[Internal and external haemorrhoids]. / Interne en externe hemorroïden.

In this article, we present 3 cases of patients with different types of haemorrhoidal disease. The first patient is a 27-year-old woman who had been experiencing incidental rectal blood loss without pain during defecation for 3 months. The second patient is a 76-year-old woman who had been bothered by varying degrees of pain from a swelling nearby the anus for 1 year. The third case involves a 31-year-old man who had had continuous severe pain in the anal area for 3 consecutive days. The first patient appeared to have internal hemorrhoids, whereas different forms of external hemorrhoids affected the patients in the other 2 cases. Internal haemorrhoids develop from the intraluminal corpus cavernosum recti; external haemorrhoids from the perianal marginal veins. Patients with internal haemorrhoids present with symptoms that include blood loss and prolaps feeling during defecation. In patients with external haemorrhoids pain is the prominent symptom. Internal haemorrhoids are treated either conservatively or surgically, depending upon their severity. Considering external haemorrhoidal disease surgical treatment provides the most rapid and persistent relief of symptoms.

Single-dose antibiotic prophylaxis for urinary catheter removal does not reduce the risk of urinary tract infection in surgical patients: a randomized double-blind placebo-controlled trial.

We conducted a double-blind, placebo-controlled randomized trial to assess the effect of single-dose prophylaxis using co-trimoxazole (960 mg) (n = 46) or ciprofloxacin (500 mg) (n = 43) vs. placebo (n = 51) before urinary catheter removal on significant bacteriuria (SBU) (primary outcome) and urinary tract infection (UTI) in surgical patients with scheduled bladder drainage for 3-14 days. SBU was determined directly after catheter removal, and UTI 12-14 days after catheter removal. After 12-14 days, incidences of SBU were 19%, 19% and 33% for patients receiving ciprofloxacin, co-trimoxazole and placebo, respectively (p ns), and incidences of UTI were 3%, 0% and 3% for patients receiving ciprofloxacin, co-trimoxazole and placebo, respectively (p ns).

Anatomical branches of the superior rectal artery in the distal rectum.

OBJECTIVE: The aim of this experimental study was to study the arterial supply of the corpus cavernosum recti in the inner wall of the distal rectum in relation to haemorrhoidal ligation therapy. METHOD: In 10 nonfixed human cadavers, the arterial vasculature of the rectum was studied using the Araldite casting method. Subsequently, the specimens were treated with methylbenzoate in order to obtain semitransparent specimens in which the corpus cavernosum recti could be studied. RESULTS: Specimens were obtained permitting study of the arterial vasculature of the rectum and corpus cavernosum recti at all levels. The superior rectal artery was found to supply the corpus cavernosum recti which consisted of a variable number of equally spaced twisting arteries. CONCLUSION: The distal rectum is supplied by the superior rectal artery. The supplying arteries of the corpus cavernosum recti are not confined to the strict locations described in the literature. This finding is of importance in surgical treatment of haemorrhoidal disease.

[Symptomatic gallstone disease: an indication for surgery]. / Symptomatisch galsteenlijden: een operatie-indicatie.

Three patients, men in the ages of 58, 66 and 56 years, respectively, had experienced 'warning colics' a considerable time before gallstone complications or severe recurrent colic. Ultrasonographically proven gallstones had not led to cholecystectomy. The 58-year-old man died of sepsis due to infected pancreatic necrosis; the other men underwent laparoscopic cholecystectomy, after which they recovered fully. Approximately 10-5% of the adult Dutch population have gallstones, but only 10% will develop symptoms. The annual risk for developing complicated gallstone disease is 1-2% in asymptomatic gallstone carriers. Of patients admitted with complicated gallstone disease, 58% have had prior 'warning colics'. Complicated gallstone disease can be prevented by timely treatment after recognition of warning colics. Cholecystectomy is indicated in patients with intermittent upper-abdominal pain and proven gallstones or sludge.

What is next in inguinal hernia surgery?

Traditionally, the inguinal hernia repair is performed through an incision in the groin. Different kinds of operations are suggested as best repairs by using the patient's own tissue, or use of prosthetic mesh to reinforce the abdominal wall. The advent of the laparoscopic repair that also uses prosthetic mesh, made it even more complex to determine the best repair. Using the Evidence Based Medicine (EBM) principles, endpoints of the treatment are not only based on recurrence rates, but also on complications, patient satisfaction, convalescence, and costs. Several meta-analyses concluded that use of mesh is superior to the non-mesh operations. More difficult to determine is which mesh repair, open or laparoscopically, is the best. The laparoscopic repair is difficult and less suitable for general practice, but the open-mesh repair results in a higher percentage of chronic postoperative pain. Further research should be focused on making the laparoscopic repair less complicated, and development of new meshes for open surgery that reduce the amount of persistent postoperative pain.

[Proximal femur fractures in the elderly in The Netherlands during the period 1991-2004: incidence, mortality, length of hospital stay and an estimate of the care capacity needed in the future]. / Proximale femurfracturen bij ouderen in Nederland in de periode 1991-2004: incidentie, sterfte, opnameduur en schatting van de in de toekomst benodigde zorgcapaciteit.

OBJECTIVE: To assess the incidence of operations for neck and pertrochanteric femur fractures during the last 15 years and to estimate the future demand for such operations in The Netherlands. DESIGN: Retrospective. METHOD: For the years 1991, 1995, 2000 and 2004, the following anonymised data were collected in the National Medical Registry of Prismant for all patients admitted to Dutch hospitals for a hip fracture: age-group, gender, length of pre- and postoperative hospital stay, destination after discharge and hospital mortality. These data were related to demographic data for the Dutch population from Statistics Netherlands (CBCS) and to estimates for the Dutch population in the future from Primos Prognostic Data. RESULTS: The average absolute increase in the period 1991-2004 was linear, with 230 fractures per year. Women were operated for a hip fracture 1.5-2 times as often as men in the same age range. The age-specific incidence remained constant over the years but the absolute number of elderly persons per age group increased. The average length of pre- and postoperative hospital stay was reduced by half during the period under investigation. The postoperative hospital mortality decreased from 8.1% in 1991 to 5.6% in 2004, and was 1.5 times as high for men aged 70 years or over as for women of the same age group. In 2004 as compared to 1991, 2.5 times as many patients were discharged to a nursing home. In view of the increasing age of the population, the total number of operated hip fractures can be expected to be 20,200 in the year 2010 and 23,900 in the year 2020. CONCLUSION: In the period 1991-2004 there was an annual increase of 230 operations for proximal femur fractures that was closely related to the ageing of the Dutch population. During the years under investigation, the incidence in the same age range was higher in women, but men had a higher hospital mortality. It is estimated that the decreasing hospital mortality and the decrease in the length of hospital stay will increase the need for nursing-home care for this category of patients.

Time-action analysis of instrument positioners in laparoscopic cholecystectomy.

BACKGROUND: Instrument positioners can position and lock a laparoscopic instrument. This study uses time-action analysis to evaluate objectively whether IPs can substitute for a surgical assistant efficiently and safely. METHODS: In four hospitals, 78 laparoscopic cholecystectomies were randomly assisted by a surgical assistant or an instrument positioner (AESOP and PASSIST) The efficiency and safety of laparoscopic cholecystectomies were analyzed with respect to time, number and type of actions, positioning accuracy, and peroperative complications. A questionnaire evaluated the difficulties for each operation and the comfort of instrument positioner use. RESULTS: The PASSIST and AESOP were able to replace the surgical assistant during laparoscopic cholecystectomies without significantly changing either the efficiency or the safety of the operation. The questionnaire showed that the surgeons preferred to operate with an instrument positioner. CONCLUSION: This study assessed objectively that instrument positioners can substitute for a surgical assistant efficiently and safely in elective laparoscopic cholecystectomies.