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Background: With the worldwide rising obesity epidemic and the aging population, it is essential to deliver (cost-)effective care that results in enhanced societal participation among knee arthroplasty patients. The purpose of this study is to describe the development, content, and protocol of our (cost-)effectiveness study that assesses a perioperative integrated care program, including a personalized eHealth app, for knee arthroplasty patients aimed to enhance societal participation post-surgery compared to care as usual., Methods: The intervention will be tested in a multicentre randomized controlled trial with eleven participating Dutch medical centers (i.e., hospitals and clinics). Working patients on the waiting-list for a total- or unicompartmental knee arthroplasty with the intention to return to work after surgery will be included. After pre-stratification on medical centre with or without eHealth as usual care, operation procedure (total- or unicompartmental knee arthroplasty) and recovery expectations regarding return to work, randomization will take place at the patient-level. A minimum of 138 patients will be included in both the intervention and control group, 276 in total. The control group will receive usual care. On top of care as usual, patients in the intervention group will receive an intervention consisting of three components: 1) a personalized eHealth intervention called ikHerstel ('I Recover') including an activity tracker, 2) goal setting using goal attainment scaling to improve rehabilitation and 3) a referral to a case-manager. Our main outcome is quality of life, based on patient-reported physical functioning (using PROMIS-PF). (Cost-)effectiveness will be assessed from a healthcare and societal perspective. Data collection has been started in 2020 and is expected to finish in 2024., Discussion: Improving societal participation for knee arthroplasty is relevant for patients, health care providers, employers and society. This multicentre randomized controlled trial will evaluate the (cost-)effectiveness of a personalized integrated care program for knee arthroplasty patients, consisting of effective intervention components based on previous studies, compared to care as usual., Trial Registration: Trialsearch.who.int; reference no. NL8525, reference date version 1: 14-04-2020., (© 2023. The Author(s).)

Background: Despite the established advantages of partial knee replacements (PKR), their usage remains limited. We investigated the effect of hospital knee arthroplasty (KA) volume and the availability of a frequently used PKR by the total KA supplier on the use of PKRs in a hospital., Methods: A total of 190,204 total knee replacements (TKR) and 18,134 PKRs were identified in the Dutch Arthroplasty Register (LROI) from 2007 to 2016. For each hospital we determined the annual absolute KA volume (TKR+PKR) into quartiles (<103, 103-197, 197-292, >292 knee replacements/year), and determined whether the TKR supplier provided a frequently used PKR. Hospitals were divided in routine PKR users (≥13 PKRs/year) or occasional/non PKR users (<13 PKRs/year). Based on these parameters, the effect of total KA volume and supplier on PKR usage was investigated, using chi-square tests. Logistic regression analysis was performed to evaluate the influence of the combination of these factors., Results: In the lowest volume group, around 15% of the hospitals used PKRs, compared to 75% in the highest volume group. Having a TKR supplier that also provides a frequently used PKR resulted in a higher likelihood of performing PKR, especially in low volume hospitals., Conclusions: Hospitals' total KA volume and the availability of a frequently used PKR appear to influence the use of PKR.

Reality technologies in the orthopaedic arena have been increasing in use over the last decade, including virtual reality (VR), augmented reality (AR), and mixed reality (MR). MR is one of the most recent innovations and perhaps the most promising for improving the overall surgical experience. The purpose of this case report was to demonstrate a complex total knee arthroplasty case where unplanned remote assistance was used for telesurgical support using the HoloLens 2., Competing Interests: Two authors (KvP, MBA) are paid employees of Zimmer Biomet. RCIvG receives consultancy fees for education from Zimmer Biomet., (Copyright © 2022 Kees van der Putten et al.)

Evidence for recommendations concerning the resumption of activities of daily life, including work and sport, after knee arthroplasty is lacking. Therefore, recommendations vary considerably between hospitals and healthcare professionals. We aimed to obtain multidisciplinary consensus for such recommendations. Using a Delphi procedure, we strived to reach consensus among a multidisciplinary expert panel of six orthopaedic surgeons, three physical therapists, five occupational physicians and one physician assistant on recommendations regarding the resumption of 27 activities of daily life. The Delphi procedure involved three online questionnaire rounds and one face-to-face consensus meeting. In each of these four rounds, experts independently decided at what time daily life activities could feasibly and safely be resumed after knee arthroplasty. We distinguished patients with a fast, average and slow recovery. After four Delphi rounds, the expert panel reached consensus for all 27 activities. For example, experts agreed that total knee arthroplasty patients with a fast recovery could resume cycling six weeks after the surgery, while those with an average and slow recovery could resume this activity after nine and twelve weeks, respectively. The consensus recommendations will subsequently be integrated into an algorithm of a personalized m/eHealth portal to enhance recovery among knee arthroplasty patients.

Objectives: Orthopaedic surgery is primarily aimed at improving function and pain reduction. Additional integrated care may enhance patient's participation in sports and work, possibly improving performance of physical activities and quality of life (QoL). We aimed to assess the effectiveness of integrated care among orthopaedic surgery patients., Design: Systematic review with meta-analysis., Data Source: Medline, EMBASE and CINAHL (until 17 June 2019)., Eligibility for Selecting Studies: We searched for controlled studies on integrated care interventions consisting of active referral to case managers, rehabilitation with participation-based goals and/or e/mHealth, with outcomes of sports and work participation, performance of physical activities and/or QoL. Outcomes were normalised to 0-100 scales and statistically pooled., Results: Seventeen articles (n=2494) of moderate quality were included reporting on patients receiving back, upper limb, knee or hip surgery. Only one study reported on return to sports and found no significant benefit. For return to work, one study did (90% vs 82%) and one did not (relative risk=1.18 (0.80 to 1.70)) observe significant benefits. Integrated care showed small effects for improving performance of physical activities (2.69 (-0.20 to 5.58); eight studies, n=1267) and QoL (2.62 (1.16 to 5.05); nine studies, n=1158) compared with usual care., Summary/conclusion: We found insufficient and inconsistent evidence for the effectiveness of integrated care for orthopaedic surgery patients regarding sport and work participation. Small effects were found for performance of physical activities and QoL. High quality research on integrated care focusing on sports and work participation is needed before integrated care can be implemented for orthopaedic surgery patients., Competing Interests: Competing interests: JA intends to set up a spin-off company concerning the implementation of a mobile application concerning the IkHerstel intervention in the Netherlands, holds a chair in Insurance Medicine paid by the Dutch Social Security Agency Is stockholder of Evalua Received grants from ZonMw/NWO, Instituut Gak, UWV, SZW, VWS, Pfizer, Achmea, CVZ/Zorg Instituut outside the submitted work. All other authors declare no conflicts of interests, financial of other., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate activity goals, intensity and achievement of these activity goals in younger knee arthroplasty (KA) patients, and to identify the differences between total knee arthroplasty (TKA) and unicondylar knee arthroplasty (UKA) patients., Design: Prospective cohort study., Setting: Department of orthopedic surgery and physical therapy practices., Participants: Patients (N=48) aged 65 years or younger who underwent KA., Intervention: Rehabilitation with goal attainment scaling (GAS)., Main Outcome Measures: GAS goals for daily life activity, work and leisure time, corresponding metabolic equivalent of task (MET) values, corrected MET values, and GAS scores at 3 and 6 months., Results: The intensity levels of all 144 formulated activity goals were light in 16% of cases, moderate in 63%, and vigorous in 21%. Intensity levels did not differ between TKA and UKA patients. Following rehabilitation using GAS, 54% of daily life activity goals, 65% of work activity goals, and 46% of leisure time activity goals were attained after 3 months. After 6 months, 91% of daily life activity goals, 93% of work activity goals, and 89% of leisure time activity goals were attained. Goal attainment did not differ between MET intensity levels. Higher goal attainment was achieved in the UKA group (100%) compared with the TKA patients (82%) after 6 months (P<.001)., Conclusions: Younger patients aim to perform many different activities of varying metabolic intensity levels following KA. After 6 months of rehabilitation using GAS, in these patients attain 91% of their preoperatively formulated activity goals, independent of the MET intensity level. After 6 months, UKA patients attain significantly more activity goals than TKA patients. GAS might be a useful objective outcome measure in evaluating clinical outcomes of individual KA patients., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Modern health care focuses on shared decision making (SDM) because of its positive effects on patient satisfaction, therapy compliance, and outcomes. Patients' knowledge about their illness and available treatment options, gained through medical education, is one of the key drivers for SDM. Current patient education relies heavily on medical consultation and is known to be ineffective., Objective: This study aimed to determine whether providing patients with information in a subdivided, categorized, and interactive manner via an educational app for smartphone or tablet might increase the knowledge of their illness., Methods: A surgeon-blinded randomized controlled trial was conducted with 213 patients who were referred to 1 of the 6 Dutch hospitals by their general practitioner owing to knee complaints that were indicative of knee osteoarthritis. An interactive app that, in addition to standard care, actively sends informative and pertinent content to patients about their illness on a daily basis by means of push notifications in the week before their consultation. The primary outcome was the level of perceived and actual knowledge that patients had about their knee complaints and the relevant treatment options after the intervention., Results: In total, 122 patients were enrolled in the control group and 91 in the intervention group. After the intervention, the level of actual knowledge (measured on a 0-36 scale) was 52% higher in the app group (26.4 vs 17.4, P<.001). Moreover, within the app group, the level of perceived knowledge (measured on a 0-25 scale) increased by 22% during the week within the app group (from 13.5 to 16.5, P<.001), compared with no gain in the control group., Conclusions: Actively offering patients information in a subdivided (per day), categorized (per theme), and interactive (video and quiz questions) manner significantly increases the level of perceived knowledge and demonstrates a higher level of actual knowledge, compared with standard care educational practices., Trial Registration: International Standard Randomized Controlled Trial Number ISRCTN98629372; http://www.isrctn.com/ISRCTN98629372 (Archived by WebCite at http://www.webcitation.org/73F5trZbb)., (©Thomas Timmers, Loes Janssen, Yvette Pronk, Babette C van der Zwaard, Sander Koëter, Dirk van Oostveen, Stefan de Boer, Keetie Kremers, Sebastiaan Rutten, Dirk Das, Rutger CI van Geenen, Koen LM Koenraadt, Rob Kusters, Walter van der Weegen. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 21.12.2018.)

Knee arthroplasty (KA) is increasingly performed, but rehabilitation and the possibility of returning to sports after KA are understudied areas. A web-based survey amongst physiotherapists was conducted to obtain insight in current rehabilitation methods and their return to sports advice after KA. 82 physiotherapists (62%) completed the survey. Broad agreement existed concerning important goals of rehabilitation, including the improvement of ROM, muscle strength, coordination and gait pattern. However, physiotherapists use a wide variety of treatment strategies to achieve these goals. Return to low-impact sports is mostly recommended, while return to intermediate- and high-impact sports is either advised against or considered impossible. The development of new evidence-based guidelines on physiotherapy after KA could lead to a more uniform approach in the rehabilitation for KA patients. Furthermore, investigating effects of individualization in the rehabilitation may prove valuable in optimising both patient outcomes and cost-effectiveness of this worldwide increasingly performed intervention.

Purpose: Indications for total and unicondylar knee arthroplasty (KA) have expanded to younger patients, in which Patient-Reported Outcome Measures (PROMs) often show ceiling effects. This might be due to higher expectations. Our aims were to explore expectations of younger patients concerning activities in daily life, work and leisure time after KA and to assess to what extent PROMs meet and evaluate these activities of importance., Methods: Focus groups were performed among osteoarthritis (OA) patients <65 years awaiting KA, in which they indicated what activities they expected to perform better in daily life, work and leisure time after KA. Additionally, 28 activities of daily life, 17 of work and 27 of leisure time were depicted from seven PROMS, which were rated on importance, frequency and bother. A total score, representing motivation for surgery, was also calculated., Results: Data saturation was reached after six focus groups including 37 patients. Younger OA patients expect to perform better on 16 activities after KA, including high-impact leisure time activities. From the PROMs, daily life and work activities were rated high in both importance and motivation for surgery, but for leisure time activities importance varied highly between patients. All seven PROMs score activities of importance, but no single PROM incorporates all activities rated important., Conclusion: Younger patients expect to perform better on many activities of daily life, work and leisure time after KA, and often at demanding levels. To measure outcomes of younger patients, we suggest using PROMs that include work and leisure time activities besides daily life activities, in which preferably scored activities can be individualized., Competing Interests: The authors declare no conflicts of interest or further financial relationship with the organization that funded the research. The authors prepared and submitted this manuscript independently from the study sponsors.

Oxford unicompartmental knee replacement (OUKR) is associated with a low perioperative complication rate. This case report describes a periprosthetic fracture of the medial femoral condyle that occurred during an OUKR. The patient was treated with a non-weight-bearing long leg cast for 6 weeks. Afterwards, the fracture had healed, and 3 months postoperatively, there was a full range of motion. Factors leading to this complication could be the impaction force or direction, or a diminished load resistance of the distal femur. Minimally displaced coronal periprosthetic fractures after OUKR can be managed conservatively without residual functional impairment., Level of Evidence: Case report, Level IV.

Total knee arthroplasty (TKA) is increasingly being performed among working patients suffering from knee osteoarthritis. Two out of ten patients do not return to work (RTW) after TKA. Little evidence is available about these patients to guide clinicians. Therefore, this study investigates patients' characteristics associated with no RTW. A multicenter retrospective cohort study was performed among working patients having undergone a primary TKA during 2005-2010. The following preoperative characteristics were assessed: age at surgery, sex, comorbidity, body mass index (BMI), preoperative sick-leave duration, patient-reported work-relatedness of knee symptoms, and physical job demands. In addition, the Knee injury and Osteoarthritis Outcome Scores (KOOS) after TKA were assessed. Backward stepwise logistic regression analyses were performed to predict no RTW. Seven hundred and sixty-four patients were approached, and 558 patients (73 %) responded. One hundred and sixty-seven met the inclusion criteria and 46 did not RTW. A preoperative sick-leave duration >2 weeks (OR 12.5, 90 % CI 5.0-31.5) was most strongly associated with no RTW. Other associations found were: female sex (OR 3.2, 90 % CI 1.3-8.2), BMI ≥ 30 (OR 2.8, 90 % CI 1.1-7.1), patient-reported work-relatedness of knee symptoms (OR 5.3, 90 % CI 2.0-14.1), and a physically knee-demanding job (OR 3.3, 90 % CI 1.2-8.9). Age and KOOS were not associated with no RTW. Especially obese female workers, with a preoperative sick-leave duration >2 weeks, who perform knee-demanding work and indicate that their knee symptoms are work-related have a high chance for no RTW after TKA. These results stress the importance of a more timely referral for work-directed care of patients at risk for no RTW after TKA.

Background: Knee arthroplasty is being increasingly performed, and also more often in a younger patient population (<65 years of age). Up to 20 % of patients remain dissatisfied after knee arthroplasty, despite the apparent technical success of the operation. Recent studies suggest that the fulfilment of patients' expectations plays an important role in achieving satisfaction. Thus, addressing preoperative expectations more explicitly might improve patient satisfaction. The primary aim of the present study is to investigate the effect of a multidisciplinary, goal attained and individualized rehabilitation on satisfaction of activities of younger patients (<65 years) after knee arthroplasty., Methods/design: A single-centre randomized controlled trial will be conducted. In total, 120 patients (<65 years of age) with knee osteoarthritis who will undergo knee arthroplasty, will be randomly allocated to either goal attainment scaling rehabilitation or usual care rehabilitation. Goal attainment scaling rehabilitation includes drafting individually set rehabilitation goals preoperatively and measuring progress of rehabilitation on a six-point scale (-3 to +2). The primary outcome is patient satisfaction concerning activities in daily life, work and leisure time, including sports. Secondary outcome measures include KOOS, OKS, SQUASH and WORQ questionnaires and activity objectively measured with the Activ8® activity monitor., Discussion: The findings of this study will help to elucidate whether goal attainment scaling is an effective rehabilitation method for achieving higher levels of patient satisfaction, with a focus on activities, in younger patients after knee arthroplasty., Trial Registration: This trial is since June 15(th) 2015 registered at the Dutch Trial Register: NTR5251 .

Background: People today are living longer and want to remain active. While obesity is becoming an epidemic, the number of patients suffering from osteoarthritis (OA) is expected to grow exponentially in the coming decades. Patients with OA of the knee are progressively being restricted in their activities. Since a knee arthroplasty (KA) is a well accepted, cost-effective intervention to relieve pain, restore function and improve health-related quality of life, indications are expanding to younger and more active patients. However, evidence concerning return to sports (RTS) and physical activity (PA) after KA is sparse., Objectives: Our aim was to systematically summarise the available literature concerning the extent to which patients can RTS and be physically active after total (TKA) and unicondylar knee arthroplasty (UKA), as well as the time it takes., Methods: PRISMA guidelines were followed and our study protocol was published online at PROSPERO under registration number CRD42014009370. Based on the keywords (and synonyms of) 'arthroplasty', 'sports' and 'recovery of function', the databases MEDLINE, Embase and SPORTDiscus up to January 5, 2015 were searched. Articles concerning TKA or UKA patients who recovered their sporting capacity, or intended to, were included and were rated by outcomes of our interest. Methodological quality was assessed using Quality in Prognosis Studies (QUIPS) and data extraction was performed using a standardised extraction form, both conducted by two independent investigators., Results: Out of 1115 hits, 18 original studies were included. According to QUIPS, three studies had a low risk of bias. Overall RTS varied from 36 to 89% after TKA and from 75 to >100% after UKA. The meta-analysis revealed that participation in sports seems more likely after UKA than after TKA, with mean numbers of sports per patient postoperatively of 1.1-4.6 after UKA and 0.2-1.0 after TKA. PA level was higher after UKA than after TKA, but a trend towards lower-impact sports was shown after both TKA and UKA. Mean time to RTS after TKA and UKA was 13 and 12 weeks, respectively, concerning low-impact types of sports in more than 90 % of cases., Conclusions: Low- and higher-impact sports after both TKA and UKA are possible, but it is clear that more patients RTS (including higher-impact types of sports) after UKA than after TKA. However, the overall quality of included studies was limited, mainly because confounding factors were inadequately taken into account in most studies.

Background and Purpose: Poor outcomes have been linked to errors in rotational alignment of total knee arthroplasty components. The aims of this study were to determine the correlation between rotational alignment and outcome, to review the success of revision for malrotated total knee arthroplasty, and to determine whether evidence-based guidelines for malrotated total knee arthroplasty can be proposed., Patients and Methods: We conducted a systematic review including all studies reporting on both rotational alignment and functional outcome. Comparable studies were used in a correlation analysis and results of revision were analyzed separately., Results: 846 studies were identified, 25 of which met the inclusion criteria. From this selection, 11 studies could be included in the correlation analysis. A medium positive correlation (ρ = 0.44, 95% CI: 0.27-0.59) and a large positive correlation (ρ = 0.68, 95% CI: 0.64-0.73) were found between external rotation of the tibial component and the femoral component, respectively, and the Knee Society score. Revision for malrotation gave positive results in all 6 studies in this field., Interpretation: Medium and large positive correlations were found between tibial and femoral component rotational alignment on the one hand and better functional outcome on the other. Revision of malrotated total knee arthroplasty may be successful. However, a clear cutoff point for revision for malrotated total knee arthroplasty components could not be identified.

The number of patients receiving a TKA during working life is increasing but little is known about the impact of TKA on patients' reintegration into the workplace. In this cross-sectional survey it was found that 173 of 480 responders worked within 2 years prior to surgery. Sixty-three percent of the working patients stopped within two weeks prior to surgery and 102 patients returned within 6 months. One third never returned to work. Activities that most improved were operating foot pedals, operating vehicles, standing and walking on level terrain. Activities that least improved were kneeling, crouching and clambering. Fifty patients scored 5 or less on the Work Ability Index. Thirty patients were dissatisfied. TKA significantly, but unequally, reduces difficulties in carrying out knee-burdening work activities., (Copyright © 2014 Elsevier Inc. All rights reserved.)

A cross-sectional study in two hospitals was performed on 807 patients with a primary Vanguard (Biomet) total knee Arthroplasty (TKA). The research questions addressed were (1) what are the two- and six year survival rates of the Vanguard, (2) what are the clinical outcome scores, (3) what are the findings at revision and (4) what are predictors for revision? The mean age at time of surgery was 67.0 (SD 10.0). The mean follow-up was 3.6 years (95% CI 3.56-3.73). At two years the survival was 97.2% for all-reasons (767 patients remaining) and 99%, for prosthesis-related-reasons (777 remaining). At six years this was 96.5% (40 remaining) and 98.6% (41 remaining). The mean clinical results (84% response on KOOS, Oxford and NRS) were good. A previous osteotomy was a risk factor for revision (hazard ratio 5.1, P=0.001). This early experience with the Vanguard shows a good survival with no adverse outcomes related to the implant and therefore further use of the implant is justified., (Copyright © 2014 Elsevier Inc. All rights reserved.)

We analysed the operative technique, morbidity and functional outcome of osteotomy and plate fixation for malunited fractures of the forearm sustained in childhood. A total of 20 consecutive patients underwent corrective osteotomy of 21 malunited fractures at a mean age of 12 years (4 to 25). The mean time between the injury and the osteotomy was 30 months (2 to 140). After removal of the plate, one patient suffered transient dysaesthesia of the superficial radial nerve. The mean gain in the range of movement was 85 degrees (20 degrees to 140 degrees ). The interval between injury and osteotomy, and the age at osteotomy significantly influenced the functional outcome (p=0.011 and p=0.004, respectively). Malunited fractures of the forearm sustained in childhood can be adequately treated by osteotomy and plate fixation with excellent functional results and minimal complications. In the case of established malunion it is advisable to perform corrective osteotomy without delay.

Objective: To evaluate the effect of a prophylactic gastrojejunostomy on the development of gastric outlet obstruction and quality of life in patients with unresectable periampullary cancer found during explorative laparotomy., Summary Background Data: Several studies, including one randomized trial, propagate to perform a prophylactic gastrojejunostomy routinely in patients with periampullary cancer found to be unresectable during laparotomy. Others suggest an increase of postoperative complications. Controversy still exists in general surgical practice if a double bypass should be performed routinely in these patients., Methods: Between December 1998 and March 2002, patients with a periampullary carcinoma who were found to be unresectable during exploration were randomized to receive a double bypass (hepaticojejunostomy and a retrocolic gastrojejunostomy) or a single bypass (hepaticojejunostomy). Randomization was stratified for center and presence of metastases. Patients with gastrointestinal obstruction and patients treated endoscopically for more than 3 months were excluded. Primary endpoints were development of clinical gastric outlet obstruction and surgical intervention for gastric outlet obstruction. Secondary endpoints were mortality, morbidity, hospital stay, survival, and quality of life, measured prospectively by the EORTC-C30 and Pan26 questionnaires. It was decided to perform an interim analysis after inclusion of 50% of the patients (n = 70)., Results: Five of the 70 patients randomized were lost to follow-up. From the remaining 65 patients, 36 patients underwent a double and 29 a single bypass. There were no differences in patient demographics, preoperative symptoms, and surgical findings between the groups. Clinical symptoms of gastric outlet obstruction were found in 2 of the 36 patients (5.5%) with a double bypass, and in 12 of the 29 patients (41.4%) with a single bypass (P = 0.001). In the double bypass group, one patient (2.8%) and in the single bypass group 6 patients (20.7%) required (re-)gastrojejunostomy during follow-up (P = 0.04). The absolute risk reduction for reoperation in the double bypass group was 18%, and the numbers needed to treat was 6. Postoperative morbidity rates, including delayed gastric emptying, were 31% in the double versus 28% in the single bypass group (P = 0.12). Median postoperative length of stay was 11 days (range 4-76 days) in the double versus 9 days (range 6-20 days) in the single bypass group (P = 0.06); median survival was 7.2 months in the double versus 8.4 months in the single bypass group (P = 0.15). No differences were found in the quality of life between both groups. After surgery most quality of life scores deteriorated temporarily and were restored to their baseline score (t = -1) within 4 months., Conclusions: Prophylactic gastrojejunostomy significantly decreases the incidence of gastric outlet obstruction without increasing complication rates. There were no differences in quality of life between the two groups. Together with the previous randomized trial from the Hopkins group, this study provides sufficient evidence to state that a double bypass consisting of a hepaticojejunostomy and a prophylactic gastrojejunostomy is preferable to a single bypass consisting of only a hepaticojejunostomy in patients undergoing surgical palliation for unresectable periampullary carcinoma. Therefore, the trial was stopped earlier than planned.

Mostly, patients with peri-pancreatic cancer (including pancreatic, ampullary and distal bile duct tumors) are diagnosed in a stage in which curative resection is not possible. The median survival rate of patients with non resectable peri-pancreatic cancer varies between 6 and 12 months. During this period palliative treatment is necessary, which should focus on major symptoms as obstructive jaundice, duodenal obstruction and pain. Controversy exists about how to provide optimal palliative treatment. Both surgical and non surgical palliative procedures relief obstructive jaundice. From early retrospective and prospective randomized studies it is known that in the early phase after treatment, more complications are found after surgical palliation, whereas in the late phase more complications are seen after endoscopic palliation. Because more recent studies clearly showed improved results after surgical palliation, current recommendations probably should be that patients with a suspected poor short-term survival (< 6 months) should be offered non surgical palliative therapy and those with a longer life expectancy may best be treated with bypass surgery. Unfortunately, valid criteria for estimating the remaining survival time are not available, except for the presence of metastases. The use of a prognostic score chart might assist in estimating the prognosis. Literature does not give sufficient information to make a well deliberated (evidence based) selection between the different types of surgical bypasses, but a choledochojejunostomy is generally preferred. After stenting, a correlation is found between survival and the development of duodenal obstruction, and between 9% and 21% of the patients who underwent a surgical biliary bypass without a prophylactic gastric bypass, will develop gastric outlet obstruction. Therefore, in patients with a relatively good prognosis it is recommended to perform routinely a double--biliary and gastric--bypass. Pain is a frequent symptom and is related with poor survival. Pain management aside from pain medication can be performed by means of a celiac plexus blockade or a thorascopic splanchnicectomy, and also radiotherapy seems to have a positive result on pain.

In patients with unresectable peripancreatic carcinoma, pain is generally treated with pain medication or with a celiac plexus blockade. Radiotherapy has also been reported to reduce pain. The efficacy of these treatment modalities is still under discussion. The aim of this study was to analyze the effects of the various types of pain management on patients who underwent palliative bypass surgery for unresectable peripancreatic carcinoma. During the period January 1995 to December 1998 a series of 98 patients underwent palliative bypass surgery, mostly for unresectable disease found during exploration. Patients were divided into three groups: palliative bypass surgery (BP), palliative bypass surgery with an intraoperative celiac plexus blockade (CPB), and palliative bypass surgery with or without celiac plexus blockade followed by high-dose conformal radiotherapy (RT). Radiotherapy was performed only in selected patients with locally advanced disease and without metastases, implying a better prognosis of the last group. The pain medication consumption, pain medication-free survival, hospital-free survival, and overall survival were analyzed. The preoperative consumption of pain medication was significantly higher in the CPB group than in the BP or RT group. The postoperative consumption of pain medication in the CPB, BP, and RT groups increased during follow-up from 15%, 17%, and 13% before surgery to 52%, 57%, and 46%, respectively, at three-fourths of the survival time (NS). This increase in consumption of pain medication was not different in the three groups. In the RT group the median pain medication-free survival was significantly longer than in the BP or CPB group (9.3 vs. 3.1 and 3.3 months; p = 0.02). The median hospital-free survival and median overall survival were significantly longer in the RT group than in the CPB group (10.3 vs. 6.8 months, p = 0.01; and 7.1 vs. 10.8 months, p = 0.01). Celiac plexus blockade as pain management did not result in an increase of the pain medication-free survival or overall survival. Therefore a positive effect of a celiac plexus blockade on pain could not be confirmed in the present study. Radiotherapy resulted in increased pain-medication survival, hospital-free survival, and overall survival compared to celiac plexus blockade. These effects are probably partly related to patient selection.

Background: Readmission after pancreatoduodenectomy because of tumour recurrence or surgery-related complications can adversely affect patient outcome., Methods: From October 1992 to June 1999, 283 consecutive resections were performed (243 for malignant disease and 40 for benign disease). The hospital mortality rate was 1 per cent (three of 283). All readmissions were analysed with regard to indication, treatment and outcome., Results: One hundred and six patients (38 per cent) were readmitted, 64 (60 per cent) because of tumour recurrence and indications such as gastrointestinal obstruction (n = 19), biliary obstruction (n = 15) and pain (n = 21), of whom 30 patients (47 per cent) were in a preterminal condition. Median hospital stay and hospital-free survival after discharge were 14 and 51 days respectively. Median survival after surgical treatment (n = 14) was 58 days, and ascites was significantly associated with poor survival. Forty-seven (44 per cent) of the patients were readmitted for surgical complications such as abscess (n = 11), fistula (n = 8) and gastrointestinal obstruction (n = 8). Median hospital stay was 15 days and median hospital-free survival after discharge was 1035 days., Conclusion: Readmission after pancreatoduodenectomy was common (38 per cent), 60 per cent for tumour recurrence and 44 per cent for surgery-related complications. Survival after surgical bypass procedures for tumour recurrence was limited, particularly when ascites was present. Patients readmitted for complications of surgery had a good prognosis.

Aim: Survival after pancreaticoduodenectomy for periampullary tumours is limited. Over the last decade peri-operative management has improved and morbidity and mortality decreased. The aim of the study was to analyse recent survival data after pancreaticoduodenectomy and to determine factors that influence survival., Methods: From October 1992 to September 1998, 204 patients with a ductal adenocarcinoma in the pancreatic head (108), distal bile duct (32), and ampulla (64) who underwent standard pancreaticoduodenectomy, were analysed with regard to histology and tumour status. Survival was calculated by using the Kaplan-Meier method. Risk factors were identified in a univariate and multivariate analysis., Results: Median survival after resection for carcinoma of the pancreatic head, distal bile duct, and ampulla were 16, 25 and 24 months, respectively (P=0.008). In the univariate analysis vein resection, blood transfusion of more than four packed red cells, the presence of tumour positive resection margins, lymph-node metastases and poor tumour differentiation significantly decreased survival. In the multivariate analysis positive resection margins, lymph-node metastases, and poor tumour differentiation independently influenced survival., Conclusions: Resection margins, lymph-node status and tumour differentiation are independent prognostic factors. Survival after standard pancreaticoduodenectomy for periampullary tumours has not improved., (Copyright 2001 Harcourt Publishers Limited.)

Background: Resection of the portal/superior mesenteric vein (PV/SMV) during pancreatoduodenectomy (PD) is disputed. Although morbidity and mortality are acceptable, survival is limited after PV/SMV resection. In this study, we evaluate the effect of PV/SMV resection., Methods: Between 1992 and 1998, there were 215 consecutive patients who underwent PD for malignant disease. Thirty-four patients underwent a PV/SMV resection. Resection was only performed when minimal venous ingrowth was found perioperatively. Surgical techniques, perioperative parameters, and survival were analyzed., Results: The percentage of PV/SMV resections was 16%. Extensive (segment) resections were performed in 6 patients. The median blood loss was 1.8 L and resection margins were microscopically tumor free in 41% of the patients. The median hospital stay was 15 days, and mortality was 0%. Median survival after PV/SMV resection for pancreatic adenocarcinoma was 14 months., Conclusions: Limited PV/SMV resection for perioperatively encountered minimal venous ingrowth during PD can be performed safely without increased morbidity and mortality but also results in a high frequency of tumor-positive resection margins.

Objective: To perform a two-part study of pancreaticoduodenectomy in the Netherlands, focusing on the effects of risk factors on outcomes in a single high-volume hospital and the effect of hospital volume on outcomes., Summary Background Data: Hospital volume and surgeon caseload can be related to the rates of complications and death, and the influence of risk factors can be volume-dependent. Provision of regionalized care should take this into account., Methods: In part A, a single-institution database on 300 consecutive patients undergoing pancreaticoduodenectomy was divided into two periods with similar numbers of patients. Overall complications, deaths, hospital stay, and risk factors were analyzed in the two periods and compared with an historical reference group. In part B, Netherlands medical registry data on age and postoperative death of patients who underwent partial pancreaticoduodenectomy from 1994 to 1998 were analyzed for the influence of hospital volume on death., Results: Between the time periods, the institutional death rate decreased from 4.9% to 0.7%, the complication rate from 60% to 41%. Median hospital stay decreased from 24 to 15 days. The death rate was not related to patient age and did not differ between surgeons. Serum creatinine levels, need for blood transfusion, and period of resection were independent risk factors for complications. The death rate after pancreaticoduodenectomy in the Netherlands was 12.6% in 1994 and 10.1% in 1998; it was greater in patients older than age 65. During the 5-year period, 40% of the procedures were performed in hospitals performing fewer than five resections per year, and the death rate was greater than in hospitals performing more than 25 resections per year., Conclusions: The overall death rate after pancreaticoduodenectomy did not decrease significantly during the period, and it was greater in low-volume hospitals and older patients. The lower death and complication rates in high-volume hospitals, including the single-center outcomes, were similar to those reported in other countries and may be due to better prevention and management of complications. Pancreaticoduodenectomy should be performed in centers with sufficient experience and resources for support.

Controversy exists about the indication for a palliative pancreatoduodenectomy. A palliative resection for patients with a pancreatic carcinoma can be performed safely nowadays with low mortality and acceptable morbidity in centers with experience. The early results in terms of mortality and morbidity are not different from resections with curative intent or even after bypass surgery. The procedure seems effective for controlling symptoms of the disease, and the quality of life after a palliative resection is acceptable and not worse than after bypass surgery. It is, however, still doubtful whether the incidence of symptom recurrence, such as jaundice, obstruction, and pain, is lower after resection than after bypass surgery. The longer survival after palliative resection could also be due to patient selection and postoperative treatment. There are no randomized trials to prove the superiority of palliative resection over bypass surgery. The safety of pancreatic resection for cancer has already changed the policy in centers with experience, and surgeons are more willing to perform a resection because the results are better or at least the same as after bypass surgery. There are, however, no results to confirm that a palliative resection should be performed routinely or to justify resection as a debulking procedure.

High-affinity binding sites for the pancreatic beta-cell hormone amylin have been reported in the kidney, and it has been postulated that these sites may be involved in the genesis of hypertension. In the present study, we have used in vivo injection of 125I-amylin and in vitro autoradiographic techniques to assess renal amylin binding in both a genetic and a surgically induced model of hypertension. In the spontaneously hypertensive rat (SHR) at 6 weeks of age, before the rise in systolic blood pressure, there was a 36% increase in density of amylin binding compared with their normotensive counterpart, the Wistar-Kyoto rat (WKY). In SHR, there was a further increase in the density of amylin binding (to 53% greater) as the systolic blood pressure rose between 6 and 12 weeks of age. Histological examination of kidneys from SHR at 12 weeks of age revealed staining for a brush border glycoprotein, normally restricted to the proximal tubules, extending from the urinary pole into half of the epithelial lining of the glomerular capsule. In contrast to WKY, these cells also bound 125I-amylin with high density in SHR. In a rat model of renal ablation and hypertension, systolic blood pressure correlated with the density of 125I-amylin binding in the renal cortex (r=.54, P=.003, n=28). The changes in amylin binding reported here suggest a possible role for this peptide and/or activation of its receptor in the genesis as well as the maintenance of hypertension.