DIENST ABDOMINALE HEELKUNDE - UZ Leuven

1ANNUAL REPORT 2006ANNUAL REPORT 2007DEPARTMENT OF ABDOMINAL SURGERYKULASUniversity Hospitals UZ LeuvenKATHOLIEKE UNIVERSITEIT LEUVENUniversity Hospitals UZ Leuven, Herestraat 49, 3000 Leuven, BelgiumMarch 2008

2The work summarised in this report was performed by the whole medical, nursing,paramedical and secretarial team of the Department of Abdominal Surgery. Every memberof the team, including those who joined us just for some weeks or months, as trainees forexample, are to be congratulated for their individual contribution to the ‘product’ deliveredin the years 2006 and 2007.Also those who have devoted much of their energy and creativity in building up thedepartment in the past should never be forgotten because they are at the basis of the actualachievements. On August 26 th 2006 Prof. Dr. em. Raymond Kerremans, former chairmanof our department from 1978 till 1997, and on February 13 th 2007 Prof. Dr. Ludo Filez,former clinical head in our department from 1988 till 2003, passed away. Therefore, thisreport starts with an In Memoriam devoted to them.The department also thanks the authorities, clinical, academic, scientific andgovernmental, that create the condition, the structure in which our team and its individualmembers can evolve.Finally, the team is most grateful to all those from within as well as from outsideour University Hospital who referred their patients for surgical care to our department andcontributed to the quality of care for our patients.This annual report, like the previous ones, still is mainly quantitative in nature.This does not mean that numbers per se prevail on quality of health care delivery. Somenumbers, however, are indicators of quality of care. Also, several publications from thedepartment report the result of ‘internal audits’. As far as feasible, reports in the comingyears will reflect to a greater extent on the qualitative aspects of our performances. Doingso, we strive to identify those areas were further progress, improvement and efficacy mightbe possible.

3IN MEMORIAMProf. em. dr. Raymond KERREMANSDworp 28 februari 1932 - Leuven 26 augustus 2006Op 26 augustus 2006 overleed gewoon hoogleraar prof. em. dr. R.Kerremans, gewoon hoogleraar en voormalig diensthoofd van dedienst abdominale heelkunde. Zijn familieleden en vrienden namenafscheid in beperkte kring. De “prof” had het zo gewild. Inderdaad,negen jaren voorheen had hij bij zijn emeritaat reeds volledigafscheid genomen van de medische en universitaire wereld om zichvolledig te kunnen wijden aan zijn hobby’s en zijn familie.Prof. em. dr. R. Kerremans was een zuiver Leuvens product. Hijgenoot er zijn volledige medische en chirurgische opleiding. Na eenzeer korte algemene heelkundige opleiding besloot hij zich, alseerste in België, te subspecialiseren in de abdominale heelkunde enwerd de vaste medewerker van Prof. dr. J. Beckers.Toen deze in 1978 onverwacht overleed nam Prof. dr. R. Kerremans de dienst abdominaleheelkunde over, inclusief lesopdrachten. Hij deed dat met grote creativiteit enpersoonlijkheid. Zijn creatieve geest en logisch denken stuurden zijn getalenteerdehanden niet alleen in zijn klinische-heelkundige praktijk maar ook in zijn hobby’s(schilderen, knutselen) en wetenschappelijk werk. Hij was wellicht de eerste chirurg aande K.U.Leuven die het aggregaat in het hoger onderwijs verwierf op basis van een in hetopenbaar verdedigd proefschrift over “Morphological and physiological aspects of analcontinence and defecation” (1969). Zijn wetenschappelijk onderzoek, o.a. in ditproefschrift vervat, genoot internationale weerklank. Door sommigen werd er naarverwezen als de “bijbel van de anorectale fysiologie en pathofysiologie”. Ook voerde hijoriginele heelkundige technieken in en stelde ze verder op punt zoals bijvoorbeeldsfinctersparende rectumresecties en duodenumsparende pancreaskopresecties. Zorg voorpatiënten, in zeer nauwe samenwerking met de verpleegkundigen, stond centraal in zijnberoepsleven, niet alleen in het ziekenhuis maar ook in het onderwijs. Hij kwam dan ookniet over als een theoreticus maar als een zeer ervaren clinicus die extreem veel belanghechtte aan wat nu multidisciplinair overleg genoemd wordt.In al zijn handelingen was Prof. dr. R. Kerremans gekenmerkt door eerlijkheid,rechtlijnigheid, nederigheid en beschermende zorgzaamheid. Zijn eerlijke rechtlijnigheiddeden hem steeds zonder omwegen afgaan op het te bereiken doel en liet ook weinig ofgeen ruimte voor ‘diplomatieke toegevingen’. Zijn nederige bescheidenheid liet geenplaats voor grootschalige ondernemingen of streven naar macht (lees: bestuursfuncties).Naar eigen zeggen genoot hij het meest van de goede werking in zijn eigen “kleine winkel”.Hij zorgde niet alleen voor patiënten en studenten maar ook voor zijn medewerkers,beschermde hen en gaf hen alle kansen om voort te bouwen op de kennis en ervaringenvan het huis en om nieuwe initiatieven op te starten.Daarom zijn zeer vele, zoniet alle patiënten, studenten, en medewerkers zeer dankbaarvoor wat prof. dr. R. Kerremans voor hen heeft betekend en gedaan.Hij heeft de eeuwige rust verdiend.

6The main clinical responsibilities and scientific interest in the various fields ofabdominal surgery have been allocated to individual staff members in consensus. Theresponsibilities for clinical and scientific fields of interest are as follows:STAFFHead of departmentPenninckxHEPATO-PANCREATO-BILIARY SURGERYClin. chiefAertsClin. chiefTopalResident surgeon A 1GASTRO-INTESTINAL SURGERYClin. ChiefClin. ChiefSupervisorD'HooreTopalLannooResident surgeon B 1COLORECTAL SURGERY and PROCTOLOGYClin. chiefD'HooreSupervisorResident surgeon B 1ABDOMINAL WALL and PEDIATRIC SURGERYClin. chiefMiserezResident surgeon C 1

7Towards a new organisation of care processes (Zorgprogramma’s)In July 2007 the direction of our University Hospitals UZ Leuven decided to re-organizeour caring system and asked to plan and introduce (in 2008-2009) care processes. Besidesmedical aspects, the operational organisation of these programs will have to be set up.Thus, the standard and efficacy of care will further improve. The ultimate aims areimproved quality of care and patient safety taking into account actual evidence-basedguidelines of good clinical practice.In October 2007 the department of Abdominal Surgery submitted the following proposalto the direction. The above mentioned repartition of fields of clinical interest andresponsibilities was respected.ZP CARE PROCESSESPts/yr RESPONSIBLEINVOLVEDSTAFMEMBERS12Gallbladder, bile ducts, pancreas,stomach (benign)Tumoral pathology liver, biliarysystem, pancreas, stomachduodenum(incl. perit. metas)500 Aerts R3 Obesity (incl. AZ Diest) 150 D'Hoore A456Inflammatory bowel disease (Crohn,ulc. colitis)Tumoral pathology small and largeintestine, rectum, anus (incl. perit.metas)Non-tumoral intestinal pathologysmall and large bowel, rectum, anus,incl. stoma care (excl IBD)Aerts, Topal, D'Hoore,Miserez, Lannoo,Penninckx320 Topal B Topal, Aerts130 D'Hoore A425 D'Hoore A620 D'Hoore A7 Abdominal wall 1000 Miserez M8Congenital abdominal surgicalpathology100 Miserez MD'Hoore, Miserez,LannooD'Hoore, Miserez,PenninckxD'Hoore, Miserez,PenninckxD'Hoore, Penninckx,Miserez, Aerts, Topal,LannooMiserez, Aerts, D'Hoore,Topal, Lannoo,PenninckxMiserez, Aerts, D'Hoore,Topal, PenninckxAll these programs are multidisciplinary, except ‘Abdominal wall’.The numbers of patients per year are estimations.All programs include the care of emergency cases. Thus, most programs involve morestafmembers than mentioned above.

8A specific project on the improvement of quality of care (medical, paramedical andsurgical) for overweight and obese patients has been submitted to the direction by Dr.Lannoo M.

9Resident-surgeonsResident-surgeons (senior-assistenten) are full-trained surgeons that stay for one year.In the ‘academic year’ August 1 st 2005 till July 31 2006 they were:Dr. Meekers FredericDr. Vandermeeren LiesbethDr. Vindevoghel KoenIn the ‘academic’ year August 1 st 2006 till July 31 2007, the 3 mandates for residentsurgeonswere filled in by the following surgeons:Dr. Hendrickx TomDr. Houben BertDr. Lannoo MatthiasDr. Van Duijvendijk Peter (from January 1 st 2007 till July 31 2007)In the ‘academic year’ August 1 st 2007 till July 31 2008, the resident-surgeons are:Dr. Debruyne DavidDr. Hompes DaphneDr. Quanten IngeSurgical traineesfrom 1 November 2005 till 31 January 2006Lannoo Matthias 6 th yrBomans Benoit 6 th yrKuppers Maarten 6 th yrRisha André 6 th yrLerut Philip 6 th yrWellens Ellen 3 rd yrfrom 1 February 2006 till 30 April 2006Lannoo Matthias 6 th yrHendrickx Tom 6 th yrHouben Bert 6 th yrChow Tsang Sey 6 th yrRobijn Jorn 4 th yrWellens Ellen 3 rd yrfrom 1 May 2006 till 31 July 2006Lannoo Matthias 6 th yr

10Hendrickx Tom 6 th yrHouben Bert 6 th yrChow Tsang Sey 6 th yrDe Wil Peter 2 nd yrMalinowska Marta 1 st yrfrom 1 August 2006 till 31 October 2006Hompes Daphne 6 th yrRisha André 6 +th yrWolthuis Albert 5 th yrDedrye Lieven 5 th yrBoecxstaens Veerle 4 th yrSlabbaert Koen 3 rd yrfrom 1 November 2006 till 31 January 2007Hompes Daphne 6 th yrRisha André 6 +th yrQuanten Inge 6 th yrD’Hondt Beelke 6 th yrLeys Els 5 th yrPirenne Yves 5 th yrfrom 1 February 2007 till 30 April 2007Hompes Daphne 6 th yrDe Pooter Karl 6 th yrD’Hondt Beelke 6 th yrWolthuis Albert 5 th yrBoecstaens Veerle 4 th yrCeulemans Pieter 3 rd yrfrom 1 May 2007 till 31 July 2007Hompes Daphne 6 th yrDe Pooter Karl 6 th yrMertens Johan 6 th yrDevroe Hannelore 5 th yrVan Genechten Eva 3 rd yrfrom 1 August 2007 till 31 October 2007Darius Tom 6 th yrD’Hondt Mathieu 5 th yrVandermieren Gerry 4 th yrDubois Marc 3 rd yrFrançois Joris 3 rd yrOyen Tom 1 st yrfrom 1 November 2007 till 31 January 2008Darius Tom 6 th yr

11Dedrye Lieven 6 th yrTiek Joyce 3 rd yrDurnez Joke 2 nd yrRoza Thomas 1 st yrOyen Tom 1 st yrVisiting surgeonsDr. Di Mauro Davide, trainee at the University of Parma, department of surgery (Prof. Dr.Roncoroni L): November 1 2005 till October 31, 2006Dr. Annelli Fulvia, trainee at the University of Brescia, department of surgery (Prof. Dr.Salerni B): March 1 till August 31, 2006Dr. Mariani Pierpaolo, Seriate Hospital Bergamo, Italy (Dr. Perrone G.): September 22 tillNovember 30, 2006Dr. Mifcovic Andrej, trainee at the University of Bratislava, department of surgery:September 2006 till February 2007.Dr. Pata Giacomo, trainee at the University of Brescia, department of surgery (Prof. Dr.Salerni B): March 1 till August 31, 2007Dr. Grous Aleksander, trainee at the University of Warsaw (Prof. Dr. Polanski):September 3 till November 2, 2007

12OVERVIEW OF ACTIVITIES IN 20071. clinical activities- 8 700 out-patient clinics of the department Abd Surgery, half a day on every day ofthe week (all staff members)- Digestive Oncology and Hepato-pancreato-biliary Oncology multidisciplinary outpatientclinic with Internal Medicine Gastroenterology, Hepatology andRadiotherapy (Dr. R. Aerts, Dr. D’Hoore A, Prof. F. Penninckx, Prof. Topal B), twohalf days/week. Multidisciplinary discussion on oncology cases are organised everyweek.Multidisciplinary clinics of pediatrics (Prof. Miserez M) once per month.Routine multidisciplinary clinics of pelvic floor pathology (Dr. D’Hoore A, Prof.Penninckx F) were suspended – at least temporarily – mainly because of shortage oftime and staff from the part of the department of Abdominal Surgery.- MCH (out-patient clinic in the city) (resident-surgeon under supervision of Dr.D’Hoore A)- AZ Diest (out-patient clinic morbid obesity): two half days per week- consults in other departments of the UZGHB (± 5/d)- emergency cases and emergency surgery (± 4/day)- 4300 surgical procedures / yearMonday (4 theatres): GI and colorectal (2), HPB day case (1), morbid obesity(Diest, 1; scheduled on Wednesday since 2008)Tuesday (4 theatres): HPB (2), colorectal (1/2 weeks), abd. wall (1/2 weeks), abd.wall day case (1)Wednesday (1 theatre): abd wall and/or pediatric (1/2 weeks) or GI and colorectal(1/2 weeks)Thursday (3 theatres): GI and colorectal (2), abd. wall (1)Friday (3 theatres): HPB (2), proctology (1)- liver transplantations (Dr. R. Aerts): these operations are not enumerated /summarized in this report because they belong to the department of AbdominalTransplantation (Prof. Dr. J. Pirenne).- pre- and postoperative care for 66 hospitalised pts + about 10 exta-muros patients inICUs or pediatrics- anorectal functional examination - manometry (Vanden Bosch A nurse, Prof. F.Penninckx)- stoma care (Vanden Bosch A nurse, Dr. D’Hoore A)

13- administration (Van Ermen G, Van De Schoot C, study nurse of the department)2. graduate teaching- at the faculty of medicine (Prof. Penninckx, Prof. Miserez, Prof. Topal, Dr. D’Hoorepm, Dr. Aerts R pm)- at the nursing school (Dr. Aerts, Dr. D’Hoore, Prof. Miserez)3. postgraduate teaching (all staff members)- 5 - 6 trainees in surgery (rotating every 3 - 6 – 12 mo.)- 3 resident-surgeons (senior-assistenten) (for 1 yr. each)- interuniversity postgraduate teaching in surgery (5 days/yr.)- intensive training in laparoscopy (Centre for Surgical Techniques, CHT, Prof. Dr. M.Miserez co-director) (10 d/yr.)- visiting trainees, surgeons or professors4. researchResearch is performed on several topics. Main subjects were: RFA (radiofrequencyablation), rt-PCR for the detection of circulating cancer cells, laparoscopic incisionalhernia repair, evaluation of meshes for hernia repair, laparoscopy training, experimentaland clinical testing of new anastomotic devices, evaluation of the Surgisis anal fistulaplug, anorectal functional evaluation.4.1. PhD thesis4.1.1. Dr. A. D'Hoore defended his PhD thesis “New surgical techniques to correctrectal prolapse syndromes” on 24th May 2007. Members of the jury were:Prof. Nicholls J (London, UK), Prof. O’Connell R (Dublin, Ireland), andfrom the KULeuven Prof. Rutgeerts P, Prof. Geboes K, Prof. Coremans G(copromotor), Prof. Penninckx F (promotor).4.1.2. Thesis project on Metabolic Syndrome prepared by Dr. Lannoo M (since2007)4.1.3. Thesis project on Pancreatic Cancer prepared by Dr. Sergeant Gregory andpresented to the Faculty Medicine (since 2006)4.1.4. Project on abdominal wall pathophysiology and repair by Peeters Ellen,M.Sci. (since 2006)4.1.5. Project on laparoscopy training by Dr. De Win Gunter (in 2006-2007) andDr. Van Bruwaene Siska (since 2007)4.2. Publications in 2007: 27 original papers, 3 letters in peer-reviewed internationaljournals, 2 book chapters and 1 report/guidelines (cf. infra)4.3. Grants

144.3.1. FWO + IWT: abdominal wall pathophysiology and repair (Miserez M)4.3.2. FWO + IWT: prognostic relevance of cancer cell dissemination andimmunosuppression in pancreatic cancer (Topal B)4.3.3. KOF (clinical research fund) mandate (D’Hoore A 2004-2007, Topal B 2007-2010)4.3.4. RIZIV, KCE, Foundation Against Cancer: PROCARE, a nationalmultidisciplinary project on rectal cancer (Penninckx F, chairman of the SteeringGroup).4.3.5. OOI project KUL (2005-2007): training in laparoscopic surgery.4.4. Study nurse. Since October 2005, the department of Abdominal Surgery engaged aClinical Trial Assistant. They were:Mrs. Tomczyk Katarzyna, from October 2005 till September 2006 (0.33 FTE)Mrs. Van den Ende Natalie, from October 2006 till September 2007 (0.5 FTE)Mrs. Vervoort Damienne, from October 2007 till December 2007 (0.5 FTE)Mrs. Hatse Sigrid, from March 2008 on..

15CLINICAL WORK AND PERFORMANCE IN NUMBERS1997 2001 2002 2006 2007outpatients abd surg 8063 8257 8780 8703outpatients at MCH ? ? ? ?outpatients in AZ Diest - - ? ?outpatients dig and hpb onco 760 726 ? ?outpatients pelvic floor/ped. 12 36 0 0outpatients pediatrics E302 ? ?total outpatients 10044 10035anorectal manometry 435 569 548 413 397cases at emergencydepartment940 1035 936 994 1078ambulatory 183 149 251 267hospitalised 852 787 743 811surg procedures (UZ GHB)° 3302 3685 3624 3395 3262surg procedures (AZ Diest) 166 193day case surgery 525 684 996 993use of operating theatres (nettotime in UZ GHB, excl. daycase surgery for 2006-7)8150 8616 8515 8632hospitalised patients 2733 2790 2506 2584 2504hospitalisation days (classic) 21525 21466 20293 19618 20908mean hospital stay (in UZGHB)7,9 7,7 7.1 7,59 8,35According to Kerncijfers Medische Diensten and KULAS° exclusive day case surgery in UZ GHB and operations in AZ Diest; inclusive poucho-, rectoscopy andpilonidal sinus surgeryCompared with 2001-2002, the number of contacts at our out-patient increased withapprox. 6 %. The number of contacts in the MCH, AZ Diest and for multidisciplinaryclinics (not registered ?) could not be provided.The number of emergency cases remained stable.The overall number of surgical procedures increased with about 5 %. The number of daycase or short stay (1 night) surgical procedures increased with 65 %. In contrast, thenumber of surgical procedures performed in the ‘main operating theatres’ of UZ GHBdecreased with about 10 % while the netto time attributed to our department in those

16theatres remained similar. This can be explained by an increasing number of ‘advancedprocedures’ (cf. infra) while the ‘easier cases’ are treated have been oerated morefrequently as day case surgery. It also seems that our repeated request to increase ouroperating time capacity in UZ GHB on a structural basis was not realized. However,this a complex problem, e.g. hospitalisation capacity would have to be increased (while theaverage length of stay is already increasing).4600N of operationsOperative procedures (N in 2001 =100 %)4500440043004200410040002001 2002 2006 20071101081061041021009896942001 2002 2006 2007The mean hospital stay for hospitalised patients in UZ GHB increased with 18 %(2007 versus 2002). The latter is related to the increasing number of patients being treatedin a day case setting, i.e. discharged from the hospital on the same day, resulting in the factthat patients who are hospitalised have a higher severity of illness and/or have morecomplex surgery.The severity of illness of hospitalised patients is increasing with less beds occupied bypatients with SOI categories 1 and 2 in recent years. Similarly, advanced surgicalprocedures proportionally increase more than ‘basic’ procedures (cf. infra sub SurgicalProcedures).

18Evolution of the workloadThe sum of the number of contacts at our outpatient clinic (E427) + operative procedures(hospitalised in UZ GHB or AZ Diest and day case patients) was made per year.Outpatient contacts in multidisciplinary clinics, in the MCH (5-10/wk) and AZ Diest(about 15/week) are not taken into account because exact numbers are not available. Incontrast with numbers mentioned in most other tables, the number of operations taken intoaccount include procto- and pouchoscopy, pilonidal sinus therapy because they are also‘time consuming’.It has to be mentioned that this ‘formula’ is an underestimating proxy of the actualworkload. Indeed, several aspects of daily clinical work are not taken into account, such asemergency cases, ward rounds, administration, … .Activities in 2001 were put at 100%.1101081061041021009896942001 2002 2006 2007The workload increased with 8 % in 2006-2007 as compared with 2001-2002. This ismuch less than the 34,4% increase observed in 2003 as compared with 1998 (cf. AnnualReport 2003). Also, in comparison with 2006, the activities did not increase further in2007. This evolution indicating stagnation is related to almost maximum use of‘facilities’ and/or limitations of growth induced by the absence of increased availabilityof facilities, including staff.Another important aspect of ‘workload’ is emergency surgery. This type of surgery eitherinterferes with planned surgical procedures (surgery to be cancelled/postponed to the next

19day for some patients), or is performed ‘afer the hours’ and/or during the night. Traineeson duty overnight have to recover the next day, increasing the workload for those on thebattle fields.There were 1027 emergency procedures in 2006 and 1149 in 2007. Emergency casescould be patients from the emergency department (in UZ GHB or AZ Diest) or patientshospitalised in our or other departments in the UZ GHB.Somewhat more than 30% of surgeries are performed as emergencies. Note that daycasesurgery was excluded for the number of planned surgery because it is performed in aseparate cluster of theatres wherein emergency cases never interfere with the plannedschedule.100%90%80%70%60%50%40%30%20%10%0%2006 2007plannedemergencyAs can be expected, about half of emergency procedures were performed during thenight. The latter was defined as a procedure being performed (completely or mainly) after21.00 (according to the nomenclature providing specific supplementary remuneration foremergency surgery.100%90%80%70%60%50%40%30%20%10%0%2006 2007daynight

20SURGICAL PROCEDURESGeneral overview (according to KULAS data)Numbers include operative procedures performed in University Clinic Gasthuisberg andAZ Diest. The latter are also presented separately (cf. infra).PROCEDURES per organsystem1998 2001 2002 2006 2007STOMACH and DUODENUM 159 248 230 292 306SMALL and LARGE INTESTINE 1076 1287 1352 1399 1405RECTUM and ANUS * 481 612 664 849 843HEPATO-PANCREATO-BILIARY 602 735 747 869 804ABDOMINAL WALL 890 864 1055 945 945TOTAL 3208 3746 4058 4354 4303* exclusive poucho- rectoscopies and pilonidal sinaus treatment. Their numbers arementioned in the following Per Procedure table.

21Per procedure (according to KULAS data)Numbers include operative procedures performed in University Clinic Gasthuisberg forhospitalised and day case patients as well as procedures performed in AZ Diest. The latterare also presented separately (cf. infra).PROCEDURE 1998 2001 2002 2006 2007STOMACH and DUODENUM 159 248 230 292 306hiatal hernia 38 27 30 16 21total gastrectomy 24 28 25 27 29subtotal gastrectomy 9 8 4 20 11partial gastrectomy (incl. Mason) 20 11 11 8 7Mason gastroplasty (a.o.) 37 28 0 0gastric bypass 23 46 101 90gastric sleeve 6 8closure of perforation 31 27 19 20 25gastroenterostomy 13 14 19 6 10gastrostomy 8 23 19 57 76pyloromyotomy 12 25 10 13 9duodenojejunostomy 2 3 1 0 3closure duodenal fistula 2 13 10 11 4bleeding ulcer 4 6 4 3miscel. stomach & duod. 5 2 3 10SMALL and LARGE INTESTINE 1076 1287 1352 1399 1405adhesiolysis 40 81 40 77 68enteroanastomosis 46 30 39 53 49stricturoplasty 17 11segmental resection 69 72 103 124 124ileo-, colostomy , Witzel 32 85 79 90anus praeter (closure) 96 93 41 52 45miscel. SI (Meckel, …) 6 6 11 4explorative laparotomy, -scopy 168 90 74 73 71(re)laparotomy/scopy hemoperit, -itis 24 97 137 89 129resection (retro)peritoneal tumour 2 9 11 19 11debulking 5 2debulking + hipec 10 9drainage peritoneal abscess 18 16 20 24 25

22miscel. (ovary, adnex., hyster.) 6 18 12 15appendicectomy 273 324 336 401 419ACE 6 0 3 6total colectomy (IRA or ileostomy) 22 40 36 31 31hemi-, partial colectomy, sigmoid 222 271 271right hemicolectomy 175 133left hemicolectoy 16 18segm. colectomy 30 31sigmoidectomy 11 cf. ARHartmann procedure 46 61 76 55 62closure after Hartmann 44 29 29 26 45miscel. (sim. bladder, colon suture) 30 30 6 7RECTUM and ANUS 481 612 664 849 843proctocolectomy 7 2 2 2 0abdomino-perineal rectum excision 28 22 26 21 28TAR (total reconstruction) 2 3 1 0 0APR perineal colostomy + ACE 7 0anterior resection 71 78 84 188 185Swenson (Hirschsprung) 6 6 6 5 5restorative proctocolectomy 70ileal pouch anal anastomosis 22 31 18 20colon pouch, CAA +/- plasty, a.o. 56 62 73 68pelvic exenteration (posterior or total) 6 14imperforatio ani 2 0 3 4 1rectum prolapse (pexy, excision) 35 33 49 51 60transanal (polyp)resection 4 4 11 11 7sphincter repair a.o. 18 21 24sphincter repair 17 11dynamic graciloplasty, artificial sphincter 1 21 2 14SNS (temp., defin.)6 23anocut. Flap 5 4 5 11silicone injection 1 2repair rectovaginal fistula 19 28 12 10 6colporrhaphia posterior 16 23 18 9 11fistula-in-ano 59 75 75 91 65fistulectomy with rectal advanc flap 7 12fistula plug 11 7anal fissure (fissurec., ILS, botox) 22 44 44 27 25haemorrhoidectomy 73

23Milligan Morgan 39 26 41 39Longo 43 48 50 67skin tags 25 12 14condylomata 1 8 2 2 1anal -, perirectal abscess 47 60 55 53 71douglas abscess 11 14 20 20miscel. anus 27 28 100 68pilonidal sinus 33* 35* 35* 46* 54*recto-, pouchoscopy 197* 158* 185* 132* 74*rectoscopy + biopsy (child

24Because of shortness of operating time and hospitalization capacity at the UniversityHospitals UZ Leuven, the Department Abdominal Surgery, in agreement with therespective hospital directions, decided to perform morbid obesity surgery at the AlgemeenZiekenhuis (AZ) Diest, about 35 km from Leuven, starting in March 2005. The localanaesthesiology and intensive care team was updated for this type of patients andpathology. One or two operating days per week were planned for elective morbid obesityrelated surgery performed by Dr. D’Hoore A, Dr Smet B, Dr. Lannoo M and Prof. MiserezM. The local surgeons, Dr. Brutsaert K as well as Dr. Meekers F since August 2007,formerly residents in our department, was asked to collaborate in the postoperativesurveillance of these patients. In compensation, our residents at UZ Gasthuisberg also hadto cover on duty calls in the AZ Diest.The procedure performed in AZ Diest can be summarized as follows:PROCEDURES 2006 2007morbid obesity related surgery 106 99other surgical procedures (total) 60 94stomach and duodenum 3 4small and large intestine 32 51rectum and anus 4 10hepato-pancreato-biliary surgery 17 19abdominal wall 4 10total 166 193In 2006-2007 the surgical activity increased with 11 % as compared with 2001-2002, i.e. 2 % per year. This increase in the number of procedures is limited because oflimitations imposed on allocated operating time and to a maximum use of resources. Thedepartment could perform more procedures if more operating theatre time would beavailable.As a consequence, we continuously had a waiting list of patients ready foroperation. Due to emergency or cancer cases, these patients with benign pathology have tobe rescheduled repeatedly resulting in significantly reduced patient satisfaction, highlystressed secretaries, and in patients cancelling their planned surgery in our clinics

25(estimation about 15 % of patients on the waiting list). Actually (March 5 th 2008) there are123 patients on our waiting list.Like in previous years, the proportion of ‘basic’ and of more ‘advanced’procedures has been evaluated. The subgrouping in basic and advanced procedures ismainly based on the competence required to perform them. Thus, procedures to bemastered by 'general' surgeons are enumerated in the 'basic' group. Also, the remunerationby the National Health Insurance System was taken into account (low price = basic), aswell as the rarity of some pathology (= advanced). However, this division is biased insome way, e.g. relatively simple or 'basic' surgery had to be performed in referred,sometimes critically ill patients (e.g. relaparotomies for peritonitis are classified under'basic' procedures). The subcategories of ‘miscellaneous’ procedures have been excludedfor this analysis.PROCEDURE 1998 2001 2002 2006 2007"BASIC" PROCEDURES 2736 2920 3146 3102 3073closure of perforation 31 27 19 18 23gastroenterostomy 13 14 19 6 10gastrostomy 8 23 19 57 76pyloromyotomy 12 25 10 13 8inguin., fem., umbil. hernia 604 507 636 508 521bilat. inguin. hernia lap.+ Stoppa) 92 126 142 119 120eventration 176 147 152 160 151evisceration 13 24 12 19 20cholecystectomy 428 428 457 409 368choledochotomy 6 9 19 50 41splenectomy 28 34 24 19 14adhesiolysis 40 81 40 75 65enteroanastomosis 46 30 39 52 48segm small bowel resection 69 72 103 123 115explor laparotomy, -scopy 168 132 114 138 122laparotomy for perit., haemorrh. 24 97 137 87 127resection peritoneal tumour (ea) 2 9 11 19 11drainage peritoneal abscess 18 16 20 24 23appendicectomy 273 324 336 384 396total colectomy 22 40 36 31 31hemi-, partial colectomy 222 271 271 226 177closure Hartmann 44 29 29 24 42anus praeter (constr., closure) 96 125 126 130 135Hartmann 46 61 76 55 60transanal (polyp)resection 4 4 11 11 7

26colporrhafia post. 16 23 18 9 11fistula in ano 59 75 75 108 83anal fissure 22 44 44 27 25haemorrhoidectomy 73 82 99 102 120peri-anal, -rectal abscess 47 60 55 53 69pilonidal sinus 33 35 35 46 54"ADVANCED" PROCEDURES 492 636 662 899 894hiatus hernia 38 27 30 16 21total gastrectomy 24 28 25 27 29subtotal gastrectomy 9 8 4 20 11partial gastrectomy (incl. Mason) 20 71 85 115 105duodenojejunostomy 2 3 1 0 3closure duodenal fistula 2 13 10 11 4gastroschisis/omphalocele 2 3 0 3 3debulking +/- hipec 15 11hepaticojejunostomy 30 37 33 22 33duodenopancreatectomy 29 48 41 51 68hemipancr. left, necrosectomy 29 41 40 45 45cystojejunostomy 6 12 7 6 3hepatectomy right 8 12 14 16 13hepatectomy left 8 7 7 24 16partial hepatectomy (incl. RFA) 26 45 45 116 102proctocolectomy 7 2 2 2 0rectum amputation, APRACE 28 22 26 27 28TAR (total reconstruction) 2 3 1 0 0pelvic exenteration 6 14anteriorresection 71 78 84 187 180Swenson (Hirschsprung) 6 6 6 5 5restorative proct(ocol)ectomy 70 78 93 91 88imperforatio ani 2 0 3 4 1rectum prolapse (pexy, excision) 35 33 49 51 58sphi. repair, DGP, AMS, SNS, ... 19 28 42 29 47repair rectovaginal fistula 19 28 12 10 6The number of basic procedures remained stable at about 3200 per yearduring the last 5 years.In contrast, the number of advanced procedures increased with 26%. It has tobe remarked that advanced procedures increased with 74% since 1998, while basicprocedures increased with 17% over the same period.

27LAPAROSCOPIC SURGERYSince the end of 2002 the department disposes of 2 modernised operating theatresfully equiped for video-conferencing and tele-communication.In 2007 39 % (1734) of all surgical procedures (4448 incl. proctology) wereperformed laparoscopically, compared with 40 % in 2002. This indicates that theimplementation of laparoscopy has reached a maximum / optimum.Type of laparoscopic procedures in 2006 and 2007 compared with 5 years ago (KULAS)2001 2002 2006 2007Hepato-pancreato-biliary 470 485 586 508explorative laparoscopy(staging)42 29 63 40liver biopsy 6 3 10 6RFA liver tumour 7 3 27 23partial hepatectomy 0 6 17 19right or lefthemihepatectomy0 0 11 12cholecystectomy 288 296 166 167cholecystectomy + rx 91 113 226 185bile duct exploration 6 8 42 36hepaticojejunostomy 0 0 1 0liver cyst marsupialisation 8 6 5 7left pancreatectomy 1 3 7 9splenectomy 21 18 10 4splenic cyst decapsulation 0 0 1 0

28Gastrointestinal 143 105 192 164pyloromyotomy 12 5 3 4Nissen fundoplication 23 24 12 16gastropexy 3 1 0 0adhesiolysis for obstruction 43 17 30 24closure ulcer perforation 5 8 9 15closure perforation (excl.ulcer)11 4 4 2Meckel resection 9 3 5 4Mason gastroplasty 31 30 0 0gastric bypass 1 85 66sleeve gastrectomy 6 8segm small bowel resection 1 6 4 7enteroanastomosis 0 5 0gastric wedge resection 5 5 6 4partial gastrectomy 1 9 3total gastrectomy 0 0 13 10gastroenterostomy 0 0 1 1Colorectal 183 248 271 258stoma construction 9 21 15 18recto(colpo)pexy 25 39 41 47hemicolectomy ri, left, segm 28 35 61 46anterior and sigmoidresection82 99 126 112total colectomy + IRA orileost.13 9 4 6abdominoperineal rectumexcision4 0 2rest proctect + CPAA 5 8 6 14Swenson 5 5 3 2imperforate anus 2 0 0proctocolectomy 1 0 0rest proctocol + IPAA 10 19 13 6Hartmann 3 2 2repair after Hartmann 2 7 0 3Appendicectomy 301 310 383 405

29Abdominal wall 360 407 337 325unilat inguin hernia repair 209 254 219 205bilat inguin hernia repair 99 113 89 102umbilical hernia repair 16 9 13 4eventration repair 36 31 16 14Miscellaneous 56 47 66 66explor laparoscopy GI 53 41 47 43relapscopy peritonitis 1 1 12 13mesent cyst excision 1 5 1 4others 1 0 6 6TOTAL 1513 1602 1835 1726Laparoscopic achievements in 2006 and 2007:- Increasing numbers of hemihepatectomy, RFA procedures, anterior resections- gastric bypass for morbid obesity, total gastrectomy for cancerEvolution of laparoscopic surgery (KULAS data)The global number (open and laparoscopic) and the percentage of procedures performedlaparoscopically are presented.1998 2001 2002 2006 2007cholecystectomy 392 428 457 421 386379 409 392 352laparo88% 89% 90% 93% 91%appendicectomy 273 324 326 401 419301 310 383 405laparo86% 93% 95% 96% 97%

30inguinal hernia repair 513 506 617 485 474308 307laparo45% 61% 60% 64% 65%colectomy & rectal excision 638 619 796 710 692257 240laparo16% 28% 31% 36% 35%The number of laparoscopic procedures performed for cancer, as emergency cases duringdaytime or overnight, and as day case surgery are illustrated in the following table.2001 2002 2006 2007for cancer 87 115 273 208as emergency day 246 171 213 236as emergency night 163 248 267 258as day case 228 294 455 446The number of laparoscopic procedures for cancer and performed as day case surgeryincreased most significantly.Data from 2006 and 2007 seem to confirm that the implementation of laparoscopy hasreached a maximum.Robotic assisted laparoscopic surgery, started at the end of 1999, was not furtherdeveloped since 2001 (no practical needs, no specific project).

31DAY CASE AND SHORT STAY SURGERYA specific Surgical Day Case Centre was officially opened in October 2002. Althoughambulatory or day case surgery was performed before that date, since then supplementaryoperating theatre time became available specifically for this type of surgical patients.Definition of day case: discharge same day at 6 pm or before.Definition of short stay: one overnight hospital stay.A distinction between day case and short stay can not be made (no information available).However, the vast majority of patients listed below was treated as day case.Over the past years, an increase in day-case procedures was planned in order to ‘gain’more operating time for hospitalised patients.The evolution of ‘day case’ surgery has been remarkable.In 2007, the global number of day cases is 967, i.e. an increase with 41 % as comparedwith 2002 (684 procedures) and about 22 % of all procedures globally performed in thedepartment (4448 procedures including procto- and pouchoscopies).A major shift from classic hospitalisation for cholecystectomy and inguinal repair (openor laparoscopic; uni- or bilateral) towards performance of the same procedures in a daycase setting is observed.It seems that an optimal implementation is reached because the absolute number ofpatients and the percentages of performance by laparoscopy for most procedures remaincomparable over the last two years.

32Listing of day case or short stay procedures performed and their proportion in theglobal number of identical procedures (KULAS data).2001 2002 2006 2007day case/global day case/global day case/global day case/global(%) (%) (%) (%)ABDOMINAL WALL 290 429/950 (45%) 481/843 (57%) 477/809 (59%)lap. unilat. inguinal hernia 118/209 (56) 170/253 (67) 180/219 (82%) 167/204 (82%)inguinal hernia (uni/bilat) 41/171 (24) 88/249 (35) 110/173 (64%) 98/162 (60%)lap. bilat inguinal hernia 48/99 (48) 70/113 (62) 63/89 (71%) 82/102 (80%)umbilical hernia (open/lap) 41/86 (48) 45/71 (63) 54/78 (69%) 66/80 (83%)simult. umbilical hernia 14/52 (27) 18/49 (37) 13/24 (54%) 16/33 (48%)excision keloid, sec suture 16/29 (55) 17/31 (55)excision superficial lesion 5/7 (71) 11/25 (44) 40/112 (36%) 19/66 (29%)abscess drainage 2/14 (14) 6/29 (21)lap repair eventration 4/36 (11) 2/31 (6) 10/16 (63%) 2/14 (14%)repair eventration 1/99 (1) 2/99 (2) 6/123 (5%) 11/129 (9%)epigastric hernia repair 0 0 5/9 (56%) 16/19 (84%)PROCTOLOGY 203 198/581 (34) 318/646 (49%) 319/590 (54%)int. sphincterotomy, fissure 39/44 (89) 37/44 (84) 27/32 (84%) 33/36 (92%)Longo haemorhoidectomy 31/43 (72) 37/48 (77) 49/50 (98%) 65/67 (97%)Milligan haemorrhoidec. 2/22 (9) 2/8 (25) 15/21 (71%) 13/17 (76%)excision 1 haem. plexus 11/17 (65) 12/18 (67) 12/20 (60%) 12/21 (57%)skin tags excision 6/7 (86) 21/25 (84) 12/12 (100%) 14/14 (100%)anal condylomata (laser) 7/8 (88) 0/2 2/2 (100%) 1/1 (100%)fistulotomy 21/40 (53) 24/38 (63) 36/59 (61%) 29/42 (69%)fistulectomy or seton 16/35 (46) 6/41 (15) 18/32 (56%) 14/23 (61%)fistula plug 0 0 11/11 (100%) 7/7 (100%)excision pilonidal sinus 27/35 (77) 24/35 (69) 33/46 (71%) 32/54 (59%)anal/anastomotic dilatation 10/14 (71) 14/26 (54) 21/44 (48%) 12/25 (48%)proctoscopy 4/41 (10) 7/52 (13) 14/42 (33%) 15/38 (39%)proctoscopy < 8 yr. 0 4/25 (16) 4/22 (18%) 2/17 (12%)pouchoscopy 7/117 (6) 3/133 (2) 13/90 (14%) 2/36 (6%)perianal abscess drainage 13/44 (30) 2/41 (5) 7/39 (18%) 8/61 (13%)ischiorect. abscess 0 4/27 (15) 1/14 (7%) 0/10 (0%)Altemeier (prolapse exc.) 1/6 (17) 1/7 (14) 1/7 (14%) 3/10 (30%)

33repair rectovag fistula or raf 3/28 (11) 0 2/17 (12%) 3/18 (17%)coagulation of polyps 2/2 (100) 0 5/5 (100%) 2/2 (100%)transanal resection/suture 3/7 (43) 0/11 3/11 (27%) 0/7 (0%)examin. UN, wound care 23/41 (56%) 26/35 (74%)transanast. drainage 1/19 (5%) 3/20 (15%)pacemaker (change,SNS) 7/9 (78%) 21/25 (84%)AMS correction 0 0/2 (0%)PTQ injection 1/1 (100%) 2/2 (100%)BILIARY SURGERY 43 39/396 (10) 156/376 (41%) 142/339 (42%)lap cholecystectomy 40/276 (14) 39/283 (14) 73/150 (49%) 81/154 (53%)lap cholecystectomy + rx 3/91 (3) 0/113 83/226 (37%) 61/185 (33%)MISCELLANEOUS 13 9 27/569 (5%) 29/567 (5%)explor. laparoscopy 9/53 (17) 5/53 (10) 14/110 (13%) 8/83 (10%)lap. appendicectomy 0 2/310 11/374 (3%) 18/401 (4%)lap adhesiolysis 4/42 (10) 2/17 (12) 2/30 (7%) 3/24 (13%)ileo/colo/gastrostomy 0/55 (0%) 0/59 (0%)549/1774 (31) 684 982 967

34ONCOLOGICAL SURGERYIn 2006 and 2007, 864 and 792 procedures were performed for cancer, respectively. Thismeans that 792/2880 abdominal procedures (excl. non-laparotomies, in particular allprocedures for anal and abdominal wall pathology, but not e.g. laparoscopicappendicectomies or cholecystectomies) = 27.5 % of all laparotomies/laparoscopieswere performed for tumours.This is an increase with 5 % compared with the 26.4 % reported for the year 2002.Per resected organ system, tumours can be summarised as follows (KULAS data):2001 2002 2006 2007OrganresectedN procedures N procedures N procedures N proceduresColon &Rectum261 275 313 285Peritoneum ? ? 26 19Liver 60 66 152 124Pancreas 59 63 76 93Stomach 40 28 52 33Abd. wall,nodes, Smallbowel,Spleen,Miscellaneous30 25Non-resective procedures for cancer (e.g. intestinal bypass, stoma construction, staging,etc): 213 procedures in 2007.The number and percentage of procedures for cancer performed by laparoscopicapproach further increased in 2007 to 26.2 % (208/792).. In 2002 115 / 618 (18.6 %)surgical procedures for cancer were performed laparoscopically, and 87 / 556 (15.6 %) in2001.

35Type of surgery for rectal cancerAs in previous years, we tried to limit the rate of abdominoperineal rectum excision(APER). In 2007, it further decreased to 9 % of patients that underwent a radicalresection (excl. local excision) for rectal cancer, an excellent performance.Also, an increasing number of pelvic exenterations were performed, mainly posterior.The types of surgical procedures for rectal cancer were as follows:Type of procedure 2001 2002 2006 2007APER 22 (18%) 20 (16%) 19 (12%) 15 (9%)Hartmann ± exenterationExenteration posteriorExenteration anteriorLow anterior resection 60 5843362109573Pouch reconstruction * 40 50 68 57Local excision 2 9 6 6Global 124 137 165 175* Pouch reconstruction includes colon J pouch, coloplasty and side-to-end colo-anal anastomsis.Stoma careStoma care is provided by Vanden Bosch A, a very dedicated stoma nurse, who takes careof in- and out-patients with an ileo-, colo- or appendicostomy. At the Friday afternoon outpatientclinic she is supervised by Dr. D’Hoore A.2006 2007N of out-patients 199 277N of hospit. patients 86 95Less than 10% of these patients (8% or 22 patients in 2006 and 5% or 18 patients in 2007)were consulting because of stoma complications requiring surgical correction.

36COST MEASUREMENT AND CONTAINMENTThe expenses related to specific, mainly disposable, materials for laparoscopic and opensurgical procedures with the use of viscerosynthesis is well known. Although from asocietal view the expenses of laparoscopic surgery are compensated by faster recovery andearlier return to work, they must be taken into account from the point of view of hospitalmanagement. Not only routine procedures, but also more advanced surgical procedures arebeing performed laparoscopically, using more and more sophisticated and/or expensivematerials.Therefore, it is of interest to monitor, i.e. know, the costs of materials used per procedure.Such data eventually will contribute to the discussions about better, more appropriate,specific reimbursement.In collaboration with the nursing staff of the opering theatres in UZ GHB (OK 1 andambulatory surgery) and Mrs Plessers Lilly a program has been implemented since 2006(after pilot studies) in order to continuously monitor the cost of materials used in all typesof surgery, not only laparoscopic surgery.The following table represents a list of procedures for which a loss/procedure wasobserved. Procedures were ranked according to their respective number in 2006.The remuneration (income) is the sum of B2 (fixed price intended to cover hospitalisationrelatedcosts) and FF mat (fixed price intended to cover the costs related toviscerosynthesis and/or laparoscopic material). The cost column is the sum of expensesrelated to viscerosynthesis or laparoscopic materials (vs) as monitored per case by thenusing staff in the operating theatres and the cost of other expenses (e.g. clothing, sutures,antiseptic, anaesthesiology related material) represented in the ‘nt vs’ column. Data for2006 and a sample of 2007 are presented in order to document the evolution.It is remarkable that the cost for hospitalisation-related expenses are not covered by theactual fixed prices for many procedures. The Technical Council Implants will have tobe informed with appropriate data in order to adapt the fixed prices.

37Table. Income and costs for selected procedures with a loss/procedure.200601-200612 200701-200709PROCEDURE income B2FFmatN cost nt-vs vsloss/procNcostntvsvsloss/proclap append 270 79 191 216 508 79 429 -238 179 449 70 377 -179lap uni inguinal 459 79 380 170 427 71 350 32 90 446 64 388 13open uni inguinal 63 63 0 103 200 166 27 -137 46 126 104 15 -63bilat lap inguinal 368 95 273 56 498 72 421 -130 51 529 65 476 -161expl laparoscopy 63 63 0 55 400 143 260 -337 34 445 192 256 -382(open) re hemicolectomy 158 158 0 39 335 237 95 -177 14 453 262 134 -295lap common bile duct exploration 95 95 0 37 521 114 393 -426 22 365 108 257 -270segmental small bowel resection 132 132 0 35 289 77 119 -157 31 315 199 128 -183low anteriorresection (tme) 689 158 543 32 1260 215 719 -571 26 1156 259 830 -467duodeno-pancreatectomy + vs mat 351 252 100 25 1031 544 531 -680 25 1020 544 664 -669duodeno-pancreatectomy + vs mat 351 252 100 25 1031 544 531 -680 25 1020 544 664 -669duodeno-pancreatectomy 252 252 0 23 747 ? ? -495 23 772 ? ? -520duodeno-pancreatectomy 252 252 0 23 747 ? ? -495 23 772 ? ? -520hartmann + vs-mat 354 158 201 20 648 248 372 -294 12 686 226 468 -332hartmann 158 158 0 20 595 260 318 -437 13 636 242 395 -478expl laparotomy 63 63 0 15 320 253 69 30 248 210 40 -185lapsc total gastrectomy 2390 221 2218 13 2989 270 2683 -599 11 3266 262 3006 -876lap splenectomy 739 79 660 11 1596 139 1471 -857 3 1311 88 1292 -572segmental colectomy 158 158 0 8 330 206 24 -172 13 379 253 26 -221total gastrectomy 940 221 735 8 1010 288 728 -70 11 1268 341 958 -328lapsc subtotal gastrectomy 2390 221 2218 8 3339 285 3056 -949 3 4235 252 3984 -1845restorative proctocolectomy 1114 189 945 5 1060 284 833 54 6 1741 396 1314 -627lapsc gastric bypass 2390 221 2218 4 3294 206 2892 -904 3 3656 260 3398 -1266high anteriorresectie + vs mat 629 158 471 3 603 210 204 26 9 1029 246 681 -400These data highly depend on the adequacy of registration and should be interpretedwith caution. It has to be taken into account that materials appropriate for the plannedprocedure were recorded, what not necessarily corresponds to the type of procedurerecorded for tarification (done by the supervising surgeon and checked by the head of thedepartment for surgery in OK1). Thus, the loss for ‘open repair inguinal hernia’ can beexplained by the fact that a lap procedure was planned, while an open repair wasperformed (and recorded for tarification). The same applies for most ‘explorativelaparoscopies’ in which a planned resection was not performed. Also, an explorativelaparoscopy preceding an open duodenopancreatectomy is/was (can not be) accounted forwhen performed in the same operative session as the resective open procedure.The loss for laparoscopic bilateral inguinal hernia repair can not yet be explained; indeed,the same materials are used as in unilateral laparoscopic inguinal hernia repair (for which

38no loss is observed); it might be that some instruments (e.g. tacker) are more frequentlyused for bilateral repair.The loss for appendectomies can be explained by &) registration of a basic set with higherprice (there are several types of basic sets), 2) use of endo-staplers. The latter has recentlybeen solved because a specific remuneration for appendicectomy with partial cecalresection has been introduced in 2007. The supervising-surgeons have to indicate thisspecific procedure for tarification.A frequent reason for loss/procedure is the fact that supervising-surgeons wrongly indicate‘open’ instead of ‘open+viscero’ on the tarification form. This explains at least (animportant) part of the results for open right hemicolectomy, segmental small bowelresection and open Hartmann procedures. Correct indication of the type and nature ofsurgery performed by the supervising-surgeon is the solution.For several procedures, it seems that the fixed price for viscerosynthesis and/orlaparoscopy does and can not cover the costs of the disposable surgical materials to beused. This is the case for open high and low anterior resection, open Hartmann, open totalor partial gastrectomy, duodenopancreatectomy (Whipple or PPPD), laparoscopicsplenectomy, laparoscopic gastric bypass (for morbid obesity). The Technical CouncilImplants will have to be informed with appropriate data in order to adapt the fixedprices.Some procedures performed laparoscopically do not (yet) have official remuneration forthe (laparoscopic) material used. They are: explorative laparoscopy, laparoscopic commonbile duct exploration (incl. cholodochoscopy),Finally, an increasing part of loss/procedure can be explained by the progressive use ofmore and/or more expensive material (e.g. Ligasure, use of curved instead of straightcircular stapler when the latter is equally appropriate, …).

39In summary, costs can be contained more or less by- opening laparoscopy sets by the OT nurse only after arrival of and checking with thesurgeon- limitation of the number of expensive disposable matrials, mainly forhemostasis/dissection- more accurate registered of a procedure as ‘open+viscero’ when viscerosynthsismaterial was used during open surgery. A procedure that started laparascopically butwas converted, has to be recorded as ‘lap’- providing data and requesting more appropriate remuneration from the Techn CouncilImplants for several procedures.These results indicate the relevance of monitoring costs of materials used at individualsurgical procedures. They also illustrate the need for standardisation and adequateregistration (by nurses and surgeons). While cost containment must be possible for routineprocedures, it is much less applicable during the ‘implementation phase’ of more advancedprocedures.

40SEMINARSFebruary 27 th 2006 - Colorectale poliepen en vroegtijdig carcinoma19.00 u. InleidingDr. A. D’Hoore, U.Z. K.U.Leuven19.05 -19.20u. Pathologische definities.Prof. Dr. N. Ectors, U.Z. K.U.Leuven19.25 – 19.40u. Coloscopische detectieDr. R. Bisschops, U.Z. K.U.Leuven20.15 -20.30u. Endo-echografie ter stagingProf. Dr. M. Hiele, U.Z. K.U.Leuven20.35 – 20.50u. Coloscopische resectieProf. Dr. I. Demedts, U.Z. K.U.Leuven20.55 – 21.10u. Transanale lokale excisie (disc excision)Prof. Dr. F. Penninckx, U.Z. K.U.Leuven21.15 – 21.40u. Résection transanale par TEMS: aspects techniques et résultatsProf. Dr. A. Kartheuser, Diensthoofd Colorectale Heelkunde, U.C.L.21.45 – 22.00u. Pathologische evaluatie en rapporteringProf. Dr. N. Ectors, U.Z. K.U.Leuven22.05 – 22.15u. BesluitDr. A. D’Hoore, U.Z. K.U.LeuvenSeptember 1 st - 2 nd 2006 - Stage Commission Proctologie du CREGG,Club de Réflexion des cabinets de groupe d’hépato-gastro-entérologie enBelgiqueOrganisation: Dr. D’Hoore Andre et Prof. Dr. Penninckx Freddy (KULeuven), avec lacollaboration de Dr. Bruyninx Luc (ULg), Prof. Dr. Kartheuser Alex (UCL) et Prof. Vande Stadt Jean (ULB).Vendredi 1 septembre 20068.00 – 16.00 retransmission en direct d’interventions proctologiques (bloc opératoire dechirurgie ambulatoire OK II) avec discussion(s).Modérateurs: Dr Devulder – Prof. Kartheuser – Prof Van de Stadt – Prof BruyninxEntre les interventions il y aura possibilité de discuter des cas difficiles en proctologie.Evolution extraordinaire après hémorrhoidectomie. Prof. Dr Van de Stadt Jean, ULB,BruxellesDyschésie grave dans le cadre d'un syndrome de Curarino: présentation d'un cas difficile àgérer. Prof. Dr Kartheuser Alex, UCL, BruxellesProlapsus rectal total chez la personne âgée et à haut risque: rectosigmoidectomie par voiepérinéale? Prof. Dr Kartheuser Alex, UCL, Bruxelles

41Douleur périanale par hernie trans-releveur (470918v368): quelle approche? Prof. Dr.Penninckx FSamedi 2 septembre 20069.00 – 12.00 (avec interruption de 20 minutes)Résultats du traitement chirurgical par rectocolpopexie antérieure de la dyschézie dûe auprolapsus interne avec ou sans solitary rectal ulcer syndrome. Dr. D’Hoore ATraitement actuelle des fistules anales et vaginales dans la maladie de CrohnNon-chirurgical. Prof. Dr. Van Assche G (KULeuven)Chirurgical. Prof. Dr. Penninckx FDéveloppements récents dans le traitement de la ‘constipation habituelle’. Prof. Dr.Penninckx FLésions perianales rares. Dr. D’Hoore (KULeuven)Traitement de préservation sphinctérienne des fistules complexes. Dr Abramawitz LaurentLes suites difficiles du traitement chirurgical d’un prolapsus du rectum. Dr Tarrerias AnneLaureDyschesie en rapport avec rectocele et prolapsus associée à une incontinence anale. DrQueralto MichelLe problème des fissures anales chroniques récidivantes malgré une sphinctérotomieinterne. Dr. Bruyninx Luc, ULg, LiègeDouleur anale chronique: mise au point et possibilités thérapeutiques. Dr. Bruyninx Luc,ULg, Liège

43November 27th 2006 - Evaluatie en behandeling van dyschezie en‘prolaps’-syndromen19u00 :19u15 :Inleiding: aanpak van dyschezieproblemenProf. Dr. F. Penninckx, U.Z. LeuvenRadiologische evaluatieDr. D. Vanbeckevoort, Radiologie, U.Z. Leuven20u15 : Animus? Evaluatie en therapieDr. M. Van Outryve, Maag-Darmziekten, U.Z. Antwerpen20u30 : Actual surgical approaches for obstructed defaecationProf. Dr. P. Boccasanta, 1st Dept. of General Surgery, OspedaleMaggiore di Milano, I.R.C.C.S. University of Milan, Italy.21.10 : Laparoscopische behandeling bij complexe rectocoeleDr. A. D’Hoore, Abdominale Heelkunde, U.Z. LeuvenJanuary 29th 2007 - Cholelithiasis: een “banale” aandoening ?19u00: Inleiding: cholecystolithiasis in BelgiëR. Aerts19u15: Cholecystectomie via dagverblijf: kost efficiëntie en effectop bedcapaciteitG. Peeters, Federaal Kenniscentrum voor de Gezondheidszorg20u15: Timing van heelkunde voor verwikkelde cholecystolithiasisG. Sergeant20u30: Cholecystolithiasis en galblaascarcinoomT. Hendickx20u45: Galwegtrauma: incidentie en behandelingR.Aerts21u00: Choledocholithiasis; is er nog plaats voor ERCP ?B.Topal21u15: Discussie

44November 8 th – 9 th 2007. Grey Turner Club meeting Leuven, UniversityClinic GasthuisbergThursday 8th NovemberSession 1 Live transmission colorectal surgery A. D'Hoore08.30-10.00About Grey TurnerHepatic metastasectomy and the role ofchemotherapyA. Botha President of the GreyTurner Club (London)R. Aerts (standby)Session 2 Live transmission colorectal surgery A. D'Hoore10.30-12.30Abdominal complications after aortic surgerySurgery for acute severe colitisFunction and quality of life after ileoanal pouchsurgeryD. Moore (Dublin)B. George (Oxford)A Shorthouse (Sheffield)(standby)Session 3 Live transmission laparoscopic surgery A. D'Hoore14.00-16.00Modern management of Boerhaave's syndromeMinimally invasive oesophagectomyStents in the upper GI tractCommon bile duct stones: a (second) chance forsurgery?N. Maynard (Oxford)T. Dehn (Reading)I. Paterson (Frimley Park,Surrey)B. TopalFriday 9th NovemberSession 4 Live transmission HPB and/or gastric surgery R. Aerts, B. Topal08.30-10.00New surgical techniques for rectal prolapsesyndromesUnderstanding Treitz's muscle; the key to asuccessful coloproctologistA. D'HooreS. Brown (Sheffield)Session 5 Live transmission HPB and/or gastric surgery R. Aerts, B. Topal10.30-12.30Diabetes mellitus and morbid obesity (surgery).Implications of the Tooke ReportEvaluation of candidate TME-trainers in thecontext of a national project on rectal cancerM. Lannoo (standby)C. Russell (London)F. PenninckxIt has been an honour for the department to welcome, some years after the ‘SurgicalTravellers’, 15 members (i.e. about half of the membership) of the exclusive Grey TurnerClub, founded in 1951.

45RESEARCHPublicationsIn 2007 D’Hoore A. defended and published his PhD thesis on “New surgical techniques tocorrect rectal prolapse syndromes”.In 2007, the staff members of the department published 27 original articles, a recordnumber per year, as well as 3 letters to the editor, 2 chapters in textbooks, and 1report (updated PROCARE guidelines for the treatment of rectal cancer).Twelve of the 27 original papers were written by staff members from the department, and11 of them were published in an international peer-reviewed journal.From 1995 – 2007, the staff members of the department published 213 papers in themedical literature, cited in Medline/PubMed. The distribution over the years and the typeof publications were as follows:YearsN of papersInitiative takingdepartmentType of publicationN ofpapers1995 71996 10 KULAS national 261997 12 international 631998 181999 13 Other departm. national 162000 17 international 1112001 162002 182003 152004 212005 172006 192007 30TOTAL 213

46Thus, the department Abdominal Surgery took the initiative in 41 % of the papers. Not badat all for professionally fully active surgeons !The stafmembers of the department are very grateful to their colleagues from otherdepartments for providing co-authorship to them. They feel confident, however, to havecontributed significantly to the material and content of these papers.The topics of the publications concern the following fields of clinical or experimentalresearch:Subject of public.N of paperscancer 70IBD 22HPB, transpl, lap 57pelvic floor andanorect. pathophys.17miscell. 50

4811: van Koperen PJ, D'Hoore A, Wolthuis AM, Bemelman WA, Slors JF. Anal fistula plug forclosure of difficult anorectal fistula: a prospective study.Dis Colon Rectum. 2007 Dec;50(12):2168-72.12: Topal B, Leys E, Ectors N, Aerts R, Penninckx F. Determinants of complications and adequacyof surgical resection in laparoscopic versus open total gastrectomy for adenocarcinoma.Surg Endosc. 2007 Aug 10; [Epub ahead of print]13: Langouche L, Vander Perre S, Wouters PJ, D'Hoore A, Hansen TK, Van den Berghe G. Effectof intensive insulin therapy on insulin sensitivity in the critically ill.J Clin Endocrinol Metab. 2007 Oct;92(10):3890-7. Epub 2007 Jul 31.14: Topal B, Van de Sande S, Fieuws S, Penninckx F. Effect of centralization ofpancreaticoduodenectomy on nationwide hospital mortality and length of stay.Br J Surg. 2007 Nov;94(11):1377-81.15: Monbaliu D, Van Gelder F, Troisi R, de Hemptinne B, Lerut J, Reding R, de Ville de Goyet J,Detry O, De Roover A, Honore P, Donckier V, Gelin M, Ysebaert D, Aerts R, Coosemans W,Pirenne J. Liver transplantation using non-heart-beating donors: Belgian experience.Transplant Proc. 2007 Jun;39(5):1481-4.16: Devreese A, Staes F, Janssens L, Penninckx F, Vereecken R, De Weerdt W. Incontinentwomen have altered pelvic floor muscle contraction patterns.J Urol. 2007 Aug;178(2):558-62. Epub 2007 Jun 14.17: Topal B, Aerts R, Penninckx F. Laparoscopic intrahepatic Glissonian approach for righthepatectomy is safe, simple, and reproducible.Surg Endosc. 2007 Nov;21(11):2111. Epub 2007 May 4.18: Farroni N, Van den Bosch A, Haustermans K, Van Cutsem E, Moons P, D'hoore A, PenninckxF. Perineal colostomy with appendicostomy as an alternative for an abdominalcolostomy:symptoms, functional status, quality of life, and perceived health.Dis Colon Rectum. 2007 Jun;50(6):817-24.19: Fevery J, Verslype C, Lai G, Aerts R, Van Steenbergen W. Incidence, diagnosis, and therapyof cholangiocarcinoma in patients with primary sclerosing cholangitis.Dig Dis Sci. 2007 Nov;52(11):3123-35. Epub 2007 Apr 12.20: Topal B, Hompes D, Aerts R, Fieuws S, Thijs M, Penninckx F. Morbidity and mortality oflaparoscopic vs. open radiofrequency ablation for hepatic malignancies.Eur J Surg Oncol. 2007 Jun;33(5):603-7. Epub 2007 Apr 6.21: Naulaers G, Meyns B, Miserez M, Leunens V, Van Huffel S, Casaer P, Weindling M,Devlieger H. Use of tissue oxygenation index and fractional tissue oxygen extraction as noninvasiveparameters for cerebral oxygenation. A validation study in piglets.Neonatology. 2007;92(2):120-6. Epub 2007 Mar 23.22: Katoonizadeh A, Decaestecker J, Wilmer A, Aerts R, Verslype C, Vansteenbergen W, Yap P,Fevery J, Roskams T, Pirenne J, Nevens F. MELD score to predict outcome in adult patients withnon-acetaminophen-induced acute liver failure.Liver Int. 2007 Apr;27(3):329-34.

4923: Miserez M, Alexandre JH, Campanelli G, Corcione F, Cuccurullo D, Pascual MH, HoeferlinA, Kingsnorth AN, Mandala V, Palot JP, Schumpelick V, Simmermacher RK, Stoppa R, FlamentJB. The European hernia society groin hernia classification: simple and easy to remember.Hernia. 2007 Apr;11(2):113-6. Epub 2007 Mar 13. Review.24: Topal B, Peeters G, Verbert A, Penninckx F. Outpatient laparoscopic cholecystectomy: clinicalpathway implementation is efficient and cost effective and increases hospital bed capacity.Surg Endosc. 2007 Jul;21(7):1142-6. Epub 2007 Jan 20.25: Ret Dávalos ML, De Cicco C, D'Hoore A, De Decker B, Koninckx PR. Outcome after rectumor sigmoid resection: a review for gynecologists.J Minim Invasive Gynecol. 2007 Jan-Feb;14(1):33-8. Review.26: Topal B, Aerts R, Hendrickx T, Fieuws S, Penninckx F. Determinants of complications inpancreaticoduodenectomy.Eur J Surg Oncol. 2007 May;33(4):488-92. Epub 2006 Dec 4.27: Hompes D, Aerts R, Penninckx F, Topal B. Laparoscopic liver resection using radiofrequencycoagulation.Surg Endosc. 2007 Feb;21(2):175-80. Epub 2006 Nov 21.28: Freson K, Stolarz K, Aerts R, Brand E, Brand-Herrmann SM, Kawecka-Jaszcz K, KuznetsovaT, Tikhonoff V, Thijs L, Vermylen J, Staessen JA, Van Geet C, for the European Project on Genesin Hypertension Investigators. -391 °C to G substitution in the regulator of G-protein signalling-2promoter increases susceptibility to the metabolic syndrome in white European men: consistencybetween molecular and epidemiological studies.J Hypertens 2007; 25: 117-125.29: Koninckx PR, Ret Davalos ML, De Cicco C, De Decker B, D’Hoore A. Response.J Minim Invasive Gynecol 2007; 14(4): 530.30: Eyben A, Aerts R, Verslype CYoung female with pancreaticobiliary maljunction presenting with acute pancreatitis: a case reportand review of the literatureActa Gastro-Enterologica Belgica 2007; 70: 363-366BOOK CHAPTERSMiserez M, Tomczyk K, Penninckx F. The local patch. In: Recurrent Hernia: Prevention andTreatment by Schumpelick V. and Fitzgibbons R.J. Chapter VII: How to treat the recurrentincisional hernia p. 226-233. 2007: Springer ISBN 978-3-540-37545-6DD’Hoore A, Penninckx F. Laparoscopic ventral rectocolpopexy for complex rectogenital prolapseChapter 19: 2007; 145-152. In: Rectal Prolapse – Diagnosis and Clinical Management by D.F.Altomare, F. Pucciani – 2007. ISBN 978-88-470-0683-6. SpringerREPORT (Guidelines)Penninckx F, Roels S, Leonard D, Laurent S, Decaestecker J, De Vleeschouwer C, Haustermans K,Ectors N, Peeters M, Van Cutsem E, Danse E, De Coninck D, Van Eycken E, Vlayen J. UpdatedPROCARE guidelines for the treatment of rectal cancer. In “Kwaliteit van rectale kankerzorg –

50Fase I – Een praktijkrichtlijn voor rectale kanker. KCE reports 69A.http://kce.fgov.be/index_nl.aspx?SGREF=8948&CREF=10459Publications in 20061: Fa-Si-Oen P, van de Gender P, Putter H, Ectors N, D'Hoore A, Topal B, Penninckx F. The effectof polyethylene glycol and butyrate on anastomotic healing in the rat colon.Tech Coloproctol. 2006 Dec;10(4):308-11. Epub 2006 Nov 27.2: Cassiman D, Roelants M, Vandenplas G, Van der Merwe SW, Mertens A, Libbrecht L,Verslype C, Fevery J, Aerts R, Pirenne J, Muls E, Nevens F. Orlistat treatment is safe inoverweight and obese liver transplant recipients: a prospective, open label trial.Transpl Int. 2006 Dec;19(12):1000-5.3: Ferrante M, Penninckx F, De Hertogh G, Geboes K, D'Hoore A, Noman M, Vermeire S,Rutgeerts P, Van Assche G. Protein-losing enteropathy in Crohn's disease.Acta Gastroenterol Belg. 2006 Oct-Dec;69(4):384-9.4: Mertens J, Penninckx F, DeWever I, Topal B. Long-term outcome after surgical treatment ofnonparasitic splenic cysts.Surg Endosc. 2007 Feb;21(2):206-8. Epub 2006 Nov 23.5: D'Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgicaltechnique and outcome for 109 patients.Surg Endosc. 2006 Oct 9; [Epub ahead of print]6: Robijn J, Sebrechts E, Miserez M. Management of incidentally found Meckel's diverticulum anew approach: resection based on a Risk Score.Acta Chir Belg. 2006 Jul-Aug;106(4):467-70.7: Stas P, D'Hoore A, Van Assche G, Geboes K, Steenkiste E, Penninckx F, Rutgeerts P, VermeireS. Miliary tuberculosis following infliximab therapy for Crohn disease: A case report and reviewof the literature.Acta Gastroenterol Belg. 2006 Apr-Jun;69(2):217-20. Review.8: Pirenne J, Hoffman I, Miserez M, Coosemans W, Aerts R, Monbaliu D, Ferdinande P, Hiele M,Van Assche G, Rutgeerts P, Janssens J, Tack J, Vlasselaers D, Desmet L, Nevens F, Veereman G,Fevery J, Lombaerts R. Selection criteria and outcome of patients referred to intestinaltransplantation: an European center experience.Transplant Proc. 2006 Jul-Aug;38(6):1671-2.9: Durnez A, Verslype C, Nevens F, Fevery J, Aerts R, Pirenne J, Lesaffre E, Libbrecht L, DesmetV, Roskams T. The clinicopathological and prognostic relevance of cytokeratin 7 and 19expression in hepatocellular carcinoma. A possible progenitor cell origin.Histopathology. 2006 Aug;49(2):138-51.10: Penninckx F, Van Eycken L, Michiels G, Mertens R, Bertrand C, De Coninck D, HaustermansK, Jouret A, Kartheuser A, Tinton N; PROCARE working group. Survival of rectal cancer patientsin Belgium 1997-98 and the potential benefit of a national project.Acta Chir Belg. 2006 Mar-Apr;106(2):149-57.

5111: Roels S, Duthoy W, Haustermans K, Penninckx F, Vandecaveye V, Boterberg T, De Neve W.Definition and delineation of the clinical target volume for rectal cancer.Int J Radiat Oncol Biol Phys. 2006 Jul 15;65(4):1129-42. Epub 2006 Jun 5.12: Brannigan AE, De Buck S, Suetens P, Penninckx F, D'Hoore A. Intracorporeal rectal staplingfollowing laparoscopic total mesorectal excision: overcoming a challenge.Surg Endosc. 2006 Jun;20(6):952-5. Epub 2006 May 12.13: Ferrante M, de Hertogh G, Hlavaty T, D'Haens G, Penninckx F, D'Hoore A, Vermeire S,Rutgeerts P, Geboes K, van Assche G. The value of myenteric plexitis to predict earlypostoperative Crohn's disease recurrence.Gastroenterology. 2006 May;130(6):1595-606.14: Van Gelder F, Van Hees D, de Roey J, Monbaliu D, Aerts R, Coosemans W, Daenen W,Pirenne J. Implementation of an intervention plan designed to optimize donor referral in a donorhospital network.Prog Transplant. 2006 Mar;16(1):46-51.15: Goethals L, Debucquoy A, Perneel C, Geboes K, Ectors N, De Schutter H, Penninckx F,McBride WH, Begg AC, Haustermans KM. Hypoxia in human colorectal adenocarcinoma:comparison between extrinsic and potential intrinsic hypoxia markers.Int J Radiat Oncol Biol Phys. 2006 May 1;65(1):246-54.16: Penninckx F, Danse E; PROCARE Workgroup. On the role of radiologists in the BelgianPROject on CAncer of the REctum, PROCARE.JBR-BTR. 2006 Jan-Feb;89(1):19-22.17: Delaere P, Hierner R, Goeleven A, D'Hoore A. Reconstruction for postcricoid pharyngealstenosis after organ preservationprotocols.Laryngoscope. 2006 Mar;116(3):502-4. No abstract available.18: Driessen A, Landuyt W, Pastorekova S, Moons J, Goethals L, Haustermans K, Nafteux P,Penninckx F, Geboes K, Lerut T, Ectors N. Expression of carbonic anhydrase IX (CA IX), ahypoxia-related protein, rather than vascular-endothelial growth factor (VEGF), a pro-angiogenicfactor, correlates with an extremely poor prognosis in esophageal and gastric adenocarcinomas.Ann Surg. 2006 Mar;243(3):334-40.19: Dyckmans K, Lerut E, Gillard P, Lannoo M, Ectors N, Hoorens A, Mathieu C, Coosemans W,Vanrenterghem Y, Kuypers D. Post-transplant lymphoma of the pancreatic allograft in a kidneypancreastransplant recipiënt: a misleading presentation – case report.Nephrol Dial Transplant 2006; 21: 3306-3310.20: Topal B. PENTALFA: Multidisciplinair management van het maagcarcinoom: heelkundigestagering en behandeling.Tijdschr voor Geneeskunde 2006; 62(19): 1387-1392.21: Goegebuer A, Pirenne J, Aerts R, Nevens F. Levertransplantatie via levende donatie bijvolwassenen : een literatuuroverzicht.Tijdschr voor Geneeskunde 2006; 62(5): 368-374.22: Mispelaere B, Ferrante M, Aerts R, Op De Beeck K, Vanbeckevoort D, Libbrecht L, RoskamsT, Van Steenbergen W, Verslype C. Een jonge man met dyspepsie en icterus.

52Tijdschr voor Geneeskunde 2006; 62(5): 390-398.23: Budiharto T, Haustermans K, Topal B, Van Cutsem E. (Neo)adjuvante behandeling bij hetmaagcarcinoom.Tijdschr voor Geneeskunde 2006; 62(19): 1393-1401

53Oral presentations at national or international scientific meetings,excluding locoregional seminars (cfr), industry-sponsored workshops and ‘consensusmeetings’ (data of Aerts R not included).2007 Speaker Title Meeting PlaceJanuary8 D'Hoore A11 Topal B13 Penninckx F24 Topal BInvited lecture: Laparoscopiccolorectal surgeryMultidisciplinair managementvan het peri-ampullair carcinomaRectum cancer: the PROCAREprojectCommon bile duct stones:surgical managementHands-on course forlaparoscopic colorectalsurgeryPentalfaBGDO 4th scientific meetingVVGEHelsinki(Finland)LeuvenGrimbergenTurnhoutFebruary1 D'Hoore AInvited lectures - Laparoscopichemicolectomy - Laparoscopictreatment of rectal prolapse5 th Colorectal DayAarhus(Denmark)16 Topal B IRCAD StrasbourgMiserez MLaparoscopic incisional herniarepair: How i do itLaparoscopic incisional herniarepair: Results andComplicationsAdvanced Workshop onLaparoscopic Ventral HerniaRepairArahova(Greece)March4 - 6 D'Hoore AInvited lecture -Recto(vagino)pexie: goederesultaten met de unilateralevoorste benaderingBekkenbodemproblematiek inonderling verband. NVECLustrumcongres Back to thefutureLeeuwarden (NL)7 D'Hoore AInvited lecture: Laparoscopicventral rectopexy for rectalprolapseNational meeting Novwegianthoraco-laparoscopicassociationOslo(Norway)9 - 11 D'Hoore AInvited lectures:- Laparoscopicventral rectopexy for rectalprolapse - Anal fistulae –excision, seton, or plugColorectal Surgery atKarolinska Institutet 2007Stockholm(Sweden)April26-27 D'Hoore AMiserez MWarm-up package – 4th EditionTraining in laparoscopyLaparoscopic ventral andincisional hernia repairInteractive workshop inlaparoscopy BGES"Warm-up Package" 4thEdition, Strasbourg,FranceStrasbourgStrasbourg

54May2 - 5 D'Hoore ALimberg flap in the treatment ofpilonidal sinus (Session: How Ido it) - Laparoscopic surgery forrectal cancer. Indications andresults (Session BGES) -Proctology: surgical techniquesin one day setting - Anal fisutalrepair, surgical technique andresearch (Session: BelgianAssociation for AmbulatorySurgeryBelgian Surgical WeekOstend2 - 5 Topal BLaparoscopic hepatic resection:Indications and results - Surgicaltreatment of common bile ductstonesBelgian Surgical WeekOstend2 - 5 Miserez MBelaps teaching day;Hirschsprung's Disease -CookSatellite Symposium:Ventral Hernia experience withSurgisis Gold, update of LAPSIStria-Belgian Surgical WeekOstend21-22 D'Hoore AInvited lectures: Laparoscopy forcolorectal malignancies. Patientselection for laparoscopicprocedures - Laparoscopic righthemicolectomy (live operation)2 nd Advances Course onColorectal SurgeryErlangen(D)23-24 Topal BInvited demos: Laparoscopictotal gastrectomy for cancer -Laparoscopic right hepatectomyfor liver neoplasmLive surgery transmissionsurgeryDundeeCuschieriCentre(UK)Miserez MCook Satellite Symposium:The LAPSIS trialDeutsche Gesellschaft fürChirurgieMunichMiserez MThe future of laparoscopicinguinal hernia repair29th International Conferenceof the European HerniaSociety,AthensJune8 - 9 Topal BGrowing influence oflaparoscopy on the managementof patients with liver tumours -Radiofrequency ablation ofhepatic malignancies:laparoscopy or laparotomy? -Patterns of failure followingcurative resection of pancreaticadenocarcinomaEHPBAVerona (I)

5527-30 D'Hoore AMiserez MInvited lectures: - Is sphincterpreservation the goal? - Is localresection adequate for smalltumors?Laparoscopic ventral andincisional hernia repair9th World Congress onGastroIntestinal CancerXXIth Congress of HungarianExperimental Surgery,Barcelona(Spain)Pecs(Hungary)JulyAugust31/8-1/9 Penninckx FInvited lecture: Réparationsphinctérienne secondaireJournées de la Commission deProctologie du CREGGDivonneles-Bains(Fr)September26-29 D'Hoore AInvited lecture: Laparoscopicventral rectopexy for rectalprolapseSecond Scientific and AnnualGeneral Meeting – EuropeanSociety of Coloproctology –ESCPMaltaPenninckx FCairman Premeeting course: coresubjects updateSecond Scientific and AnnualGeneral Meeting – EuropeanSociety of Coloproctology –ESCPMalta27-28 Topal BMiserez MLaparoscopic total gastrectomyfor cancer - Laparoscopic righthepatectomy for liver cancerHernies de l'aine: EuropeanGuidelinesLive surgery transmissionsurgeryMesh 2007Rome (I)ParisOctober13 Penninckx FInvited lecture: Avoidance ofabdominoperineal rectumexcision versus quality of lifeafter sphincter saving proceduresfor low rectal cancer18 Penninckx F Le projet PROCARE18-19 D'Hoore A20-28 Penninckx F23-24 D'Hoore A Sfincterrepair28-30 D'Hoore AStarters package – 8 th Edition –Laparoscopic colorectal surgeryInvited lecture: Laparoscopicsurgery for rectal cancerTME for rectal cancer:introduction, video - Splenicflexure mobilization - Righthemicolectomy for cancerBVRO/ABRO AutumnMeeting Conservative therapyin pelvic malignanciesRéunion Interdisciplinaire deGastro-entérologieInteractive workshop inlaparoscopy BGES78º Congreso Argentino deCirugíaCursus Praktischevaardigheden in deverloskunde VlaamseWerkgroep VerloskundeColorectal MasterClassKortrijkLiègeStrasbourgBuenosAires(Arg)ElewijtElancourt(Fr)

5627-31 D'Hoore AMiserez MMiserez MMiserez MInvited lectures: - Clinics ingastroenterology and hepatology1, IBD: clinical cases - Rectovaginalfixation procedures: theoptimal transabdominalprocedureThe use of collagen meshesin elective ventral hernia repair;the LAPSIS trialChronic post-herniorrhaphy pain:open vs. laparoscopic, a criticalreview*The use of collagen meshesin elective ventral hernia repair;the LAPSIS trial*The new EHS classification foringuinal hernia repair15 th United EuropeanGastroenterology WeekRotterdam InteractiveCongress on HerniaSymposium on open inguinalhernia treatment,II International Symposiumon Biomaterials in abdominalwall surgery: present andfutureParis (Fr)RotterdamElancourt(Fr)MadridNovember22-23 D'Hoore AInvited key note lecture: Intraoperativestrategies to guide IBDsurgery14 th Postgraduate NovemberSymposiumLinköping(Sweden)December7 D'Hoore A Anastomostic leak7 Penninckx F Insufficient bowel length13-14 D'Hoore AReconstruction after TME andsphincter saving rectal resections6th BSCRS Postgraduatecourse: Colorectal nightmares6th BSCRS Postgraduatecourse: Colorectal nightmares7th BGES Interactive Meetingin Laparoscopy: Basics for thefuture. Virtual live – advancedproceduresBrusselsBrusselsElancourt(Fr)2006 Speaker Title Meeting PlaceJanuary14 Penninckx FPROCARE presentation anddiscussionBGDO3rd scientificmeeting Clinicalchallenges in GI OncologyGrimbergenFebruary3 - 4 D'Hoore APenninckx FInvited lecture: Rectal prolapseand obstructive defecation:lessons from the surgeonInvited lecture: Rectocoele:perineal repairProgress in gynaecologicalendoscopy – 5thInternational MeetingProgress in gynaecologicalendoscopy – 5thInternational MeetingLeuvenLeuven

5717 D'Hoore AMiserez MMiserez MInvited lectures: Reconstructionafter total mesorectal excision andabdominoperineal resection -Optimizing success when treatingperianal Crohn’s diseaseHow to treat the recurrentincisional hernia laparoscopically:the local patchLaparoscopic treatment ofincisional hernia: how i do it.17th Annual InternationalColorectal DiseaseSymposium: aninternational exchange ofmedical and surgicalconcepts and endorectalultrasonography course4th Suvretta MeetingCorso di Aggiornamentoper nuove technicheoperativeFort Lauderdale(USA)St MoritzNaplesMarch15-16 D'Hoore A17-18 D'Hoore A25 D'Hoore A30 D'Hoore ADe ileale pouch voor colitisulcerosaInvited lectures: Laparoscopicmanagement in diverticulardisease - PNE and SNS: aneducational videoPerianale aandoeningen vaninflammatoir darmlijdenHeelkundige aanpak van acute enchronische verwikkelingen vanbariatrische heelkundeCursorisch onderwijs inmaag-darm-leverziektenCardiff Six Nations, GI-MasterclassLentesymposium VlaamseVereniging voorGastroenterologiePENTALFA:Complicaties van obesitaschirurgieVeldhoven (NL)Cardiff (UK)GenkLeuvenApril22 Topal BMiserez MInvited lecture: Laparoscopicliver surgeryEndoscopic surgical skills labs:what have we learned? - Theideal training package forsurgeons and gynaecologists?19th European Congressof Obstetrics andGynaecologyCuraçaoTorinoMay18-19 D'Hoore A Colorectal MasterClass Elancort (Fr)Miserez M29-30 D'Hoore ACook Satellite Symposium:New advances in ventral herniarepairInvited lectures: Laparoscopicsurgery for colonic and rectalcancer – what is the evidence? -Laparoscopic assisted colonicresectionDeutsche Gesellschaft fürChirurgieInternational Symposiumand Workshop: Advancedcourse in colorectalsurgeryBerlinErlangen (D)June15-16 D'Hoore AMasterClass in Gastric Bypass –Pig LabBGES-SOSB-BAST-EESBruuge AZ StJan

5816 Miserez MMiserez MMasterClass in Gastric Bypass –Pig LabDiagnosis of hernia by imagingBGES-SOSB-BAST-EES3 rd International HerniaCongressCHT LeuvenBostonJuly5 Penninckx FInvited lecture: Perianal Crohn'sdiseaseACPGBINewcastle (UK)August31/8 - 1/9 D'Hoore AInvited lectures: Live surgery:Rectal prolapse - Laparoscopicanterior mesh rectopexy - Resultsof laparoscopic anterior meshrectopexy - Faecal incontinence:Panel discussion - Laparoscopicrectum operationsNordic postgraduatecourse in pelvic floordisordersJyväskyläi,FinlandSeptember13-16 D'Hoore A13-16 Penninckx F30 Topal BMiserez MInvited lecture: Live demo:Laparoscopic colon resectionInvited lecture: Surgery forconstipationPostoperative care of patients andmanagement of complicationsafter liver resectionMesh biology - Laparoscopicincisional hernia repair: How i doitFirst Scientific and AnnualGeneral Meeting ESCPFirst Scientific and AnnualGeneral Meeting ESCPBSHBPS2nd Geneva SurgicalExpert daysLisboa(Portugal)Lisboa(Portugal)BrusselsGenevaOctober7 D'Hoore A19-20 D'Hoore AMiserez M20-25 Penninckx F21 D'Hoore A22 D'Hoore AChirurgische aspecten van defamiliale polyposeIntroduction - Laparoscopiccolorectal surgery - colonLaparoscopic ventral andincisional hernia repairECCO Consensus on Ulcerativecolitis - Panel Clinic Acuteabdominal painLaparoscopische heelkunde bijcolorectal carcinomaInvited lecture: Laparoscopicresections for colorectal cancerFAPASeventh BAST/BGESStarters Package(interactive workshop inLaparoscopyStarters Package 7thEdition14th United EuropeanGastroenterology WeekOncologie Kempen 2006:Nieuwe trends in deoncologische behandeling14th United EuropeanGastroenterology WeekBrusselIRCAD/EITSStrasbourgStrasbourgBerlin (D)TurnhoutBerlin (D)November

592 - 3 D'Hoore A2 - 3 Penninckx FInvited lectures: Left sidedlaparoscopic colectomyInvited lecture:Radiochemotherapy versusradiotherapy as neoadjuvanttherapy for resectable rectalcancer10 D'Hoore A Laparoscopic ventral rectopexy23-25 D'Hoore AInvited lecture: Pelvic floor repair– the role of the colorectal surgeon24 D'Hoore A Theorie SfincterrepairMiserez MMiserez MThe pain issue in minimallyinvasive groin hernia repairLaparoscopic incisonal andventral hernia repairFourth update oncoloproctologyFourth update oncoloproctologyBGES Videocongress: 15years of laparoscopicsurgery: where are wenow?Annual meeting of theIrish Society ofGastroenterologyCursus: Praktischevaardigheden in deverloskunde – Vlaamsewerkgroep verloskundeRotterdam InteractiveCongress on HerniaThird Annual Conferenceof the British HerniaSocietyAmsterdam (NL)Amsterdam (NL)BrusselsDublin (IRL)DiegemRotterdamNottingham (UK)December8 Penninckx FMiserez MSurgical treatment for obstructiveCrohn's diseaseLichtenstein hernioplasty: how ido it -The use of SIS in electiveventral hernia repair -Imaging ofhernia and of the infected mesh5th BSCRS Postgraduatecourse: IBDUpdates on Hernia Repair,2nd Winter Meeting,BrusselsDelphi (Gr)

60Actual Research Grants (anno 2007)FWO + IWT: abdominal wall pathophysiology and repair (Miserez M).OOI project KULeuven (2005-2007): training in laparoscopic surgery (Miserez M).FWO + IWT: prognostic relevance of cancer cell dissemination and immunosuppression inpancreatic cancer (Topal B).KOF (clinical research fund) mandate for D’Hoore A (2004-2007) and Topal B (2007-2010).RIZIV: governmental support for PROCARE, a national multidisciplinary project on rectalcancer (Penninckx F, chairman of the Steering Group).

61Addendum: Strategic plan presented to the directors of the UZGasthuisberg on March 18 th 2008.Strategische doelstellingen 2008 - 20121. verbetering performantie2. verbetering profilering3. aanpassing bestaffingProblemenProject 1 - CapaciteitOK capaciteitHOS capaciteitwachtlijst, herplanning(en)Acties ABD AZ Diest ?ERAS info + implementatieActies anderen OK1 meer OK tijd structureelHOS // OK planningERAS + ‘vpl’ ondersteuningAZ Diest (?)Project ERAS (short track)Project 2 - Kwaliteitszorg10090807060% 50403020100Hospitalisatieduur KULAS 20011 2 3 4 5 6 7 8 9 10dagenkan alleen voor ‘routine’ ingrepenlap.assist. (N =90)open (N = 110)ProblemenActies ABDActies anderenPAZA → zaal ← ITE, zaal → Spdcontinuiteit stomazorg‘beperkte’ registratie QCIopvang functiestoornis na SSO+ med/vpl ondersteuningmedium care+ datanurse (QCI)Project 3 - Kwaliteitsproject ObesitasProject 4 - Nieuwe technologieën &ingrepenProblemenN ptn met overgewicht‘geen’ multidisc dienstverleningProblemenrectumresectie bij ypCRperinoneale carcinomatoseeinde mandaat IDWActies ABDActies anderenkwaliteitsprojectin UZ GHB + AZ DiestPhD planmultidisc bestaffing in UZ + AZActies ABDActies anderenverdere uitbouw HIPECsamenwerking met IDW…/…TEMS instrumentarium+ aanpassing bestaffing (cfr)…/…

62Project 5 - Inkomsten – UitgavenProject 6 - Vlaams ZHnetwerk KULeuvenProblemenniet toewijzen multidisc rdplnegatief saldo sommige ingr.Problemengeen interactieopleiding en toekomst ASO’sActies ABDafspraak/controle toewijzing rdplcorrecte registratie OKcontrole registratie OK verder‘sanering’ werkingskost/ingreepActies ABDbevragingASO ‘loopbaan planning’multicentrische VZHN studiesProject 7 - Wetenschappelijke profileringProject 8 - Werkbelasting Staf, ASO’s, VplProblementijdsgebrekN ‘eigen’ publicatiesProblemenextreme klinische werkbelastingActies ABDActies anderen+ 1 VTE laboranteprojecten (RCT’s)grantssamenwerking andere univ. centrasamenwerking in VZHNaanpassing med staf (cfr)Acties ABDActies anderen+1 VTE research study nurse ABDzaal/raadpl med/vpl medewerk(st)erondersteuning ERAS project (cfr)datanurse (kwaliteitsregistratie)ondersteuning obesitas project (cfr)aanpassing medische staf (cfr)Aanpassing medische staf ABD2008 – 2009 ML resident → SV/AKH2010 – 2011 X resident → SV/AKH (cfr ook IDW)2011 – 2012 + 1 VTE (FP emer.)