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IMPORTANCE: Postoperative pancreatic fistula is a potentially life-threatening complication after pancreatoduodenectomy. Evidence for best management is lacking. OBJECTIVE: To evaluate the clinical outcome of patients undergoing catheter drainage compared with relaparotomy as primary treatment for pancreatic fistula after pancreatoduodenectomy. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, retrospective, propensity-matched cohort study was conducted in 9 centers of the Dutch Pancreatic Cancer Group from January 1, 2005, to September 30, 2013. From a cohort of 2196 consecutive patients who underwent pancreatoduodenectomy, 309 patients with severe pancreatic fistula were included. Propensity score matching (based on sex, age, comorbidity, disease severity, and previous reinterventions) was used to minimize selection bias. Data analysis was performed from January to July 2016. EXPOSURES: First intervention for pancreatic fistula: catheter drainage or relaparotomy. MAIN OUTCOMES AND MEASURES: Primary end point was in-hospital mortality; secondary end points included new-onset organ failure. RESULTS: Of the 309 patients included in the analysis, 209 (67.6%) were men, and mean (SD) age was 64.6 (10.1) years. Overall in-hospital mortality was 17.8% (55 patients): 227 patients (73.5%) underwent primary catheter drainage and 82 patients (26.5%) underwent primary relaparotomy. Primary catheter drainage was successful (ie, survival without relaparotomy) in 175 patients (77.1%). With propensity score matching, 64 patients undergoing primary relaparotomy were matched to 64 patients undergoing primary catheter drainage. Mortality was lower after catheter drainage (14.1% vs 35.9%; P = .007; risk ratio, 0.39; 95% CI, 0.20-0.76). The rate of new-onset single-organ failure (4.7% vs 20.3%; P = .007; risk ratio, 0.15; 95% CI, 0.03-0.60) and new-onset multiple-organ failure (15.6% vs 39.1%; P = .008; risk ratio, 0.40; 95% CI, 0.20-0.77) were also lower after primary catheter drainage. CONCLUSIONS AND RELEVANCE: In this propensity-matched cohort, catheter drainage as first intervention for severe pancreatic fistula after pancreatoduodenectomy was associated with a better clinical outcome, including lower mortality, compared with primary relaparotomy.

AbstractIntroduction:The completeness of the pathological examination of resected colon cancer specimens is important for further clinical management. We reviewed the pathological reports of 356 patients regarding the five factors (pT-stage, tumor differentiation grade, lymphovascular invasion, tumor perforation and lymph node metastasis status) that are used to identify high-risk stage II colon cancers, as well as their impact on overall survival (OS).Methods:All patients with stage II colon cancer who were included in the first five years of the MATCH study (1 July 2007 to 1 July 2012) were selected (n = 356). The hazard ratios of relevant risk factors were calculated using Cox Proportional Hazards analyses.Results:In as many as 69.1% of the pathology reports, the desired information on one or more risk factors was considered incomplete. In multivariable analysis, age (HR: 1.07, 95%CI 1.04–1.10, p < .001), moderately- (HR: 0.35, 95%CI 0.18–0.70, p = .003) and well (HR 0.11, 95%CI 0.01–0.89, p = .038) differentiated tumors were significantly associated with OS.Conclusions:Pathology reports should better describe the five high-risk factors, in order to enable proper patient selection for further treatment. Chemotherapy may be offered to stage II patients only in select instances, yet a definitive indication is still unavailable.

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Case series suggest that laparoscopic peritoneal lavage might be a promising alternative to sigmoidectomy in patients with perforated diverticulitis. We aimed to assess the superiority of laparoscopic lavage compared with sigmoidectomy in patients with purulent perforated diverticulitis, with respect to overall long-term morbidity and mortality.

Coene P-PLO, Groen AK, Davids PHP, Hardman M, Tytgat GNJ, Huibregtse K. Bile viscosity in patients with biliary drainage. Effect of co-trimoxazole and N-acetylcysteine and role in stent clogging. Scand J Gastroenterol 1994;29:757-763.Background: The main disadvantage of endoscopic insertion of an endoprosthesis is the tendency of the stent to clog after a few months. In this study we determined the role of bile viscosity in stent clogging. Methods: Sixty patients were stented with 10 Fr 11-cm stents. The stents were electively removed after 2 months, and a bile sample was obtained simultaneously. Bile viscosity was measured with a coaxial rotation viscometer. The influence of treatment with antibiotics and a mucolytic agent on viscosity was assessed in a randomized trial. Results: Bile viscosity correlated significantly with DNA and total protein concentration. After treatment with either iV-acetylcysteine or co-trimoxazole a lower mean value of the viscosity was observed, but this was not statistically significant. There was no correlation between bile viscosity and the amount of sludge adhering to the stents. Conclusions: In most patients bile viscosity plays a limited role in stent clogging. Only in patients with excessively high viscosity do mucolytic agents or treatment with antibiotics seem to have a role.