[A patient with a possible Mirizzi's syndrome]. / Een patiënt met een mogelijk mirizzi-syndroom.

BACKGROUND: Mirizzi's syndrome is a rare cause of jaundice. The syndrome refers to common hepatic duct obstruction or choledoch duct obstruction caused by extrinsic compression of an impacted stone in the gallbladder neck or cystic duct. CASE DESCRIPTION: A 42-year-old woman was referred to the emergency department with symptoms indicative of obstructive icterus. Endoscopic retrograde cholangiopancreatography (ERCP) and a CT scan revealed signs of Mirizzi's syndrome but no indications of malignancy. Laparoscopic cholecystectomy was decided upon. This procedure revealed that the obstruction was caused by a gallbladder carcinoma. CONCLUSION: Of those patients suspected of having Mirizzi's syndrome, retrospectively 5-28% prove to have carcinoma of the gallbladder. Therefore in Mirizzi's syndrome before carrying out laparoscopic cholecystectomy a careful diagnostic approach is essential. This includes ERCP or MRI cholangiopancreaticography (MRCP) and a CT scan. Even after these investigations the surgeon should only perform laparoscopic surgery with caution, as it is often converted to an open procedure and because of the risk of presence of a malignancy.

Comparison of Doppler-guided haemorrhoidal artery ligation without mucopexy and rubber band ligation for haemorrhoids.

BACKGROUND AND STUDY AIMS: Recurrences after Doppler-guided haemorrhoidal artery ligation (DG-HAL) tend to occur in patients with concurrent mucosal prolapse. We retrospectively compared the results of DG-HAL and rubber band ligation (RBL) for the treatment of haemorrhoidal disease. PATIENTS AND METHODS: From 2005 to 2009, all patients who underwent either a DG-HAL procedure or RBL were selected. Follow-up was done by telephone using a standardised questionnaire survey to assess patient satisfaction and complaints. When recurrent disease was suspected, patients revisited the clinic for further examination and treatment. RESULTS: A total of 239 DG-HAL patients and 47 RBL patients were analysed. Sixty-seven percent in the DG-HAL group and 79% in the RBL group had an improvement in symptoms after one treatment (p=0.22). Forty-six DG-HAL patients (19%) needed a second procedure versus three patients (6%) in the RBL group (p<0.05). Cox regression analysis showed a significant difference in disease recurrence in favour of RBL (hazard ratio (HR) 3.71, 95% confidence interval (CI) 1.13-12.2). Patients in the DG-HAL group with recurrent haemorrhoids had a higher incidence of mucosal prolapse. CONCLUSION: DG-HAL seems very effective in treating lower-grade haemorrhoids. In more advanced disease, recurrence occurs due to persisting mucosal prolapse. RBL seems much more effective in reducing the prolapse and the chance of recurrence.

[New guideline on acute appendicitis: routine preoperative imaging is too simple]. / Nieuwe richtlijn acute appendicitis: routinematige preoperatieve beeldvorming is te simpel.

With 16,000 operations every year, acute appendicitis is one of the most common surgical diagnoses in Dutch emergency rooms. Diagnosis is based on clinical features: history, physical examination and laboratory testing. When the diagnosis is made, surgeons tend to operate quickly to prevent complications. In some cases this means that a healthy appendix is removed. The Dutch College of Surgeons wanted to reduce the number of removed healthy appendixes. This topic is discussed worldwide and the introduction of imaging is widely suggested. Ultrasonography and CT are said to be highly reliable in diagnosing appendicitis. While this may be the case in a research setting, it has been shown that in general hospitals they are not so reliable. Furthermore, the rise in the use of preoperative imaging has not brought down the negative appendectomy rate. We believe that imaging should be reserved for certain groups of patients. In the clear-cut cases it only increases the cost, patient burden and risk of complications; preoperative imaging should not be performed routinely.

Intrathoracic drainage of a perforated prepyloric gastric ulcer with a type II paraoesophageal hernia.

BACKGROUND: With an incidence of less than 5%, type II paraesophageal hernias are one of the less common types of hiatal hernias. We report a case of a perforated prepyloric gastric ulcer which, due to a type II hiatus hernia, drained into the mediastinum. CASE PRESENTATION: A 61-year old Caucasian man presented with acute abdominal pain. On a conventional x-ray of the chest a large mediastinal air-fluid collection and free intra-abdominal air was seen. Additional computed tomography revealed a large intra-thoracic air-fluid collection with a type II paraesophageal hernia. An emergency upper midline laparotomy was performed and a perforated pre-pyloric gastric ulcer was treated with an omental patch repair. The patient fully recovered after 10 days and continues to do well. CONCLUSION: Type II paraesophageal hernia is an uncommon diagnosis. The main risk is gastric volvulus and possible gastric torsion. Intrathoracic perforation of gastric ulcers due to a type II hiatus hernia is extremely rare and can be a diagnostic and treatment challenge.

Individualized dosing regimen for prothrombin complex concentrate more effective than standard treatment in the reversal of oral anticoagulant therapy: an open, prospective randomized controlled trial.

Prothrombin Complex Concentrate (PCC) is indicated for the acute reversal of oral anticoagulation therapy. To compare the efficacy of a "standard" dosage of 20 ml PCC equivalent to about 500 IU factor IX (group A), and an "individualized" dosage based on a target-INR of 2.1 or 1.5, the initial-INR and the patient's body weight (group B), we performed an open, prospective, randomized, controlled trial. The in vivo response and in vivo recovery of factor II, VII, IX and X in these patients on oral anticoagulation was determined. Ninety three patients (group A: 47; group B: 46) with major bleedings or admitted for urgent (surgical) interventions were enrolled. PCC and Vitamin K (10 mg) were administered intravenously. We evaluated the effect of treatment by the decrease of INR and the clinical outcome. The number of patients reaching the target-INR 15 min after the dosage of PCC was significantly higher in the group treated with an "individualized" dosage, compared to the group treated with a standard dose, (89% versus 43%; p<0.001). So, we conclude that for the acute reversal of oral anticoagulant therapy, an "individualized" dosage regimen of PCC based on the target-INR, the initial-INR, and body weight of the patient, is significantly more effective in reaching the target-INR than a "standard" dosage. The in vivo response and in vivo recovery found in this study was higher then in patients with isolated factor deficiencies. This suggests that the pharmacokinetics in patients on oral anticoagulants may be different.