The ileo neo rectal anastomosis: long-term results of surgical innovation in patients after ulcerative colitis and familial adenomatous polyposis.

PURPOSE: Restorative proctocolectomy with ileo neo rectal anastomosis (INRA) combines cure of ulcerative colitis (UC) or familial adenomatous polyposis (FAP) with restoration of intestinal continuity. Evaluation of long-term results was needed to determine if there is a place for INRA in the armamentarium of a surgeon besides the ileal pouch anal anastomosis (IPAA). METHODS: All patients with INRA were included in the analysis. Patient demographics and clinical and follow-up data (morbidity, dietary problems, defecation frequency, fecal continence, anal and neorectal physiology, and neorectal mucosa assessment) were registered prospectively. RESULTS: Seventy-nine patients were enrolled, and in 58 patients (50 UC, 8 FAP), INRA was successful. In 21 patients, intraoperative conversion to IPAA was needed. In 49 patients with INRA, a functional reservoir was achieved. No pelvic sepsis or bladder or sexual dysfunction occurred. Thirteen patients experienced episodes of reservoir inflammation. Median bowel movements of six (5, 8) with a nocturnal defecation frequency of one were recorded with fecal continence or minor incontinence. Anal manometry and neorectal physiology showed a decrease in resting pressure and an increase in squeeze pressure and maximum tolerated volume. The median follow-up was 8.1 years (6.7, 10.1). CONCLUSIONS: This is an example of a surgical innovation with a theoretical potential to be superior to the current technique. This potential was not confirmed in short- and long-term evaluations. Hence, IPAA is currently the best available alternative to a conventional ileostomy.

A prospective cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track multimodal management, for surgical patients with colon carcinomas (TAPAS study).

BACKGROUND: The present developments in colon surgery are characterized by two innovations: the introduction of the laparoscopic operation technique and fast recovery programs such as the Enhanced Recovery After Surgery (ERAS) recovery program. The Tapas-study was conceived to determine which of the three treatment programs: open conventional surgery, open 'ERAS' surgery or laparoscopic 'ERAS' surgery for patients with colon carcinomas is most cost minimizing? METHOD/DESIGN: The Tapas-study is a three-arm multicenter prospective cohort study. All patients with colon carcinoma, eligible for surgical treatment within the study period in four general teaching hospitals and one university hospital will be included. This design produces three cohorts: Conventional open surgery is the control exposure (cohort 1). Open surgery with ERAS recovery (cohort 2) and laparoscopic surgery with ERAS recovery (cohort 3) are the alternative exposures. Three separate time periods are used in order to prevent attrition bias. Primary outcome parameters are the two main cost factors: direct medical costs (real cost price calculation) and the indirect non medical costs (friction method). Secondary outcome parameters are mortality, complications, surgical-oncological resection margins, hospital stay, readmission rates, time back to work/recovery, health status and quality of life. Based on an estimated difference in direct medical costs (highest cost factor) of 38% between open and laparoscopic surgery (alfa = 0.01, beta = 0.05), a group size of 3 x 40 = 120 patients is calculated. DISCUSSION: The Tapas-study is three-arm multicenter cohort study that will provide a cost evaluation of three treatment programs for patients with colon carcinoma, which may serve as a guideline for choice of treatment and investment strategies in hospitals. TRIAL REGISTRATION: ISRCTN44649165.

The influence of mechanical bowel preparation in elective lower colorectal surgery.

OBJECTIVE: This study evaluates the effects of mechanical bowel preparation (MBP) on anastomosis below the peritoneal verge and questions the influence of MBP on anastomotic leakage in combination with a diverting ileostomy in lower colorectal surgery. SUMMARY BACKGROUND DATA: In a previous large multicenter randomized controlled trial MBP has shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in lower colorectal surgery with or without a diverting ileostomy remains unclear. METHODS: This study is a subgroup analysis of a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP. Primary end point was the occurrence of anastomotic leakage and secondary endpoints were septic complications and mortality. RESULTS: Total of 449 Patients underwent a low anterior resection with a primary anastomosis below the peritoneal verge. The incidence of anastomotic leakage was 7.6% for patients who received MBP and 6.6% for patients who did not. Significant risk factors for anastomotic leakage were the American Society of Anesthesiologists-classification (P = 0.005) and male gender (P = 0.007). Of total, 48 patients received a diverting ileostomy during initial surgery; 27 patients received MBP and 21 patients did not. There were no significant differences regarding septic complications and mortality between both groups. CONCLUSION: MBP has no influence on the incidence of anastomotic leakage in low colorectal surgery. Furthermore, omitting MBP in combination with a diverting ileostomy has no influence on the incidence of anastomotic leakage, septic complications, and mortality rate.

Improving the false-negative rate of CT in acute appendicitis-Reassessment of CT images by body imaging radiologists: a blinded prospective study.

PURPOSE: To compare the accuracy of computed tomography (CT) analyzed by individual radiology staff members and body imaging radiologists in a non-academic teaching hospital for the diagnosis of acute appendicitis. PATIENTS AND METHODS: In a prospective study 199 patients with suspected acute appendicitis were examined with unenhanced CT. CT images were pre-operatively analyzed by one of the 12 members of the radiology staff. In a later stage two body imaging radiologist reassessed all CT images without knowledge of the surgical findings and without knowledge of the primary CT diagnosis. The results, independently reported, were correlated with surgical and histopathologic findings. RESULTS: In 132 patients (66%) acute appendicitis was found at surgery, in 67 patients (34%) a normal appendix was found. The sensitivity of the primary CT analysis and of the reassessment was 76% and 88%, respectively; the specificity was 84% and 87%; the positive predictive value was 90% and 93%; the negative predictive value was 64% and 78%; and the accuracy was 78% and 87%. CONCLUSION: Reassessment of CT images for acute appendicitis by body imaging radiologists results in a significant improvement of sensitivity, negative predictive value and accuracy. To prevent false-negative interpretation of CT images in acute appendicitis the expertise of the attending radiologist should be considered.

[The use of imaging in the case of suspected acute appendicitis: opinion of Dutch surgeons]. / Beeldvormend onderzoek bij vermoeden van appendicitis acuta: mening van chirurgen in Nederland.

OBJECTIVE: To gauge the opinion of Dutch surgeons concerning the use of ultrasound and CT in the case of a suspected acute appendicitis. DESIGN: Written survey. METHOD: All 1020 members of the Association of the Surgeons of the Netherlands received a questionnaire with 8 statements concerning the diagnosis of acute appendicitis. The statements could be answered with 'agree', 'disagree', or 'no opinion'. RESULTS: The questionnaire was returned by 439 members (43%). A majority (64%) of these respondents established the diagnosis acute appendicitis on the basis of clinical symptoms, whereas a minority (22%) routinely performed ultrasound. For a classical presentation, 45% of the respondents thought ultrasound was indicated; for less than 3 classical symptoms, 70% of the respondents thought ultrasound was indicated. For women of fertile age, 74% of the respondents thought ultrasound was indicated. Approximately half (46%) of the surgeons always had access to a radiologist who could reliably perform ultrasound imaging, whereas 34% did not. The combination of ultrasound and CT was considered to be a reliable diagnostic procedure by 74% of the surgeons. CONCLUSION: The majority of the surgeons considered acute appendicitis to be mainly a clinical diagnosis.

The Tilburg double blind randomised controlled trial comparing inguinal hernia repair according to Lichtenstein and the transinguinal preperitoneal technique.

BACKGROUND: Anterior open treatment of the inguinal hernia with a tension free mesh has reduced the incidence of recurrence and direct postoperative pain. The Lichtenstein procedure rules nowadays as reference technique for hernia treatment. Not recurrences but chronic pain is the main postoperative complication in inguinal hernia repair after Lichtenstein's technique. Preliminary experiences with a soft mesh placed in the preperitoneal space showed good results and less chronic pain. METHODS: The TULIP is a double-blind randomised controlled trial in which 300 patients will be randomly allocated to anterior inguinal hernia repair according to Lichtenstein or the transinguinal preperitoneal technique with soft mesh. All unilateral primary inguinal hernia patients eligible for operation who meet inclusion criteria will be invited to participate in this trial. The primary endpoint will be direct postoperative- and chronic pain. Secondary endpoints are operation time, postoperative complications, hospital stay, costs, return to daily activities (e.g. work) and recurrence. Both groups will be evaluated.Success rate of hernia repair and complications will be measured as safeguard for quality.To demonstrate that inguinal hernia repair according to the transinguinal preperitoneal (TIPP) technique reduces postoperative pain to <10%, with alpha = 0,05 and power 80%, a total sample size of 300 patients was calculated. DISCUSSION: The TULIP trial is aimed to show a reduction in postoperative chronic pain after anterior hernia repair according to the transinguinal preperitoneal (TIPP) technique, compared to Lichtenstein.In our hypothesis the TIPP technique reduces chronic pain compared to Lichtenstein. TRIAL REGISTRATION: ISRCTN 93798494.

Improving diagnosis of acute appendicitis: results of a diagnostic pathway with standard use of ultrasonography followed by selective use of CT.

BACKGROUND: Preoperative imaging has been demonstrated to improve diagnostic accuracy in appendicitis. This prospective study assessed the accuracy of a diagnostic pathway in acute appendicitis using ultrasonography (US) and complementary contrast-enhanced multidetector CT in a general community teaching hospital. STUDY DESIGN: One hundred fifty-one patients with clinically suspected appendicitis followed the designed protocol: patients underwent operations after a primary performed positive US (graded compression technique) or after complementary CT (contrast-enhanced multidetector CT) when US was negative or inconclusive. Patients with positive CT findings underwent operations. When CT was negative for appendicitis, they were admitted for observation. Results of US and CT were correlated with surgical findings, histopathology, and followup. RESULTS: Positive US was confirmed at operation in 71 of 79 patients and positive CT was confirmed in all 21 patients. All 39 patients with negative CT findings recovered without operations. The negative appendicitis rate was 8% and perforation rate was 9%. The sensitivity and specificity of US was 77% and 86%, respectively. The sensitivity and specificity of CT was both 100%. The sensitivity and specificity of the whole diagnostic pathway was 100% and 86%, respectively. CONCLUSIONS: A diagnostic pathway using primary graded compression US and complementary multidetector CT in a general community teaching hospital yields a high diagnostic accuracy for acute appendicitis without adverse events from delay in treatment. Although US is less accurate than CT, it can be used as a primary imaging modality, avoiding the disadvantages of CT. For those patients with negative US and CT findings, observation is safe.

Randomized clinical trial of small-incision and laparoscopic cholecystectomy in patients with symptomatic cholecystolithiasis: primary and clinical outcomes.

OBJECTIVE: To evaluate the primary and clinical outcomes in laparoscopic and small-incision cholecystectomy. DESIGN: Blinded randomized single-center trial emphasizing methodologic quality and generalizability. SETTING: General teaching hospital in the Netherlands. PATIENTS: A total of 257 patients undergoing cholecystectomy for symptomatic cholecystolithiasis. INTERVENTIONS: Laparoscopic cholecystectomy and small-incision cholecystectomy, performed mainly by surgical residents. MAIN OUTCOME MEASURES: Complications and symptom relief were primary outcome measures; conversion rate, operative time, and hospital stay were secondary outcome measures. Feasibility of performing both procedures by residents was evaluated as well. RESULTS: In the 257 patients, surgical residents performed 105 laparoscopic and 118 small-incision cholecystectomies. There were no significant differences in complications, conversion rates, and hospital stay. Operative time was significantly shorter with the small-incision technique. CONCLUSIONS: No differences in primary clinical outcome measures were found between laparoscopic and small-incision cholecystectomy in this randomized trial with emphasis on methodologic quality and generalizability. The gold standard status of laparoscopic cholecystectomy is questionable. Trial Registration isrctn.org Identifier: ISRCTN67485658.

Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial.

BACKGROUND: Mechanical bowel preparation is a common practice before elective colorectal surgery. We aimed to compare the rate of anastomotic leakage after elective colorectal resections and primary anastomoses between patients who did or did not have mechanical bowel preparation. METHODS: We did a multicentre randomised non-inferiority study at 13 hospitals. We randomly assigned 1431 patients who were going to have elective colorectal surgery to either receive mechanical bowel preparation or not. Patients who did not have mechanical bowel preparation had a normal meal on the day before the operation. Those who did were given a fluid diet, and mechanical bowel preparation with either polyethylene glycol or sodium phosphate. The primary endpoint was anastomotic leakage, and the study was designed to test the hypothesis that patients who are given mechanical bowel preparation before colorectal surgery do not have a lower risk of anastomotic leakage than those who are not. The median follow-up was 24 days (IQR 17-34). We analysed patients who were treated as per protocol. This study is registered with ClinicalTrials.gov, number NCT00288496. FINDINGS: 77 patients were excluded: 46 who did not have a bowel resection; 21 because of missing outcome data; and 10 who withdrew, cancelled, or were excluded for other reasons. The rate of anastomotic leakage did not differ between both groups: 32/670 (4.8%) patients who had mechanical bowel preparation and 37/684 (5.4%) in those who did not (difference 0.6%, 95% CI -1.7% to 2.9%, p=0.69). Patients who had mechanical bowel preparation had fewer abscesses after anastomotic leakage than those who did not (2/670 [0.3%] vs 17/684 [2.5%], p=0.001). Other septic complications, fascia dehiscence, and mortality did not differ between groups. INTERPRETATION: We advise that mechanical bowel preparation before elective colorectal surgery can safely be abandoned.

Comparison of CT and sonography in the diagnosis of acute appendicitis: a blinded prospective study.

OBJECTIVE: Our objective was to compare the accuracy of CT and sonography in a general community teaching hospital for the diagnosis of acute appendicitis in patients with suspected acute appendicitis. SUBJECTS AND METHODS. In this prospective study, 199 consecutive patients with clinical signs and symptoms of acute appendicitis were examined with sonography (graded compression technique) and CT (focused unenhanced single-detector helical CT [5-mm section thickness]. CT was performed from the L2 vertebral body to the pubic symphysis, and no patients were given oral, rectal, or IV contrast medium. The primary sonographic criterion for diagnosing acute appendicitis was an incompressible appendix with a transverse outer diameter of 6 mm or larger with incompressible periappendicular inflamed fat with or without an appendicolith. The primary CT criterion for diagnosing acute appendicitis was the identification of an appendix with a transverse outer diameter of 6 mm or larger with associated periappendiceal inflammatory changes. The results, independently reported, were correlated with surgical and histopathologic findings. RESULTS: One hundred thirty-two patients had acute appendicitis at surgery, and 67 patients did not. The sensitivity of CT and sonography was 76% and 79%, respectively; the specificity was 83% and 78%; the accuracy was 78% and 78%; the positive predictive value was 90% and 87%; and the negative predictive value was 64% and 65%. CONCLUSION: Unenhanced focused single-detector helical CT and graded compression sonography performed in a general community teaching hospital by both body imaging radiologists and general radiology staff members have a similar accuracy for the diagnosis of acute appendicitis.