Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands.

OBJECTIVE: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR). METHODS: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests. RESULTS: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively). CONCLUSION: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Emergency TREPP for Strangulated Inguinal Hernia Repair: A Consecutive Case Series.

Background Patients with strangulated inguinal hernia (SIH) require emergency surgical treatment. International guidelines do not specify the surgical technique of preference. Frequently, an open anterior approach such as the Lichtenstein technique is used. The TransREctus sheath Pre-Peritoneal (TREPP) technique is an alternative, open posterior approach, which has shown promising results in the elective treatment of inguinal hernias. This study aims to evaluate the feasibility and safety of the TREPP technique in the emergency setting of SIHs. Materials and Methods After medical ethical approval was warranted, all consecutive patients, who underwent emergency TREPP (e-TREPP) at a high-volume hernia institute, were retrospectively included from 2006 up to and including 2016. Data retrieved from the electronic patient files were combined with the findings during a long-term outcome physical investigation at an outpatient department visit. e-TREPP was, prior to the start of the study, defined as TREPP performed immediately at the operation room. Results Thirty-three patients underwent e-TREPP for SIH. Ten patients were clinically evaluated, ten patients were deceased, nine patients could not be contacted, and four patients did not or could not consent. Of the ten deceased patients, one patient died perioperatively due to massive aspiration followed by cardiac arrest. Nine patients died due to other causes. Two patients developed a recurrence after (after 13 days and 16 months respectively). Two patients were surgically treated for a wound infection (mesh removal in one). No patient reported chronic postoperative inguinal pain. Conclusion e-TREPP in experienced hands seems feasible and safe (Level of Evidence 4) for the treatment of patients with strangulated inguinal hernia, with percentages of postoperative complications comparable to other techniques.

Case series of recurrent inguinal hernia after primary TREPP repair: re-TREPP seems feasible and safe.

INTRODUCTION: The Trans REctussheath PrePeritoneal (TREPP) mesh repair was introduced in 2006 to decrease the risk of postoperative inguinal pain in hernia surgery. For the repair of a recurrent inguinal hernia after a primary TREPP an alternative open anterior route (Lichtenstein) may seem the most logical option, but coincides with an increased risk of chronic postoperative inguinal pain. Therefore, this study aimed to evaluate the feasibility of a second TREPP procedure to repair a recurrent inguinal hernia after an initial TREPP repair. METHODS: Consecutive patients with a recurrent inguinal hernia after a primary TREPP, repaired by a re-TREPP were retrospectively included in the study. Data, retrieved from the electronic patient files, were combined with the clinical findings at the outpatient department where the patients were physically investigated according to a priorly written and registered protocol. RESULTS: Overall about 1800 TREPPs were performed between 2006 and 2013. Since the introduction of TREPP in 2006, 40 patients presented with a recurrence in our center. From this group 19 patients were re-operated with the TREPP technique. No intraoperative complications occurred. There was one conversion from re-TREPP to Lichtenstein and no re-recurrences occurred to date. Ten out of 19 patients could be clinically evaluated with a mean follow-up period of 37 months (range 11-95). None of these patients (n=10) complained of chronic postoperative inguinal pain. Two patients reported discomfort. One patient died non procedure related, three weeks after re-TREPP of sudden cardiac death. CONCLUSION: These first experiences with re-TREPP for secondary inguinal hernia repair are encouraging for the aspects of feasibility and safety, particularly in experienced surgical hands.

The TREPP as alternative technique for recurrent inguinal hernia after Lichtenstein's repair: A consecutive case series.

BACKGROUND: Recurrent inguinal hernias after initial repair with mesh are preferably treated via an alternative route (e.g. posterior after anterior). For recurrent inguinal hernias after an anterior repair such as Lichtenstein's, an endoscopic approach such as the total extraperitoneal or transabdominal preperitoneal technique (TEP or TAPP) is recommended if expertise is present. The TransREctus sheath PrePeritoneal (TREPP) technique is a promising open posterior technique and could be an alternative to endoscopic methods. This study aims to evaluate the results of the TREPP technique for recurrent inguinal hernia. MATERIALS AND METHODS: Consecutive patients who underwent a TREPP repair for recurrent hernia after initial operation according to Lichtenstein were included in a retrospective manner. A minimum of one year follow-up after the TREPP repair was maintained. Data retrieved from the patient files were combined with the findings at an outpatient department visit. RESULTS: Between January 2006 and December 2013 fifty-two patients were eligible for inclusion of which 38 patients were clinically evaluated. The mean follow-up of these thirty-eight patients was 65 months (range 17-108 months) in which 2 patients had developed a re-recurrence. One patient reported chronic postoperative inguinal pain (CPIP) since the TREPP and four patients experienced CPIP since the primary inguinal hernia repair. Peri-operative and <30 day complications were rare and no severe adverse events occurred. CONCLUSION: TREPP seems to be a feasible alternative for recurrent inguinal hernia repair after an initial operation according to Lichtenstein. It may yield extra advantages compared to endoscopic repairs, such as a short learning curve, spinal anesthesia and lower costs.

Teaching the transrectus sheath preperiotneal mesh repair: TREPP in 9 steps.

BACKGROUND: The preperitoneal mesh position seems preferable to reduce the number of patients with postoperative chronic pain after inguinal hernia surgery. The transrectus sheath preperitoneal mesh repair (TREPP) is gaining popularity. Teaching a new technique requires a standardized approach to achieve an optimal learning curve. The aim of this paper was to provide a step-by-step teaching module for hernia surgeons learning the TREPP. METHODS: Literature was critically reviewed and the forthcoming nine surgical steps of the new TREPP technique and its rationale are described in this article. The TREPP hernia repair technique is illustrated with an online education video and three photos of the anatomical landmarks and the proposed mesh position of TREPP. RESULTS: The nine steps of TREPP are described extensively and the critical steps are presented in a standardized way for surgical educational purposes. Also the rationale and technical considerations of inguinal hernia experts are presented. DISCUSSION: TREPP may be a promising technique for groin hernia surgery. To date there have been no major complications with the TREPP repair which is currently the subject of a RCT. The learning curve of TREPP is being investigated and teaching of this technique requires standardization for trainee surgeons. CONCLUSION: TREPP potentially merges the advantages of a preperitoneal positioned mesh with an open technique. Initial results are promising and TREPP seems to be applicable in different hospitals in the Netherlands. Since the start of an active teaching program, TREPP has been introduced and accepted well by dedicated hernia surgeons in other hospitals in the Netherlands and Europe.

Trans rectus sheath extra-peritoneal procedure (TREPP) for inguinal hernia: the first 1,000 patients.

INTRODUCTION: After the introduction of mesh in inguinal hernia repair, the focus to improve surgical technique has changed from recurrence to chronic postoperative inguinal pain. At present, the most common surgical techniques are the Lichtenstein hernioplasty and total extraperitoneal procedure. Both techniques have their own specific disadvantages, with regard to potential nerve damage and the necessity of general anesthesia, respectively. OBJECTIVE: The goal of this study was to evaluate the results of a new technique in which the inguinal nerves are not at risk, and in which general anesthesia is not needed: trans rectus sheath extraperitoneal procedure (TREPP). MATERIAL AND METHODS: Between 2006 and 2010, a total of 1,000 patients were treated for inguinal hernia with TREPP. A questionnaire concerning pain, sensibility changes, patient satisfaction, and recurrence was sent to all patients. RESULTS: The questionnaire was completed by 932 patients. Almost 90% of patients had not experienced any pain since the surgical procedure; 8% of patients reported experiencing some pain, but less than preoperatively; and 2% of patients reported an increase in pain postoperatively. Recurrence occurred in 1 and 3% were unsure about this. Reduced sensibility of the scar, scrotum, and upper leg was reported by 12.4, 1.4, and 1.5%, respectively. Overall, 97.4% of patients were satisfied with the results of the surgical procedure. The time period in which TREPP was performed was not associated with any of the outcome measures. CONCLUSION: TREPP has proven to be a feasible new technique for inguinal hernia repair, with excellent results, justifying a randomized controlled trial in which TREPP should be compared with standard techniques.

The transrectus sheath preperitoneal mesh repair for inguinal hernia: technique, rationale, and results of the first 50 cases.

INTRODUCTION: Laparoscopic and endoscopic hernia repair popularized the preperitoneal mesh position due to promising results concerning less chronic pain. However, considerable proportions of severe adverse events, learning curves, or added costs have to be taken into account. Therefore, open preperitoneal mesh techniques may have more advantages. The open approach to the preperitoneal space (PPS) according to transrectus sheath preperitoneal (TREPP) mesh repair is through the sheath of the rectus abdominus muscle. This technique provides an excellent view of the PPS and facilitates elective or acute hernia reduction and mesh positioning under direct vision. In concordance with the promising transinguinal preperitoneal inguinal hernia repair experiences in the literature, we investigated the feasibility of TREPP. METHODS: A rationale description of the surgical technique, available level of evidence for thoughts behind technical considerations. Furthermore, a descriptive report of the clinical outcomes of our pilot case series including 50 patients undergoing the TREPP mesh repair. RESULTS: A consecutive group of our first 50 patients were operated with the TREPP technique. No technical problems were experienced during the development of this technique. No conversions to Lichtenstein repair were necessary. No recurrences and no chronic pain after a mean follow-up of 2 years were notable findings. CONCLUSION: This description of the technique shows that the TREPP mesh repair might be a promising method because of the complete preperitoneal view, the short learning curve, and the stay-away-from-the-nerves principle. The rationale of the TREPP repair is discussed in detail.

[Cystic adventitial degeneration of the popliteal artery; an unexpected cause of intermittent claudication]. / Cysteuze adventitiadegeneratie van de A. poplitea; een onverwachte oorzaak van claudicatio intermittens.

Three men, aged 48, 44 and 51 years, were referred to the vascular surgery outpatient clinic because of acute intermittent claudication in one leg. The first patient had no medical history and no vascular risk factors, the second patient was receiving drug treatment for hypercholesterolaemia and diabetes mellitus and the third patient smoked. After additional radiological diagnostics, cystic adventitial degeneration of the popliteal artery was diagnosed in all patients. All 3 patients were operated. Only circumferential resection of the cystic adventitia and the outer layer of the media, so-called exarteriectomy, was performed in the second patient. The other 2 patients underwent resection of the affected popliteal artery followed by an autologous vein graft. The post-operative course was uncomplicated. The diagnosis of cystic adventitial degeneration was confirmed histopathologically. Cystic adventitial degeneration is localised only in the popliteal artery in 85-90% of cases. It is probably caused by incorporation of mesenchymal cells in the wall of the popliteal artery during embryogenesis. The disease is often progressive and, if left untreated, may lead to critical ischaemia due to arterial occlusion. Surgical intervention is therefore necessary, with exarteriectomy as the preferred technique, especially because the patients are often young.

Malignant pancreatic tumour within the spectrum of tuberous sclerosis complex in childhood.

UNLABELLED: A 12-year-old boy with tuberous sclerosis complex (TSC) presented with a large retroperitoneal tumour. Exploratory surgery revealed an infiltrative tumour originating from the pancreas, with local metastases to the lymph nodes. The histologal diagnosis was a malignant islet cell tumour. Retrospectively measured pancreatic hormone levels, however, were normal. A connection between the malignancy and TSC was demonstrated by loss of heterozygosity of the TSC2 gene in the tumour. The primary mutation Q478X in this patient was identified in exon 13 of the TSC2 gene on chromosome 16. CONCLUSION: Pancreatic islet cell tumours have been mainly associated with multiple endocrine neoplasia syndrome type 1. In our case we demonstrate a direct relationship of this tumour to tuberous sclerosis complex, in the absence of further signs of multiple endocrine neoplasia syndrome type 1.

Percutaneous endoscopic gastrostomy for patients with severe cerebral injury.

Early enteral nutrition improves the outcome of severely injured patients. To provide enteral nutrition, various methods are available. In a restrospective study we analysed the outcome of 24 severely traumatized patients (mean ISS = 44), in whom a percutaneous endoscopic gastrostomy (PEG) was used for enteral nutrition. All patients had been admitted to the intensive care unit with major cerebral injury. The mean duration of intensive care treatment and the in hospital stay were 28 and 71 days, respectively. PEG was introduced 14 days after hospital admittance. Enteral nutrition through the PEG was administered for 45 days. Four patients died, 8 patients were discharged from the hospital while being fed via the PEG and 12 patients resumed normal feeding and the PEG was removed. Three severe complications occurred; 1 patient aspirated massively and died; in 2 patients intra-abdominal leakage of the enteral nutrition occurred. Both patients recovered from this complication. We conclude that because of the advantages of early enteral nutrition on the one hand and the drawbacks of nasogastric feeding tubes on the other, in injured patients with severe cerebral damage, PEG placement is justified, despite the risk of complications.

[Feeding tubes for tube feeding]. / Voedingssondes voor sondevoeding.

Several techniques are available for the provision of enteral nutritional support. Nasal tubes, gastrostomy tubes and jejunostomy tubes can be distinguised. Nasal tubes are used for short-term support, gastrostomy tubes (preferably via a percutaneous endoscopic gastrostomy) for long-term support (over 4 to 6 weeks), while (needle catheter) jejunostomy tubes are most often used to provide early enteral nutrition immediately after operations on the proximal gastrointestinal tract. The most frequent complications are: with the nasal tube dislodging, clogging and aspiration, with the gastrostomy tube peristomal infection and with the jejunostomy tube, obstruction. It should further be noted that the quantity of enteral nutrition prescribed and that actually administered may differ substantially so that patients with a feeding device may even become malnourished. With proper patient selection and secure control of the energy balance, feeding tubes are simple (temporary) devices that improve the patient's health and quality of life.

Colour duplex ultrasonographic imaging and provocation of popliteal artery compression.

OBJECTIVES: Provoked compression of the popliteal artery by active plantar flexion of the foot is still mainstay in the assessment of the popliteal artery entrapment syndrome. In this study, the effects of several provocation manoeuvres of the foot on the flow patterns of the popliteal arteries of normal healthy volunteers were evaluated. DESIGN: Experimental study among healthy volunteers in a vascular laboratory. MATERIALS AND METHODS: The popliteal artery of 16 healthy volunteers was studied with Duplex scanning in rest and during active and passive plantar and dorsal flexion of the foot. RESULTS: Active plantar flexion was the only movement that influenced popliteal artery flow patterns. Changes were found in 27 arteries (85%), consisting of either a complete occlusion (n = 19, 59%), a significant lumen reduction (n = 4, 13%) or a low flow state (n = 4, 13%). CONCLUSION: Compression of the popliteal artery by active plantar flexion of the foot is a physiologic phenomenon and its value in the assessment of patients suspected of the popliteal artery entrapment syndrome is limited.

Percutaneous endoscopic gastrostomy (PEG): comparison of push and pull methods and evaluation of antibiotic prophylaxis.

BACKGROUND AND STUDY AIMS: Infection of the gastrostomy opening after placement of a percutaneous endoscopic gastrostomy (PEG) catheter has been reported to occur quite often, especially when the pull method is used. We therefore compared complications occurring with the pull and push methods, and evaluated the role of antibiotic prophylaxis. PATIENTS AND METHODS: In a prospective study, 100 consecutive patients were randomly assigned to group A (pull plus antibiotic prophylaxis: amoxycillin-clavulanic acid 3 x 1.2 g i.v. over 24 hours; 37 patients), group B (pull without antibiotic prophylaxis; 34 patients) and group C (push without antibiotic prophylaxis; 29 patients). The indications for PEG placement were dysphagia due to oropharyngeal tumors (56%), neurological disease (32%), or other (12%). Patients were evaluated twice weekly for one month after the PEG placement. RESULTS: PEG catheters were successfully placed in 96% of the patients. The total procedure-related complication rate was significantly lower in group A than in groups B and C (28%, 58%, and 70%, respectively; p < 0.01). Major complications occurred in one patient in group A (seeding metastasis of a hypopharyngeal carcinoma in the gastrostomy tract), and in four patients in group B (three cases of peritonitis and one aspiration, resulting in two deaths), but in none of the group C patients. Group A patients experienced fewer peristomal infections than the other two groups (14%, 30%, and 41%, respectively: p = 0.05). The risk of peristomal pain was similar (11%, 15%, and 11%, respectively; p = n.s.). In three patients in group C, the PEG catheter had to be replaced by the pull method, due to repeated dislocation of the balloon catheter. CONCLUSIONS: The complication rate with PEG placement is high with both the push and pull methods. The complication rate with the pull method is significantly reduced when antibiotic prophylaxis is used.

Metastasis of hypopharyngeal carcinoma into the gastrostomy tract after placement of a percutaneous endoscopic gastrostomy catheter.

Percutaneous endoscopic gastrostomy catheters are frequently placed in patients with pharyngeal tumors. In this article, we report a patient with a metastasis of a large hypopharyngeal carcinoma in the gastrostomy tract, probably caused by placement of a percutaneous endoscopic gastrostomy catheter by the pull method. The metastasis decreased considerably in size after high-dose radiation therapy (as had the original hypopharyngeal tumor). The patient subsequently had a curative resection of the residual metastatic tumor, but one month after the operation he died of a cerebrovascular accident.

[Spontaneous dissection of the iliac artery; treatment with a stent]. / Spontane dissectie van de A. iliaca; behandeling met een stent.

In three relatively young patients (two women of 61 and 44 and a man of 42) spontaneous dissections of the iliac artery were diagnosed. Pain in the groin, with radiation to back or upper leg were the main presenting symptoms, twice leading to groin exploration for femoral hernia. Duplex sonography is an excellent non-invasive examination to visualise the dissection and its haemodynamic importance. Sooner or later all dissections lead to invasive therapy. In one patient a aorto-bi-iliac prosthesis was inserted, in the other two an intravascular self-expandable stent (Wall stent), with both anatomically and functionally good results. Long-term results of application of a Wall stent for this purpose are not available yet, but it looks very promising.

[Risk factors for the development of recurrences in patients with breast carcinoma without axillary lymph node metastases]. / Risicofactoren voor het ontstaan van recidieven bij patiënten met een mammacarcinoom zonder okselkliermetastasen.

The influence of a number of risk factors on development of tumour recurrence was studied retrospectively in a group of breast cancer patients without axillary lymph node metastases, all treated identically and with long follow-ups. Of 71 patients all data could be retrieved. This group had a median duration of follow-up of five years. Thirteen patients (18.3%) had had a recurrence of carcinoma after a median disease-free period of 41 months (range 3-124 months). These patients at the time when breast cancer was diagnosed had had a lower median age than patients who had remained free of tumour recurrence, 48 (40-70) as against 59.5 (30-81) years. Factors having a statistically significant prognostic importance for recurrence of tumour were age at the time of diagnosis of breast carcinoma, histological tumour grade and nuclear DNA content. Identifying groups of patients with a higher or lower risk of tumour recurrence appears possible by combination of risk factors. Although patients with breast cancer without axillary lymph node metastases are supposed to have a favourable prognosis, there appear to exist subgroups with a raised risk for development of a recurrence. These groups might be prime candidates for prospective randomized studies of the usefulness of adjuvant therapy.