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ABSTRACT: Biliary complications after liver surgery are difficult to manage. Endoscopic retrograde cholangiopancreatography (ERCP) with stenting of the common bile duct is not commonly practiced in children for this purpose. The aim of this retrospective review is to evaluate the role of ERCP as both a diagnostic and a therapeutic tool in the management of biliary complications after liver resection in children.
The charts of all patients from 0 to 18years old who underwent partial liver resection in a tertiary children's hospital in Amsterdam, the Netherlands, between 2000 and 2010 were retrospectively reviewed.
Forty-five children (median age: 3.6years, range: 2months-17years) underwent partial liver resection. Post-operative biliary complications occurred in 13 children. Ten patients were suffering from bile leakage. Eight of them underwent ERCP with stent placement after which leakage stopped in 5 patients. Three patients presented with a post-operative biliary tract stricture. ERCP with dilation and stent placement was performed in 2 of them, which solved the problem in one patient. ERCP demonstrated the nature (bile leak and/or biliary tract stricture(s)), extent, and location of the lesion in 8 of 10 children. There were no serious procedure related complications. Rescue procedures in the other patients included hepaticojejunostomy and liver transplant.
ERCP with stenting of the common bile duct has a diagnostic and therapeutic role in the management of bile leaks after partial liver resection in children. The value of ERCP in the management of a stricture of the biliary tract is less conclusive.
Journal of Pediatric Surgery 02/2013; 48(2):418-24. · 1.45 Impact Factor
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ABSTRACT: PurposeThis study assessed long-term functional outcome and explored risk factors for fistula recurrence in patients surgically treated
for cryptoglandular fistulas.
MethodsThree hundred ten consecutive patients were surgically treated for perianal fistulas. After exclusion of patients with inflammatory
bowel disease or HIV, 179 patients remained. Patients were divided into two groups: those who received fistulotomy for low
perianal fistulas and those who received rectal advancement flap for high perianal fistulas. Time to fistula recurrence was
the main outcome and Cox proportional hazard models were used to assess the importance of various risk factors. Functional
outcome was assessed using the Vaizey and colorectal functional outcome (COREFO) questionnaires.
ResultsThe median follow-up duration was 76months (range, 7–134). The 3-year recurrence rate for low perianal fistulas treated by
fistulotomy (n = 109) was 7 percent (95 percent confidence interval, 1–13 percent). In high transsphincteric fistulas treated
by rectal advancement flap (n = 70), the recurrence rate was 21 percent (95 percent confidence interval, 9–33 percent). In
both groups, soiling was reported at 40 percent. None of the seven potential risk factors examined were statistically significant.
ConclusionsFistula recurrence rate after fistulotomy was low. No clear risk factors were found. Overall functional outcome in terms of
continence was good. However, a substantial amount of patients reported soiling.
Diseases of the Colon & Rectum 04/2012; 51(10):1475-1481. · 3.13 Impact Factor
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ABSTRACT: The purpose of this study was to prospectively compare rectal resection (RR) with colonic resection on sexual, urinary and bowel function and quality of life in both short-term and long-term.
Eighty-three patients who underwent RR were compared to 53 patients who underwent a colonic resection leaving the rectum in situ (RIS). A questionnaire assessing sexual, urinary and bowel functioning with a quality of life questionnaire (SF-36) was sent to all participants preoperatively, 3 and 12 months postoperatively and approximately 8 years after the onset of the study.
Short-term dysfunction included diminished sexual activity in female RR patients at 3 months and significantly more erectile dysfunction in RR patients 1 year postoperatively. Long-term dysfunction included more frequent and more severe erectile dysfunction in RR patients compared to RIS patients. These short-term and long-term outcomes did not influence overall quality of life. The incidence of urinary dysfunction was comparable between both groups. Bowel functioning was significantly better in the RIS group compared to the RR group 3 months and 1 year postoperatively.
Patients who underwent RR experienced up to 1 year postoperatively more sexual and bowel function problems than RIS patients. However, short-term and long-term dysfunction did not influence overall quality of life. Erectile dysfunction in male RR patients persisted in time, whereas other aspects of sexual, urinary and bowel function after RR and colonic resection are similar after a median follow-up of 8.5 years.
International Journal of Colorectal Disease 09/2011; 26(12):1549-57. · 2.38 Impact Factor
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ABSTRACT: The Malone antegrade continence enema (MACE) procedure has been previously described as a safe and effective option for the treatment of children with chronic defecation disorders when maximal medical therapy and conventional treatment have failed.
To evaluate clinical success, complications, and quality of life of children with chronic defecation disorders with a MACE stoma.
A retrospective analysis of 23 patients who underwent the construction of a MACE stoma was performed. Preoperative and postoperative data were evaluated. A specific questionnaire was used to assess patient satisfaction.
A significant increase was found in defecation frequency (1.0 [range, 0-4] pretreatment vs 5.5 [range, 0-28] posttreatment per week; P < .006) and a significant decrease in fecal incontinence frequency (10 [range, 0-14] pretreatment vs 0 [range, 0-14] posttreatment per week; P < .034). Postoperative complications of the MACE procedure were fecal leakage (43%), wound infection (52%), and stomal stenosis (39%). A total of 86% of the patients were satisfied with the results of the Malone stoma (n = 21).
The MACE procedure is an effective treatment in children with intractable defecation disorders. Postoperative complications are, however, not uncommon. Further refinement of the technique focused to reduce the complication rate is necessary to expand the application of this approach.
Journal of Pediatric Surgery 08/2011; 46(8):1603-8. · 1.45 Impact Factor
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ABSTRACT: Preoperative radiotherapy followed by rectal resection with total mesorectal excision (TME) and colo-anal anastomosis severely compromises anorectal function, which has been attributed to a decrease in neorectal capacity and neorectal compliance. However, to what extent altered motility of the neorectum is involved, is still unknown. The aim of the study was to compare the motor response to (prolonged) filling of the (neo-)rectum in patients after preoperative radiotherapy and rectal resection with that in healthy volunteers (HV).
Neorectal function (J-pouch or side-to-end anastomosis) was studied in 15 patients (median age 61 years, 10 males) 5 months after short-term preoperative radiotherapy (5 x 5 Gy) and rectal resection with TME for rectal cancer and compared with that of 10 volunteers (median age 41 years, 7 males). Furthermore, patients with a colonic J-pouch anastomosis (n=6) were compared with patients with a side-to-end anastomosis (n=9). (Neo-)rectal sensitivity was assessed using a stepwise isovolumetric and isobaric distension protocol. (Neo-)rectal motility was determined during prolonged distension at the threshold of the urge to defecate.
The neorectal volume of patients at the threshold of the urge to defecate (125 +/-45 ml) was significantly lower when compared with that of HV (272+/-87 ml, P<0.05). The pressure threshold, however, did not differ between patients (26+/-9 mm Hg) and HV (21+/-5 mm Hg) and neither did the pressure threshold differ between patients with a J-pouch and those with side-to-end anastomosis. In HV, no rectal contractions were observed during prolonged rectal distension. In contrast, in all 15 patients, prolonged isovolumetric and isobaric distension induced 3 (range 0-5) rectal contractions/10 min, which were associated with an increase in sensation in half of the patients.
Patients who underwent preoperative radiotherapy and rectal resection with TME, but not HV, developed contractions of the neo-rectum in response to prolonged distension. We suggest that this neorectal "irritability" represents a new pathophysiological mechanism contributing to the urgency for defecation after this multimodality treatment.
The American Journal of Gastroenterology 01/2009; 104(1):133-41. · 7.28 Impact Factor
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ABSTRACT: To analyze, retrospectively in a population-based study, the management and survival of patients with recurrent rectal cancer initially treated with a macroscopically radical resection obtained with total mesorectal excision (TME).
All rectal carcinomas diagnosed during 1998 to 2000 and initially treated with a macroscopically radical resection (632 patients) were selected from the Amsterdam Cancer Registry. For patients with recurrent disease, information on treatment of the recurrence was collected from the medical records.
Local recurrence with or without clinically apparent distant dissemination occurred in 62 patients (10%). Thirty-two patients had an isolated local recurrence. Ten of these 32 patients (31%) underwent radical re-resection and experienced the highest survival (three quarters survived for at least 3 years). Eight patients (25%) underwent non-radical surgery (median survival 24 mo), seven patients (22%) were treated with radio- and/or chemotherapy without surgery (median survival 15 mo) and seven patients (22%) only received best supportive care (median survival 5 mo). Distant dissemination occurred in 124 patients (20%) of whom 30 patients also had a local recurrence. The majority (54%) of these patients were treated with radio- and/or chemotherapy without surgery (median survival 15 mo). Twenty-seven percent of these patients only received best supportive care (median survival 6 mo), while 16% underwent surgery for their recurrence. Survival was best in the latter group (median survival 32 mo).
Although treatment options and survival are limited in case of recurrent rectal cancer after radical local resection obtained with TME, patients can benefit from additional treatment, especially if a radical resection is feasible.
World Journal of Gastroenterology 11/2008; 14(39):6018-23. · 2.47 Impact Factor
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ABSTRACT: After colorectal surgery, patients often experience impaired functional outcome. Faecal incontinence grading systems and self-assessment questionnaires are frequently used to assess these complaints. The available faecal incontinence grading systems have been validated, but have a limited focus, while more comprehensive questionnaires, which have been developed, have not been validated.
To investigate the reliability and validity of a newly developed, colorectal functional outcome (COREFO) questionnaire and of Dutch translations of the Hallböök questionnaire and an adapted version of the Vaizey questionnaire.
Two hundred fifty-seven patients with and without impaired functional outcome after (colorectal) surgery received a booklet containing the three questionnaires in random order by mail. One hundred seventy-nine (70%) completed them, and 160 patients (90%) completed a retest within, on average, 18 days.
Reliability and validity were adequate for the COREFO and Hallböök questionnaire, with slight differences in the psychometric analyses in favour of the COREFO questionnaire. Significantly more patients found the COREFO questionnaire to reflect their problems best. The reliability of the Vaizey questionnaire was not sufficient.
The newly developed COREFO questionnaire and the previously unvalidated Hallböök questionnaire are both suitable instruments to evaluate functional outcome after colorectal surgery. The psychometric analyses showed a slight difference in favour of the COREFO questionnaire and significantly more patients preferred the COREFO questionnaire to the other questionnaires. Therefore, we prefer to use the COREFO questionnaire in future research.
International Journal of Colorectal Disease 04/2005; 20(2):126-36. · 2.38 Impact Factor
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Journal of the American College of Surgeons 06/2004; 198(5):846-51. · 4.55 Impact Factor
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Journal of Surgical Oncology 03/2004; 85(2):93-7. · 2.10 Impact Factor
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ABSTRACT: A loop ileostomy is constructed to protect a distal anastomosis, and closure is usually performed not earlier than after two to three months. Earlier closure might reduce stoma-related morbidity, improve quality of life, and still effectively protect the distal anastomosis. This pilot study was designed to investigate the feasibility of early closure of loop ileostomies, i.e., during the same hospital admission as the initial operation.
Twenty-seven consecutive patients with a protective loop ileostomy were included. If patient's recovery was uneventful, water-soluble contrast enema examination was performed, preferably after seven to eight days. If no radiologic signs of leakage were detected, the ileostomy was closed during the same hospital admission.
Twenty-seven patients (8 females; mean age, 60 years) were analyzed. Eighteen patients had early ileostomy closure on average 11 (range, 7-21) days after the initial procedure. In nine patients the procedure was postponed because of leakage of the anastomosis (n = 3), delayed recovery (n = 1), small bowel obstruction (n = 1), gastroparesis (n = 1), logistic reasons (n = 2), or irradical cancer resection followed by radiotherapy (n = 1). There was no mortality and four mild complications occurred after early closure: superficial wound infection (n = 2), intravenous-catheter sepsis (n = 1), small bowel obstruction (n = 1).
Closure of a loop ileostomy early after the initial operation was feasible in 18 of 27 patients and was associated with low morbidity and no mortality.
Diseases of the Colon & Rectum 01/2004; 46(12):1680-4. · 3.13 Impact Factor
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Gastroenterology 01/2003; 124(4). · 11.68 Impact Factor
