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C H C Dejong

Publications and source records attributed to C H C Dejong.

13 recordsLinked to original sources
PubMed2007

A protocol is not enough to implement an enhanced recovery programme for colorectal resection.

BACKGROUND: Single-centre studies have suggested that enhanced recovery can be achieved with multimodal perioperative care protocols. This international observational study evaluated the implementation of an enhanced recovery programme in five European centres and examined the determinants affecting recovery and length of hospital stay. METHODS: Four hundred and twenty-five consecutive patients undergoing elective open colorectal resection above the peritoneal reflection between January 2001 and January 2004 were enrolled in a protocol that defined multiple perioperative care elements. One centre had been developing multimodal perioperative care for 10 years, whereas the other four had previously undertaken traditional care. RESULTS: The case mix was similar between centres. Protocol compliance before and during the surgical procedure was high, but it was low in the immediate postoperative phase. Patients fulfilled predetermined recovery criteria a median of 3 days after operation but were actually discharged a median of 5 days after surgery. Delay in discharge and the development of major complications prolonged length of stay. Previous experience with fast-track surgery was associated with a shorter hospital stay. CONCLUSION: Functional recovery in 3 days after colorectal resection could be achieved in daily practice. A protocol is not enough to enable discharge of patients on the day of functional recovery; more experience and better organization of care may be required.

Aged↗
PubMed2006

Patterns in current anaesthesiological peri-operative practice for colonic resections: a survey in five northern-European countries.

BACKGROUND: For colorectal surgery, evidence suggests that optimal management includes: no pre-operative fasting, a thoracic epidural analgesia continued for 2 days post-operatively, and avoidance of fluid overload. In addition, no long-acting benzodiazepines on the day of surgery and use of short-acting anaesthetic medication may be beneficial. We examined whether these strategies have been adopted in five northern-European countries. METHODS: In 2003, a questionnaire concerning peri-operative anaesthetic routines in elective, open colonic cancer resection was sent to the chief anaesthesiologist in 258 digestive surgical centres in Scotland, the Netherlands, Denmark, Sweden and Norway. RESULTS: The response rate was 74% (n = 191). Although periods of pre-operative fasting up to 48 h were reported, most (> 85%) responders in all countries declared to adhere to guidelines for pre-operative fasting and oral clear liquids were permitted until 2-3 h before anaesthesia. Solid food was permitted up to 6-8 h prior to anaesthesia. In all countries more than 85% of the responders indicated that epidural anaesthesia was routinely used. Except for Denmark, long-acting benzodiazepines were still widely used. Short-acting anaesthetics were used in all countries except Scotland where isoflurane is the anaesthetic of choice. With the exception of Denmark, intravenous fluids were used unrestrictedly. CONCLUSION: In northern Europe, most anaesthesiologists adhere to evidence-based optimal management strategies on pre-operative fasting, thoracic epidurals and short-acting anaesthetics. However, premedication with longer-acting agents is still common. Avoidance of fluid overload has not yet found its way into daily practice. This may leave patients undergoing elective colonic surgery at risk of oversedation and excessive fluid administration with potential adverse effects on surgical outcome.

Anesthesia↗
PubMed2006

[Elective colon surgery according to a 'fast-track' programme].

In fast-track surgical programmes, a variety ofperioperative elements are combined in an intensive multidisciplinary approach for the purpose of preserving the preoperative body composition and organ functions and actively stimulating functional recovery. Such programmes have already been introduced in several surgical procedures. The essence of fast-track colon surgery consists of extensive preoperative counselling, adequate preoperative nutrition with the avoidance of prolonged fasting, a minimum of invasive procedures and anaesthesia, no routine use of drains and nasogastric tubes, adequate perioperative analgesia encompassing high thoracic epidural anaesthesia, rapid mobilisation, rapid resumption of postoperative feeding, and medicinal support with prokinetics and laxatives. A systematic review shows that this programme accelerates recovery and hence shortens the primary and total hospital stay.

Colectomy↗
PubMed2006

Systematic review of enhanced recovery programmes in colonic surgery.

BACKGROUND: Fast track (FT) programmes optimize perioperative care in an attempt to accelerate recovery, reduce morbidity and shorten hospital stay. The aim of this review was to assess FT programmes for elective segmental colonic resections. METHODS: A systematic review was performed of all randomized controlled trials and controlled clinical trials on FT colonic surgery. The main endpoints were number of applied FT elements, hospital stay, readmission rate, morbidity and mortality. Quality assessment and data extraction were performed independently by three observers. RESULTS: Six papers were eligible for analysis (three randomized controlled and three controlled clinical trials), including 512 patients. FT programmes contained a mean of nine (range four to 12) of the 17 FT elements as defined in the literature. Primary hospital stay (weighted mean difference - 1.56 days, 95 per cent confidence interval (c.i.) - 2.61 to - 0.50 days) and morbidity (relative risk 0.54, 95 per cent c.i. 0.42 to 0.69) were significantly lower for FT programmes. Readmission rates were not significantly different (relative risk 1.17, 95 per cent c.i. 0.73 to 1.86). No increase in mortality was found. CONCLUSIONS: FT appears to be safe and shortens hospital stay after elective colorectal surgery. However, as the evidence is limited, a multicentre randomized trial seems justified.

Aged↗
PubMed2006

Sacral neuromodulation; does it affect colonic transit time in patients with faecal incontinence?

OBJECTIVE: Sacral neuromodulation (SNM) has been a successful treatment in urinary voiding disorders for years. A concomitant effect on bowel function was observed leading to the treatment of faecal incontinence with SNM. In this study we describe the effect of SNM on bowel frequency and (segmental) colonic transit time. PATIENTS AND METHODS: Fourteen patients with faecal incontinence who qualified for permanent SNM underwent a colon transit study before and one month after permanent implant. Patients completed a three-week bowel habits diary before and during stimulation. RESULTS: Median incontinence episodes and days per week before SNM were, 8.7 and 4.2, respectively, and both decreased significantly to 0.67 (P = 0001) and 0.5 (P = 0001) during trial screening and to 0.33 (P = 0001) and 0.33 (P = 0001) after permanent implant. The median number of bowel movements per week decreased from 14.7 (6.7-41.7) to 10.0 (3.7-22.7)(P = 0005) during trial screening and to 10.0 (6.0-24.3)(P = 0008) during permanent stimulation. Resting and squeeze pressures did not change significantly during stimulation. Segmental colonic transit time before and during stimulation for right colon, left colon and recto sigmoid were, respectively, 6 (0-25) vs 5 (0-16) hours, 2 (0-29) vs 4 (0-45) hours and 7 (28) vs 8 (0-23) hours. No significant changes were found in both segmental and total colonic transit time; 17 (1-65) vs 25 (0-67) hours. CONCLUSION: SNM in patients with fecal incontinence led to a significant decrease of bowel movements however (segmental) colonic transit time was not influenced.

Adult↗
PubMed2005

Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection.

BACKGROUND & AIMS: Clinical care of patients undergoing colonic surgery differs between hospitals and countries. In addition, there is considerable variation in rates of recovery and length of hospital stay following major abdominal surgery. There is a need to develop a consensus on key elements of perioperative care for inclusion in enhanced recovery programmes so that these can be widely adopted and refined further in future clinical trials. METHODS: Medline database was searched for all clinical studies/trials relating to enhanced recovery after colorectal resection. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. A combination of evidence-based and consensus methodology was used to develop the resulting enhanced recovery after surgery (ERAS) clinical care protocol. RESULTS AND CONCLUSIONS: Within traditional perioperative practice there is considerable evidence supporting a range of manoeuvres which, in isolation, may improve individual aspects of recovery after colonic surgery. The present manuscript reviews these issues in detail. There is also growing evidence that an integrated multimodal approach to perioperative care can result in an overall enhancement of recovery. However, effects on major morbidity and mortality remain to be determined. A protocol is presented which is in current use by the ERAS Group and may provide a standard of care against which either current or future novel elements of an enhanced recovery approach can be tested for their effect on outcome.

Colon↗
PubMed2005

Effect of sacral neuromodulation on the rectum.

BACKGROUND: Sacral neuromodulation (SNM) is a new treatment for faecal incontinence. At present the exact underlying mechanism is still unclear. Modulation of the sacral reflex arcs might have an effect on rectal sensitivity, wall tension and compliance. METHODS: Fifteen consecutive patients with faecal incontinence who qualified for SNM underwent barostat measurements before and during neuromodulation. An 'infinitely' compliant plastic bag with a volume of 600 ml was placed in the rectum and connected to a computer-controlled barostat system. An isobaric phasic distension protocol was used. Patients were asked to report rectal filling sensations: first sensation (FS), earliest urge to defaecate (EUD) and an irresistible, painful urge to defaecate (maximum tolerated volume; MTV). Rectal wall tension and compliance were calculated. RESULTS: During isobaric phasic distension each patient experienced all rectal filling sensations at the time of stimulation. Median volume thresholds decreased significantly during stimulation, from 98.1 to 44.2 ml for FS (P = 0.003), from 132.3 to 82.8 ml for EUD (P = 0.001) and from 205.8 to 162.8 ml for MTV (P = 0.002). Pressure thresholds tended to be lower for all filling sensations, but only that to evoke MTV was reduced significantly by stimulation (37.3 versus 30.3 mmHg; P = 0.005). Median rectal wall tension for all filling sensations decreased significantly with stimulation. There was no significant difference between compliance before and during stimulation. CONCLUSION: SNM affects rectal sensory perception, but further research is required to clarify the mechanism.

Adult↗
PubMed2004

Increased expression of proteasome subunits in skeletal muscle of cancer patients with weight loss.

Atrophy of skeletal muscle is common in patients with cancer and results in increased morbidity and mortality. In order to design effective therapy the mechanism by which this occurs needs to be elucidated. Most studies suggest that the ubiquitin-proteasome proteolytic pathway is most important in intracellular proteolysis, although there have been no reports on the activity of this pathway in patients with different extents of weight loss. In this report the expression of the ubiquitin-proteasome pathway in rectus abdominis muscle has been determined in cancer patients with weight loss of 0-34% using a competitive reverse transcriptase polymerase chain reaction to measure expression of mRNA for proteasome subunits C2 and C5, while protein expression has been determined by western blotting. Overall, both C2 and C5 gene expression was increased by about three-fold in skeletal muscle of cachectic cancer patients (average weight loss 14.5+/-2.5%), compared with that in patients without weight loss, with or without cancer. The level of gene expression was dependent on the amount of weight loss, increasing maximally for both proteasome subunits in patients with weight loss of 12-19%. Further increases in weight loss reduced expression of mRNA for both proteasome subunits, although it was still elevated in comparison with patients with no weight loss. There was no evidence for an increase in expression at weight losses less than 10%. There was a good correlation between expression of proteasome 20Salpha subunits, detected by western blotting, and C2 and C5 mRNA, showing that increased gene expression resulted in increased protein synthesis. Expression of the ubiquitin conjugating enzyme, E2(14k), with weight loss followed a similar pattern to that of proteasome subunits. These results suggest variations in the expression of key components of the ubiquitin-proteasome pathway with weight loss of cancer patients, and suggest that another mechanism of protein degradation must be operative for patients with weight loss less than 10%.

Aged↗
PubMed2002

[Sacral neuromodulation is effective in the treatment of fecal incontinence with intact sphincter muscles; a prospective study].

OBJECTIVE: To evaluate the therapeutic effect of sacral neuromodulation on faecal incontinence in patients with structurally intact sphincters. DESIGN: Prospective. METHOD: In the period April 1st, 2000 to November 30th, 2001, patients with faecal incontinence and structurally intact sphincters were included, with or without previous surgery, in whom medicinal treatment and biofeedback therapy gave no improvement. Incontinence was defined as involuntary loss of stool at least once a week, which was objectified by completion of a 3-week bowel habit diary. Patients underwent 3 weeks of trial stimulation during which they also kept a diary. The trial stimulation was considered successful if the diary showed a > or = 50% improvement in continence. RESULTS: 38 patients (31 women) with an average age of 54 years (range: 26-73) underwent trial stimulation. Trail stimulation was carried out using a permanent electrode in 6 patients and using peripheral neural evaluation in the remaining 32 patients. Two patients did not respond to peripheral neural evaluation. Upon assessment after the trial stimulation period. continence was found to have improved by > or = 50% in 31 (82%) patients. The number of incontinence episodes decreased by an average of 86% (range: 50-100). In 27 patients an implantable pulse generator was implanted for continuous stimulation. During the average follow-up of 6 months the effect remained satisfactory. Anal manometry during stimulation showed no increase of sphincter pressures. CONCLUSION: Sacral neuromodulation was of therapeutic value in most of the patients treated for faecal incontinence without sphincter damage.

Adult↗
PubMed2002

Treatment of hepatic metastases of neuroendocrine malignancies: a 10-year experience.

BACKGROUND: Liver metastases from neuroendocrine tumours may give rise to symptoms due to hormone production or mass effect. Accepted management options include administration of somatostatin-analogues, selective chemoembolisation or hepatic resection. The aim of this study was to review the management of hepatic neuroendocrine metastases in our unit. METHODS: Patients with neuroendocrine tumours presenting between 1989 and 1999 were identified from pathology, radiology and surgical databases. Case notes were retrospectively reviewed for demographic data, treatment modality and outcome. Response to treatment was based on biochemistry, radiology or symptoms, and response rates were defined accordingly. RESULTS: Thirty patients with a mean age of 55 years presented with, or later developed liver metastases. The most frequent presenting symptoms were abdominal pain (63%), diarrhoea (40%), weight loss (33%) and flushing (13%). Five patients underwent liver resection with complete symptomatic response, nine underwent chemoembolisation with a 75% response rate (either biochemically, radiologically or symptomatic) and fifteen were treated with a somatostatin-analogue, with a response rate of 86%. Median survival from detection of metastases was 45 months. CONCLUSIONS: Liver resection provides good symptomatic relief, but it is only indicated in a small proportion of patients with metastatic neuroendocrine tumours. Both chemoembolisation and somatostatin-analogues offer useful symptomatic control for these patients with good survival prospects.

Adult↗