Current Issue : July - September Volume : 2016 Issue Number : 3 Articles : 4 Articles
Background: Endoscopic mucosal resection (EMR) is currently the most used technique for resection of large distal\ncolorectal polyps. However, in large lesions EMR can often only be performed in a piecemeal fashion resulting\nin relatively low radical (R0)-resection rates and high recurrence rates. Endoscopic submucosal dissection (ESD)\nis a newer procedure that is more difficult resulting in a longer procedural time, but is promising due to the\nhigh en-bloc resection rates and the very low recurrence rates. We aim to evaluate the (cost-)effectiveness\nof ESD against EMR on both short (i.e. 6 months) and long-term (i.e. 36 months). We hypothesize that in the\nshort-run ESD is more time consuming resulting in higher healthcare costs, but is (cost-) effective on the\nlong-term due to lower patients burden, a higher number of R0-resections and lower recurrence rates with\nless need for repeated procedures.\nMethods: This is a multicenter randomized clinical trial in patients with a non-pedunculated polyp larger than\n20 mm in the rectum, sigmoid, or descending colon suspected to be an adenoma by means of endoscopic\nassessment. Primary endpoint is recurrence rate at follow-up colonoscopy at 6 months. Secondary endpoints\nare R0-resection rate, perceived burden and quality of life, healthcare resources utilization and costs, surgical\nreferral rate, complication rate and recurrence rate at 36 months. Quality-adjusted-life-year (QALY) will be estimated\ntaking an area under the curve approach and using EQ-5D-indexes. Healthcare costs will be calculated by multiplying\nused healthcare services with unit prices. The cost-effectiveness of ESD against EMR will be expressed as incremental\ncost-effectiveness ratios (ICER) showing additional costs per recurrence free patient and as ICER showing additional\ncosts per QALY.\nDiscussion: If this trial confirms ESD to be favorable on the long-term, the burden of extra colonoscopies and\nrepeated procedures can be prevented for future patients....
Background: Most patients with gastroesophageal reflux disease experience symptomatic relapse after stopping\nacid-suppressive medication. The aim of this study was to compare willingness to continue treatment with\nesomeprazole on-demand versus continuous maintenance therapy for symptom control in patients with\nnon-erosive reflux disease (NERD) after 6 months.\nMethods: This multicenter, open-label, randomized, parallel-group study enrolled adults with NERD who were\nheartburn-free after 4 weeksââ?¬â?¢ treatment with esomeprazole 20 mg daily. Patients received esomeprazole 20 mg\ndaily continuously or on-demand for 6 months. The primary variable was discontinuation due to unsatisfactory\ntreatment. On-demand treatment was considered non-inferior if the upper limit of the one-sided 95 % confidence\ninterval (CI) for the difference between treatments was <10 %.\nResults: Of 877 patients enrolled, 598 were randomized to maintenance treatment (continuous: n = 297;\non-demand: n = 301). Discontinuation due to unsatisfactory treatment was 6.3 % for on-demand and 9.8 % for\ncontinuous treatment (difference âË?â??3.5 % [90 % CI: âË?â??7.1 %, 0.2 %]). In total, 82.1 and 86.2 % of patients taking\non-demand and continuous therapy, respectively, were satisfied with the treatment of heartburn and regurgitation\nsymptoms, a secondary variable (P = NS). Mean study drug consumption was 0.41 and 0.91 tablets/day, respectively.\nOverall, 5 % of the on-demand group developed reflux esophagitis versus none in the continuous group (P < 0.0001).\nThe Gastrointestinal Symptom Rating Scale Reflux dimension was also improved for continuous versus on-demand\ntreatment. Esomeprazole was well tolerated.\nConclusions: In terms of willingness to continue treatment, on-demand treatment with esomeprazole 20 mg was\nnon-inferior to continuous maintenance treatment and reduced medication usage in patients with NERD who had\nachieved symptom control with initial esomeprazole treatment...
Background: The routine use of preoperative biliary drainage before pancreaticoduodenectomy (PD) remains\ncontroversial. This observational retrospective study compared stented and non-stented patients undergoing PD to\nassess any differences in post-operative morbidity and mortality.\nMethods: A total of 180 consecutive patients who underwent PD and had intra-operative bile cultures performed\nbetween January 2010 and February 2013 were retrospectively identified. All patients received peri-operative\nintravenous antibiotic prophylaxis, primarily cefazolin.\nResults: Overall incidence of post-operative surgical complications was 52.3 %, with no difference between stented\nand non-stented patients (53.4 % vs. 51.1 %; p = 0.875). However, stented patients had a significantly higher\nincidence of deep incisional surgical site infections (SSIs) (p = 0.038). In multivariate analysis, biliary stenting was\nconfirmed as a risk factor for deep incisional SSIs (p = 0.044). Significant associations were also observed for cardiac\ndisease (p = 0.010) and BMI �25 kg/m2 (p = 0.045). Enterococcus spp. were the most frequent bacterial isolates in bile\n(74.5 %) and in drain fluid (69.1 %). In antimicrobial susceptibilty testing, all Enterococci isolates were cefazolin-resistant.\nConclusion: Given the increased risk of deep incisional SSIs, preoperative biliary stenting in patients underging PD\nshould be used only in selected patients. In stented patients, an antibiotic with anti-enterococcal activity should be\nchosen for PD prophylaxis....
Background/Aims. Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer (CRC). In addition,\nthere may be an association between leukemia and lymphoma and IBD.We conducted a systematic review and meta-analysis of the\nIBD literature to estimate the incidence of CRC, leukemia, and lymphoma in adult IBD patients. Methods. Studies were identified\nby a literature search of PubMed, Cochrane Library, Medline,Web of Science, Scopus, EMBASE, and ProQuest Dissertations and\nTheses. Pooled incidence rates (per 100,000 person-years [py]) were calculated through use of a random effects model, unless\nsubstantial heterogeneity prevented pooling of estimates. Several stratified analyses and meta regression were performed to explore\npotential study heterogeneity and bias. Results. Thirty-six articles fulfilled the inclusion criteria. For CRC, the pooled incidence rate\nin CD was 53.3/100,000 py (95% CI 46.3ââ?¬â??60.3/100,000). The incidence of leukemia was 1.5/100,000 py (95% CI âË?â??0.06ââ?¬â??3.0/100,000)\nin IBD, 0.3/100,000 py (95% CI âË?â??1.0ââ?¬â??1.6/100,000) in CD, and 13.0/100,000 py (95% CI 5.8ââ?¬â??20.3/100,000) in UC. For lymphoma,\nthe pooled incidence rate in CD was 0.8/100,000 py (95% CI âË?â??0.4ââ?¬â??2.1/100,000). Substantial heterogeneity prevented the pooling of\nother incidence estimates. Conclusion.The incidence of CRC, leukemia, and lymphoma in IBD is low....
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