Long-term survival after perforated diverticulitis.

AIM: Short-term survival after emergency surgery for perforated diverticulitis is poor. Less is known about long-term survival. The aims of this study were to evaluate long-term survival after discharge from hospital and to identify factors associated with prognosis. METHOD: All patients who underwent emergency surgery for perforated diverticulitis in five hospitals in Rotterdam, the Netherlands, between 1990 and 2005, were included. The association between type of surgery (Hartmann's procedure or primary anastomosis) and long-term survival was analysed using multivariate Cox regression analysis, taking into account age American Society of Anesthesiology (ASA) classification, Hinchey score, Mannheim Peritonitis Index (MPI) and surgeon's experience. In addition, survival of the patients was compared with that of the matched general Dutch population. RESULTS: Of 340 patients included in the study, 250 were discharged alive from hospital. The overall 5-year survival was 53%. Survival was significantly impaired compared with the expected matched gender-, age- and calendar time-specific survival. Overall survival was significantly related to age and ASA classification. Hinchey score, MPI, number of re-interventions, the surgeon's experience and type of procedure did not influence long-term survival, although a trend was found for Hartmann's procedure to be a risk factor for poorer survival compared with primary anastomosis (hazard ratio for mortality: 1.88; 95% confidence interval, 0.96-3.67; P = 0.07). CONCLUSION: Long-term survival of patients after perforated diverticulitis is limited and mainly caused by the poor general condition of the patients, rather than by the severity of the primary disease or calendar-time and type of procedure.

Reversal of Hartmann's procedure after perforated diverticulitis through the stomal side without additional incisions: the SIR procedure.

AIMS: Reversal of Hartmann's procedure (HP) is a complex operation and only performed in 50-60% of the patients. Stomal incision reversal (SIR), a new minimally invasive procedure for HP reversal, was assessed and compared to the standard surgical approach. METHODS: 16 patients who had undergone HP for perforated diverticulitis underwent HP reversal by SIR. The only incision in SIR is the one to release the end colostomy. Intra-abdominal adhesiolysis is done manually. A stapled end-to-end colorectal anastomosis is created. The 16 patients who underwent SIR were compared with 32 control patients who were matched according to gender, age, American Society of Anesthesiologists (ASA) classification and Hinchey stage. RESULTS: The operation time was shorter after SIR than after reversal by laparotomy [75 min (58-208) vs. 141 min (85-276); p < 0.001]. Patients after SIR had a shorter hospital stay than patients after laparotomy [4 days (2-22) vs. 9 days (4-64); p < 0.001]. The numbers of total postoperative surgical complications (early and late) were not different (p = 0.13). The anastomotic leakage rate was similar in both groups (6%). The conversion rate in the SIR group was 19% (n = 3). CONCLUSION: SIR compared favorably with HP reversal by laparotomy in terms of operation time and hospital stay, without increasing the number of postoperative complications.

Easy cleaning of the scope's lens in a syringe to prevent condensation during laparoscopic surgery.

BACKGROUND: Condensation on the scope's lens resulting from differences between room temperature and intraabdominal temperature is a disturbing problem for laparoscopic surgeons. Anti lens condensation solutions prevent fogging in the intraabdominal environment but are troublesome to apply to the scope. METHODS: A simple method of cleaning the lens with a syringe is reported. RESULTS: The described procedure appears to be a very simple, cheap, and effective technique for preventing condensation on the scope lens. CONCLUSION: The use of a simple syringe can prevent bothersome condensation on the scope lens during laparoscopic surgery.

Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure?

OBJECTIVE: Hartmann's procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis. METHOD: All 158 patients who had survived emergency surgery for acute perforated diverticulitis in five teaching hospitals in The Netherlands between 1995 and 2005 and underwent HP or PA with DI were retrospectively studied. Age, gender, ASA-classification, severity of primary disease, delay of stoma reversal, surgeon's experience, surgical procedure and type of anastomosis were analysed in relation to outcome after stoma reversal. RESULTS: Of the 158 patients, 139 had undergone HP and 19 PA with DI. The reversal-rate was higher in patients with DI (14/19; 74%) compared to HP (63/139; 45%) (P = 0.027) Delay between primary surgery and stoma reversal was shorter after PA with DI compared with HP (3.9 vs 9.1 months; P < 0.001). Cumulative postreversal morbidity after HP was 44%. Early surgical complications occurred in 22 of 63 patients. Morbidity after DI reversal was 15% (P < 0.001). Three patients died after HP reversal, none died after DI reversal. Anastomotic leakage was observed in 10 patients after HP reversal. This was less frequently observed when the operation was performed by a specialist colorectal surgeon (10%vs 33%; P = 0.049) and when a stapled anastomosis was performed (4%vs 24%; P = 0.037). CONCLUSIONS: Reversal of HP should only be performed by an experienced colorectal surgeon, preferably performing a stapled anastomosis, or probably not be performed at all, as it is accompanied by high postoperative morbidity and even mortality. It is important that these findings are taken in account for when performing primary emergency surgery for acute perforated diverticulitis.

Proposal for a multidisciplinary approach to the patient with morbid obesity: the St. Franciscus Hospital morbid obesity program.

Morbid obesity is a serious disease as it is accompanied by substantial co-morbidity and mortality. The prevalence is increasing to an alarming extent, in Europe as well as in the United States. In the past few decades, bariatric surgery has developed and gained importance. It currently represents the only long-lasting therapy for this group of patients, resulting in an efficient reduction in body weight and obesity-related medical conditions, mostly cardiovascular in nature. The importance of a standardized protocol, the use of selection criteria, and a multidisciplinary approach have been stressed but not yet described in detail. Therefore, in this article, the multidisciplinary approach and the treatment protocol that have been applied in our hospital for more than 20 years are set out in a detailed manner. The application of a strict protocol may help to select and follow-up motivated patients and to organize multidisciplinary research activities.

[Diagnostic image (341). A man with left thoracic pain. Incarcerated diaphragmatic hernia of the transverse colon]. / Diagnose in beeld (34I). Een man met pijn in de linker thoraxhelft. Traumatische, geïncarcereerde hernia diapharagmatica.

A 28-year-old man with a previous (old) left thoracic stab wound, developed an incarcerated diaphragmatic hernia of the transverse colon which was repaired laparoscopically.

[Diagnostic image (289). A woman with the sensation that an internal air bubble comes up]. / Diagnose in beeld (289). Een vrouw met het gevoel dat bij haar een luchtbel naar boven komt.

A 35-year-old woman was analysed because she had the recurrent sensation of an internal air bubble coming up. She was suffering from a gastric leiomyoma in the cardia-fundus area, which was removed laparoscopically.

Technique for instant stapling of the sigmoid mesentery and mesorectum in laparoscopic colorectal surgery.

BACKGROUND: Dissection of the mesentery of the distal sigmoid or rectum before transection with a linear stapler in laparoscopic colorectal surgery is time consuming, can cause irritating bleeding, and can harm the vascularization of the distal part of the bowel anastomosis. METHODS: A new linear stapling technique in laparoscopic colorectal surgery is presented. This technique is used to perform transection of the distal sigmoid or proximal rectum with a linear stapler by instant stapling of both the mesentery/mesorectal fat and the intestine instead of standard preliminary dissection. This technique was performed in a pilot study of 27 laparoscopic colorectal operations for benign or malignant disease. RESULTS: In none of the 27 patients was leakage of the anastomosis observed. CONCLUSIONS: This new technique is safe and effective. It saves time, avoids troublesome dissection of the mesentery/mesorectum, which can cause bleeding or damage to the bowel, and preserves vascularization of the distal part of the anastomosis.

[Introduction of laparoscopic colorectal surgery in the Sint Franciscus Gasthuis, Rotterdam, 2002/2005]. / Introductie van laparoscopische colorectale chirurgie in het Sint Franciscus Gasthuis, Rotterdam, 2002/'05.

OBJECTIVE: Analysis of the introduction of laparoscopic colorectal surgery in practice DESIGN: Retrospective and descriptive. METHOD: The introduction process of laparoscopic colorectal surgery in the Sint Franciscus Gasthuis (hospital) in Rotterdam, The Netherlands, was divided into 3 phases: the pioneers phase (1 August 2002 to 31 August 2004), the course phase (1 September 2004 to 31 December 2004) and the implementation phase (1 January 2005 to 31 August 2005). All patients who received elective laparoscopic colorectal resection (n = 88) of the total 255 patients who, according the current standard could be treated laparoscopically, were analysed for iatrogenic complications, operation time and the percentage that was performed by surgical residents. RESULTS: The percentage of elective colorectal procedures that were performed laparoscopically increased significantly in the 3 phases from 17% (27/163), to 50% (18/36) and 77% (43/56). Of these procedures, 30% (8/27), 17% (3/18) and 16% (7/43) were converted to an open procedure respectively. During the pioneers phase, 5 iatrogenic complications occurred: 2 ureter stenoses, 1 colon lesion, 1 inferior mesenteric artery bleeding lesion and 1 renal vein bleeding resulting in secondary splenectomy. During the course and implementation phases, no iatrogenic complication lesion occurred. The average operation time decreased from 191 via 186 to 182 minutes, despite the fact that the percentage of procedures performed by surgical residents increased from 15% (4/27), to 22% (4/18) and to 44% (19/43) in the respective phases and despite the fact that the amount of rectum resections increased from 19% (5/27) via 44% (8/18) to 37% (16/43). CONCLUSION: Specific training in laparoscopic colorectal surgery was combined with a safe and fast introduction of this technique in practice and the training program of surgical residents. This training could therefore avoid iatrogenic complication.

[Surgical treatment of rectal prolapse]. / Chirurgische behandeling van de rectale prolaps.

Rectal prolapse must be distinguished from anal prolapse or mucosal prolapse since the treatment differs. The only effective treatment for rectal prolapse is surgery. The fact that rectal prolapse causes severe disability and that the morbidity of the current surgical treatment is low justifies surgery even at advanced age. Moreover, the success rate is high. Ventral rectopexy seems to be the surgical technique of choice on the grounds of the anatomical advantages (preservation of rectal innervation and lifting of the middle compartment) and the results (low recurrence rates and reduction of constipation). The laparoscopic approach is just as effective as an open procedure and results in less morbidity, quicker recovery and lower medical costs.

A new device for bone anchor fixation in laparoscopic sacrocolpopexy: the Franciscan laparoscopic bone anchor inserter.

BACKGROUND: A laparoscopic modification of the sacrocolpopexy procedure with mesh and bone anchor fixation with the Franciscan laparoscopic bone anchor inserter was developed. METHODS: We developed a laparoscopic bone anchor inserter for the placement of a titanium bone anchor in sacral segment 3 as fixation for the mesh in laparoscopic sacrocolpopexy procedures performed in women with posthysterectomy vault prolapse. RESULTS: Surgery successfully corrected vaginal vault prolapse. Laparoscopic bone anchor insertion with this new and simple device took 2 minutes and provided a firm anchor for mesh fixation. MRI demonstrated an anatomically preferable vaginal axis toward the hollow of the sacrum. CONCLUSION: Application of the newly developed Franciscan laparoscopic bone anchor inserter in laparoscopic sacrocolpopexy is an easy and safe procedure that provides firm fixation and excellent anatomical results.

Prevention of lens condensation in laparoscopic surgery by lens heating with a thermos flask.

Condensation on the scope lens as a result of differences between room and intraabdominal temperatures is a disturbing problem for laparoscopic surgeons. Despite the use of anti-lens condensation solutions, this cannot be entirely avoided. The authors report a simple, cheap, and effective method for preventing lens condensation by lens heating using a sterilized thermos flask filled with hot water.

[Intestinal incarceration due to a Bochdalek's hernia]. / Darmincarceratie door een hernia van Bochdalek.

A 67-year-old male presented with abdominal pain followed by respiratory distress. Imaging revealed a right-sided Bochdalek's hernia. At thoracotomy two days later, an incarcerated small bowel segment was removed, with a protracted post-operative course. In adults, a Bochdalek's hernia is rare and usually asymptomatic. However, when symptoms do occur, incarceration of the intestinal contents is frequent and accompanied by high mortality. The severely protracted course after delayed treatment of a symptomatic Bochdalek's hernia described here illustrates the importance of early recognition and surgical intervention.

Surgery for locally recurrent rectal cancer.

After the diagnosis of a locally recurrent rectal cancer, imaging is the first step to estimate the extent and location of the local tumour growth and the presence or absence of distant metastases. The aim of the treatment is a R0 resection (microscopically tumour free circumferential margin) by multimodality treatment consisting of pre-operative radiation, extended resection and intra-operative radiotherapy by either electron beam irradiation or with high dose rate brachytherapy. Filling the pelvic cavity with vital tissue such as an omentoplasty should considered carefully. With this treatment the overall three-year survival rate of a group of 33 patients was 60% with a local control rate of 73%. The combination of chemotherapy as a radiosensitizer resulted in an increase of R0 resections by 20%. Introduction of TME surgery and pre-operative radiotherapy has created a new situation with limited possibilities due to dose-accumulation toxicity of the radiotherapy and extensive scarring of the tissues making estimation of the extent of the tumour growth more difficult. The prevention of local recurrence by proper selection of primary cases, the training of experienced surgeons and the optimal use of pre-operative radiotherapy is the way forward to improve results.

Anaesthesia for advanced rectal cancer patients treated with combined major resections and intraoperative radiotherapy.

BACKGROUND AND OBJECTIVE: Multimodality treatment for patients with locally advanced primary or locally recurrent rectal cancer, including high-dose preoperative external beam radiotherapy, extensive surgery and intraoperative radiation therapy, decreases the local recurrence rates and improves survival. During this aggressive operation, the anaesthesiologist is faced with potential problems such as major transfusion requirements, hypothermia, intraoperative position changes, the need to transport the patient to the intraoperative radiation therapy applicator, and the risks associated with remote monitoring of the patient during the 10 min intraoperative radiation therapy application. The anaesthetic management and perioperative results were evaluated for the anaesthetic results and the complications. METHODS: One-hundred-and-six patients undergoing the multimodality treatment between February 1994 and March 2000 for locally advanced primary (n = 50) and locally recurrent rectal cancer (n = 56) were retrospectively evaluated for their anaesthetic results and complications. RESULTS: All patients were operated upon using a combination of general and epidural anaesthesia. The average duration of anaesthesia was 6 (range 3-10.5) h and the mean blood loss 3.6 (range 0.4-14) L. All patients recovered well from anaesthesia. Two patients (2%) died in the intensive care unit (34 and 48 days postoperatively) because of adult respiratory distress syndrome following postoperative haemorrhage. Severe haemorrhage during or after the operation was significantly related with the development of adult respiratory distress syndrome (P < 0.0001). CONCLUSION: With adequate preoperative assessment and optimalization of the patient's condition, maintaining peroperative haemodynamic stability with the help of adequate remote monitoring, early and fast transfusion, and multidisciplinary communication, anaesthetic complications can be minimized.

Comparison of intraoperative radiation therapy-containing multimodality treatment with historical treatment modalities for locally recurrent rectal cancer.

PURPOSE: Treatment protocols for patients with locally recurrent rectal cancer have changed in the last two decades. Subsequently, treatment goals shifted from palliation to possible cure. In this retrospective study, we explored the treatment variables that may have contributed to the improvement in outcome by comparing three treatment modalities from two collaborating institutions in patients with similar tumor characteristics. METHODS: Ninety-four patients were treated with electron-beam radiation therapy only (1975-1990), 19 with combined preoperative electron-beam radiation therapy and surgery (1989-1996), and 33 with intraoperative radiation therapy-multimodality treatment (1994-1999). Intraoperative radiation therapy was delivered either as intraoperative electron-beam radiotherapy (10-17.5 Gy) in 20 patients or as intraoperative high-dose-rate brachytherapy (10 Gy) in 13 patients. No patient had received prior electron-beam radiation therapy. RESULTS: The three-year survival, disease-free survival, and local control rates were 14, 8, and 10 percent, respectively, in the electron-beam radiation therapy-only group and 11, 0, and 14 percent, respectively, in the combined electron-beam radiation therapy-surgery group. The overall intraoperative radiation therapy-multimodality treatment group showed significantly better three-year survival, disease-free survival, and local control rates of 60, 43, and 73 percent, respectively, compared with the historical control groups (P < 0.001). CONCLUSION: The outcome of patients with locally recurrent rectal cancer was improved after the introduction of intraoperative radiation therapy-multimodality treatment.

[Local tumor control and (disease-free) survival after surgery with pre- and intraoperative radiotherapy for primary non-resectable rectal carcinoma and local recurrence]. / Lokale tumorcontrole en (ziektevrije) overleving na chirurgie met pre- en intraoperatieve radiotherapie voor primair irresectabel rectumcarcinoom en locoregionaal recidief.

OBJECTIVE: Survey of the results of multimodality treatment for primary irresectable rectum carcinoma and local recurrence of rectal cancer. DESIGN: Retrospective. METHODS: During the period 1 February 1994 to 31 August 1999, 43 patients with locally advanced primary rectal cancer (25 men and 18 women; mean age: 64 years (range: 36-86)) and 53 patients with a local recurrence (33 men and 20 women; mean age: 61 years (39-82)) were treated with a multimodality treatment: i.e. preoperative radiotherapy (doses 50.4 Gy, or 30.0 Gy in the case of reirradiation), extensive surgery and intraoperative radiotherapy (doses 10-17.5 Gy). This treatment took place at two hospitals in the Netherlands, the Catharina Hospital in Eindhoven and, since 1997, the Daniel den Hoed Cancer Centre in Rotterdam. In 2000 data were collected for the local control and (disease-free) survival; these were analysed using the Kaplan-Meier method. Patients also completed a questionnaire about the quality of life at a median period of 14 months (range: 4-60) after the operation; the response level was 96% (76/79). RESULTS: After 3 years, the local control, disease-free survival and survival rates for the locally advanced primary rectal cancer group were 74%, 60% and 55% respectively, and for the locally recurrent rectal cancer group 64%, 34% and 50% respectively. Tumour resection with microscopically negative margins had a statistically significant positive effect on the local control and disease-free survival in both groups as well as on the survival in the locally advanced primary patient group. Seven of the 96 patients (7%) died as a result of complications. Of the patients with a primary irresectable carcinoma or a local recurrent tumour who completed the questionnaire the results were as follows: 56% and 63% respectively had been able to resume employment, 53% and 59% respectively had been able to resume their previous lifestyle, 15% and 27% respectively indicated radicular pain as a new symptom, 26% and 46% respectively stated problems with walking, 42% and 44% respectively stated problems with urinating and 59% and 52% respectively a reduction in sexual activity.

Abdominosacral resection for primary irresectable and locally recurrent rectal cancer.

PURPOSE: The purpose of this study was to present a technique of abdominosacral resection and its results in patients with locally advanced primary or locally recurrent rectal cancer with dorsolateral fixation. METHODS: Between 1994 and 1999, 13 patients with locally advanced primary rectal cancer and 37 patients with locally recurrent rectal cancer underwent abdominosacral resection as part of a multimodality treatment, i.e., preoperative irradiation, surgery, and intraoperative irradiation. After the abdominal phase, the patient was turned from supine to prone position to perform the transsacral phase of the resection. RESULTS: Margins were microscopically negative in 26 patients (52 percent), microscopically positive in 18 (36 percent), and positive with gross residual disease in 6 patients. Operation time ranged from 210 to 590 (median, 390) minutes, and blood loss ranged from 400 to 10,000 (median, 3,500) ml. No operative or hospital deaths occurred. Postoperative complications occurred in 41 patients (82 percent); most notable were perineal wound infections or dehiscence (n = 24, 48 percent). Other complications were postoperative urinary retention or incontinence (n = 9, 18 percent), peritonitis (n = 4), grade II neuropathy (n = 1), and fistula formation (n = 3). Kaplan-Meier 3-year overall survival, disease-free survival, and local control rates were, respectively, 41 percent, 31 percent, and 61 percent. Completeness of the resection (negative vs. positive margins) was a significant factor influencing survival (P = 0.04), disease-free survival (P = 0.0006), and local control (P = 0.0002). CONCLUSION: The abdominosacral resection provides wide access and may be the therapeutic solution for the accomplishment of a radical resection for distally situated, dorsally or dorsolaterally fixed primary or locally recurrent rectal cancers.

Urologic and sexual morbidity following multimodality treatment for locally advanced primary and locally recurrent rectal cancer.

AIMS: In the treatment of patients with locally advanced primary or locally recurrent rectal cancer much attention is given to the oncological aspects. In long-term survivors, urogenital morbidity can have a large effect on the quality of life. This study evaluates the functional outcome after multimodality treatment in these patient groups. PATIENTS AND METHODS: Between 1994 and August 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with multimodality treatment: i.e. high-dose preoperative external beam radiation therapy, followed by extended surgery and intraoperative radiotherapy. The medical records of the 121 patients were reviewed. To assess long-term urogenital morbidity, all patients still alive, with a minimum follow-up of 4 months, were asked to fill out a questionnaire about their voiding and sexual function. Seventy-six of the 79 currently living patients (96%) returned the questionnaire (median FU 14 months, range 4-60). RESULTS: The questionnaire revealed identifiable voiding dysfunction as a new problem in 31% of the male and 58% of the female patients. In 42% of patients after locally advanced primary and 48% after locally recurrent rectal cancer treatment bladder dysfunction occurred. The preoperative ability to have an orgasm had disappeared in 50% of the male and 50% of the female patients, and in 45% of patients after locally advanced primary and in 57% after locally recurrent rectal cancer treatment. CONCLUSION: Multimodality treatment for locally advanced primary and recurrent rectal cancer results in acceptable urogenital dysfunction if weighed by the risk of uncontrolled tumour progression. Long-term voiding and sexual function is decreased in half of the patients. Preoperative counselling of these patients on treatment-related urogenital morbidity is important.