporation, PCNA expression and flow cytometry were used to evaluate liver cell proliferation. RESULTS: The assessment of proliferating liver cells by PCNA expression and BrdU incorporation was more reliable than autoradiography. PCNA expression correlated well with BrdU incorporation (r = .68, P = .003) and autoradiography (r = .57, P = .02) in regenerating liver. BrdU incorporation and PCNA expression were higher in hepatectomized rats as compared to sham-operation rats at days 1-4 after hepatectomy. Flow cytometry of propidium-stained nuclei from livers of hepatectomized rats showed a higher proportion of S-phase nuclei as compared to S-phase nuclei in control rats. The correlation coefficients of the number of S-phase nuclei, BrdU-positive nuclei and PCNA-positive nuclei were .39 (P < .02) and .56 (P < .0005), respectively. CONCLUSION: Flow cytometry and PCNA expression are simple and reliable methods of studying proliferation in metastases containing rat liver after partial hepatectomy.

Serum obtained from rats after partial hepatectomy enhances growth of cultured colon carcinoma cells.

Tumour-bearing rats were randomized to a 70% partial hepatectomy or a sham operation. At days 1, 3 or 14, portal and systemic serum was obtained and colon carcinoma cells were cultured in the presence of 5, 10, 20 or 50% serum. Proliferation and epidermal growth factor receptor (EGFr) expression was measured in tumour cells. Proliferation was 25-40% higher in tumour cells cultured with portal serum after hepatectomy than after sham operation when using serum obtained at day 3, but not days 1 and 14 after operation. In cultures with serum obtained at day 14 after operation CC 531 cells showed a 30% higher proliferation rate with systemic hepatectomy serum than CC 531 cells with sham systemic serum. These effects were not mediated by a change in EGFr mRNA and protein levels as the used colon carcinoma cells did not reveal EGFr activity by any of the three detection methods used.

Surgical treatment of giant haemangioma of the liver.

BACKGROUND: The treatment of giant symptomatic haemangioma of the liver is still controversial. This retrospective study reviewed the results of surgical treatment. METHODS: Twenty-eight patients with symptomatic giant haemangioma of the liver were treated by liver resection (n = 24) or liver transplantation (n = 4). The median diameter of the haemangiomas was 11 (range 5-20) cm. RESULTS: Complications occurred in five of the 24 patients treated by partial liver resection, although all survived and remain alive and well more than 2 years after surgery. In six patients there was residual haemangioma in the liver remnant which did not enlarge during the 2-year follow-up. In four patients the haemangioma was considered irresectable and liver transplantation was performed. One died after a 'two-stage' liver transplantation; the remaining three patients are alive and well, 1, 4 and 9 years after transplantation. CONCLUSION: Liver resection is the treatment of choice for giant haemangioma of the liver where possible. In selected cases liver transplantation is indicated.

Fracture of the thoracic spine with paralysis and esophageal perforation.

A 17-year-old young man presented with a highly unstable fracture dislocation of the third and fourth thoracic vertebrae with neurological deficit, in which the fractured spine had perforated the thoracic esophagus. Open reduction and internal fixation of the spinal fractures in combination with aggressive treatment of the mediastinitis caused by esophageal perforation, consisting of two re-thoracotomies, was performed. Two years after the accident, the patient had recovered well. The neurological deficit had recovered, and there were no difficulties with swallowing.

The effect of partial hepatectomy on tumor growth in rats: in vivo and in vitro studies.

Residual tumor in the remnant liver after partial hepatectomy (PH) for colorectal liver metastases is a serious clinical problem. This fact is reflected by the high number of recurrences after potentially curative liver resections. Liver regeneration, it appears, might influence the growth of remaining micrometastases in the liver. Using rats, we demonstrated enhancement of growth of a syngeneic colon carcinoma (CC 531) in the remnant liver after 70% PH. Fourteen days after PH, tumor weights in the liver were twice as high as those of sham-operated rats. This difference in tumor weight was not found in extrahepatic tumors. In vitro experiments did not show stimulation of cultured CC 531 cells by portal or systemic serum withdrawn 24 hours or 14 days after hepatectomy as compared with sera obtained after sham operation. Co-cultures of CC 531 cells and hepatocytes (in ratios of 1:10 or 1:1) demonstrated a higher 3H-thymidine incorporation than was the case in separately cultured cells. In co-cultures, bromodeoxyuridine (BrdU) incorporation in DNA was found primarily in CC 531 cells and rarely in hepatocytes. Cell density appeared to be of influence on 3H-thymidine incorporation in co-cultures. Hepatocytes were found to have a stimulating effect on CC 531 cells in low-density cultures, whereas high-density cultures exhibited an inhibiting effect after a culture time of 120 hours. These results show that, depending on cell density in co-cultures, a paracrine stimulating influence of hepatocytes on this type of colon carcinoma cells (CC 531) might be responsible for the increased tumor growth in vivo.

Inferior vena cava obstruction after orthotopic liver transplantation.

Post-operative inferior vena cava (IVC) obstruction is reported as an uncommon complication after orthotopic liver transplantation (OLT). We report 6 cases after 245 OLT's in the period between March '79 and December '92. Compression or torsion of the IVC or a technical problem were underlying causes. Oligo-anuria was observed in almost all patients and was probably caused by renal vein hypertension. Doppler ultrasound has become an important tool for the diagnosis of this complication. Operative treatment was performed in almost all cases in order to correct causative factors. Thrombi above or at the level of the upper anastomosis of the IVC should be removed via the right atrium, during cardio-pulmonary bypass, in order to prevent pulmonary embolism. Thrombi in the IVC caudal to the liver can be removed by cavotomy with high positive end expiratory pressure ventilation.