Najaarsvergadering, 26 November 2010

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<ul><li><p>ASN ABSTRACTS 2011</p><p>ASN ABSTRACTS 2011</p><p>Association of Surgeons from the Netherlands (ASN): Najaarsvergadering, 26 November 2010, Ede, the Netherlands</p><p>Surgical treatment for colorectal carcinoma in the Netherlands; whichfactors are most predictive for postoperative mortality?</p><p>N. E. Kolfschoten1, P. J. Marang van de Mheen2, G. A. Gooiker1,E. H. Eddes3, J. Kievit1,2, R. A. E. M. Tollenaar1, M Wouters1, onbehalf of the Dutch Surgical Colorectal Audit group1Leiden University Medical Centre, Department of Surgery 2Leiden UniversityMedical Centre, Department of Medical Decision Making 3Deventer Hospital,Department of Surgery</p><p>Outcome after the resection of a colorectal carcinoma differs between hospitalsin the Netherlands. These differences are partially explained by variation incase-mix. The purpose of this study was to determine which case-mix factors arepredictive for postoperative mortality after resection of colon (CC) and rectumcarcinomas (RC).Patients that underwent a resection of a rst presentation of a colorectalcarcinoma in 2009 that were included in the Dutch Surgical Colorectal Auditwere analyzed. Case-mix factors that were predictive for postoperative mortalityin the univariate model were entered in the multivariate logistic regressionmodel.We included 4517 patients with CC and 1899 with RC. For CC, Age, ASAclassication, Charlson score, disseminated disease, a preoperative tumourcomplication and urgency of the resection were independent predictors forpostoperative mortality. For RC Age, gender, ASA class and a preoperativetumour complication were independent predictors. Previous abdominal surgery,Body mass index (BMI), surgical procedure, tumour stage, preoperativeradiotherapy and extended resection for a locally advanced tumour or metastasiswere not independently predictive.Older age, comorbidity and a preoperative tumor complication were the mostimportant case-mix factors predicting mortality after resection of a colorectalcarcinoma. Although extended resections and procedures in patients with a highBMI are considered complex procedures, they were not associated with a higherprobability for mortality. As the population is getting older, and the incidenceof colorectal carcinoma is rising, further research should focus on improvingcare for elderly patients with comorbidities, and patients with a preoperativetumour complication.</p><p>Peri-operative care after esophageal resection in the Netherlands</p><p>D. Faraj1, J. J. Bonenkamp2, F. J. H. vd Wildenberg 1, J. H. W. de Wilt2,C. Rosman1</p><p>1Department of Surgery, Canisius-Wilhelmina Hospital, PO BOX 9015, 6500 GS,Nijmegen, The Netherlands 2Department of Surgery, Radboud University NijmegenMedical Center, Nijmegen, The Netherlands</p><p>Introduction: Surgery for esophageal cancer causes signicant morbidity andmortality, but in spite of this, a national guideline for optimal peri-operativecare is lacking in TheNetherlands. The objective of this study was to investigatethe existing peri-operative care in Dutch hospitals where esophageal resectionsare performed.Methods: A questionnaire dealing with all aspects of peri-operative care wassend to all Dutch hospitals where esophageal resections are performed.</p><p>Results: 86% (24/28) of the centers responded. Most hospitals (40%) performbetween 11 and 20 resections each year. 83% of the hospitals have a peri-operative care protocol. 54% of the hospitals use pre-operative physiotherapy.6 centers perform a minimal invasive approach for esophageal resection. After atranshiatal resection an intraabdominal drain is placed in 25% of the centers. In25% of the centers, a routine thoracic drain was placed; in 42% of the centersthis was only done when the pleura parietalis have been opened. The proximalanastomosis is drained in 50% of the centers. 96% of the centers use nasogastricdecompression of the gastric tube. Radiological contrast evaluation of thecervical anastomosis prior to oral intake is done in 63% of the centers. 75% ofthe hospitals intend to discharge patients without feeding via jejunostomy. 38%of the hospital do not have discharge guidelines.Conclusion: In the Netherlands, there is little uniformity in peri-operativecare in patients undergoing resection for esophageal cancer. In order toimprove patient outcome, evidence based peri-operative care protocols shouldbe developed and put it into practise.</p><p>Long-term outcome of patients with locally advanced gastrointestinalstromal tumor after neoadjuvant treatment with imatinib mesylatefollowed by surgery: A Dutch multicentric perspective</p><p>R. Tielen1, C. Verhoef3, F. van Coevorden5, H. Gelderblom7,S. Sleijfer4, H. H. Hartgrink6, J. J. Bonenkamp1,W. T. A. van der Graaf2, J. H. W. de Wilt1</p><p>Department of 1Surgical Oncology and 2Medical Oncology, Radboud UniversityNijmegen Medical Centre, Nijmegen, The Netherlands; Department of 3Surgicaland 4Medical Oncology, Erasmus Medical Centre, Daniel Den Hoed Cancer Centre,Rotterdam, The Netherlands; Department of 5Surgical Oncology, The NetherlandsCancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands;Department of 6Surgical and 7Medical Oncology, Leiden University Medical Centre,The Netherlands</p><p>Background: Patients with locally advanced gastrointestinal stromal tumors(GISTs) have a high risk of tumor perforation, incomplete tumor resections,and often require multivisceral resections. Long-term disease-free and overallsurvival is usually impaired in this group of patients. Multimodality treatmentwith neoadjuvant imatinib followed by surgery seems to have a benecial effectin terms of improved surgical results and long-term outcome. We report on alarge cohort of locally advanced GIST patients that have been treated in fourcenters in the Netherlands specialized in the treatment of soft-tissue sarcoma.Methods: Between August 2001 and February 2010, fty-three patientsunderwent surgery for locally advanced GIST after neoadjuvant imatinibtreatment. Data of all patients were retrospectively collected from four Dutchcenters. Primary endpoints were PFS and OS.Results: After a median of 9 (range 155) months of neoadjuvant imatinibtreatment, all patients underwent surgery. No tumor perforation occurred, anda complete surgical (R0) resection was achieved in 45 patients (85%). Five-yearPFS was 65%, and 5-year OS was 87%. Eight patients had recurrent/metastaticdisease. At recent follow-up, 41 patients had no evidence of disease, 4 patientswere alive with disease, 3 patients died of disease, 3 patients had died of otherreasons, and 2 patients were lost to follow-up.Conclusions: Neoadjuvant imatinib in locally advanced GIST is feasible andenables a high rate of R0 resections without tumor rupture. The combination of</p><p>While every effort is made by the Editorial Team and the Publishers to avoid inaccurate or misleading information appearing in BJS, data within theindividual abstracts are the responsibility of the Authors. The BJS society, the Publishers and members of the Editorial Team accept no liability whatsoeverfor the consequences of any such inaccurate or misleading data, opinion or statement.</p><p> 2011 British Journal of Surgery Society Ltd British Journal of Surgery 2011; 98(S6): 14Published by John Wiley &amp; Sons Ltd</p></li><li><p>S2 ASN abstracts: Najaarsvergadering</p><p>imatinib and surgery in patients with locally advanced GIST seems to improvePFS and OS.</p><p>The standardized mortality ratio is not reliable for the assessmentof quality of care for patients with pancreatic cancer</p><p>Y. R. B. M. van Gestel1, V. E. P. P. Lemmens1,2, J. W. Coebergh1,2,H. J. T. Rutten3, S. W. Nienhuijs3, I. H. J. T. de Hingh3</p><p>1Eindhoven Cancer Registry, Comprehensive Cancer Centre South (IKZ), Eindhoven,the Netherlands 2Department of Public Health, Erasmus University Medical Centre,Rotterdam, the Netherlands 3Department of Surgery, Catharina Hospital, Eindhoven,the Netherlands</p><p>Background: In the Netherlands, Hospital Standardized Mortality Ratios(HSMRs) will be disclosed to the general public next year. The SMR forpancreatic cancer appeared to be increased in our hospital. This is alarmingsince our hospital serves as a regional referral center for these patients toimprove quality of care. The aim of this study was to retrospectively analyze thepancreatic cancer patients who died in our hospital.Patients and Methods: During 2006 and 2008, 178 patients were admittedto our hospital with pancreatic cancer as the primary diagnosis. The observedin-hospital mortality rate was 15 patients while the predicted mortality ratewas 12 patients. The 3 excess deaths resulted in an increased SMR of 128.The medical records of the 15 patients who died during the hospital stay werereviewed.Results: In total, 84 patients underwent surgery for pancreatic cancer of whom3 patients (36%) died in the postoperative period. Furthermore, 1 cardiaccompromised patient died due to complications after endoscopic retrogradecholangiopancreatography.The remaining 11 patients were all admitted with end-stage disease and severesymptoms to receive palliative care only.Conclusions: The in-hospital mortality rate after pancreatic surgery isacceptable and in accordance with the (international) literature. The increasedSMR appeared to be mainly caused by the admission of palliative patients. Asthe SMR model does not adjust for reason of admission, use of this measure isnot appropriate to make a reliable comparison between hospitals for quality ofcare of pancreatic cancer.</p><p>Screening for AAA in men with peripheral arterial disease is effective</p><p>R. R. Smeets, J. A. Ten Bosch, D. E. J. G. J. Dolmans, A. G. Krasznai,R. J. Th. J. WeltenDepartment of Surgery, Atrium Medical Centre, Heerlen, The Netherlands</p><p>Introduction: Despite of recent evidence there is currently no screeningprogram for abdominal aortic aneurysm (AAA) in the Netherlands. The presentstudy aims to identify a subgroup in which screening might be effective.Patients and Methods: Between 2004 and 2009, all men older than 55 whowere referred to the outpatient clinic of a large teaching hospital under suspicionof peripheral arterial disease (PAD)were screened for presence of an AAA.Thesepatients received an ankle-brachial index measurement and an ultrasound of theabdominal aorta and iliac arteries. Patient history, co-morbidity and risk factorswere registered.Results: Of all referred men older than 55 (n = 1061), 1032 (973%) receiveda screening ultrasound and were included in the study. In this population 112AAAs (&gt; 3 cm) were detected (109%), 16 measured &gt; 5 cm. Peripheral arterialdisease was present in 764 of the 1032 screened patients (741%). An AAA waspresent in 75% of patients without PAD and in 12% of patients with PAD.Except PAD (p = 0038) our study showed other risk factors, namely: increaseof age (P &lt; 0001) a prior cerebrovascular accident (p = 0020), smoking (p =0035), cardiac history and hypertension. In our study period (median follow-up37 years) 32 patients (286%) with a proven AAA reached operation criteria.Conclusion: Screening for AAA in men older than 55 years of age withperipheral arterial disease is effective. In addition, this data suggests thatscreening for AAA in all patients, in suspicion of PAD, that have been referredto the vascular surgery outpatient clinic is effective.</p><p>Patients with a post-Pfannenstiel pain syndrome: consider abdominalwall endometriosis</p><p>T. Verhagen, M. J. A. Loos, L. Mulders, M. R. Scheltinga,R. M. H. RoumenDepartments of Surgery and Gynaecology/Obstetrics Maxima Medical CentreVeldhoven, the Netherlands</p><p>Introduction:Chronic pain after Pfannenstiel incisionsmay be caused by nerveentrapment. However, pain is occasionally due to abdominal wall endometriosis(AWE). Aim of the study is to describe the clinical picture of AWE and discussresults of surgery.Materials and Methods: Women with a Pfannenstiel incision performedbetween January 2000 and August 2010 with a histological diagnosis of AWEunderwent an interview and physical examination. Pain was measured at varioustime points using VAS (0100).Results: All Pfannenstiel incisions (n = 21) were performed for cesareandeliveries. Pain had started at a median of 38 months after the initial procedure.It was moderate to severe (mean VAS = 44 [95%CI: 3255]) and appearedrelated to the menstrual cycle in three-quarters of the women. Nine reportedcyclic swelling. More than half of the population (n = 11) suffered fromfunctional impairments due to the pain (severe, n = 5). Surgical removal wasperformed some 15 months after onset of pain. All women were pain free3 months after AWE removal (VAS = 44 [95%CI: 3255] versus 5 [95%CI:19], p = 0002). However, at follow up (26 mo), six initially pain free womenexperienced renewed pain which was based on recurrent AWE in four.Conclusions: Pain in a Pfannenstiel incision several years after a cesareandelivery may be caused by abdominal wall endometriosis. AWE pain is oftencyclic and a mass may be palpated. The pain is substantial and may lead tosevere functional impairment. Surgical removal is successful on the long termbut recurrent disease is not uncommon.</p><p>High variability between systems that predict non-sentinel lymphnode involvement in the individual sentinel node positive breastcancer patient</p><p>I. van den Hoven, G. Kuijt, A. Voogd, R. RoumenDepartment of Surgery, Maxima Medical Centre, Veldhoven, The Netherlands.</p><p>Introduction: Several systems have been developed to predict the risk of non-sentinel lymph node (non-SLN) involvement in the sentinel lymph node (SLN)positive breast cancer patient. Aim of the study was to compare the predictedprobabilities and scores of the available models and to evaluate their variability,within these patients.Patients and Methods: Data were collected on SLN positive breast cancerpatients with a completion axillary lymph node dissection (ALND). Predictedprobabilities and scores for non-SLN metastasis were calculated using 9predictive systems. The number of patients that were considered low-riskor with a probability of 10%, by at least one of the different systems wascalculated. For each nomogram a box plot was constructed and the inter quartilerange (IQR) calculated. Ten patients were randomly selected from the rst (lowrisk) percentile to compare the various predicted probabilities and scores forthis selected group.Results: Almost two-thirds (642%, n = 77) of patients (n = 120) wereassigned to the low-risk/low-probability group according at least one model.None of the patients carried a low risk according to all nine systems. CompletionALND demonstrated non-SLN metastasis in more than one thirds (35%, n =27) of these patients. At group level, considerable variation in distribution ofthe predicted probabilities was observed. At individual level, the variability inpredicted probabilities for 10 randomly selected patients was huge.Conclusions:There is an unacceptable high variability in individual predictedprobabilities and scores, according to the various available systems that predictnon-SLN metastasis in SLN-positive breast cance...</p></li></ul>