Guideline 'Diagnosis and treatment of oesophageal carcinoma'

An evidence-based guideline for the diagnosis and treatment of oesophageal carcinoma was developed on the initiative of the Netherlands Society of Gastroenterohepatology in cooperation with the Dutch Institute for Healthcare Improvement (CBO) and the Dutch Association of Comprehensive Cancer Centres. If a patient with oesophageal carcinoma is eligible for treatment with curative intent, they should undergo thoracic and abdominal CT, ultrasound investigation of the supraclavicular region and endoscopic ultrasonography for staging purposes. Endoscopic therapy is the preferred treatment for high-grade dysplasia or early cancer in Barrett's oesophagus confined to the mucosa. Surgical resection is indicated if the tumour invades the submucosa. If resection of the oesophageal carcinoma is performed with curative intent, one should aim for radical resection. The type and extent of the resection depends on the location of the tumour. There is evidence that the mortality rate following surgery can be reduced by performing it in centres with ample experience with oesophageal cancer surgery. Preoperative chemotherapy and radiotherapy may improve survival in patients with oesophageal carcinoma. Palliative treatment for oesophageal carcinoma should be considered in cases of local invasion of surrounding organs, metastases, poor physical condition of the patient or recurrent disease after previous curative treatment. Psychosocial support is an important element in the follow-up of patients with oesophageal carcinoma.     

Parent participation in paediatric rehabilitation treatment centres in the Netherlands: a parents' viewpoint

AIM: The importance of family-centred care and services has been increasingly emphasized in paediatric rehabilitation. One aspect of family-centred care is parent involvement in their child's treatment. The aims of this study were (1) to describe how, and to what extent parents are involved in the paediatric rehabilitation treatment process in the Netherlands; (2) to determine the level of parents' satisfaction about the services they and their child have received; and (3) to describe what ideas parents have to enhance their involvement in the treatment process. METHODS: A total of 679 parents of children aged 1-20 years who participated in our longitudinal study on family centred care in the Netherlands. The children had various diagnoses and were treated in nine out of 23 Dutch paediatric rehabilitation centres. A random sample of 75 parents was interviewed within 4 weeks after completion of the Measure of Processes of Care and the Client Satisfaction Questionnaire. A Quality of Care cycle with six stages was used to structure the evaluation. RESULTS: The data showed that parents are involved in all stages of their child's rehabilitation process in various ways. The average level of parent satisfaction about the services received was high. According to the interviewed parents, the communication between professionals and parents, parents' involvement in goal setting, and parents' involvement in treatment could be improved upon. CONCLUSION: Parents are to a large extent involved in all stages of the treatment process in Dutch paediatric rehabilitation settings. Although parents valued the services received, they suggested various ways to enhance parent participation.     

Fifty years of plastic surgery in the Netherlands. V. History

For many centuries plastic surgical operations have been practised incidentally by general surgeons. Both World Wars combined with a multidisciplinary approach have been instrumental to the development of plastic surgery as a specialty. The Great War experience of maxillofacial surgery was for some surgeons in Europe a reason to dedicate their lives solely towards plastic surgery. A prominent Dutch surgeon in this field was J.F.S. Esser. With his systematic study and clinical application of arterial flaps in plastic surgery he proved to be far ahead of his time. Plastic surgery as such was established in the Netherlands after World War II in 1950 by the triumvirate Koch, Raadsveld and Honig. In the beginning, plastic surgery was strongly British influenced, while now, 50 years later, European cooperation on harmonization of the training in plastic surgery of a good quality is in progress.     

One hundred years of the Association of Surgeons in the Netherlands. III. Gastrointestinal surgery

On 27 February 1989 the Nederlandse Vereniging voor Gastro-Intestinale Chirurgie [Netherlands Association for Gastrointestinal Surgery] was founded. The aim--improvement of quality by integrating scientific and clinical work--was already formulated 10 years previously by the Gastrointestinal Surgery Working Group. The integration proceeded carefully; the Netherlands Association for Gastrointestinal Surgery began as a chapter of the Association of Surgeons in the Netherlands and as a working group within the Dutch Gastroenterology Association. Meanwhile new techniques have been investigated and introduced and surgical oncology is a growing area of collaboration with the Dutch Association for Surgical Oncology. In the future minimally invasive interventions and robot surgery will come to the fore, reflux disease and inflammatory bowel diseases will decrease as an operative indication and early diagnosis will play a greater role.     

Quality of care a matter of experience

In an evidence-based review of the relationship between volume and quality of care, the independent Dutch Institute for Healthcare Improvement (CBO) concluded that volume appears to be related to outcome for certain surgical procedures (case fatality after pancreatic and oesophageal cancer) and that quality of care might be improved by centralisation. The Dutch Institute for Healthcare Improvement also identified conditions required for centralisation, particularly acceptance by professionals and hospitals. In the USA, programmes to improve quality ofcare initiated by the Leapfrog Group using volume criteria or, more recently, using 'public reporting' and 'pay for performance' principles have led to improvements in quality. In Canada, the Surgical Oncology programme within the Cancer System Quality Index programme has reduced case fatality following pancreatic resection. The Canadian programme was based not only on volume but also on standards, guidelines, rapid access strategies and publicly available performance assessments. In The Netherlands, the Dutch Health Care Inspectorate is introducing the so-called performance indicators of care. Other initiatives are underway to develop a system with multiple quality criteria as in Canada. These programmes should not be restricted to surgical procedures but should include complex procedures in other specialties as well.     

The effect of specialised medical procedures on the hosptial standardised mortality ratio in cardiac centers

OBJECTIVE: To examine the impact of specialised medical procedures (SMPs) on the hospital standardized mortality ratio (HSMR) in Dutch cardiac centres. DESIGN: Retrospective, calculation of the HSMR. METHOD: Data from 2004 from the National Medical Registration (LMR) were used to calculate the HSMR in 12 cardiac centres and all other hospitals in the Netherlands. The HSMRwas then recalculated for the 12 cardiac centres excluding either percutaneous transluminal coronary angioplasty (PTCA) or open heart surgery or both to determine the impact of these SMPs on the HSMR. RESULTS: Exclusion of SMPs from the HSMR calculation changed the HSMR for individual cardiac centres, ranging from a 4.7% decrease to a 5.3% increase. Change in HSMR was related to the relative frequency of the two procedures at each cardiac centre. Mortality risk was lower than average for PTCA and higher than average for open heart surgery. PTCA accounted for 5.6%-20.2% of total admissions in the 12 cardiac centres. A relatively high proportion of PTCA procedures was associated with a lower HSMR, to a maximum decrease of nearly 7% in one cardiac centre. Open heart surgery accounted for 2.1%-12.6% of total admissions per cardiac centre. A relatively high proportion ofopen heart procedures was associated with an increased HSMR, to a maximum increase of nearly 8% in one cardiac centre. CONCLUSION: Specialised medical procedures for heart conditions influence the HSMR of cardiac centres. The increase or decrease in HSMR is related to the relative frequency of PTCA and open heart surgery. These results can be used to help interpret the differences in HSMR among cardiac centres and other hospitals.     

The Dutch Health Council report on haemopoietic stem cells

The Dutch Health Council advised the government on the use of haemopoietic stem cells in clinical medicine in September 2003. Most stem cell transplantations (SCTs) are performed in closely co-operating centres for haematological intensive care, and these centres are required to have a license from the government. The introduction of non-myeloablative SCT, exploiting the immunological effects of donor T cells, extends the variety of diseases for which SCT is a useful treatment option, as well as extending the age limits. The capacity of the centres appears to be sufficient, but their finances are not. This, together with strict adherence to accepted indications, is probably one of the main reasons why the number of SCTs performed in the Netherlands is rather low as compared to other European countries. The Council stresses that the harvesting and handling of umbilical cord stem cells is a public rather than a private matter, with the purpose of creating a bank for these preparations from which patients may benefit if the need so dictates. The Council pleads for support to advance the basic research on stem cells and the immunological aspects of stem cell transplantation.     

Paediatric cardiology in a sub-regional cardiothoracic unit

The aim of this study was to examine the pattern of referrals the number of admissions, cardiac catheterisations and surgical procedures-including outcome-in infants and children referred to a sub-regional cardiothoracic unit during a 6-year period. The unit is served by one paediatric cardiologist and four general cardiothoracic surgeons, two of whom undertake paediatric surgery. Referrals were received from within the Trent Regional Health Authority, and from three other health Regions. During the study period 2,097 infants and children were admitted to the unit with cardiac disease, and 730 underwent cardiac surgery. The proportion of admissions undergoing surgery increased significantly with time, as did the neonatal and infant surgical procedures and infant surgical procedures. Overall, the surgical mortality did not alter with time, and was comparable to the national average. The results show an increase in the demand for cardiac investigations and surgery, and this was most evident in infants, particularly for open procedures. This unit serves a large population with proven needs, and the number of children treated falls within the range of existing supra-regional centres. The combination of available expertise, and a cost-effective patient outcome measure, should place such units in a category of high priority for resource allocation.     

Diagnosis and treatment of esophageal cancer in the Netherlands: wide variation in the second line

OBJECTIVE: To survey the diagnostic procedures and treatment strategies currently employed in hospitals for patients with oesophageal cancer. DESIGN: Questionnaire. METHOD: A questionnaire was sent to all clinicians working in the field of gastroenterology in the Netherlands. This questionnaire focused on clinical preferences regarding diagnostic procedures and treatment strategies for oesophageal cancer. Also, six hypothetical patient vignettes were presented in order to investigate which factors affected choice of treatment, in particular surgical treatment. RESULTS: The response rate was 64% (426/667); 336 questionnaires were relevant to the investigation. Almost 90% of the clinicians treated fewer than 20 patients annually, usually in their own hospital. CT was the most frequently used staging procedure; endoscopic ultrasound was less frequently used (42% used it in less than half the patients). The treatment choice for the patient vignettes varied widely among clinicians. Factors influencing the choice to operate or not were: metastases, loco-regional tumour ingrowth, poor general health, and advanced age with 8, 22, 20, and 53%, respectively, of the clinicians still considering surgery in the presence of one of these factors as opposed to 99% if none of these factors were present. Surgeons opted for operation more often than internists and gastroenterologists. Stent placement was the most frequently chosen method to palliate malignant dysphagia. CONCLUSION: There is a wide variation in the use of diagnostic procedures and treatment strategies for patients with oesophageal cancer in the Netherlands. This stresses the need for scientifically based practice guidelines, taking into account specific patient and tumour characteristics.     

Oesophageal atresia

Fifty years ago this congenital anomaly was incompatible with survival. Advances in neonatal intensive care, anaesthesia and surgical techniques permit successful correction in the vast majority of patients. Death in a patient with oesophageal atresia is now rarely attributable to that anomaly, but occurs in the very premature and those babies with other associated major anomalies.     

The 'Inguinal Hernia' guideline of the Association of Surgeons of the Netherlands

The 'Inguinal hernia' guideline was written over a period of two years by nine surgeons (including one epidemiologist) from all regions of the Netherlands with demonstrable clinical and scientific expertise in the area of inguinal surgery after a training course on 'The development of evidence-based guidelines'. A draft of the guideline was on the website of the Association of Surgeons of the Netherlands for a period of three months, during which time the members of the society could comment on its contents interactively. The guideline comprises chapters on risk factors and prevention, diagnostics, indications for treatment, treatment, day surgery, antibiotics, thrombosis prophylaxis, training, anaesthesia, postoperative pain control, complications, costs, aftercare, and specific aspects of inguinal hernia in children. For the treatment of adult patients a mesh technique is recommended. The Lichtenstein technique is recommended as the first choice for uncomplicated primary inguinal hernia. Laparo-endoscopic techniques can be used by trained teams for specific indications. Other techniques have not been compared with the current methods of treatment sufficiently. It is recommended that the operations be carried out in daycare and that the use of local anaesthesia should be considered more often. The diagnosis of inguinal hernia in a child is based on the physical examination. It is recommended that the surgeon should not rely solely on the history but confirm the presence of a hernia personally. The treatment of a paediatric inguinal hernia is always operative. Generally, the younger the child, the more urgent the operation because of the increased risk of incarceration in infants, particularly premature babies. There is no indication for routine exploration of the contralateral groin. If an incarcerated hernia cannot be reduced, emergency operation is necessary and referral to a paediatric surgical centre must be considered. The implementation and effectiveness of the guideline will be measured by taking an inventory of all inguinal hernia operations performed in the Netherlands before and after its publication.     

One hundred years of the Netherlands Association of Surgeons. II. The evolution of the Association

The Association of Surgeons in the Netherlands was founded 100 years ago with the objective to further surgery in general; from 1948 onward a separate objective was to further the interests of surgeons. The Association has developed into an active scientific society that ensures that quality of Dutch surgical practice, that stimulates the development of surgery and that organizes the training of surgeons. The number of operations has more than doubled in the past 25 years, despite the limited increase in the number of surgeons owing to a great leap in efficiency. This has led to a differentiation in the surgical discipline, with a number of sub-associations. The currents quality policy emphasizes certification of clinics, the development of guidelines, mandatory attendance to ongoing training programmes, a registry of complications, adequate patient information, visitation of clinics and a compulsory specialization course for all surgical residents.     

Dutch Institute for Healthcare Improvement guideline, "Treatment of breast cancer"

The first Dutch evidence-based guideline for the treatment of breast cancer has been developed to realise the optimal care of breast cancer patients in the Netherlands. This was possible due to the close cooperation of the Dutch Institute for Healthcare Improvement [Dutch acronym: CBO] and the Dutch Consultative Committee on Breast Cancer [Dutch acronym: NABON]. A broad, multidisciplinary working group was appointed to develop the guideline. This group consisted of surgeons, radiotherapists, internists, pathologists, a radiologist, a nuclear medicine specialist, a plastic surgeon and a clinical geneticist, all of whom had been given a mandate to represent their respective professional societies. In addition to these medical specialists, there were physiotherapists, oncology nurses, psychologists, staff from comprehensive cancer centres and the Dutch Institute for Healthcare Improvement and representatives from the Dutch Breast Cancer Association. This CBO guideline is divided into seven chapters: local treatment of operable breast cancer, systemic adjuvant treatment, locoregionally advanced disease, follow-up, locoregional recurrence, metastasised disease, and the psychosocial aspects of breast cancer. Although the guideline is not intended as a set of instructions that must be rigidly adhered to, deviations from the guideline must be motivated, principally on the basis of published scientific information. To obtain insight into the actual use of the guidelines 'Screening and diagnostics' and 'Treatment of breast cancer' the work group advocates a nationwide prospective registration of all breast cancer patients, including follow-up. Steps to this end have been undertaken. In this way, the CBO guideline will contribute to a further optimisation of breast cancer care in the Netherlands.     

The relationship between surgical delay for a hip fracture and the complication risk

OBJECTIVE: To investigate the factors that contribute to surgical delay and whether this delay can be associated with post-operative complications. DESIGN: Retrospective cohort study. METHOD: Patients admitted with a hip fracture between 1 January 2001-31 December, 2003 to the Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands, were included. The delay before surgery was recorded in 446 patients who underwent surgical treatment for a hip fracture. As possible predictors of delay before surgery, the following factors were investigated: demographic and other patient information, pre-operative medication, co-morbidities, pre-operative acute co-morbidities, classification according to the American Society of Anesthesiologists (ASA) and whether or not the patient had already had surgery to the same hip. To measure the effect of delay before surgery, we investigated post-operative complications like: delirium, decubitus ulcers, urinary tract infections, pulmonary infections, pulmonary embolism, deep vein thrombosis, wound infection, failure ofosteosynthesis and in-hospital mortality. RESULTS: In total, 446 patients, 98 male and 348 female, with a mean age of 82.2 years met the inclusion criteria. Distinct predictors of delay before surgery were: ASA-classification, pre-operative urinary tract infection, pre-operative chest infection, pre-operative delirium, pre-operative anaemia and re-operation. There was no significant association between delay of surgery and the occurrence of post-operative complications. CONCLUSION: Presence of a pre-operative medical condition has an important effect on surgical delay for a hip fracture. The assumption of the Dutch Healthcare Inspectorate that delay of surgery for hip fracture causes more complications could not be confirmed.     

Mental health care and the opposition movement in The Netherlands

In The Netherlands, there is a more or less recognized movement in the field of mental health care which is referred to as the psychiatric opposition movement or the patients movement. The nucleus of the Dutch movement consists of patients and ex-patients. As far as mental health professionals are participating in the movement, they do so as more or less passive supporters of a movement dominated by patients and ex-patients. This article is dealing with two questions. The first question is how and to what degree the opposition movement in The Netherlands has succeeded in breaking through or at least questioning the closed nature of Dutch mental health care system. The second question will be whether the dilemma between resistance and dependence in the position of patients and ex-patients is visible in the activities of the opposition movement, and whether this dilemma acted as an obstacle to their efforts to influence the mental health care debate in The Netherlands. An effort is being made to answer this question by describing the position of the opposition movement with respect to the Insanity Law and with respect to the organization of mental health care. In conclusion, three stages were found to be crucial in the development of Dutch opposition movement. In the 1970s, the opposition movement appeared to operate within the borders of a closed system in which the medical profession had a high degree of autonomy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transhiatal or transthoracic resection of esophageal carcinoma based on tumor location, positive high-thoracic lymph nodes and preoperative physical condition

The limited transhiatal resection for the surgical treatment of oesophageal cancer is aimed at limiting early postoperative complications by not performing lateral thoracotomy and formal lymphadenectomy. The extended transthoracic approach with two-field lymphnode dissection is intended to improve long-term survival. The recurrence pattern after transhiatal resection suggests that a subgroup of patients might benefit from the more extended approach. In a large randomized trial in two high-volume Dutch academic hospitals, extended resection resulted in more postoperative (pulmonary) complications and a prolonged postoperative recovery time, but when compared to transhiatal resection, had only a limited impact on quality of life. The estimated 5-year survival advantage after extended resection was 10% (95% confidence interval: -3% to +23%). Subgroup analysis indicated a 17% 5-year survival advantage for patients with oesophageal cancer, but only a 1% advantage for patients with cancer of the cardia or gastro-oesophageal junction. The individualized operative approach for patients with potentially curable oesophageal cancer is based on tumour location, positive high-thoracic lymph nodes and preoperative physical condition.     

Une mort tres douce

Summary This study considers the range of thinking about end-of-life decisions (ELD) in France from a Dutch point of view, taking a small number of interviews with important French opinion-leaders as a basis. Until today, end-of-life care in France has been clouded with uncertainty pending the enactment of more specific definitions and regulations. French physicians could face a dilemma in treating a dying patient, caught between an official ban on ELD and a professional obligation to treat cases individually. The practical consequence of this climate is a lack of accountability of the French physician towards colleagues and patients. Rationalistic, paternalistic, and religious traditions have been obstructive to the adoption of regulatory reforms. In November 2004, Parliament accepted a law proposal by which the practice of the withholding and withdrawal of life-saving therapies would become more transparent, which would diminish the physician’s fear of legal persecution. This proposal was then converted into law by the Senate. In the Netherlands, euthanasia – the active termination of life – is legal and regulated according to specific criteria. The Dutch approach has been shaped by an Anglo-Saxon emphasis on individual autonomy, and conforms to a broad preference in Dutch society to disclose and regulate controversial activities rather than to tolerate them sub rosa. As the Dutch regulations have been enacted, reporting rates – but not euthanasia cases – have risen. Compliance with the criteria and doctor–patient communication have been high. The French vigilance of professional autonomy provides a valuable example to the Dutch. The Dutch, in return, offer the French concrete examples for ELD policy. J.J.M. van Delden is Professor of Medical Ethics at the University Medical Center in Utrecht, the Netherlands.