Search

Background Quality assurance is acknowledged as a crucial factor in the assessment of oncological surgical care. The aim of this study was to develop a composite measure of multiple outcome parameters defined as ‘textbook outcome’, to assess quality of care for patients undergoing oesophagogastric cancer surgery. Methods Patients with oesophagogastric cancer, operated on with the intent of curative resection between 2011 and 2014, were identified from a national database (Dutch Upper Gastrointestinal Cancer Audit). Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. Hospital variation in textbook outcome was analysed after adjustment for case-mix factors. Results In total, 2748 patients with oesophageal cancer and 1772 with gastric cancer were included in this study. A textbook outcome was achieved in 29·7 per cent of patients with oesophageal cancer and 32·1 per cent of those with gastric cancer. Adjusted textbook outcome rates varied from 8·5 to 52·4 per cent between hospitals. The outcome parameter ‘at least 15 lymph nodes examined’ had the greatest negative impact on a textbook outcome both for patients with oesophageal cancer and for those with gastric cancer. Conclusion Most patients did not achieve a textbook outcome and there was wide variation between hospitals.

Zika virus (ZIKV) is an emerging virus involved in recent outbreaks in Brazil. The association between the virus and Guillain-Barré syndrome (GBS) or congenital disorders has raised a worldwide concern. In this work, we investigated a rare Zika case, which was associated with GBS and spontaneous retained abortion. Using specific anti-ZIKV staining, the virus was identified in placenta (mainly in Hofbauer cells) and in several fetal tissues, such as brain, lungs, kidneys, skin and liver. Histological analyses of the placenta and fetal organs revealed different types of tissue abnormalities, which included inflammation, hemorrhage, edema and necrosis in placenta, as well as tissue disorganization in the fetus. Increased cellularity (Hofbauer cells and TCD8+ lymphocytes), expression of local pro-inflammatory cytokines such as IFN-γ and TNF-α, and other markers, such as RANTES/CCL5 and VEGFR2, supported placental inflammation and dysfunction. The commitment of the maternal-fetal link in association with fetal damage gave rise to a discussion regarding the influence of the maternal immunity toward the fetal development. Findings presented in this work may help understanding the ZIKV immunopathogenesis under the rare contexts of spontaneous abortions in association with GBS.

Background Studies comparing laparoscopic and open appendicectomy are difficult to interpret owing to several types of bias, and the results often seem of limited clinical importance. National audits can be valuable to provide insight into outcomes following appendicectomy at a population level. Methods A prospective, observational, resident-led, nationwide audit was carried out over a period of 2 months, including all consecutive adult patients who had surgery for suspected acute appendicitis. Complications after laparoscopic and open appendicectomy were compared by means of logistic regression analysis; subgroup analyses were performed for patients with complicated appendicitis. Results A total of 1975 patients were included from 62 participating Dutch hospitals. A normal appendix was seen in 3·3 per cent of patients. Appendicectomy was performed for acute appendicitis in 1378 patients, who were analysed. All but three patients underwent preoperative imaging. Laparoscopy was used in 79·5 per cent of patients; the conversion rate was 3·4 per cent. A histologically normal appendix was found in 2·2 per cent. Superficial surgical-site infection was less common in the laparoscopic group (odds ratio 0·25, 95 per cent c.i. 0·14 to 0·44; P < 0·001). The rate of intra-abdominal abscess formation was not significantly different following laparoscopic or open surgery (odds ratio 1·71, 0·80 to 3·63; P = 0·166). Similar findings were observed in patients with complicated appendicitis. Conclusion Management of acute appendicitis in the Netherlands is preferably performed laparoscopically, characterized by a low conversion rate. Fewer superficial surgical-site infections occurred with laparoscopy, although the rate of abscess formation was no different from that following open surgery. A low normal appendix rate is the presumed effect of a mandatory preoperative imaging strategy.

Background: Complex surgical procedures such as esophagectomy and gastrectomy for cancer are associated with substantial morbidity and mortality. The purpose of this study was to evaluate trends in postoperative morbidity, mortality, and associated failure-to-rescue (FTR), in patients who underwent a potentially curative resection for esophageal or gastric cancer in the Netherlands, and to investigate differences between the two groups. Methods: All patients with esophageal or gastric cancer who underwent a potentially curative resection, registered in the Dutch Upper GI Cancer Audit (DUCA) between 2011 and 2014, were included. Primary outcomes were (major) postoperative complications, postoperative mortality and FTR. To investigate groups' effect on the outcomes of interest a mixed model was used. Results: Overall, 2644 patients with esophageal cancer and 1584 patients with gastric cancer were included in this study. In patients with gastric cancer, postoperative mortality (7.7% in 2011 vs. 3..8% in 2014) and FTR (38% in 2011 and 19% in 2014) decreased significantly over the years. The adjusted risk of developing a major postoperative complication was lower (OR 0.54; 95% CI 0.42-0.70), but the risk of FTR was higher (OR 1.85; 95% CI 1.05-3.27) in patients with gastric cancer compared to patients with esophageal cancer. Conclusion: Once a postoperative complication occurred, patients with gastric cancer were more likely to die compared to patients with esophageal cancer. Underlying mechanisms like patient selection, and differences in structure and organization of care should be investigated. Next to morbidity and mortality, failure-to-rescue should be considered as an important outcome measure after esophagogastric cancer resections. (C) 2017 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved

Background In 2011, the Dutch Upper Gastrointestinal Cancer Audit (DUCA) group began nationwide registration of all patients undergoing surgery with the intention of resection for oesophageal or gastric cancer. The aim of this study was to describe the initiation and implementation of this process along with an overview of the results. Methods The DUCA is part of the Dutch Institute for Clinical Auditing. The audit provides (surgical) teams with reliable, weekly updated, benchmarked information on process and (case mix-adjusted) outcome measures. To accomplish this, a web-based registration was designed, based on a set of predefined quality measures. Results Between 2011 and 2014, a total of 2786 patients with oesophageal cancer and 1887 with gastric cancer were registered. Case ascertainment approached 100 per cent for patients registered in 2013. The percentage of patients with oesophageal cancer starting treatment within 5 weeks of diagnosis increased significantly over time from 32·5 per cent in 2011 to 41·0 per cent in 2014 (P < 0·001). The percentage of patients with a minimum of 15 examined lymph nodes in the resected specimen also increased significantly for both oesophageal cancer (from 50·3 per cent in 2011 to 73·0 per cent in 2014; P < 0·001) and gastric cancer (from 47·5 per cent in 2011 to 73·6 per cent in 2014; P < 0·001). Postoperative mortality remained stable (around 4·0 per cent) for patients with oesophageal cancer, and decreased for patients with gastric cancer (from 8·0 per cent in 2011 to 4·0 per cent in 2014; P = 0·031). Conclusion Nationwide implementation of the DUCA has been successful. The results indicate a positive trend for various process and outcome measures.

Although the incidence of perforation after endoscopic procedures of the colon is low, the rising number of procedures could pose relevant health problems. Recognizing risk factors and optimizing treatment may reduce perforation incidence and the probability of (severe) complications. This study aimed to determine perforation frequency and the management of endoscopic colonoscopic perforation. A retrospective review of patient records was performed for all patients with iatrogenic colonic perforations after sigmoido/colonoscopy between 1990 and 2005. The patients’ demographic data, endoscopic procedural information, perforation location, therapy, and outcome were recorded. In the 16-year period, 30,366 endoscopic colonic procedures were performed. In total, 35 colonic perforations occured (0.12%). All the patients underwent a laparotomy: for primary repair in 18 cases (56%), for resection with anastomosis in 8 cases (25%), and for resection without anastomosis in 6 cases (19%). In three patients (8.6%), no perforation was found. The postoperative course was uncomplicated in 21 cases (60%) and complicated in 14 cases (40%), including mortality for 3 patients (8.6% resulting from perforations and 0.01% resulting from total endoscopic colon procedures). The relative risk ratio of colonoscopic and sigmoidoscopic procedures for perforations was 4. Therapeutic procedures show a delay in presentation and diagnosis compared with diagnostic procedures. Of the 35 perforations, 26 (74%) occurred in the sigmoid colon. Iatrogenic colonic perforation is a serious but rare complication of colonoscopy. A perforation risk of 0.12% was found. The perforation risk was higher for colonoscopic procedures than for sigmoidoscopic procedures. The sigmoid colon is the area at greatest risk for perforation. Immediate operative management, preferably primary repair and sometimes resection, appears to be a good strategy for most patients.

Infective endocarditis is relatively uncommon in the pediatric population, but when it does occur, results in substantial morbidity and mortality. Children at risk for endocarditis are typically those with an underlying congenital heart condition. Furthermore, an endocardial abscess is a very rare yet serious complication of infective endocarditis. We describe a case of a 23-month-old previously healthy male infant with no known congenital heart disease who returned to the emergency department after a recent hospitalization for pneumococcal bacteremia, presenting acutely ill but without fever. He was found to be in congestive heart failure due to endocarditis and an aortic root abscess.

The first fatal case caused by the new genome type 7i is described in an 8-month-old boy requiring long-term respiratory support who developed Reye's syndrome, acute respiratory distress, and bronchiolitis obliterans with fatal evolution. Adenovirus was detected in nasopharyngeal secretions and was persistently positive during hospitalization. IgM and IgG adenovirus antibody titers measured in serum by enzyme-linked immunoassay (EIA) were 1:32 and 1:800, respectively. Serum interleukins (IL) and interferons (IFN) measured by EIA were as follows: IL-2, 110 pg/ml; IL-6, 300 pg/ml; IL-8, 7,000 pg/ml; TNF-alpha, 35 pg/ml, IL-1 and IL-4 undetectable, IFN-alpha 2,200 pg/ml, and IFN-gamma 700 pg/ml. Virologic studies showed that adenovirus isolated belonged to subgenus B, and digestion of viral DNA with Bam HI, Sma I, Bgl II, and Hind III identified the isolate as belonging to genome type 7i. Autopsy showed bronchiolitis obliterans with diffuse alveolar damage and perivenular fatty degeneration with polymorphonuclear infiltrates in the periportal spaces. The difficulty in obtaining adequate oxygenation with minimization of iatrogenic oxygen injury is discussed.

Objectives To test the hypothesis that instituting a process of routine daily review of rhythm alarms in non-cardiac patients in the pediatric intensive care unit would yield clinically important disturbances that would otherwise go undetected. Study design A prospective observational study was performed over a consecutive 28-day period. Total bedside monitor alarms, rhythm alarms, and heart rate (HR) trends were recorded. Rhythm alarm recordings were reviewed independently by two study team members. Medical records for patients with critical arrhythmias were reviewed to evaluate for prior knowledge of the event and to correlate with clinical data. Results We evaluated 86 patients (343 patient-days). There were 54 656 total monitor alarms (159.3 alarms/patient-day), of which 19 970 (37%) were rhythm alarms, including 4032 (20%) critical arrhythmias. Fifty-six percent of the critical alarms were artifactual. Seventeen of the 1786 ventricular tachycardia alarms represented true episodes that occurred in 5 patients. Two patients' care were altered as a result of detection of the arrhythmia in the review process. Eight hundred sixty-five (98%) of the 883 true critical alarms reviewed were for extreme HR. Eighty-three percent (5172) of the 6239 true non-critical alarms reviewed were HR alarms. Conclusions Daily review of rhythm alarms improves detection of clinically relevant arrhythmias in non-cardiac pediatric intensive care unit patients.

Infection is a common problem in hepatobiliary surgery. Keighly and Lewis et al. reported infected bile in 31-33% of patients after an operation for biliary disease. Such patients had an increased risk of post-operative infections compared to patients with sterile bile1’2. These findings are confirmed by reports from Flemma et al. and Maddocks et al.. They found that bacteria are common in bile under pathological conditions like stones in the common bile duct, the presence of strictures especially partial strictures or cholangitis3’4. Keighly and Blenkhard also reported a strong relation between per-operative bile cultures and cultures from wound abscesses and blood after surgery on the biliary tract in patients with infected bile. In 64% of the wound abscesses and in 90% of the episodes of bacteraemia the same micro-organisms were observed as had previously been identified in the bile5. Micro-organisms frequently found in these cultures are gram-negative bacteria like E coli, Klebsiella spp or Pseudomonas spp. Sometimes gram-positives are found like Streptococcus faecalis. In patients with a biliodigestive anastomosis anaerobes may be found2’5. Intra-abdominal infections after liver resection are common. Incidences varying between 8 and 30% have been reported from different institutions6’7’8. Moreover, in liver transplant programs infection is 9 10 11 still the major cause of morbidity and mortality’ Therefore, the possible mechanisms of infection of the hepatobiliay system should be one of the major interests in hepatobiliary surgery. Bacteria may enter the liver and biliary tract in two ways. Either directly via the transsphincteric route or indirectly by translocation through the intestinal mucosa via the portal blood or the lymphatic system12’13, In both instances the gastrointestinal tract is the source of the invading micro-organisms. Normally, the upper part of the gastro-intestinal tract contains only few bacteria. This is due to the combined influence of acid secretion of the stomach and the inhibitory action of bile and pancreatic juices on many micro-organisms. The majority of the bacteria present are gram-negative cocci and baccilli. Occasionally

A 23-yr-old female presented with progressive dyspnoea and epigastrical pain after 2 days of severe upper abdominal pain with heavy, profuse vomiting. There was no history of dysphagia or gastric reflux. The patient was born with spina bifida, which was complicated with paralysis beneath L1, neurogenic bladder disease, hydrocephalus (for which a ventriculo-peritoneal shunt had been placed), and progressive thoracic scoliosis. Furthermore, she had a history of allergic bronchial asthma and had recently been treated with amoxycilline/clavulanicacid because of a urinary tract infection. Chronic medications included an oral contraconceptive and fluoxetine. On physical examination the patient was in severe respiratory distress. She was cyanotic, very agitated and was lying in a strange position with her head between her paralysed legs, making physical examination very difficult. Furthermore, the patient's body temperature was 35°C, with a blood pressure of 60/30 mmHg, a heart rate of 30 beats·min−1 and no signal on the pulse oximeter. On pulmonary examination there were diminished breathing sounds with hypersonore percussion on the right side. On the left-hand side there were normal …

Background: There is a growing interest in the use of local anaesthesia for inguinal hernia repair. It certainly seems to be an acceptable alternative for the elderly. Supporting intravenous sedation, however, still requires monitoring, anaesthetic personnel and some preparations for the patient. Therefore we set up a feasibility study of hernia repair under local anaesthesia without intravenous sedation or monitoring in elderly patients. Method: A total of 62 patients (aged 65 years or more) with unilateral inguinal hernia received a Mesh Plug Repair. Prospectively collected data included procedure-related complications and information on pain and quality of life as measured by Short Form 36. Results: No procedure-related complications were noted. Comparing the preoperative scores, the SF-36 on day 14 (n=61) did not differ significantly. After a median follow-up of ten months (n=54), significantly higher scores were found for scales of physical and emotional role and pain (all p

Objective: To determine if bacterial translocation and endotoxin absorption occur in organ donors with an anatomically intact gastrointestinal tract. Design: Case series. Setting: Intensive care units in general and university hospitals. Patients: Twenty-one (multiple) organ donors. Intervention: None. Main Outcome Measures: Occurrence of factors that may promote bacterial translocation and/or endotoxin absorption. Bacterial concentration in mesenteric lymph nodes, abdominal fluid, blood, liver, lung, and spleen. Endotoxin level in abdominal fluid, peripheral blood, and portal blood. Anatomical integrity of the bowel wall. Results: Factors that may promote bacterial translocation and/or endotoxin absorption were present in all organ donors. Culture specimens revealed bacteria in 14 organ donors (67%). In 210 (81%) of 260 culture specimens, the bacteria isolated were identical to those isolated from the bowel content, demonstrating bacterial translocation. Endotoxin was found in nine (53%) of 17 abdominal fluid samples, in four (19%) of 21 peripheral blood samples, and in two (10%) of 21 portal blood samples. Light- and electron-microscopic examination of the bowel wall showed no anatomical abnormalities. Conclusion: Bacterial translocation and endotoxin absorption are frequent among organ donors and may adversely influence organ function in transplant recipients and other critically ill patients. (Arch Surg. 1994;129:1063-1066)

Background Since 1994 the ‘components separation technique’ has been used for the repair of large abdominal wall defects, thus avoiding the use of prosthetic material. Methods The results of the method were evaluated retrospectively in 40 patients. There were ten women and 30 men, of mean age 50·3 years and mean body mass index 27·4 kg m−2. All had midline hernias that could not be closed primarily. Hernias occurred in 25 patients after acute surgery of whom 11 had open treatment of generalized peritonitis. Reconstruction was performed under clean conditions in 27 patients, clean contaminated in seven and contaminated or dirty in six. In 13 patients the reconstruction was combined with bowel surgery. Results The postoperative course was complicated in 15 patients: one case of wound dehiscence, five haematomas, two seromas, six wound infections and one case of respiratory insufficiency. One patient died 6 days after operation from mesenteric thrombosis. After a mean follow-up of 8·5 (range 0–20) months recurrent hernias were found in eight patients. One patient had an enterocutaneous fistula in a newly created umbilicus. All recurrences appeared after clean operations. Conclusion The ‘components separation technique’ is useful for the reconstruction of large abdominal wall defects, especially under contaminated conditions where the use of prosthetic material is contraindicated. Moreover the technique can be used to close the abdomen at an early stage after open treatment of peritonitis. Devascularization of the skin and a large wound surface created by mobilization of the skin and subcutis are major drawbacks. Release of the external oblique muscle via separate skin incisions can prevent these problems and makes the method applicable for patients with an enterostomy.

Background Patients with secondary peritonitis are treated by surgery and intravenous antibiotics depending on the micro-organisms cultured from abdominal fluid samples. However, such samples may not be representative of the origin of the intra-abdominal infection. Therefore, this study determined (1) whether different micro-organisms are cultured from abdominal fluid, peritoneum and blood samples, and (2) whether fluorescence in situ hybridization (FISH), with 16S ribosomal RNA-targeted probes applied on peritoneum samples, is more efficient than standard culturing techniques. Methods In a pilot study, samples of abdominal fluid, peritoneum and blood were obtained from two groups of patients: six patients with secondary peritonitis (peritonitis group) and five patients without peritonitis (control group). Results Standard culturing techniques revealed coagulase-negative staphylococci (CNS) and yeast in abdominal fluid samples in three of six patients; Escherichia coli, enterococci, CNS and Citrobacter in peritoneum samples in five of six patients; and no micro-organisms in the blood samples from the peritonitis group. In the control group, CNS were cultured from the abdominal fluid samples in one of five patients, while no micro-organisms were cultured from peritoneum samples and CNS were cultured from the blood samples in one of five patients. The FISH technique revealed a large number of various anaerobic bacteria in peritoneum samples in one of six patients in the peritonitis group. In the control group no bacteria were detected. Conclusion Micro-organisms cultured from abdominal fluid differ from those cultured from peritoneum samples. The FISH technique confirmed these findings in only one case. However, it is a promising technique for the identification and localization of bacteria causing secondary peritonitis.