Retrospective Multicenter Study on Risk Factors for Surgical Site Infections after Appendectomy for Acute Appendicitis.

BACKGROUND: Surgical site infections (SSI) are seen in up to 5% of patients after appendectomy for acute appendicitis. SSI are associated with prolonged hospital stay and increased costs. The aim of this multicenter study was to identify factors associated with SSI after appendectomy for acute appendicitis. METHODS: Patients who underwent appendectomy for acute appendicitis between June 2014 and January 2015 in 6 teaching hospitals in the southwest of the Netherlands were included. Patient, diagnostic, intra-operative and disease-related factors were collected from the patients' charts. Primary outcome was surgical site infection. Multivariable logistic regression was performed to identify independent risk factors for SSI. RESULTS: Some 637 patients were included. Forty-two patients developed a SSI. In univariable analysis body temperature >38°C, CRP>65 and complex appendicitis were associated with SSI. After multivariable logistic regression with stepwise backwards elimination, complex appendicitis was significantly associated with SSI (OR 4.09; 95% CI 2.04-8.20). Appendiceal stump closure with a stapler device was inversely correlated with SSI (OR 0.40; 95% CI 0.24-0.97) Conclusions: Complex appendicitis is a risk factor for SSI and warrants close monitoring postoperatively. The use of a stapler device for appendiceal stump closure is associated with a reduced risk of SSI.

Long-term clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial.

BACKGROUND: Long-term comparisons of supervised exercise therapy (SET) and endovascular revascularization (ER) for patients with intermittent claudication are scarce. The long-term clinical effectiveness of SET and ER was assessed in patients from a randomized trial. METHODS: Consenting patients with intermittent claudication were assigned randomly to either SET or ER. Outcome measures on functional performance (pain-free and maximum walking distance, ankle : brachial pressure index), quality of life (QoL) and number of secondary interventions were measured at baseline and after approximately 7 years of follow-up. Repeated-measurement and Kaplan-Meier methods were used to analyse the data on an intention-to treat-basis. RESULTS: A total of 151 patients were randomized initially to either SET or ER. After 7 years, functional performance (P < 0.001) and QoL (P ≤ 0.005) had improved after both SET and ER. Long-term comparison showed no differences between the two treatments, except in the secondary intervention rate, which was significantly higher after SET (P = 0.001). Nevertheless, the total number of endovascular and surgical interventions (primary and secondary) remained higher after ER (P < 0.001). CONCLUSION: In the longer term, SET-first or ER-first treatment strategies were equally effective in improving functional performance and QoL in patients with intermittent claudication. The substantially higher number of invasive interventions in the ER-first group supports a SET-first treatment strategy for intermittent claudication. REGISTRATION NUMBER: NTR199 (http://www.trialregister.nl).

[A man with a painful thumb]. / Een man met een pijnlijke duim.

A 22-year-old man presented with a subluxation of the metacarpophalangeal joint of his left thumb. Correct anatomical position was obtained with manual reposition. The hand was immobilised for 2 weeks and was thereafter actively mobilised. After 1 month he was free of pain and the function of his thumb had completely recovered.

Long-term follow-up evaluation of chronic pain after endoscopic total extraperitoneal repair of primary and recurrent inguinal hernia.

BACKGROUND: Long-term data on chronic pain after endoscopic total extraperitoneal (TEP) hernia repair are hardly available. METHODS: Between January 1997 and December 1998, 416 patients with consecutive primary and recurrent inguinal hernia underwent endoscopic TEP hernia repair. Long-term follow-up evaluation was carried out from June 2007 to June 2008. The primary outcome measure was persistent pain and discomfort interfering with daily activity. RESULTS: The overall response rate was 66% (273 of 416 patients). Of the 416 patients, 85 (20%) had died of causes unrelated to hernia repair and 58 (14%) were lost to follow-up. A total of 177 patients were physically examined in the outpatient clinic. Because 96 patients were not able to visit the outpatient' clinic, they completed the survey by telephone. The median follow-up period was 10 years (range, 9-11 years). After TEP repair, 16 patients (6%) reported chronic groin pain, and 10 patients (4%) still experience pain at this writing after the 10-year follow-up period. One of the patients has experienced persistent pain and discomfort interfering with daily activity. Patients with preoperative pain have reported significantly more chronic pain (P = 0.03). CONCLUSIONS: Chronic groin pain after TEP repair of primary and recurrent inguinal hernia seems to have a low incidence after a 10-year follow-up period.

Iatrogenic diaphragmatic hernia complicating nephrectomy: top-down or bottom-up?

Hernias of the diaphragm are rarely reported as a complication of abdominal surgery. We review a case of a 47-year-old female who presented with dyspnoea and chest pain one day after left radical nephrectomy for renal cell carcinoma. Plain and cross-sectional imaging identified a large left-sided diaphragmatic hernia containing omentum, spleen, splenic flexure, and stomach. Our patient underwent a thoracotomy and, after hernia reduction, the diaphragmatic defect was repaired using non-absorbable sutures and a mesh. She made an uneventful recovery. The potential cause is discussed and the published literature on this rare complication is reviewed briefly.

[Guideline 'Chronic Achilles tendinopathy, in particular tendinosis, in sportsmen/sportswomen']. / Richtlijn 'Chronische achillestendinopathie, in het bijzonder de tendinosis, bij sporters'.

--Chronic Achilles tendinopathy in sports often leads to various therapeutic strategies, medical shopping and frequently to inability to perform at the desired level. --Although it is clear that this chronic tendinopathy is not an inflammatory disease of the tendon, the cause of the degeneration of the tendon fibres is not understood. --The main therapeutic measure--based on scientific evidence--is eccentric calf-muscle training for at least 3 months. --Recent therapies such as sclerotherapy ofneovascularizations in and around the Achilles tendon appear to be promising, but more studies are required. --About 20% of the patients tend to be refractive to conservative measures. --In selected cases surgery can be undertaken, with percutaneous longitudinal tenotomy proving effective in 75-80% of the cases.

Totally extraperitoneal repair for bilateral inguinal hernia: does mesh configuration matter?

BACKGROUND: The endoscopic preperitoneal approach has numerous advantages for the reconstruction of bilateral inguinal hernias. Repair may be achieved using either one large or two small meshes. The aim of this study was to investigate whether one of the techniques was superior in terms of recurrence and complication rate. METHODS: Data obtained from 113 patients who underwent surgery between January 1998 and December 2001 was reviewed. For the sake of this study, 86% of all patients were examined for hernia recurrence at an additional outpatient visit. RESULTS: The findings showed recurrence rates, of 3.5% for single mesh and 3.7% for double mesh. This difference was not significant. Complication rates did not differ significantly between the groups. CONCLUSIONS: Endoscopic preperitoneal bilateral hernia repair is a safe and reliable technique in the hands of experienced surgeons. The rate of hernia recurrence and complications is low and independent of the mesh configuration (single or double). Mesh configuration based on personal preference is permissible.

The place of the posterior surgical approach for lesions of the rectum.

BACKGROUND: Although there are many advantages of a posterior approach to rectal disease, these procedures are not widely accepted because many surgeons fear the postoperative complications. METHODS: The medical records were reviewed of 57 patients who underwent a posterior approach to the rectum between January 1980 and December 2002. RESULTS: Twenty-eight men and 29 women with a mean age of 70.5 (range 47-83) years underwent either a posterior transsacral (n = 52) or a transsphincteric (n = 5) procedure. Indications for surgery were benign lesions (n = 33), e.g. villous adenoma, rectal prolapse and endometriosis as well as invasive adenocarcinoma (n = 24). All patients with an invasive adenocarcinoma were classified as ASA grade III or IV. Postoperative morbidity occurred in 12 patients (21%), consisting of temporary incontinence, anastomotic leakage, wound infection, and hemorrhage. There was no mortality. During a mean follow-up of 29 (range 2-86) months, 3 patients with a villous adenoma and 2 patients who were treated for a malignant lesion had a locally recurrent lesion. CONCLUSION: We believe that a posterior approach to the rectum should be considered for various benign and selected malignant diseases, especially in case of elderly patients or patients with a compromised general condition, and has to be a part of the surgeon's armamentarium.

Long-term results after modified Gallie technique for incisional hernia repair: results in 19 patients.

BACKGROUND: A modified forgotten technique for repairing large incisional hernias is described together with its long-term results in 19 patients. A synthetic mesh with 1-cm wide spokes radiating from the mesh is placed preperitioneally, overlapping the fascial defect. The spokes are pulled through rectus sheaths and muscle and sutured ventrally, thereby creating a solid reconstruction withstanding shrinking of the mesh. METHOD: Nineteen patients were operated on (13 primary incisional hernia, minimal fascial defect 10 cm). Notes on patients were reviewed, and the patients were contacted for follow-up examination. RESULTS: No major complications occurred. After a median of 49 months, 17 patients were reviewed at the outpatient clinic. Two possible recurrences were detected, of which one was operated on. This proved to be bulging of the mesh, resulting in a recurrence of 1 out of 17 (6%). CONCLUSION: From these results, it is concluded that Gallie's technique using synthetic mesh is a safe and effective repair for incisional hernia and deserves more attention, especially for large fascial defects.

[Diagnostic image (172). A man with blisters after the use of a cold pack. Cryotrauma caused by frozen cold pack]. / Diagnose in beeld (172). Een man met blaren na gebruik van een diepgevroren pakking. Cryoletsel door een diepgevroren pakking.

A 19-year-old soccer player developed cryotrauma after the prolonged application of a cold pack to a sprained ankle.

Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail.

The proximal femoral nail (PFN) is a recently introduced intramedullary system, designed to improve treatment of unstable trochanteric fractures of the hip. In a multicentre prospective clinical study, the intra-operative use, complications and outcome of treatment using the PFN (n = 211) were compared with those using the gamma nail (GN) (n = 213). The intra-operative blood loss was lower with the PFN (220 ml v 287 ml, p = 0.001). Post-operatively, more lateral protrusion of the hip screws of the PFN (7.6%) was documented, compared with the gamma nail (1.6%, p = 0.02). Most local complications were related to suboptimal reduction of the fracture and/or positioning of the implant. Functional outcome and consolidation were equal for both implants. Generally, the results of treatment of unstable trochanteric fractures were comparable for the PFN and GN. The pitfalls and complications were similar, and mainly surgeon- or fracture-related, rather than implant-related.

[The necrology meeting as an instrument for quality of care improvement; experiences at the Ikazia Hospital, 1990-2000]. / De necrologiebespreking als instrument voor kwaliteitsverbetering; ervaringen in het Ikazia Ziekenhuis, 1990-2000.

The death of a patient highlights the demand for quality of care. Publication of hospital mortality figures risks incorrect interpretation and does not lead to an improvement in care. However, an above-average hospital mortality rate can be a sign of poor quality in a particular aspect of care. In the necrology meeting, the evaluation of this quality must take place with critical self-reflection, to detect opportunities by which to improve the quality of care. Quantitative data to support the necrology meeting are necessary to improve the quality. This requires systematic registration and a valid code system. In the Department of Surgery at the Ikazia Hospital Rotterdam, the Netherlands, an ABC coding system is used which indicates whether the patient died of the disease or complications, whether the death was influenced by identifiable shortcomings in the diagnostic work-up, surgical treatment or non-surgical treatment, or whether no shortcoming could be identified, and whether autopsy was carried out or refused. A more detailed registration model is developed which may be more useful in future necrology meetings and in the evaluation of these meetings.

Size of lesion is not a criterion for resection during management of giant liver haemangioma.

BACKGROUND: The unknown natural history and risk of complications of large haemangiomas may pose therapeutic dilemmas. The authors describe their experience with the management of giant haemangiomas. METHODS: Patients with a giant haemangioma were identified by a survey of the hospital database. Forty-nine patients with a haemangioma of at least 4 cm in diameter presented between January 1990 and December 2000. Medical records were analysed retrospectively. RESULTS: Eleven patients had surgical treatment and 38 were managed conservatively. The median diameter of the tumours was 8.0 cm in surgically treated patients and 6.0 cm in the group managed by observation. Surgery-related morbidity occurred in three patients, and abdominal complaints persisted in three of ten patients with a symptomatic lesion. During a median follow-up of 52 months, 12 non-operated patients had mild abdominal complaints, considered to be unrelated to the lesion. In these patients symptoms either diminished or became minimal during follow-up. Complications did not occur. CONCLUSION: Observation of giant haemangiomas can be performed safely. The authors advocate resection of cavernous liver haemangiomas only in patients with persistent severe symptoms.

The vascular laboratory in practice: a national survey in the Netherlands.

OBJECTIVES: to overview Dutch vascular laboratory practice and specifically the variation in duplex criteria. METHODS: a questionnaire was sent to all vascular laboratories in The Netherlands (n=140). RESULTS: the response rate of the inquiry was 64% (n=89). There is no consensus on interpretation of outcome. In 22% of the clinics (n=20) a diagnostic angiography will be omitted when a percutaneous angioplasty is advised on account of duplex ultrasound. Only 5% (n=4) relies upon duplex ultrasound for operation without diagnostic angiography. In 44% (n=39) a PSV (peak systolic velocity) of 125 cm/s is used to identify a>70% or internal carotid artery stenosis. In 44% (n=39) a PSV of 210 cm/s and 10% (n=9) a PSV > or =150 cm/s is used. For grading a relevant stenosis in the femoro-politeal arteries a PSV ratio > or =2.5 is chosen in 75% (n=67). Criteria used for graft surveillance shows also a wide variation. CONCLUSIONS: a commission for the accreditation of vascular laboratories should be established with the goal of creating standards and performing quality control.

Technical considerations and pitfalls in laparoscopic live donornephrectomy.

BACKGROUND: Recent developments in laparoscopic solid organ surgery suggest a possible reduction in postoperative discomfort and disability for kidney donors. Technical aspects and the influence of surgical experience in laparoscopic donor nephrectomy were evaluated. METHODS: The clinical outcome of 57 laparoscopic donor nephrectomies (LapNx) was compared with that for a historic control group of 27 open donor nephrectomies (OpenNx). RESULTS: Three conversions to open nephrectomy (5.2%) were necessary. Postoperative complications were minor and comparable in both groups. Patients who underwent laparoscopic surgery demonstrated significantly less postoperative pain and a shorter hospital stay, but operative time and warm ischemia time were significantly longer. Graft survival after LapNx was 100% during a median follow-up period of 13 months. Operative time for LapNx decreased considerably with experience gained and seemed to be less for right nephrectomy. Stenotic ureter-bladder anastomoses occurred after LapNx in four patients during the first half year (7.0%), but this problem seemed to be resolved after modification of the technique. CONCLUSION: LapNx is associated with less postoperative discomfort and improved convalescence.

Splenic abscess after lithotripsy of pancreatic duct stones.

We describe a case of splenic abscess following lithotripsy of pancreatic stones, for which emergency splenectomy eventually had to be performed. It is important to be aware of this complication, because splenic abscess is still a life-threatening entity.

Intraperitoneal polypropylene mesh repair of incisional hernia is not associated with enterocutaneous fistula.

BACKGROUND: Incisional hernia repair with prosthetic material is followed by fewer recurrences than primary repair. Polypropylene is the most commonly used prosthetic material but may cause entero- cutaneous fistulas. The aim of this study was to determine whether enterocutaneous fistulas developed after incisional hernia repair with polypropylene mesh and to evaluate clinical outcome after incisional hernia repair. METHODS: A retrospective analysis of the outcome of incisional hernia repair with polypropylene mesh between 1982 and 1998 was conducted. Follow-up data were obtained from medical records and questionnaires. RESULTS: Polypropylene incisional hernia repair was performed in 136 patients. Median follow-up was 34 months. No enterocutaneous fistulas developed. Wound infection occurred in 6 per cent. Wound sinus formation occurred in two patients. No mesh was removed because of infection and no persisting infection of the mesh occurred. CONCLUSION: Enterocutaneous fistula formation appears to be very rare after incisional hernia repair with polypropylene mesh, regardless of intraperitoneal placement, omental coverage or closing of the peritoneum.

Comparison of one-lung ventilation and high-frequency ventilation in thoracoscopic surgery.

OBJECTIVE: To report our experience of the use of high frequency ventilation (HFV) in thoracoscopic surgery. DESIGN: Retrospective study. SETTING: University Hospital Rotterdam, The Netherlands. SUBJECTS: 31 patients (18 men and 13 women, mean age 42 years, range 26-67 years) who underwent 46 thoracoscopic procedures between January 1992 and December 1997. INTERVENTIONS: Until October 1994 patients had conventional mechanical ventilation with a double-lumen tube. Since then HFV has been used. MAIN OUTCOME MEASURES: Duration of induction, oxygen saturation, and end-tidal carbon dioxide tension. RESULTS: 25 procedures were done with a double-lumen endotracheal tube for one-lung ventilation and in 21 HFV was used. Induction of anaesthesia took significantly less time in the HFV group (median 14 minutes) compared with one-lung ventilation group (median 31 minutes) (p < 0.05). There were no significant differences between the groups in either SaO2 or end-tidal CO2. CONCLUSION: HFV is both safe and simple for use in thoracoscopic surgery.

[Laparoscopic splenectomy for hematological diseases; results in 28 patients]. / Laparoscopische splenectomie voor hematologische aandoeningen; resultaten bij 28 patiënten.

OBJECTIVE: To evaluate the first results of laparoscopic splenectomy for haematological diseases and the learning curve. DESIGN: Retrospective. PATIENTS AND METHODS: Data of all patients who underwent a laparoscopic splenectomy in October 1994-July 1998 in the University Hospital Rotterdam, Department of surgery, the Netherlands, were collected from electronic databases. Data on postoperative complications were collected from medical records. Patients with splenomegaly (> 15 cm) were not eligible for the procedure. RESULTS: 28 patients were eligible for a laparoscopic splenectomy. The male:female ratio was 1:4. The mean age was 35 years. The indications for surgery were idiopathic thrombocytopenic purpura (ITP; n = 24), Gilbert syndrome (n = 1), spherocytosis (n = 1), thalassaemia (n = 1) and haemolytic anaemia with ITP (n = 1). Conversion to an open procedure was necessary in 5 of 28 laparoscopic splenectomies (18%). The median operating time was 172 minutes. Complications occurred in four patients: pneumonia (n = 2), bleeding (n = 1) and urosepsis (n = 1). The median hospital stay was 5 days (range: 1-18). The first 14 laparoscopic splenectomies differed from the following 14 by a higher conversion rate (p = 0.01), a longer operation time (p = 0.002) and a longer hospital stay (p = 0.004). In 23 out of 25 patients with ITP the thrombocyte count became normal. CONCLUSION: Laparoscopic splenectomy is associated with a learning curve, with a high incidence of conversion in the early procedures. It appears to be a safe and effective operation.