ObjectiveTo perform a two-part study of pancreaticoduodenectomy in the Netherlands, focusing on the effects of risk factors on outcomes in a single high-volume hospital and the effect of hospital volume on outcomes. Summary Background DataHospital volume and surgeon caseload can be related to the rates of complications and death, and the influence of risk factors can be volume-dependent. Provision of regionalized care should take this into account. MethodsIn part A, a single-institution database on 300 consecutive patients undergoing pancreaticoduodenectomy was divided into two periods with similar numbers of patients. Overall complications, deaths, hospital stay, and risk factors were analyzed in the two periods and compared with an historical reference group. In part B, Netherlands medical registry data on age and postoperative death of patients who underwent partial pancreaticoduodenectomy from 1994 to 1998 were analyzed for the influence of hospital volume on death. ResultsBetween the time periods, the institutional death rate decreased from 4.9% to 0.7%, the complication rate from 60% to 41%. Median hospital stay decreased from 24 to 15 days. The death rate was not related to patient age and did not differ between surgeons. Serum creatinine levels, need for blood transfusion, and period of resection were independent risk factors for complications.The death rate after pancreaticoduodenectomy in the Netherlands was 12.6% in 1994 and 10.1% in 1998; it was greater in patients older than age 65. During the 5-year period, 40% of the procedures were performed in hospitals performing fewer than five resections per year, and the death rate was greater than in hospitals performing more than 25 resections per year. ConclusionsThe overall death rate after pancreaticoduodenectomy did not decrease significantly during the period, and it was greater in low-volume hospitals and older patients. The lower death and complication rates in high-volume hospitals, including the singlecenter outcomes, were similar to those reported in other countries and may be due to better prevention and management of complications. Pancreaticoduodenectomy should be performed in centers with sufficient experience and resources for support.In the past, pancreaticoduodenectomy has been associated with a high rate of complications (40 -60%) and a high death rate (up to 20%). Combined with a dismal prognosis, in particular for patients with pancreatic carcinoma, this led to a nihilistic approach by some clinicians.1 In experienced centers, death rates have decreased dramatically, 2-6 which has encouraged other surgeons to perform pancreatic resections in nonspecialized units. The complication and death rates of surgery depend on many variables, including the presence of malignancy, the severity of jaundice, nutritional status, infection, and impaired renal function. 7,8 These factors have allowed better patient selection. In parallel, several reports since 1995 have highlighted the influence of hospital volume on hospital death.

Aim: N-3 fatty acids, especially eicosapentaenoic acid (EPA), may possess anticachectic properties. This trial compared a protein and energy dense supplement enriched with n-3 fatty acids and antioxidants (experimental: E) with an isocaloric isonitrogenous control supplement (C) for their effects on weight, lean body mass (LBM), dietary intake, and quality of life in cachectic patients with advanced pancreatic cancer. Methods: A total of 200 patients (95 E; 105 C) were randomised to consume two cans/day of the E or C supplement (480 ml, 620 kcal, 32 g protein ¡ 2.2 g EPA) for eight weeks in a multicentre, randomised, double blind trial. Results: At enrolment, patients' mean rate of weight loss was 3.3 kg/month. Intake of the supplements (E or C) was below the recommended dose (2 cans/day) and averaged 1.4 cans/day. Over eight weeks, patients in both groups stopped losing weight (Dweight E: 20.25 kg/month versus C: 20.37 kg/month; p = 0.74) and LBM (DLBM E: +0.27 kg/month versus C: +0.12 kg/month; p = 0.88) to an equal degree (change from baseline E and C, p,0.001). In view of evident non-compliance in both E and C groups, correlation analyses were undertaken to examine for potential dose-response relationships. E patients demonstrated significant correlations between their supplement intake and weight gain (r = 0.50, p,0.001) and increase in LBM (r = 0.33, p = 0.036). Such correlations were not statistically significant in C patients. The relationship of supplement intake with change in LBM was significantly different between E and C patients (p = 0.043). Increased plasma EPA levels in the E group were associated with weight and LBM gain (r = 0.50, p,0.001; r = 0.51, p = 0.001). Weight gain was associated with improved quality of life (p,0.01) only in the E group. Conclusion: Intention to treat group comparisons indicated that at the mean dose taken, enrichment with n-3 fatty acids did not provide a therapeutic advantage and that both supplements were equally effective in arresting weight loss. Post hoc dose-response analysis suggests that if taken in sufficient quantity, only the n-3 fatty acid enriched energy and protein dense supplement results in net gain of weight, lean tissue, and improved quality of life. Further trials are required to examine the potential role of n-3 enriched supplements in the treatment of cancer cachexia.

BackgroundPeople today are living longer and want to remain active. While obesity is becoming an epidemic, the number of patients suffering from osteoarthritis (OA) is expected to grow exponentially in the coming decades. Patients with OA of the knee are progressively being restricted in their activities. Since a knee arthroplasty (KA) is a well accepted, cost-effective intervention to relieve pain, restore function and improve health-related quality of life, indications are expanding to younger and more active patients. However, evidence concerning return to sports (RTS) and physical activity (PA) after KA is sparse.ObjectivesOur aim was to systematically summarise the available literature concerning the extent to which patients can RTS and be physically active after total (TKA) and unicondylar knee arthroplasty (UKA), as well as the time it takes.MethodsPRISMA guidelines were followed and our study protocol was published online at PROSPERO under registration number CRD42014009370. Based on the keywords (and synonyms of) ‘arthroplasty’, ‘sports’ and ‘recovery of function’, the databases MEDLINE, Embase and SPORTDiscus up to January 5, 2015 were searched. Articles concerning TKA or UKA patients who recovered their sporting capacity, or intended to, were included and were rated by outcomes of our interest. Methodological quality was assessed using Quality in Prognosis Studies (QUIPS) and data extraction was performed using a standardised extraction form, both conducted by two independent investigators.ResultsOut of 1115 hits, 18 original studies were included. According to QUIPS, three studies had a low risk of bias. Overall RTS varied from 36 to 89 % after TKA and from 75 to >100 % after UKA. The meta-analysis revealed that participation in sports seems more likely after UKA than after TKA, with mean numbers of sports per patient postoperatively of 1.1–4.6 after UKA and 0.2–1.0 after TKA. PA level was higher after UKA than after TKA, but a trend towards lower-impact sports was shown after both TKA and UKA. Mean time to RTS after TKA and UKA was 13 and 12 weeks, respectively, concerning low-impact types of sports in more than 90 % of cases.ConclusionsLow- and higher-impact sports after both TKA and UKA are possible, but it is clear that more patients RTS (including higher-impact types of sports) after UKA than after TKA. However, the overall quality of included studies was limited, mainly because confounding factors were inadequately taken into account in most studies.Electronic supplementary materialThe online version of this article (doi:10.1007/s40279-015-0421-9) contains supplementary material, which is available to authorized users.

BackgroundKnee osteotomies are proven treatment options, especially in younger patients with unicompartmental knee osteoarthritis, for certain cases of chronic knee instability, or as concomitant treatment for meniscal repair or transplantation surgery. Presumably, these patients wish to stay active. Data on whether these patients return to sport (RTS) activities and return to work (RTW) are scarce.ObjectivesOur aim was to systematically review (1) the extent to which patients can RTS and RTW after knee osteotomy and (2) the time to RTS and RTW.MethodsWe systematically searched the MEDLINE and Embase databases. Two authors screened and extracted data, including patient demographics, surgical technique, pre- and postoperative sports and work activities, and confounding factors. Two authors assessed methodological quality. Data on pre- and postoperative participation in sports and work were pooled.ResultsWe included 26 studies, involving 1321 patients (69% male). Mean age varied between 27 and 62 years, and mean follow-up was 4.8 years. The overall risk of bias was low in seven studies, moderate in ten studies, and high in nine studies. RTS was reported in 18 studies and mean RTS was 85%. Reported RTS in studies with a low risk of bias was 82%. No studies reported time to RTS. RTW was reported in 14 studies; mean RTW was 85%. Reported RTW in studies with a low risk of bias was 80%. Time to RTW varied from 10 to 22 weeks. Lastly, only 15 studies adjusted for confounders.ConclusionEight out of ten patients returned to sport and work after knee osteotomy. No data were available on time to RTS. A trend toward performing lower-impact sports was observed. Time to RTW varied from 10 to 22 weeks, and almost all patients returned to the same or a higher workload.Electronic supplementary materialThe online version of this article (doi:10.1007/s40279-017-0726-y) contains supplementary material, which is available to authorized users.

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The number of patients receiving a TKA during working life is increasing but little is known about the impact of TKA on patients' reintegration into the workplace. In this cross-sectional survey it was found that 173 of 480 responders worked within 2 years prior to surgery. Sixty-three percent of the working patients stopped within two weeks prior to surgery and 102 patients returned within 6 months. One third never returned to work. Activities that most improved were operating foot pedals, operating vehicles, standing and walking on level terrain. Activities that least improved were kneeling, crouching and clambering. Fifty patients scored 5 or less on the Work Ability Index. Thirty patients were dissatisfied. TKA significantly, but unequally, reduces difficulties in carrying out knee-burdening work activities.

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PurposeIndications for total and unicondylar knee arthroplasty (KA) have expanded to younger patients, in which Patient-Reported Outcome Measures (PROMs) often show ceiling effects. This might be due to higher expectations. Our aims were to explore expectations of younger patients concerning activities in daily life, work and leisure time after KA and to assess to what extent PROMs meet and evaluate these activities of importance.MethodsFocus groups were performed among osteoarthritis (OA) patients <65 years awaiting KA, in which they indicated what activities they expected to perform better in daily life, work and leisure time after KA. Additionally, 28 activities of daily life, 17 of work and 27 of leisure time were depicted from seven PROMS, which were rated on importance, frequency and bother. A total score, representing motivation for surgery, was also calculated.ResultsData saturation was reached after six focus groups including 37 patients. Younger OA patients expect to perform better on 16 activities after KA, including high-impact leisure time activities. From the PROMs, daily life and work activities were rated high in both importance and motivation for surgery, but for leisure time activities importance varied highly between patients. All seven PROMs score activities of importance, but no single PROM incorporates all activities rated important.ConclusionYounger patients expect to perform better on many activities of daily life, work and leisure time after KA, and often at demanding levels. To measure outcomes of younger patients, we suggest using PROMs that include work and leisure time activities besides daily life activities, in which preferably scored activities can be individualized.