Wetenschappelijk Jaarverslag

Transcriptie

1 Wetenschappelijk Jaarverslag Sint Franciscus Gasthuis 2012

2 Niets uit deze uitgave mag worden gekopieerd zonder toestemming van de uitgever. ISBN (print): NUR: 870 Trefwoorden: wetenschappelijk onderzoek; geneeskunde.

3 Wetenschappelijk Jaarverslag 2012 Sint Franciscus Gasthuis Blom JHM Cohen Tervaert JW Geerlings CJC van de Geijn GJM de Jongh KA Kerver AJH Rudolphus A Rotterdam, april 2012; Serie Wetenschappelijk Jaarverslag SFG, nr UW ZORG, ONZE PASSIE

4 INHOUDSOPGAVE pagina Inhoudsopgave 4 Voorwoord 5 Anesthesiologie 6 Apotheek 8 Cardiologie 10 Chirurgie 12 Dermatologie 23 Gynaecologie 26 Intensive Care 30 Interne Geneeskunde 32 Kindergeneeskunde 47 Klinische Chemie 48 Leerhuis 53 Longziekten 55 MDL 62 Neurologie 68 Oogheelkunde 73 Orthopedie 75 Pathologie/ Pathan 77 Psychiatrie 79 Reumatologie 81 Spoedeisende Hulp (SEH) 88 Urologie 91 Verpleegkunde 95 Promoties 98 Abstracts Voordrachten Wetenschapsdag SFG Abstracts Posters Wetenschapsdag SFG Artikelenindex 128 Auteursindex 130 4

5 WOORD VOORAF One size fits all De uitgaven voor de gezondheidszorg stijgen ieder jaar. De overheid en ziektekosten - verzekeraars maken plannen om de gezondheidszorg betaalbaar te houden.deze plannen worden, zo mogelijk, gebaseerd op wetenschappelijk onderzoek (evidence-based medicine). Hierbij wordt de patiënt een gemiddelde patiënt. In werkelijkheid is de patiënt echter variabel: man óf vrouw, jong óf oud, sterk óf zwak, allochtoon óf autochtoon om een aantal karakteristieken te benoemen. Met patiëntgebonden onderzoek laten wij in het SFG zien hoe evidence-based medicine werkt en waar het one size fits all model faalt. In 2012 publiceerden in het Sint Franciscus Gasthuis werkzame medisch specialisten en arts-assistenten een groot aantal artikelen in gezaghebbende internationale tijdschriften. Absolute hoogtepunten zijn de publicatie van de treach studie, waarbij onderzocht werd hoe patiënten met reuma het beste behandeld kunnen worden (Annals of the Rheumatic Diseases) en de genetische (GWAS) studie die onderzocht welke genen belangrijk zijn bij het kleiner worden van het volume van de hippocampus (een maat voor vroege dementie) (Nature Genetics). Onderzoek vanuit het Sint Franciscus Gasthuis werd verder gepresenteerd door middel van voordrachten en posters. En twee echte SFG-onderzoekers verdedigden met succes hun proefschrift: dr. A. Alipour en mw. dr. I. Leeuwenburgh. In diverse andere proefschriften werd het Sint Franciscus Gasthuis terug gevonden in het dankwoord, vanwege diverse bijdragen. Wetenschappelijk onderzoek is belangrijk voor ons topklinisch STZ ziekenhuis. Het levert een belangrijke bijdrage aan de opleiding van medisch specialisten, verpleegkundigen en andere medewerkers in het Sint Franciscus Gasthuis. Daarnaast draagt het bij aan het verder verbeteren van de hoog gespecialiseerde zorg die in het Sint Franciscus Gasthuis aan patiënten wordt geboden. De Raad van Bestuur stimuleert het wetenschappelijk klimaat op diverse manieren. In 2012 werd in goed overleg met de Centrale Opleidingscommissie, de Medische Staf en het Leerhuis besloten om prof. dr. Jan Willem Cohen Tervaert aan te trekken als specialist manager wetenschap met als doel het wetenschappelijk onderzoek in de komende jaren op een nog hoger niveau te brengen. Samen met hem wil het Sint Franciscus Gasthuis de wetenschappelijke "size" creëren die past bij patiëntenzorg en opleidingen op top-niveau! Namens de Raad van Bestuur, Karen Kruijthof 5

6 ANESTHESIOLOGIE ANESTHESIOLOGIE

7 ANESTHESIOLOGIE Overige artikelen Vetemboliesyndroom na een totale knie arthroplastiek. van Bergeijk H, van Velzen C, de Quelerij M, Doornaar M, van der Klooster J, de Feiter PW, den Heijer T, Verbrugge SJC. Nederlands Tijdschrift voor Anesthesiologie 2012; 25 (4): Prevalence and determinants of complications in a bariatric ICU population. de Queleri j M, van Velzen C, Luitwieler R, Meijer N, Gadiot RPM, van der Voet J, van der Klooster J, de Feiter P, Mannaerts GHH, Verbrugge SJC. Nederlands Tijdschrift voor Anesthesiologie 2012; 25 (5): Voordrachten Pijnstilling op de afdeling. Quist RJ. Rotterdam: Sint Franciscus Gasthuis, Wetenschappelijk café, 1 februari Anesthesiologische aspecten van bariatrische chirurgie. Verbrugge SJC. Dordrecht: Albert Schweitzer Ziekenhuis, Schakels in de zorg, 20 en 29 maart Comorbiditeit en complicaties bij de bariatrische patient: De waarde IC opname criteria. Verbrugge SJC. Rotterdam: Sint Franciscus Gasthuis, Wetenschapsdag, 13 april Comorbidity and complications in patients undergoing bariatric surgery: the value of the ICU admission criteria. Meijer N, de Quelerij M, van Velzen C, Luitwieler R, Gadiot RPM, van der Voet J, van der Klooster J, de Feiter PW, Mannaerts GHH, Verbrugge SJC. Maastricht: MECC Congrescentrum, Anesthesiologendagen 2012, vrijdag 11 mei Pijnbestrijding bij kanker. Quist RJ. Rotterdam: Sint Franciscus Gasthuis, Oncologie aan de Bergse Plas. Workshop voor huis artsen, 10 oktober Obesity, Bariatric Surgery and Anesthesia. De Quelerij M. Rotterdam: Sint Franciscus Gasthuis. Advanced course in Laparoscopic Sleeve Gastrectomy and Logistics, 6 november Workshop NIV- interfaces en tracheacannules. Verbrugge SJC, Brouwers AJBW. Ede: Congrescentrum de Reehorst, NVIC Mechanische beademingsdagen 2012, 22 en 23 november Cursief: werkzaam in het Sint Franciscus Gasthuis 7 UW ZORG, ONZE PASSIE

8 APOTHEEK APOTHEEK

9 APOTHEEK Overige artikelen Twee medicatiedistributiesystemen in het zorghotel, locatie Sint Franciscus Gasthuis; een observationele vergelijking. Soema LM, Van Dijck-van Boetzelaer CWT, Heetman-Meijer CFM, Birnie E, Robijn RH, Schouten JP. Pharm Weekbl 2012;6:a1227. Voordracht Van leidingwater tot steriele substitutievloeistof. Kwaliteitsborging van water voor on-line HDF. Geerlings CJC. Utrecht: Cursus interne geneeskunde voor 2e/3e jaars ziekenhuisapothekers in opleiding, 15 februari Nierfunctiestoornissen en dialyse. Van den Oever FJ. Utrecht: Nascholing apothekers Nierfunctiestoornissen en dialyse, 29 november Poster Therapeutic drug monitoring of caffeine in preterm neonates. Bosma MS, Van Tuijl SGL, Mooij MG, Kamerbeek A, Geerlings CJC. Milaan: Congres European Association of Hospital Pharmacy, 20 tot 23 maart A practical thrice weekly ertapenem dosing regime for chronic hemodialysis patients. Bosma MS, Geerlings CJC, De Man P, Touw DJ, Rietveld AP. Veldhoven: Nederlandse Nefrologiedagen 2012,3 en 4 april A practical thrice weekly ertapenem dosing regime for chronic hemodialysis patients. Bosma MS, Geerlings CJC, De Man P, Touw DJ, Rietveld AP. Nunspeet: Nederlandse Ziekenhuisfarmaciedagen, 10 en 11 mei Cursief: werkzaam in het Sint Franciscus Gasthuis

10 CARDIOLOGIE CARDIOLOGIE

11 CARDIOLOGIE Pubmed artikelen Intrinsic versus laser-induced fluorescence spectroscopy for coronary atherosclerosis: a generational comparison model for testing diagnostic accuracy. van de Poll SW, Angheloiu GO, Georgakoudi I, Motz JT, Haka AS, Podrez E, Fitzmaurice M, Dasari RR, Feld MS, Kramer JR. Appl Spectrosc Dec;66(12): doi: / PMID: Abstract Laser-induced fluorescence (LIF) and intrinsic fluorescence spectroscopy (IFS) have been used experimentally for diagnosing coronary atherosclerosis. In this study, we demonstrated the diagnostic superiority of IFS at 342-nm excitation (IFS(342)) versus LIF (LIF(342)) and described a protocol for head-to-head comparison of old (LIF) versus new (IFS) generations of similar diagnostic methods, labeled as generational comparison model. IFS(342) and LIF(342) were modeled with basis spectra of media, fibrous caps, and superficial foam cells and of their correspondent chemicals (elastin, collagen, and lipoproteins). The average accuracy and receiver operating characteristic area under the curve of IFS(342) in single-, double-, and triple-parameter diagnostic algorithm iterations, geared toward identifying 84 atherosclerotic specimens from a group of 117 coronary segments, was 90% ± 1% and 0.87 ± 0.025, superior to LIF(342) (84% ± 3% and 0.84 ± 0.016; P = and 0.02, respectively) in a generational comparison model. A somnolent man found in the park rhythm puzzle. Pieters C, van de Poll SW. Neth Heart J Sep;20(9): doi: /s PMID: Geen abstract. PMC: Free PMC article. Onion-like masses in the left ventricle. Baars JE, Edward Visser W, Hoedemaeker R, Pieters C, van Miltenburg AJ. Eur Heart J Cardiovasc Imaging Oct 2. [Epub ahead of print] PMID: Geen abstract Overige artikelen A somnolent man found in the park answer. Pieters C, van de Poll SW. Neth Heart J Sep;20(9):379. doi: /s Cursief: werkzaam in het Sint Franciscus Gasthuis

12 CHIRURGIE CHIRURGIE

13 CHIRURGIE Pubmed artikel Treatment outcome in breast cancer patients with ipsilateral supraclaviculair lymph node metastasis at time of diagnosis: A review of the literature. Grotenhuis BA, Klem TMAL, Vrijland WW. Eur J Surg Oncol Dec 8. doi:pii: S (12) PMID: In the revised 6th edition of the AJCC-TNM staging system for breast cancer, metastasis in ipsilateral supraclavicular lymph node(s) is considered as a locoregional disease and classified as N3c rather than M1 distant disease. The aim of this review was to search the recent literature in order to investigate whether the reported treatment outcome of patients with ipsilateral supraclavicular metastases in breast cancer patients justifies this revision. A review of the recent English-language literature (January 2001-June 2012) concerning breast cancer with supraclavicular involvement was performed. A total number of six studies were included in the current review. All reported comparable data with regard to treatment outcome after multimodality treatment, despite considerable heterogeneity in study populations. Patients with ipsilateral supraclavicular lymph node involvement showed outcomes more similar to locally advanced breast cancer patients rather than patients with distant tumor spread. It seems that the 2002 revision of the AJCC-TNM staging system for breast cancer has appropriately reclassified patients with supraclavicular disease to a new category (N3c). Re-diplacement of stable both-bone forearm fractures in children: A randomised controlled multicentre trial. Colaris JW, Allema JH, Biter LU, de Vries MR, van der Ven CP, Bloem RM, Kerver AJH, Reijman M, Verhaar JAN. Injury.2012 Dec 3.doi:pii:S (12) /j.injury PMID: CHIRURGIE INTRODUCTION: Displaced metaphyseal both-bone fractures of the distal forearm are generally reduced and stabilised by an above-elbow cast (AEC) with or without additional pinning. The purpose of this study was to find out if re-displacement of a reduced stable metaphyseal both-bone fracture of the distal forearm in a child could be prevented by stabilisation with Kirschner wires. METHODS: Consecutive children aged <16 years with a displaced metaphyseal both-bone fracture of the distal forearm (n=128) that was stable after reduction were randomised to AEC with or without percutaneous fixation with Kirschner wires. The primary outcome was re-displacement of the fracture. RESULTS: A total of 67 children were allocated to fracture reduction and AEC and 61 to reduction of the fracture, fixation with Kirschner wires and AEC. The follow-up rate was 96% with a mean follow-up of 7.1 months. Fractures treated with additional pinning showed less re-displacement (8% vs. 45%), less limitation of pronation and supination (mean limitation 6.9 (±9.4) vs (±13.6) ) but more complications (14 vs. 1). CONCLUSIONS: Pinning of apparent stable both-bone fractures of the distal forearm in children might reduce fracture re-displacement. The frequently seen complications of pinning might be reduced by a proper surgical technique. 13

14 CHIRURGIE Below-elbow cast for metaphyseal both-bone fractures of the distal forearm in children: a randomised multicentre study. Colaris JW, Biter LU, Allema JH, Bloem RM, van der Ven CP, de Vries MR, Kerver AJH, Reijman M, Verhaar JAN. Injury.2012 Jul;43(7): doi: /j.injury Epub 2012 Apr 6. PMID: INTRODUCTION: Minimally displaced metaphyseal both-bone fractures of the distal forearm in children are often treated with an above-elbow cast (AEC). Treatment with a below-elbow cast (BEC) could give more comfort, but might lead to fracture displacement reducing pronation and supination. Because this has not been systematically investigated, we set up a randomised multicentre study. The purpose of this study was to find out whether BEC causes equal limitation of pronation and supination but with higher comfort level, compared with AEC. PATIENTS AND METHODS: In four hospitals, consecutive children aged<16 (mean 7.1) years with a minimally displaced metaphyseal both-bone fracture of the distal forearm were randomised to 4 weeks BEC (n=35) or 4 weeks AEC (n=31). Primary outcome was limitation of pronation and supination 6 months after initial trauma. The secondary outcomes were cast comfort, limitation of flexion/extension of wrist/elbow, complications, cosmetics, complaints, and radiological assessment. RESULTS: A group of 35 children received BEC and 31 children received AEC. All children attended for the final examination at a mean follow-up of 7.0 months (range months). Limitation of pronation and supination 6 months after initial trauma showed no significant difference between the two groups [4.4 (± 5.8) for BEC and 5.8 (± 9.8) for AEC]. Children treated with BEC had significantly higher cast comfort on a visual analogue scale [5.6 (± 2.7) vs. 8.4 (± 1.4)] and needed significantly less help with dressing (8.2 days vs days). Six complications occurred in the BEC group and 14 in the AEC group. Other secondary outcomes were similar between the two groups. Laparoscopic sleeve gastrectomy with an extensive posterior mobilization: technique and preliminary results. Gadiot RPM, Biter LU, Zengerink HJ, de Vos tot Nederveen Cappel RJ, Elte JWF, Castro Cabezas M, Mannaerts GHH. Obes Surg Feb;22(2):320-9.doi: /s PMID: BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is becoming increasingly popular as a stand-alone procedure for the treatment of morbidly obese patients. A direct posterior approach to the angle of His was developed at our department to improve visualization of the difficult dissection of the short gastric vessels and to facilitate proper mobilization of the stomach around the left crus enabling safe realization of a tight sleeve. The technique and its preliminary results are described. METHODS: LSG by posterior approach was performed in a consecutive series of 445 (110 male/335 female, age years, mean body mass index 46 kg/m(2) (range 35-76)) patients between 2007 and RESULTS: Weight loss defined as mean percent excess weight loss (%EWL) was 71% (±26%) at 1 year, 69% (±25%) at 2 years, and 55% (±27%) at 3 years. Sixteen patients (4%) developed postoperative intra-abdominal hematoma, 8 patients (2%) anastomotic leakage, and 6 patients intra-abdominal abscess (1%), requiring reoperation in 20 patients (4%). Five patients (1%) had pulmonary embolism. Thirty-day mortality rate was 0.2%.

15 CHIRURGIE CONCLUSIONS: LSG by the posterior approach is a safe and effective procedure, enabling a tight sleeve formation leading to satisfactory %EWL results. Since long-term results of LSG are unknown, further studies are needed to define the exact place of the LSG as a standalone bariatric procedure. Cancer stem cells and their potential implications for the treatment of solid tumors. Grotenhuis BA, Wijnhoven BP, Van Lanschot JJ. J Surg Oncol.2012 Aug 1; 106(2): Review. PMID: BACKGROUND AND OBJECTIVES: There is increasing evidence that a variety of human cancers is maintained by a subset of cells, cancer stem cells (CSCs), which sustain tumor growth, underlie its malignant behavior, and possibly initiate distant metastases. The aim of this review is to evaluate the current evidence for the existence of CSCs and the implications on the present management and treatment of solid tumors. METHODS: A retrospective review of the English-language literature ( ) concerning CSCs and their therapeutic implications was performed. RESULTS: CSCs are characterized by two main properties of normal stem cells: Self-renewal and differentiation, which are best assayed by serial transplantation experiments in immunodeficient mice. Cell-surface antigens that mark cell populations enriched for CSCs have been identified in various solid tumors. As such, the very existence of CSCs has vast clinical implications with regard to cancer treatment. The development of tailor-made CSC-targeted therapies (including therapies directed at these CSC-specific surface markers, and reversal of the intrinsic resistance of CSCs to chemo- and radiotherapy) entails great promises. However, normal stem cell toxicity and treatment resistance have been recognized as serious problems. CONCLUSION: The growing evidence indicating that CSCs drive and maintain various types of solid human malignancies has important implications for the treatment of patients. However, over the years the development of CSC-targeted therapies has faced a number of potential hurdles, which must be considered carefully in order to maximize the chance that such therapies will be successful. Treatment outcome in breast cancer patients with ipsilateral supraclavicular lymph node metastasis at time of diagnosis: A review of the literature. Grotenhuis BA, Klem TMAL, Vrijland WW. Eur J. Surg Oncol Dec 8. Epub ahead of print. PMID: INTRODUCTION: In the revised 6th edition of the AJCC-TNM staging system for breast cancer, metastasis in ipsilateral supraclavicular lymph node(s) is considered as a locoregional disease and classified as N3c rather than M1 distant disease. The aim of this review was to search the recent literature in order to investigate whether the reported treatment outcome of patients with ipsilateral supraclavicular metastases in breast cancer patients justifies this revision. METHODS: A review of the recent English-language literature (January 2001-June 2012) concerning breast cancer with supraclavicular involvement was performed. RESULTS: A total number of six studies were included in the current review. All reported comparable data with regard to treatment outcome after multimodality treatment, despite considerable 15

16 CHIRURGIE heterogeneity in study populations. Patients with ipsilateral supraclavicular lymph node involvement showed outcomes more similar to locally advanced breast cancer patients rather than patients with distant tumor spread. CONCLUSION: It seems that the 2002 revision of the AJCC-TNM staging system for breast cancer has appropriately reclassified patients with supraclavicular disease to a new category (N3c). Long-term functional outcome of patients with longitudinal radial deficiency: cross-sectional evaluation of function, activity and participation. Holtslag I, Wijk IV, Hartog H, Van der Molen AM, Van der Sluis C. Disabil Rehabil 2012 Nov 20. Epub ahead of print. PMID: PURPOSE: To evaluate all functional aspects of patients with longitudinal radial dysplasia and to clarify the relationship between body functions on the one hand and limitations in activity and participation on the other hand. Methods: Thirty-one arms of seventeen adult patients with longitudinal radial dysplasia were analysed. Body function was assessed by measuring grip and pinch strength and active range of motion (ROM) of the hand. Activities were measured using the Sequential Occupational Dexterity Assessment, to measure perceived restrictions in participation the Impact on Participation and Autonomy questionnaire was used. Relationships between severity of dysplasia, body function, participation and activity were determined. Results: Patients with a severe type scored significantly lower in body function scores than patients with a mild form. Patients with limited active finger joint motion performed worse on activities. We found no significant differences in activity and participation between mild or severe types and found no correlation in participation scores. Conclusion: Although considerable restrictions in joint mobility and strength were revealed, little or no limitations on the activity and participation level were found. Limitations in body functions hardly influenced capacity on activity level and did not influence participation in societal roles. 16 Treatment of breast cancer cells by IGF1R tyrosine kinase inhibitor combined with conventional systemic drugs. Hartog H, Van der Graaf WT, Boezen HM, Wesseling J. Anticancer Res Apr; 32(4): PMID: AIM: Insulin-like growth factor-1 receptor (IGF1R) is a tyrosine kinase receptor mediating cell growth and survival of cancer cells. We studied responses to IGF1R tyrosine kinase inhibitor NVP-AEW541 combined with conventional systemic drugs in breast cancer cell lines of different clinical subtype. MATERIALS AND METHODS: Sensitivity to NVP-AEW541, single treatment and combinations with tamoxifen, trastuzumab, doxorubicin or paclitaxel, was tested in MCF7, SKBR3 and T47D cells. Cells were assayed for proliferation, cell death, cell cycle distribution and phosphorylation of proteins downstream of IGF1R. RESULTS: Treatment of NVP-AEW541 resulted in reduced proliferation, G-1 cell cycle arrest and reduced phosphorylation of protein kinase B (AKT) and extracellular-signal-regulated protein kinase (ERK). Sensitivity to IGF1R tyrosine kinase inhibition was low in T47D cells, despite their high IGF1R expression. NVP-AEW541 combined with trastuzumab had synergistic cytotoxic effects in T47D

17 CHIRURGIE cells, and additive effects were shown in MCF7 and SKBR3 cells. Also, combination with doxorubicin had antagonistic effects in T47D cells. Doxorubicin caused up-regulation of phosphorylated ERK in T47D cells, which was not inhibited by NVP-AEW541. CONCLUSION: Antagonistic effects should be anticipated when IGF1R inhibitors are combined with conventional systemic drugs in a subset of breast tumors. Development of functional biomarkers predicting tumor response to tailored IGF1R therapy is warranted. The surgical anatomy of the small saphenous vein and adjacent nerves in relation to endovenous thermal ablatio. Kerver AL, Van der Ham AC, Theeuwes HP, Eilers PH, Poublon AR, Kerver AJH, Kleinrensink GJ. J Vasc Surg 56 (1): PMID: BACKGROUND: Thermal damage to peripheral nerves is a known complication of endovenous thermal ablation (EVA) of the small saphenous vein (SSV). Therefore, the main objective of this anatomic study was to define a safe zone in the lower leg where EVA of the SSV can be performed safely. METHODS: The anatomy of the SSV and adjacent nerves was studied in 20 embalmed human specimens. The absolute distances between the SSV and the sural nerve (SN) (closest/nearest branch) were measured over the complete length of the leg (>120 data points per leg), and the presence of the interlaying deep fascia was mapped. The distance between the SSV and the tibial nerve (TN) and the common peroneal nerve was assessed. A new analysis method, computer-assisted surgical anatomy mapping, was used to visualize the gathered data. RESULTS: The distance between the SSV and the SN was highly variable. In the proximal one-third of the lower leg, the distance between the vein and the nerve was <5 mm in 70% of the legs. In 95%, the deep fascia was present between the SSV and the SN. In the distal two-thirds of the lower leg, the distance between the vein and the nerve was <5 mm in 90% of the legs. The deep fascia was present between both structures in 15%. In 19 legs, the SN partially ran beneath the deep fascia. In the saphenopopliteal region, the average shortest distance between the SSV and the TN was 4.4 mm. In 20%, the distance was <1 mm. The average, shortest distance between the SSV and the common peroneal nerve was 14.2 mm. The distance was <1 mm in one leg. CONCLUSIONS: At the saphenopopliteal region, the TN is at risk during EVA. In the distal two-thirds of the lower leg, the SN is at risk for (thermal) damage due to the small distance to the SSV and the absence of the deep fascia between both structures. The proximal one-third of the lower leg is the optimal region for EVA of the SSV to avoid nerve damage; the fascia between the SSV and the SN is a natural barrier in this region that could preclude (thermal) damage to the nerve. Bariatric surgery with OR teams that stayed fixed during the day: a mulicenter analyzing the effects on patiënt outcomes, teamwork and safety climate and duration. Stepaniak PS, Heij C, Buise MP, Mannaerts GHH, Smulders JF, Nienhuis SW. Anesth Analg 2012, Epub 2012 nov 9. PMID: BACKGROUND: Bariatric surgery durations vary considerably because of differences in surgical procedures and patient factors. We studied the effects on patient outcomes, teamwork and safety climate, and procedure durations resulting from working with operating 17

18 CHIRURGIE room (OR) teams that remain fixed for the day instead of OR teams that vary during the day. METHODS: Data were collected in 2 general teaching hospitals, consisting of patientrelated demographic and intraoperative data and of staffrelated survey data on team work and safety climate. The procedure durations of fixed and conventional OR teams were analyzed by comparison of means tests and by regression methods to control for the effects of surgeon, surgical experience, and procedure type. RESULTS: For both hospitals, we obtained the following 4 results for working on bariatric procedures with OR teams that remained fixed for the day. First, patient outcomes did not worsen. Second, teamwork and safety climate (both measured on a 5-point scale) improved significantly, for teamwork (95% confidence interval [CI], 0.54 to 1.18) and for safety climate (95% CI, 0.40 to 1.11). Third, the procedures were performed significantly faster, as both the mean and the SD of procedure durations decreased. After correcting for learning effects, the average reduction of durations was 10.8% (99% CI, 5.0% to 15.3%, or 4 to 13 minutes). This gain was mainly realized for surgical time (12%; 99% CI, 5% to 18%, or 3 to 11 minutes). The effect on peripheral time, defined as procedure time minus surgical time, is not significant (3%; 99% CI, -6% to 12%, or -1 to 3 minutes). Fourth, additional gains were obtained by performing the same type of procedure multiple times within the same day (5% per every next procedure of the same type; 99% CI, 3% to 7%, or 3 to 6 minutes). Yield of routine molecular analyses in colorectal cancer patiënt 70 years to detect underlying Lynch syndrome. Van Lier MG, Leenen CH, Wagner A, Ramsoekh D, Dubbing HJ, Van den Ouweland AM, Westenend PJ, De Graaf EJ, Wolters LM, Vrijland WW, Kuipers EJ, Van Leerdam ME, Steyerberg EW, Dinjens WN; LIMO Study Group. J Pathol Apr; 226(5): doi: /path Epub 2012 Jan 17. PMID: Although early detection of Lynch syndrome (LS) is important, a considerable proportion of patients with LS remains unrecognized. We aimed to study the yield of LS detection by routine molecular analyses in colorectal cancer (CRC) patients until 70 years of age. We prospectively included consecutive CRC patients 70 years. Tumour specimens were analysed for microsatellite instability (MSI), immunohistochemical mismatch-repair protein expression and MLH1-promoter methylation. Tumours were classified as either: (a) likely caused by LS; (b) sporadic microsatellite-unstable (MSI-H); or (c) microsatellite-stable (MSS). Predictors of LS were determined by multivariable logistic regression. A total of 1117 CRC patients (57% males, median age 61 years) were included. Fifty patients (4.5%, 95% CI ) were likely to have LS, and 71 had a sporadic MSI-H tumour (6.4%, 95% CI ). Thirty-five patients likely to have LS (70%) were aged > 50 years. A molecular profile compatible with LS was detected in 10% (15/144) of patients aged 50, in 4% (15/377) of those aged and in 3% (20/596) of patients > 61 years. Compared to MSS cases, patients likely to have LS were significantly younger (OR 3.9, 95% CI ) and more often had right-sided CRCs (OR 14, 95% CI ). In conclusion, molecular screening for LS in CRC patients 70 years leads to identification of a molecular profile compatible with LS in 4.5% of patients, with most of them not fulfilling the age criterion ( 50 years) routinely used for LS assessment. Routine use of MSI testing may be considered in CRC patients up to the age of 70 years, with a central role for the pathologist in the selection of patients. 18

19 CHIRURGIE Comparison of the 6th and 7th Editions of the UICC-AJCC TNM Classification for Esophageal Cancer. Talsma K, Van Hagen P, Grotenhuis BA, Steyerberg EW, Tilanus HW, Van Lanschot JJ, Wijnhoven BP. Ann Surg Oncol Jul; 19(7): PMID: BACKGROUND: The new 7th edition of the Union for International Cancer Control-American Joint Committee on Cancer (UICC-AJCC) tumor, node, metastasis (TNM) staging system is the ratification of data-driven recommendations from the Worldwide Esophageal Cancer Collaboration database. Generalizability remains questionable for single institutions. The present study serves as a validation of the 7th edition of the TNM system in a prospective cohort of patients with predominantly adenocarcinomas from a single institution.methods: Included were patients who underwent transhiatal esophagectomy with curative intent between 1991 and 2008 for invasive carcinoma of the esophagus or gastroesophageal junction. Excluded were patients who had received neoadjuvant chemo(radio)therapy, patients after a noncurative resection and patients who died in the hospital. Tumors were staged according to both the 6th and the 7th editions of the UICC-AJCC staging systems. Survival was calculated by the Kaplan-Meier method, and multivariate analysis was performed with a Cox regression model. The likelihood ratio chi-square test related to the Cox regression model and the Akaike information criterion were used for measuring goodness of fit. RESULTS: A study population of 358 patients was identified. All patients underwent transhiatal esophagectomy for adenocarcinoma. Overall 5-year survival rate was 38%. Univariate analysis revealed that pt stage, pn stage, and pm stage significantly predicted overall survival. Prediction was best for the 7th edition, stratifying for all substages.conclusions: The application of the 7th UICC-AJCC staging system results in a better prognostic stratification of overall survival compared to the 6th edition. The fact that the 7th edition performs better predominantly in patients with adenocarcinomas who underwent a transhiatal surgical approach, in addition to findings from earlier research in other cohorts, supports its generalizability for different esophageal cancer practices. Long-term and perioperative corticosteroids in anastomotic leakage: a prospective of 259 left-sided colorectal anastomoses. Slieker J, Komen NA, Mannaerts GHH, Karsten TM, Willemsen P, Murawska M, Jeekel J, Lange JF. Arch Surg 2012; 147 (8); PMID: OBJECTIVE: To determine the risk factors for symptomatic anastomotic leakage (AL) after colorectal resection. DESIGN: Review of records of patients who participated in the Analysis of Predictive Parameters for Evident Anastomotic Leakage study. SETTING: Eight health centers. PATIENTS: Two hundred fifty-nine patients who underwent left-sided colorectal anastomoses. INTERVENTION: Corticosteroids taken as long-term medication for underlying disease or perioperatively for the prevention of postoperative pulmonary complications. MAIN OUTCOME MEASURES: Prospective evaluations for risk factors for symptomatic AL. RESULTS: In 23% of patients, a defunctioning stoma was constructed. The incidence of AL was 7.3%. The clinical course of patients with AL showed that in 21% of leaks, the drain indicated leakage; in the remaining patients, computed tomography or laparotomy resulted equally often in the 19

20 CHIRURGIE detection of AL. In 50% of patients with AL, a Hartmann operation was needed. The incidence of AL was significantly higher in patients with pulmonary comorbidity (22.6% leakage), patients taking corticosteroids as longterm medication (50% leakage), and patients taking corticosteroids perioperatively (19% leakage). Perioperative corticosteroids were prescribed in 8% of patients for the prevention of postoperative pulmonary complications. CONCLUSIONS: We found a significantly increased incidence of AL in patients treated with long-term corticosteroids and perioperative corticosteroids for pulmonary comorbidity. Therefore, we recommend that in this patient category, anastomoses should be protected by a diverting stoma or a Hartmann procedure should be considered to avoid AL. Overige publicaties Preoperative Assessment of Tumor Location an Station-Specific Lymfh Node Status in Patients with Adenocarcinoma of the Gastroesophageal Junction. Grotenhuis BA, Wijnhoven BP, Poley JW, Hermans JJ, Biermann K, Spaander MC, Bruno MJ, Tilanus HW, Van Lanschot JJ. World J Surg Sep 27. Epub ahead of print. Onderzoek Onderarmgips bij distale fracturen van radius en ulna een multicentrisch gerandomiseerd onderzoek bij kinderen. Colaris JW, Biter LU, Allema JH, Bloem RM, Van de Ven CP, De Vries MR, Kerver AJH, Reijman M, Verhaar J. Ned Tijdschr Geneesk.2012; 156:A5332. Voordrachten Onderarmgips in de behandeling van de fractura antebrachii. Een gerandomiseerde multicenter studie. Colaris JW, Allema JH, Biter LU, De Vries MR, Van der Ven CP, Bloem RM, Kerver AJH, Reijman M, Verhaar JAN. Veldhoven: NOV najaarsvergadering, 4-5 oktober Rotterdam Advanced Foot Ankle Trauma Course. Improving through Practice. Schepers T, Den Hartog D, Kleinrensink GJ, Kerver AJH, Reijman M, Verhaar JAN. Rotterdam: SkillsLab, Erasmus MC, 9 maart De nieuwe richtlijn behandeling polsfracturen. Kerver AJH, Klem TMAL. Rotterdam: Regionale Refereeravond Heelkunde, 16 april