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1.
N Engl J Med ; 385(15): 1372-1381, 2021 10 07.
Artigo em Inglês | MEDLINE | ID: mdl-34614330

RESUMO

BACKGROUND: Infected necrotizing pancreatitis is a potentially lethal disease that is treated with the use of a step-up approach, with catheter drainage often delayed until the infected necrosis is encapsulated. Whether outcomes could be improved by earlier catheter drainage is unknown. METHODS: We conducted a multicenter, randomized superiority trial involving patients with infected necrotizing pancreatitis, in which we compared immediate drainage within 24 hours after randomization once infected necrosis was diagnosed with drainage that was postponed until the stage of walled-off necrosis was reached. The primary end point was the score on the Comprehensive Complication Index, which incorporates all complications over the course of 6 months of follow-up. RESULTS: A total of 104 patients were randomly assigned to immediate drainage (55 patients) or postponed drainage (49 patients). The mean score on the Comprehensive Complication Index (scores range from 0 to 100, with higher scores indicating more severe complications) was 57 in the immediate-drainage group and 58 in the postponed-drainage group (mean difference, -1; 95% confidence interval [CI], -12 to 10; P = 0.90). Mortality was 13% in the immediate-drainage group and 10% in the postponed-drainage group (relative risk, 1.25; 95% CI, 0.42 to 3.68). The mean number of interventions (catheter drainage and necrosectomy) was 4.4 in the immediate-drainage group and 2.6 in the postponed-drainage group (mean difference, 1.8; 95% CI, 0.6 to 3.0). In the postponed-drainage group, 19 patients (39%) were treated conservatively with antibiotics and did not require drainage; 17 of these patients survived. The incidence of adverse events was similar in the two groups. CONCLUSIONS: This trial did not show the superiority of immediate drainage over postponed drainage with regard to complications in patients with infected necrotizing pancreatitis. Patients randomly assigned to the postponed-drainage strategy received fewer invasive interventions. (Funded by Fonds NutsOhra and Amsterdam UMC; POINTER ISRCTN Registry number, ISRCTN33682933.).

2.
Nutrients ; 13(7)2021 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-34371860

RESUMO

Identification of low muscle mass becomes increasingly relevant due to its prognostic value in cancer patients. In clinical practice, mid-upper arm muscle circumference (MAMC) and bioelectrical impedance analysis (BIA) are often used to assess muscle mass. For muscle-mass assessment, computed tomography (CT) is considered as reference standard. We investigated concordance between CT, BIA, and MAMC, diagnostic accuracy of MAMC, and BIA to detect low muscle mass and their relation with the clinical outcome malnutrition provided with the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF). This cross-sectional study included adult patients with advanced esophageal and gastrointestinal cancer. BIA, MAMC, and PG-SGA-SF were performed. Routine CT-scans were used to quantify psoas muscle index (PMI) and skeletal muscle area. Good concordance was found between CTPMI and both BIAFFMI (fat free mass index) (ICC 0.73), and BIAASMI (appendicular skeletal muscle index) (ICC 0.69) but not with MAMC (ICC 0.37). BIAFFMI (94%), BIAASMI (86%), and MAMC (86%) showed high specificity but low sensitivity. PG-SGA-SF modestly correlated with all muscle-mass measures (ranging from -0.17 to -0.43). Of all patients with low muscle mass, 62% were also classified with a PG-SGA-SF score of ≥4 points. Although CT remains the first choice, since both BIA and MAMC are easy to perform by dieticians, they have the potential to be used to detect low muscle mass in clinical practice.


Assuntos
Antropometria/métodos , Impedância Elétrica , Músculo Esquelético/fisiopatologia , Avaliação Nutricional , Sarcopenia/diagnóstico , Idoso , Braço/diagnóstico por imagem , Braço/fisiopatologia , Índice de Massa Corporal , Estudos Transversais , Neoplasias Esofágicas/complicações , Neoplasias Esofágicas/fisiopatologia , Feminino , Neoplasias Gastrointestinais/complicações , Neoplasias Gastrointestinais/fisiopatologia , Humanos , Masculino , Desnutrição/complicações , Desnutrição/fisiopatologia , Pessoa de Meia-Idade , Músculo Esquelético/diagnóstico por imagem , Estado Nutricional , Estudos Prospectivos , Reprodutibilidade dos Testes , Sarcopenia/etiologia , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X
3.
JAMA Surg ; 156(7): 601-610, 2021 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-33978698

RESUMO

Background: Transthoracic minimally invasive esophagectomy (MIE) is increasingly performed as part of curative multimodality treatment. There appears to be no robust evidence on the preferred location of the anastomosis after transthoracic MIE. Objective: To compare an intrathoracic with a cervical anastomosis in a randomized clinical trial. Design, Setting, and Participants: This open, multicenter randomized clinical superiority trial was performed at 9 Dutch high-volume hospitals. Patients with midesophageal to distal esophageal or gastroesophageal junction cancer planned for curative resection were included. Data collection occurred from April 2016 through February 2020. Intervention: Patients were randomly assigned (1:1) to transthoracic MIE with intrathoracic or cervical anastomosis. Main Outcomes and Measures: The primary end point was anastomotic leakage requiring endoscopic, radiologic, or surgical intervention. Secondary outcomes were overall anastomotic leak rate, other postoperative complications, length of stay, mortality, and quality of life. Results: Two hundred sixty-two patients were randomized, and 245 were eligible for analysis. Anastomotic leakage necessitating reintervention occurred in 15 of 122 patients with intrathoracic anastomosis (12.3%) and in 39 of 123 patients with cervical anastomosis (31.7%; risk difference, -19.4% [95% CI, -29.5% to -9.3%]). Overall anastomotic leak rate was 12.3% in the intrathoracic anastomosis group and 34.1% in the cervical anastomosis group (risk difference, -21.9% [95% CI, -32.1% to -11.6%]). Intensive care unit length of stay, mortality rates, and overall quality of life were comparable between groups, but intrathoracic anastomosis was associated with fewer severe complications (risk difference, -11.3% [-20.4% to -2.2%]), lower incidence of recurrent laryngeal nerve palsy (risk difference, -7.3% [95% CI, -12.1% to -2.5%]), and better quality of life in 3 subdomains (mean differences: dysphagia, -12.2 [95% CI, -19.6 to -4.7]; problems of choking when swallowing, -10.3 [95% CI, -16.4 to 4.2]; trouble with talking, -15.3 [95% CI, -22.9 to -7.7]). Conclusions and Relevance: In this randomized clinical trial, intrathoracic anastomosis resulted in better outcome for patients treated with transthoracic MIE for midesophageal to distal esophageal or gastroesophageal junction cancer. Trial Registration: Trialregister.nl Identifier: NL4183 (NTR4333).

4.
Surg Endosc ; 35(7): 3492-3505, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32681374

RESUMO

BACKGROUND: Time of diagnosis (TOD) of benign esophageal perforation is regarded as an important risk factor for clinical outcome, although convincing evidence is lacking. The aim of this study is to assess whether time between onset of perforation and diagnosis is associated with clinical outcome in patients with iatrogenic esophageal perforation (IEP) and Boerhaave's syndrome (BS). METHODS: We searched MEDLINE, Embase and Cochrane library through June 2018 to identify studies. Authors were invited to share individual patient data and a meta-analysis was performed (PROSPERO: CRD42018093473). Patients were subdivided in early (≤ 24 h) and late (> 24 h) TOD and compared with mixed effects multivariable analysis while adjusting age, gender, location of perforation, initial treatment and center. Primary outcome was overall mortality. Secondary outcomes were length of hospital stay, re-interventions and ICU admission. RESULTS: Our meta-analysis included IPD of 25 studies including 576 patients with IEP and 384 with BS. In IEP, early TOD was not associated with overall mortality (8% vs. 13%, OR 2.1, 95% CI 0.8-5.1), but was associated with a 23% decrease in ICU admissions (46% vs. 69%, OR 3.0, 95% CI 1.2-7.2), a 22% decrease in re-interventions (23% vs. 45%, OR 2.8, 95% CI 1.2-6.7) and a 36% decrease in length of hospital stay (14 vs. 22 days, p < 0.001), compared with late TOD. In BS, no associations between TOD and outcomes were found. When combining IEP and BS, early TOD was associated with a 6% decrease in overall mortality (10% vs. 16%, OR 2.1, 95% CI 1.1-3.9), a 19% decrease in re-interventions (26% vs. 45%, OR 1.9, 95% CI 1.1-3.2) and a 35% decrease in mean length of hospital stay (16 vs. 22 days, p = 0.001), compared with late TOD. CONCLUSIONS: This individual patient data meta-analysis confirms the general opinion that an early (≤ 24 h) compared to a late diagnosis (> 24 h) in benign esophageal perforations, particularly in IEP, is associated with improved clinical outcome.

5.
Int J Surg ; 79: 257-264, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32387211

RESUMO

BACKGROUND: Approximately nine percent of all acute appendectomies are unintentionally performed on a normal appendix. Failure of treatment (negative appendectomy or missed appendicitis) is associated with higher morbidity and mortality when compared to appendectomy for uncomplicated appendicitis. The Laparoscopic APPendicitis (LAPP) score was developed in order to systematically evaluate the appendix for the presence of inflammation. This study aims to determine whether the LAPP score reduces the negative appendectomy rate without missing appendicitis. METHODS: From September 2013 through May 2016, 322 adult patients presenting with a clinical suspicion of acute appendicitis and an indication for diagnostic laparoscopy were included and analyzed in this multicenter prospective validation study. Depending on the LAPP score, the appendix was either removed (n = 300) or left in situ (n = 22). These patients were compared to a historical control group of 584 patients treated at the same hospitals. The appendix was examined by a pathologist and the negative appendectomy rate was calculated. RESULTS: The negative appendectomy rate was significantly lower when the LAPP score was used (4,7% vs. 8,4%; P = 0,034). None of the patients with a negative LAPP score, in which the appendix remained in situ, developed acute appendicitis within three months. There were no significant differences in operation time, complications, or readmissions. Using the LAPP score was associated with significantly higher rates of preoperative radiological imaging (98% vs. 70%; P < 0,001). After adjusting for covariables, including radiological imaging, use of the LAPP score led to fewer treatment failures when compared to not using the LAPP score (OR: 0,48, 95% C.I. 0,251 to 0,914; P = 0,025). CONCLUSION: The LAPP score is a safe and simple tool to reduce the negative appendectomy rate during laparoscopic surgery without missing cases of acute appendicitis.


Assuntos
Apendicectomia/estatística & dados numéricos , Apendicite/cirurgia , Laparoscopia/métodos , Doença Aguda , Adulto , Apendicectomia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
6.
Transplant Direct ; 6(2): e527, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32095513

RESUMO

Graft survival rates after intestinal transplantation (ITx) are still the lowest in comparison to other solid organ transplants. One of the main reasons is the frequent occurrence of acute cellular rejection (ACR). Vedolizumab is an antibody against α4ß7+ integrin involved in gut-homing of T cells which has been approved for inflammatory bowel diseases (IBD). We report its off-label use to treat ACR after ITx. Methods: Following abdominal wall transplantation (AWTx) and ITx, clinical course was followed biochemically. Sequential small intestinal biopsies were taken preceding, during, and after ACR treatment with vedolizumab, following the standard therapy regime for IBD. Rejection was diagnosed histologically, and proinflammatory (α4ß7+, interleukin-17+) and regulatory (FoxP3+) T cells were analyzed by immunohistochemistry. Results: ACR in both the ITx and AWTx resolved upon vedolizumab treatment, which was safe, evidenced by clearing an astrovirus and primary cytomegalovirus infection. Only a slight reduction of α4ß7+ cells in the mucosa was observed, and α4ß7+ and regulatory T cells could still move into the lamina propria upon infection. Conclusions: Vedolizumab is a safe treatment option for ACR after ITx but its mechanism is probably not only based on inhibition of gut-selective T-cell homing.

7.
JAMA ; 323(3): 237-247, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31961419

RESUMO

Importance: For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier surgery could mitigate disease progression, providing better pain control and preserving pancreatic function. Objective: To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes. Design, Setting, and Participants: The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for ≤2 months or weak opioids for ≤6 months) were included. The 18-month follow-up period ended in March 2018. Interventions: There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed. Main Outcomes and Measures: The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 [increasing score indicates more pain severity]). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey [SF-36]); and mortality. Results: Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, -12 points [95% CI, -22 to -2]; P = .02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P = .10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P < .001). Treatment complications (27% vs 25%), mortality (0% vs 0%), hospital admissions, pancreatic function, and quality of life were not significantly different between early surgery and the endoscopy-first approach. Conclusions and Relevance: Among patients with chronic pancreatitis, early surgery compared with an endoscopy-first approach resulted in lower pain scores when integrated over 18 months. However, further research is needed to assess persistence of differences over time and to replicate the study findings. Trial Registration: ISRCTN Identifier: ISRCTN45877994.


Assuntos
Cálculos/terapia , Drenagem , Endoscopia , Litotripsia , Manejo da Dor/métodos , Ductos Pancreáticos/cirurgia , Pancreatite Crônica/terapia , Adulto , Analgésicos Opioides/uso terapêutico , Área Sob a Curva , Cálculos/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Medição da Dor , Pancreatite Crônica/complicações , Pancreatite Crônica/cirurgia
8.
Trials ; 20(1): 239, 2019 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-31023380

RESUMO

BACKGROUND: Infected necrosis complicates 10% of all acute pancreatitis episodes and is associated with 15-20% mortality. The current standard treatment for infected necrotizing pancreatitis is the step-up approach (catheter drainage, followed, if necessary, by minimally invasive necrosectomy). Catheter drainage is preferably postponed until the stage of walled-off necrosis, which usually takes 4 weeks. This delay stems from the time when open necrosectomy was the standard. It is unclear whether such delay is needed for catheter drainage or whether earlier intervention could actually be beneficial in the current step-up approach. The POINTER trial investigates if immediate catheter drainage in patients with infected necrotizing pancreatitis is superior to the current practice of postponed intervention. METHODS: POINTER is a randomized controlled multicenter superiority trial. All patients with necrotizing pancreatitis are screened for eligibility. In total, 104 adult patients with (suspected) infected necrotizing pancreatitis will be randomized to immediate (within 24 h) catheter drainage or current standard care involving postponed catheter drainage. Necrosectomy, if necessary, is preferably postponed until the stage of walled-off necrosis, in both treatment arms. The primary outcome is the Comprehensive Complication Index (CCI), which covers all complications between randomization and 6-month follow up. Secondary outcomes include mortality, complications, number of (repeat) interventions, hospital and intensive care unit (ICU) lengths of stay, quality-adjusted life years (QALYs) and direct and indirect costs. Standard follow-up is at 3 and 6 months after randomization. DISCUSSION: The POINTER trial investigates if immediate catheter drainage in infected necrotizing pancreatitis reduces the composite endpoint of complications, as compared with the current standard treatment strategy involving delay of intervention until the stage of walled-off necrosis. TRIAL REGISTRATION: ISRCTN, 33682933 . Registered on 6 August 2015. Retrospectively registered.


Assuntos
Cateterismo , Drenagem/métodos , Pancreatite Necrosante Aguda/terapia , Tempo para o Tratamento , Cateterismo/efeitos adversos , Cateterismo/mortalidade , Drenagem/efeitos adversos , Drenagem/mortalidade , Estudos de Equivalência como Asunto , Humanos , Tempo de Internação , Estudos Multicêntricos como Assunto , Países Baixos , Pancreatite Necrosante Aguda/diagnóstico , Pancreatite Necrosante Aguda/microbiologia , Pancreatite Necrosante Aguda/mortalidade , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
9.
Am J Surg ; 218(2): 368-373, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30587332

RESUMO

BACKGROUND: Cholecystectomy is considered the standard treatment for acute cholecystitis and symptomatic gallstones. An increasing number of frail elderly patients are being referred for this surgical treatment. A better understanding of surgical outcome in the elderly is needed to improve quality of care. METHODS: A retrospective analysis of 565 patients who underwent cholecystectomy was performed. Focus of the analyses was on postoperative complications and its predictors. RESULTS: The study population was divided in two cohorts; aged <70. More complications were found in patients aged ≥70 years. More elderly patients were admitted to the intensive care, respectively 4.0% and 14.1% (P = 0.045). Hospital mortality was 6% in patients aged ≥70 years vs 0.6% in patients <70. CONCLUSION: In elderly patients, the complication and mortality rate following cholecystectomy is higher than previously reported. For high-risk patients aged ≥70 with cholecystitis, alternative therapies should be considered as a bridge to surgery or definite treatment.


Assuntos
Colecistectomia , Complicações Pós-Operatórias/epidemiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
11.
Lancet ; 391(10115): 51-58, 2018 01 06.
Artigo em Inglês | MEDLINE | ID: mdl-29108721

RESUMO

BACKGROUND: Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes. METHODS: In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711. FINDINGS: Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio [RR] 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine [18%] patients in the endoscopy group vs six [13%] patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint. INTERPRETATION: In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference. FUNDING: The Dutch Digestive Disease Foundation, Fonds NutsOhra, and the Netherlands Organization for Health Research and Development.


Assuntos
Desbridamento , Drenagem , Endoscopia do Sistema Digestório , Pancreatite Necrosante Aguda/cirurgia , Cirurgia Vídeoassistida , Idoso , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Países Baixos , Resultado do Tratamento
12.
Pancreas ; 46(4): 518-523, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28196022

RESUMO

OBJECTIVES: Percutaneous catheter drainage (PCD) is often the first invasive treatment step for infected necrotizing pancreatitis. A proactive PCD strategy, including frequent and early drain revising and upsizing, may reduce the need for surgical necrosectomy and could improve outcomes, but data are lacking. METHODS: Necrotizing pancreatitis patients were identified from in-hospital databases (2004-2014). Patients with primary PCD for infected necrotizing pancreatitis were included. Outcomes of patients from 1 center using a proactive PCD strategy were compared with 3 standard strategy centers. RESULTS: In total, 369 (25.9%) of 1427 patients received a diagnosis of necrotizing pancreatitis, and 117 (31.7%) of 369 patients underwent primary PCD for infected necrosis: 42 in the proactive group versus 75 in the standard group. Patients in the proactive group had more drain-related procedures (median, 3; interquartile range [IQR], 2-4; versus 2; IQR, 1-2; P < 0.001) and larger final drain sizes (median, 16F; IQR, 14F-20F; versus 14F; IQR, 12F-14F; P < 0.001). Fewer patients underwent additional necrosectomy in the proactive group, 12 (28.6%) versus 39 (52.0%) (adjusted odds ratio, 0.349; 95% confidence interval, 0.137-0.889; P = 0.027), with similar hospital stay and mortality. CONCLUSIONS: A proactive PCD strategy is associated with reduced need for necrosectomy in infected necrotizing pancreatitis, compared with standard PCD, with similar clinical outcomes.


Assuntos
Drenagem/métodos , Pancreatite Necrosante Aguda/terapia , Adulto , Idoso , Cateteres , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Análise de Regressão , Estudos Retrospectivos , Resultado do Tratamento
13.
Transpl Int ; 30(2): 162-169, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27864901

RESUMO

Little is known about the actual kidney graft temperature during the 2nd warm ischemia time (WIT2). We aimed to determine the actual temperature course of the WIT2, with emphasis on the 15 °C metabolic threshold. Data of 152 consecutive adult living donor kidney transplantations were collected. The mean WIT2 was 41.3 ± 10.1 (SD) minutes with a temperature of 5.4 °C at baseline which gradually increased to 13.7, 17.4, and 20.2 °C after 10, 20, and 30 min, respectively. The percentage of kidneys with a temperature of 15 °C or higher was 81.2% after 20 min and 97.5% after 30 min. Duration of surgery (95% CI: -0.017 to -0.002, P = 0.02), multiple veins (95% CI: 0.0003-2.720, P = 0.05) and WIT2 (95% CI: 0.016-0.099, P = 0.006) were associated with a rapid temperature increase. No correlation could be determined between a rapid temperature rise and diminished graft function. This study showed a rapid increase in kidney temperature during WIT2, wherein the 15 °C threshold was reached within 20 min in more than 80% of the patients.


Assuntos
Transplante de Rim , Temperatura , Coleta de Tecidos e Órgãos , Isquemia Quente , Adulto , Idoso , Feminino , Humanos , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
14.
Transplant Direct ; 2(1): e55, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27500248

RESUMO

The number of organ donors is limited by many contraindications for donation and poor quality of potential organ donors. Abdominal infection is a generally accepted contraindication for donation of abdominal organs. We present a 43-year-old man with lethal brain injury, blunt abdominal trauma, and intestinal perforation. After withdrawal of life-sustaining treatment and circulatory arrest, a minilaparotomy confirmed abdominal contamination with intestinal content. After closure of the abdomen, organs were preserved with in situ preservation with an aortic cannula inserted via the femoral artery. Thereafter, the kidneys were procured via bilateral lumbotomy to reduce the risk of direct bacterial contamination; lungs were retrieved following a standard practice. There was no bacterial or fungal growth in the machine preservation fluid of both kidneys. All organs were successfully transplanted, without postoperative infection, and functioned well after 6 months. We hereby show that direct contamination of organs can be avoided with the use of in situ preservation and retroperitoneal procurement. Intestinal perforation is not an absolute contraindication for donation, although the risk of bacterial or fungal transmission has to be evaluated per case.

15.
Best Pract Res Clin Gastroenterol ; 30(2): 263-80, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27086890

RESUMO

Short bowel syndrome (SBS) is a serious condition with considerable morbidity and mortality. When treatment with parenteral nutrition fails and life-threatening complications occur, autologous intestinal reconstruction (AIR) should be considered before intestinal transplantation (ITx). Single or combined ITx should be reserved for patients with severe liver disease and as last resort in the treatment of SBS. Longitudinal intestinal lengthening and tailoring (LILT) has proven its value in AIR, but its availability depends on the expertise of the surgeons. Serial transverse enteroplasty (STEP) has similar success rates as LILT and fewer patients progress to ITx. STEP is also applicable at small bowel dilatation in ultra-short bowel syndrome. The scope may be widened when duodenal dilatation can be treated as well. Spiral intestinal lengthening and tailoring (SILT) is a promising alternative. More research is needed to confirm these findings. Therefore we suggest an international data registry for all intestinal lengthening procedures.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Síndrome do Intestino Curto/cirurgia , Humanos , Nutrição Parenteral
16.
ANZ J Surg ; 86(5): 386-90, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-24846566

RESUMO

BACKGROUND: Gastric cancer is one of the leading causes of cancer-related deaths worldwide. Large Western trials have shown overall 5-year survival rates of 36-47%. Surgical resection remains the mainstay of curative treatment. We report the outcomes at a single Australian centre. METHODS: We analysed a prospectively kept database of patients after gastric resection for adenocarcinoma at a tertiary Australian hospital. Disease-specific survival (DSS) was considered the primary end-point. RESULTS: One hundred and seventy-three patients underwent gastrectomy with curative intent. Average age at diagnosis was 68, with 72% being male patients. One hundred patients had a total gastrectomy and 73 had subtotal. The average number of lymph nodes examined was 23. All patients were discussed in a multidisciplinary setting. Perioperative morbidity rate was 31%, with 3.5% 30-day mortality. Five-year DSS was 67.4% with 91.2%, 76.7% and 39.3% for stage 1, 2 and 3 disease, respectively. Five-year overall survival considering death from any cause was 47.4%. CONCLUSION: This large Australian single centre study shows outcomes equivalent to other Western series and approaches that of Japanese data. High survival figures can be achieved when gastrectomy is performed by an experienced institution through a multi-modality approach with adequate staging, aggressive and appropriate resection and selective use of perioperative therapy.


Assuntos
Adenocarcinoma/terapia , Estadiamento de Neoplasias , Neoplasias Gástricas/terapia , Adenocarcinoma/diagnóstico , Adenocarcinoma/epidemiologia , Terapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Morbidade/tendências , New South Wales/epidemiologia , Prognóstico , Estudos Retrospectivos , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/epidemiologia , Taxa de Sobrevida/tendências
17.
Gastric Cancer ; 18(2): 256-61, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24858392

RESUMO

BACKGROUND: Survival after curative gastrectomy for gastric cancer varies depending on region. The 5-year survival rates in Western trials reach 36-47% compared with 40-60% in Japanese studies. We analyzed the outcomes of Asian and non-Asian patients at a single Australian institution. METHODS: We analyzed a prospectively kept database of patients following gastric resection between 1994 and 2010 at a tertiary Australian hospital. Overall survival was the primary endpoint. RESULTS: A total of 160 patients underwent a R0 gastrectomy with curative intent, of whom 26 (16%) were of Asian descent. Asian patients had a significantly younger age at diagnosis (60 ± 16 vs. 70 ± 11, p < 0.05) and longer overall survival (log-rank p = 0.018). Poor prognostic factors common to both groups included increased tumor length, higher T-score, higher LN ratio, poor tumor differentiation, and the presence of perineural or perivascular invasion. Multivariate analysis showed that non-Asian patients, higher T-score, higher N-score, and perivascular involvement were all independent predictors of poorer outcome. CONCLUSIONS: This study shows superior overall survival in Asian patients despite similar clinicopathological and treatment data. The younger age at diagnosis in Asian patients may suggest a different disease process between ethnicities. Targeted therapies based on population-specific tumor biology may potentially be beneficial.


Assuntos
Adenocarcinoma/mortalidade , Grupo com Ancestrais do Continente Asiático/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Gastrectomia/mortalidade , Neoplasias Gástricas/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias , Prognóstico , Estudos Prospectivos , Neoplasias Gástricas/patologia , Neoplasias Gástricas/cirurgia , Taxa de Sobrevida
18.
Am J Clin Nutr ; 101(1): 79-86, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25527753

RESUMO

BACKGROUND: Home parenteral nutrition (HPN) and intestinal transplantation (ITx) are the 2 treatment options for irreversible intestinal failure (IF). OBJECTIVE: This study simulated the disease course of irreversible IF and both of these treatments--HPN and ITx--to estimate the cost-effectiveness of ITx. DESIGN: We simulated IF treatment in adults as a discrete event model with variables derived from the Dutch Registry of Intestinal Failure and Intestinal Transplantation, the Intestinal Transplant Registry, hospital records, the literature, and expert opinions. Simulated patients were enrolled at a rate of 40/mo for 10 y. The maximum follow-up was 40 y. Survival was simulated as a probabilistic function. ITx was offered to 10% of patients with <12 mo of remaining life expectancy with HPN if they did not undergo ITx. Costs were calculated according to Dutch guidelines, with discounting. We evaluated the cost-effectiveness of ITx by comparing models conducted with and without ITx and by calculating the cost difference per life-year gained [incremental cost-effectiveness ratio (ICER)]. RESULTS: The average survival was 14.6 y without ITx and 14.9 y with ITx. HPN costs were €13,276 for treatment introduction, followed by €77,652 annually. The costs of ITx were ∼€73,000 during the first year and then €13,000 annually. The ICER was €19,529 per life-year gained. CONCLUSION: Our simulations show that ITx slightly improves survival of patients with IF in comparison with HPN at an additional cost of €19,529 per life-year gained.


Assuntos
Enteropatias/cirurgia , Intestinos/transplante , Modelos Biológicos , Centros Médicos Acadêmicos , Adulto , Estudos de Coortes , Simulação por Computador , Análise Custo-Benefício , Progressão da Doença , Seguimentos , Custos de Cuidados de Saúde , Humanos , Enteropatias/economia , Enteropatias/mortalidade , Enteropatias/fisiopatologia , Intestinos/fisiopatologia , Registros Médicos , Países Baixos , Nutrição Parenteral Total no Domicílio/economia , Sistema de Registros , Índice de Gravidade de Doença , Análise de Sobrevida
19.
BMC Gastroenterol ; 13: 161, 2013 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-24274589

RESUMO

BACKGROUND: Infected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes. METHODS/DESIGN: The TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs. DISCUSSION: The TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.


Assuntos
Infecções Bacterianas/cirurgia , Pancreatite Necrosante Aguda/cirurgia , Infecções Bacterianas/complicações , Desbridamento/métodos , Drenagem/métodos , Endoscopia/métodos , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Países Baixos , Pancreatite Necrosante Aguda/complicações , Resultado do Tratamento
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