Hjalmar C. van Santvoort

Background: There is a paucity of data on the cost‐utility of endoscopic ultrasonography‐guided gastroenterostomy (EUS‐GE) compared with surgical gastrojejunostomy (SGJ) as palliative treatment of malignant gastric outlet obstruction. Methods: In the ENDURO trial, 98 patients with malignant gastric outlet obstruction from 12 Dutch hospitals were randomized between EUS‐GE ( N = 48) and SGJ ( N = 50). Cost utility was evaluated from a healthcare perspective with a time horizon of 1 month. A bottom‐up approach was used to calculate the costs of each intervention, including the per‐minute price of the endoscopy and operating room (OR), considering personnel, construction, inventory and overhead costs. Other in‐hospital costs were calculated using insurance claim data. Effectiveness was displayed as quality‐adjusted life years (QALY). Bootstrapping was performed to estimate uncertainty. Results: The calculated per‐minute price for the endoscopy room was €8.64 (US $9.34). The per‐minute price for an OR was €11.78 (US $12.74). The mean intervention costs were estimated at €4405.40 (US $4762.68) for EUS‐GE and €3393.71 (US $3668.93) for SGJ. Mean total in‐hospital costs were lower following EUS‐GE (€5172 [US $5591]) than after SGJ (€10,458 [US $11,306]), mainly due to a shorter length of hospital stay following EUS‐GE. Bootstrapping showed that 99.9% of iterations resulted in lower costs for EUS‐GE. Mean difference in 1‐month QALY contribution was 0.004 in favor of EUS‐GE. Most iterations fall within the bottom right quadrant (95.6%) of the cost‐effectiveness plane, indicating lower costs and improved QALY contribution for EUS‐GE. Discussion: In this study, EUS‐GE was more cost effective than SGJ. The additional intervention costs were clearly outweighed by a decrease in in‐hospital costs after the procedure.

Infected (peri-)pancreatic necrosis (IPN) is a severe complication that occurs in approximately 30% of patients with acute necrotizing pancreatitis.1 IPN is associated with mortality rates of 15%–3...

IntroductionSocial deprivation, which is exaggerated by lower household income, shortens life expectancy and worsens cancer survival. In pancreatic adenocarcinoma, novel treatment strategies aim to extend survival and centralization of care has increased distance to hospital. The effect of distance to hospital and different treatment regimens on survival stratified by household income remains unexplored.MethodsA nationwide retrospective study using Netherlands Cancer Registry data (2017–2022) included patients with localized pancreatic adenocarcinoma. Patients were categorized into three groups based on household income (lowest, intermediate and highest income) and two distance groups based on median distance to hospital. Multivariable logistic and Cox regression analyses assessed the effect of lower household income and distance on treatment and survival. Kaplan-Meier curves were used for univariable survival analysis.ResultsAmong 5,926 patients, individuals from lower household income received less anti-cancer treatment (44% lowest vs. 63% highest, P<0.001). Living within 14km increased the likelihood of resection (Odds ratio (OR) 1.44, 95%CI 1.28-1.63, P<0.001) and adjuvant chemotherapy (OR 1.29, 95%CI 1.18–1.71, P<0.001). Median survival was 7 months (lowest income), 9 months (intermediate), and 11 months (highest income) (P<0.001). In the multivariable analysis, worse survival in the lowest income group persisted after case-mix adjustment (HR (highest vs lowest): 0.92, 95% CI 0.86-0.98, P<0.001). However, after additional adjustment for treatment differences, survival differences between income groups disappeared (P=0.180).ConclusionLower household income negatively impacts the likelihood of receiving treatment for patients with pancreatic adenocarcinoma. Additionally, distance to hospital is negatively associated with the probability of receiving resection and subsequent treatment.

Background: Current guidelines provide recommendations for morphology-based surgery in patients with symptomatic chronic pancreatitis (CP). International studies evaluating the use and impact of these guidelines across Europe are lacking.Methods: Post-hoc analysis in the prospective multicenter international ESCOPA study, including patients undergoing surgery for CP in 22 centers in 13 countries (June 2021 - November 2022), with a 6-month follow-up. Patients were stratified into morphological subtypes: ‘isolated dilated main pancreatic duct (MPD)’, ‘isolated enlarged pancreatic head (PH)’, ‘combined dilated MPD and enlarged PH’, and ‘small duct disease’. Treatment was based on the European HaPanEU and International IAP-APA-JPS-EPC guidelines. Primary outcomes were 90-day major morbidity, mortality, and pain relief at 6 months. Practice variation was assessed, including a case-based survey.Results: Overall, 207 patients underwent surgery for symptomatic CP with 1.4% 90-day mortality and 72.6% pain relief. Per morphological subtype, the type of surgery varied widely: mostly duodenum-preserving pancreatic head resections (DPPHR) for ‘combined dilated MPD and enlarged PH’ (22/47, 46.8%, p=0.016); and mostly formal pancreatectomy for both ‘isolated dilated MPD’ (31/96, 63.3%, p=0.040) and ‘small duct disease’ (33/50, 66.0%, p=0.004). Guideline-concordant surgery (n=124, 66%) was not associated with major morbidity (concordant 12.9% vs discordant 18.8%, p=0.387), 90-day mortality (1.6% vs 1.6%, p>0.999), and pain relief (75.3% vs 66.7%, p=0.468). Guideline-based drainage/parenchyma preserving surgery was not associated with lower major morbidity (9.2% vs 18.9%, p=0.177) and mortality (0 vs 1.9%, p=0.449) vs formal pancreatectomy. The survey confirmed variability in the use of surgery per morphological subtype which may be related to conflicting recommendations (n=4) and the unclear role for formal pancreatectomy (e.g. pancreatoduodenectomy) and V-shaped pancreatectomy in current guidelines.Conclusion: The next generation of unified guidelines for surgery in symptomatic chronic pancreatitis should resolve the current conflicting recommendations and address the role of formal pancreatectomy and V-shaped pancreatectomy.

Background: Composite outcome measures aim to provide a more holistic view when determining the effectiveness and safety of surgical interventions. Recently, “Ideal Outcome” (IO) harmonized the European and American composite outcome of pancreatic surgery. The rate of IO after pancreatoduodenectomy was 54%, but it is unknown after left pancreatectomy(LP). Methods: This transatlantic analysis included patients after LP from the audits in North America (National Surgical Quality Improvement Program), Germany (Studien-, Dokumentations- und Qualitätszentrum), the Netherlands (Dutch Pancreatic Cancer Audit), and Sweden (Swedish National Pancreatic and Periampullary Cancer Registry) (2014–2020). IO is obtained in the absence of (1) in-hospital mortality, (2) severe complications (Clavien-Dindo≥3), (3) postoperative pancreatic fistula (International Study Group of Pancreatic Surgery grade B/C), (4) reoperation, (5) hospital stay exceeding the 75th percentile, and (6) readmission. Clinical predictors of IO were identified using a multivariable logistic regression. Results: Overall, 20,126 patients after LP were included (37.8% minimally invasive). The rate of IO after LP was 59.1%. The rate of IO varied among the 4 audits: North America, 58.5%; Germany, 53.4%; the Netherlands, 56.9%; and Sweden, 61.7% ( P P P <0.001) compared with open LP. No difference in the IO was observed between robot-assisted and laparoscopic LP. Conclusions: The new composite outcome measure IO was reached in 59% of patients after LP and varied between 4 transatlantic audits. Minimally invasive LP was associated with higher rates of IO. IO can be used for evaluating, comparing, and improving patient outcomes between the 4 audits, especially regarding postoperative pancreatic fistula.

Acute pancreatitis is a common gastrointestinal disease leading to hospitalisation. Recent advancements in its management have primarily focussed on the development of early phase medical interventions targeting inflammatory pathways, optimisation of supportive treatment (including fluid resuscitation, pain management and nutritional management), appropriate use of antibiotics, implementation of minimally invasive interventions for infected necrosis, and the necessity of follow‐up for long‐term complications. These advancements have significantly improved personalised management and overall outcomes of acute pancreatitis. Despite these efforts, early‐phase medical interventions to mitigate disease progression are still lacking and acute pancreatitis remains a heterogeneous disease. Future research and clinical trials are imperative to further optimise current strategies and develop new therapeutic approaches. This review presents an evidence‐based approach to the management of acute pancreatitis, highlighting recent developments.