To identify an optimal imaging strategy for the accurate detection of urgent conditions in patients with acute abdominal pain.Fully paired multicentre diagnostic accuracy study with prospective data collection.Emergency departments of two university hospitals and four large teaching hospitals in the Netherlands.1021 patients with non-traumatic abdominal pain of >2 hours' and <5 days' duration. Exclusion criteria were discharge from the emergency department with no imaging considered warranted by the treating physician, pregnancy, and haemorrhagic shock.All patients had plain radiographs (upright chest and supine abdominal), ultrasonography, and computed tomography (CT) after clinical and laboratory examination. A panel of experienced physicians assigned a final diagnosis after six months and classified the condition as urgent or non-urgent.Sensitivity and specificity for urgent conditions, percentage of missed cases and false positives, and exposure to radiation for single imaging strategies, conditional imaging strategies (CT after initial ultrasonography), and strategies driven by body mass index and age or by location of pain.661 (65%) patients had a final diagnosis classified as urgent. The initial clinical diagnosis resulted in many false positive urgent diagnoses, which were significantly reduced after ultrasonography or CT. CT detected more urgent diagnoses than did ultrasonography: sensitivity was 89% (95% confidence interval 87% to 92%) for CT and 70% (67% to 74%) for ultrasonography (P<0.001). A conditional strategy with CT only after negative or inconclusive ultrasonography yielded the highest sensitivity, missing only 6% of urgent cases. With this strategy, only 49% (46% to 52%) of patients would have CT. Alternative strategies guided by body mass index, age, or location of the pain would all result in a loss of sensitivity.Although CT is the most sensitive imaging investigation for detecting urgent conditions in patients with abdominal pain, using ultrasonography first and CT only in those with negative or inconclusive ultrasonography results in the best sensitivity and lowers exposure to radiation.
Esophagectomy with gastric tube reconstruction is a highly complex surgical procedure.With regard to mobilization of the stomach and optimal gastric tube preparation and anastomosis, there are several important intraoperative steps that can influence the outcome of the operation.This study aims to describe the optimal mobilization of the stomach for gastric tube reconstruction and explore the best place in the gastric tube for intrathoracic anastomosis after esophagectomy.A search of the literature was performed and results are described in a descriptive review.Based on literature and our own experience we describe important operating steps for laparoscopic stomach mobilisation for gastric tube reconstruction.Steps to create additional length include preserving the left gastroepiploic artery, transecting the right gastric artery, extended duodenal mobilization, and duodenal diversion with roux-Y reconstruction.Several techniques for intrathoracic anastomosis are described in literature.Several imaging techniques, of which fluorescence imaging is the most commonly used, are available to assess the vascularization of the gastric tube and to assist in determining the best place in the gastric tube for intra thoracic anastomosis.Although there is little evidence of exact technique on stomach mobilization and location for an intrathoracic anastomosis, many techniques are used by different authors with varying results.
Abstract: Acute appendicitis is a common cause of acute abdomen and both computed tomography (CT) and ultrasonography (US) are used in the diagnostic work-up of these patients. In general, imaging has high accuracy in diagnosing acute appendicitis. Although the imaging features of appendicitis are well known, in some patients findings are less conclusive. This pictorial essay will give an overview of difficult US and CT cases of patients suspected of acute appendicitis. Keywords: acute appendicitis, ultrasonography, CT
Shared decision-making has become of increased importance in choosing the most suitable treatment strategy for early rectal cancer, however, clinical decision-making is still primarily based on physicians' perspectives. Balancing quality of life and oncological outcomes is difficult, and guidance on patients' involvement in this subject in early rectal cancer is limited. Therefore, this study aimed to explore preferences and priorities of patients as well as physicians' perspectives in treatment for early rectal cancer.In this qualitative study, semi-structured interviews were performed with early rectal cancer patients (n = 10) and healthcare providers (n = 10). Participants were asked which factors influenced their preferences and how important these factors were. Thematic analyses were performed. In addition, participants were asked to rank the discussed factors according to importance to gain additional insights.Patients addressed the following relevant factors: the risk of an ostomy, risk of poor bowel function and treatment related complications. Healthcare providers emphasized oncological outcomes as tumour recurrence, risk of an ostomy and poor bowel function. Patients perceived absolute risks of adverse outcome to be lower than healthcare providers and were quite willing undergo organ preservation to achieve a better prospect of quality of life.Patients' preferences in treatment of early rectal cancer vary between patients and frequently differ from assumptions of preferences by healthcare providers. To optimize future shared decision-making, healthcare providers should be aware of these differences and should invite patients to explore and address their priorities more explicitly during consultation. Factors deemed important by both physicians and patients should be expressed during consultation to decide on a tailored treatment strategy.
Abstract Aim To determine the accuracy and optimal cut-off values of CRP to predict anastomotic leakage. Background and methods CRP is commonly used by surgeons to raise suspicion of anastomotic leakage and other infectious complications in gastrointestinal surgery, but optimal cut-off values and diagnostic accuracy are undetermined. A prospective observational study was conducted including consecutive patients with an esophageal carcinoma scheduled for an esophagectomy with gastric tube reconstruction between April 2016 and October 2018 in the Amsterdam UMC, location AMC, The Netherlands. CRP was measured routinely on post-operative day (POD) 3, 5 and 7. Anastomotic leakage was confirmed if a defect or leakage of oral contrast was seen on a CT-scan or by endoscopy or if saliva was draining form the neck incision in clinical suspicion of leakage. The diagnostic accuracy of CRP was assessed by receiver operator curve (ROC) analysis. Youden’s index was adopted to determine the cut-off value. Results 200 patients were included. POD 5 showed the highest area under the ROC to predict anastomotic leakage with a cut-off value of 120 mg/L. The optimal cut-off value for CRP to predict anastomotic leakage or any complication is shown in table 1 with the corresponding area under the ROC, sensitivity, specificity, positive predicting value and negative prediction value. Conclusion CRP on postoperative day 5 is a feasible marker to predict anastomotic leakage, using a cut-off value of 120 mg/L, resulting in a negative predicting value of 96% and a specificity of 92%. When CRP exceeds 120 mg/L on postoperative day 5 additional investigations should be considered.
Intraoperative indocyanine green fluorescence angiography (ICG-FA) may be of added value during pouch surgery, in particular after vascular ligations as lengthening maneuver. The aim was to determine quantitative perfusion parameters within the efferent/afferent loop and explore the impact of vascular ligation. Perfusion parameters were also compared in patients with and without anastomotic leakage (AL).All consenting patients that underwent FA-guided ileal pouch-anal anastomosis (IPAA) between July 2020 and December 2021 were included. After intravenous bolus injection of 0.1 mg/kg ICG, the near-infrared camera (Stryker Aim 1688) registered the fluorescence intensity over time. Quantitative analysis of ICG-FA from standardized regions of interests on the pouch was performed using software. Fluorescence parameters were extracted for inflow (T0, Tmax, Fmax, slope, Time-to-peak) and outflow (T90% and T80%). Change of management related to FA findings and AL rates were recorded.Twenty-one patients were included, three patients (14%) required vascular ligation to obtain additional length, by ligating terminal ileal branches in two and the ileocolic artery (ICA) in one patient. In nine patients the ICA was already ligated during subtotal colectomy. ICG-FA triggered a change of management in 19% of patients (n = 4/21), all of them had impaired vascular supply (ligated ileocolic/ terminal ileal branches). Overall, patients with intact vascular supply had similar perfusion patterns for the afferent and efferent loop. Pouches with ICA ligation had longer Tmax in both afferent as efferent loop than pouches with intact ICA (afferent 51 and efferent 53 versus 41 and 43 s respectively). Mean slope of the efferent loop diminished in ICA ligated patients 1.5(IQR 0.8-4.4) versus 2.2 (1.3-3.6) in ICA intact patients.Quantitative analysis of ICG-FA perfusion during IPAA is feasible and reflects the ligation of the supplying vessels.
Abstract Background Serum C‐reactive protein (CRP) is commonly used by surgeons to raise suspicion of anastomotic leakage and other infectious complications, but most studies on optimal cut‐off values are retrospective with a small sample of patients. The aim of this study was to determine the accuracy and optimal cut‐off value of CRP for anastomotic leakage in patients following esophagectomy for cancer. Materials and methods Consecutive minimally invasive esophagectomy for esophageal cancer patients was included in this prospective study. Anastomotic leakage was confirmed if a defect or leakage of oral contrast was seen on a CT scan, by endoscopy or if saliva was draining from the neck incision. Diagnostic accuracy of CRP was assessed by receiver operator curve (ROC) analysis. Youden's index was adopted to determine the cut‐off value. Results A total of 200 patients were included between 2016 and 2018. Postoperative day 5 showed the highest area under the ROC (0.825) and optimal cut‐off value of 120 mg/L. This resulted in a sensitivity of 75%, specificity of 82%, negative predicting value of 97%, and positive predicting value of 32%. Conclusions CRP on postoperative day 5 can be used as a negative predictor for and can be used as a marker to raise suspicion of anastomotic leakage following esophagectomy for esophageal cancer. When CRP exceeds 120 mg/L on postoperative day 5, additional investigations should be considered.
