Hospital admissions of patients aged over 80 with acute abdominal complaints.

OBJECTIVE: Evaluation of the outcome of patients aged over 80 with acute abdominal complaints, who were admitted to the hospital through the emergency department. DESIGN: Retrospective study. SETTING: City hospital, the Netherlands. PATIENTS: 132 patients aged over 80 with acute abdominal complaints who were admitted through the emergency department in 1997. MAIN OUTCOME MEASURES: Diagnosis at admission and discharge or necropsy, diagnostic tests, treatment, morbidity, and mortality. RESULTS: In 27 of 132 patients (20%) the diagnosis on discharge or at necropsy differed from the initial diagnosis in the emergency department; in 18 patients (14%) an important diagnosis was missed and the severity was underestimated. Within the first 24 hours, 97% (n = 128) had blood tests, 63% (n = 83) urine tests, 58% (n = 76) plain radiograph of the abdomen, 20% (n = 26) ultrasonography, and 3% (n = 4) computed tomography (CT) of the abdomen. Of all the patients admitted, 35 (27%) were operated on. The hospital mortality of the admitted patients was 17% (n = 23) and of those operated on 34% (n = 12). The mortality in the 27 misdiagnosed patients was 59% (n = 16). The morbidity among the 109 surviving patients was 22%. CONCLUSIONS: Mortality was high among those aged over 80 with acute abdominal complaints who were admitted through the emergency department, particularly among those who were operated on and those who were misdiagnosed. Guidelines for an earlier and more comprehensive diagnostic approach could lead to better insight into the prognosis and thereby to more adequate and better-targeted treatment.

Prognostic role of thymidylate synthase, thymidine phosphorylase/platelet-derived endothelial cell growth factor, and proliferation markers in colorectal cancer.

5-Fluorouracil (5FU)-based therapy is given to patients with advanced colorectal cancer and as adjuvant treatment. Thymidylate synthase (TS) is the target for 5FU, and may have a prognostic role for the outcome of 5FU-based therapy together with proliferation markers such as p53 and Ki67. Thymidine phosphorylase (TP, also known as platelet-derived endothelial cell growth factor) may be of importance both in the 5FU drug activation pathway and in tumor angiogenesis, similar to vascular endothelial growth factor (VEGF). TS and TP levels were determined biochemically in fresh-frozen tumor specimens of 32 untreated patients with colorectal cancer, whereas in paraffin-embedded tissue samples, immunohistochemistry was performed for TS, TP, and additional prognostic markers such as p53, Ki67, and VEGF as well as microvessel density. All factors were correlated with patient characteristics such as age, gender, Dukes' stage, angio-invasion, and differentiation grade. TS and TP as measured by various assays were correlated with overall and disease-free survival in this patient group. TP enzyme activity and protein expression correlated with each other. A significant correlation was found between TP enzyme activity and 5-fluoro-2'-deoxyuridine-5'-monophosphate binding activity. VEGF expression correlated significantly with TP immunostaining and Ki67 index. Survival analysis revealed a significant relation of TS levels to the overall survival in this small patient group and a significant correlation between TP activity and disease-free survival. TS and TP both were of prognostic significance in these patients with colorectal cancer. The interesting relationship of TS and TP with angiogenesis and proliferation needs further investigation.

[Nonspecific symptoms due to gastrointestinal stromal tumors]. / Aspecifieke klachten bij gezwellen van de maag-darmwand.

Three patients, two women aged 64 and 52 years and one man aged 78 years, had non-specific symptoms and they had signs of a tumour at imaging examination. Immunohistochemical study of operation preparations led to the diagnosis of 'gastrointestinal stromal tumour' (GIST). It is important to consider the possibility of a GIST at surgery, because the potential malignancy requires a resection with free margins.

[Prospective follow-up of patients with abdominal symptoms treated by emergency room physicians]. / Prospective follow-up van patiënten met buikklachten behandeld door een eerstehulparts.

In order to evaluate the functioning of emergency room (ER) physicians, patients seen at the ER of the Onze Lieve Vrouwe Gasthuis. Amsterdam, the Netherlands, for abdominal symptoms without having been referred by the GP, were questioned by letter about the course of events two weeks after their visit. Of the 1853 patients with abdominal symptoms attending the ER in July-December 1997, 1221 had no referral letter; of these, 933 were treated independently by the ER physician. Of the latter, 814 were sent a letter, to which 663 of them responded. 307 of them had visited the GP and 48 an ER. Of these 48 patients, 17 had been admitted and 14 of them had been operated. In seven of the 17 patients, the condition had not been recognized by the ER physician at the first visit.

Treatment of self-referred patients with abdominal complaints by emergency physicians. A prospective observational study in an emergency department in The Netherlands.

The quality of the treatment by emergency physicians of patients with abdominal complaints, who visited the emergency department (ED) of a city hospital (OLVG), Amsterdam, The Netherlands, was evaluated in a prospective observational study. During 6 months 1853 patients with abdominal complaints visited the emergency department of the OLVG hospital, 1221 patients (66%) without referral by a general practitioner (GP). Of these 1221 patients, 933 (76%) were treated by the emergency physician without consulting a specialist. Of these 933 patients, 814 were included in our follow-up study. A questionnaire was sent to them 1 week after visiting the ED. The response rate was 81% (663 patients). Of these 633 patients 48 patients sought medical help within 2 weeks after being discharged from the ED (38 patients in the same hospital and 10 patients in another hospital). Of these 48 patients, 17 were admitted to the hospital and 14 of them were operated on. After evaluation of these 17 patients we could conclude that seven patients were initially misdiagnosed by the emergency physician (1.1%). It is concluded that most patients with abdominal complaints visit the ED of this hospital without referral by their GP. Of these patients, the emergency physician can treat 76% without further specialist consultation. In seven patients (1.1%) the diagnosis was missed.

[Good results from treatment of patients with abdominal pain at the emergency department of the Amsterdam OLVG Hospital]. / Goede resultaten van de behandeling van patiënten met buikklachten op de afdeling Spoedeisende Hulp van het Onze Lieve Vrouwe Gasthuis te Amsterdam.

OBJECTIVE: Evaluation of the treatment of patients with abdominal complaints at the first aid department of a city hospital, where patients were treated by emergency doctors (EMD) in combination with specialists. DESIGN: Retrospective, descriptive. SETTING: Onze Lieve Vrouwe Gasthuis, first aid department, Amsterdam, the Netherlands. PATIENTS AND METHOD: Data were collected on diagnosis, treatment and course in 3235 patients with abdominal complaints seen at the first aid department in 1997. Non-referred patients were treated by EMD who if necessary consulted a specialist. Referred patients were seen by specialists. RESULTS: Of the 2931 patients who visited the first aid department once, 1975 patients (67%) were seen after self-referral. Of this group, 1557 patients (79%) were treated by the EMD alone and could be sent to the general practitioner (GP) without consulting a specialist. These accounted for 53% of the 2931 patients with abdominal complaints. The EMD used fewer additional tests than the specialist. Of the patients, 91% could be treated conservatively, only 9% were operated. Fifty-three patients died. Analysis of the group of 304 patients who visited the first aid department more than once in the year of study, showed that in 28 cases the diagnosis was missed (in 17 cases by the EMD and in 11 by the specialist). Of this group 23 had to be operated upon. CONCLUSION: The organisation of a first aid department like that in the OLVG, with EMDs and specialists, appeared efficient; the rates of morbidity, mortality and missed diagnoses are acceptable. With relatively few additional tests, the EMD appeared to be able to differentiate between GP care and hospital care.

[More recurrencies than expected following inguinal hernia surgery]. / Meer recidieven na liesbreukchirurgie dan verwacht.

OBJECTIVE: To make an inventory of inguinal hernia repairs performed in one year, and to analyse the number of and origin of recurrent hernias. DESIGN: Retrospective. SETTING: Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands. METHOD: Analysis of all hernia operations performed in Amsterdam and Amstelveen in 1994 in male patients over 18 years of age. Request of national data, computer data from the hospitals, hand count of all operation reports and investigation of patient files. RESULTS: In 1994, 1108 patients were operated for inguinal hernia on one or two sides. In 216/1108 (19.5%) cases recurrent hernia was involved. According to national statistics this occurred in 175/1123 (15.6%). In the two University hospitals 25.7% of all repairs were for a recurrent hernia, in the two hospitals with a surgical training programme this proportion was 17.9% and in the five hospitals without a training programme it was 18.6%. Of the early recurrences (within two years) 82.5% (47/57) were reoperated in the same hospital as before but of the late recurrences (more than 10 years) this proportion was only 26.8%. Only 16.6% (36/216) of the patients with a recurrence were reoperated by the same surgeon who had performed the prior operation. Most popular method for repair was a Bassini (59%). In the training hospitals more early recurrences were repaired than in the non-training hospitals. CONCLUSION: The percentage of hernia repairs for recurrent hernia is higher than national statistics suggest and higher than expected. Surgeons have little insight into their performance as many recurrences are repaired by another surgeon and many recurrences occur after ten years. Better training and more use of modern techniques may improve results.

Role of the Shouldice technique in inguinal hernia repair: a systematic review of controlled trials and a meta-analysis.

The Shouldice technique for inguinal hernia repair has been suggested by some authors as the best conventional method against which other methods using prostheses should be compared. The paper which follows is a systematic review involving a comprehensive search of the medical literature to identify all clinical trials (article or abstract) evaluating the Shouldice repair. After assessment of certain quality criteria, the best studies were pooled in a meta-analysis. Nine publications were found with 11 study arms. In ten studies the results of the Shouldice technique were better than the results of the control arm. Six studies could be pooled in a meta-analysis of 2500 patients; Shouldice was significantly better than control methods (relative risk 0.62 (95 per cent confidence interval 0.45-0.85)). In spite of possible bias caused by different variables (modifications in operative technique, suture material, level of surgeon, follow-up methods and outcome measurement), the results of this systematic review suggest that the Shouldice method is the best current conventional technique for inguinal hernia repair.

[Continent ileostomy following discontinuation of ileoanal anastomosis with ileum reservoir; good results in 7 patients]. / Een continent ileostoma na opheffen van een ileoanale anastomose met ileumreservoir; goede resultaten bij 7 patiënten.

OBJECTIVE: To study the results of constructing a continent ileostomy in cases of problems with a former ileoanal pouch operation. DESIGN: Retrospective and questionnaire study. SETTING: Onze Lieve Vrouwe Gasthuis, department of General Surgery, Amsterdam, the Netherlands. METHOD: The operations of 7 patients in the period 1988 to 1993 were analysed for indication and postoperative results; the long term functioning was determined by means of a questionnaire. Indications for removal of the ileoanal pouch were septic problems in the true pelvis, untreatable inflammation of the pouch with high defecation frequency and incontinence. RESULTS: The results in all 7 patients were good. No postoperative complications were observed. However, supra-anal sinus problems developed in the next 2 years in 6 out of the 7 patients and in 4 had to be treated by operation. The follow-up after 5 years on average showed that functioning was good in all patients. Because the continent ileostomy gave minimal trouble in work, sport and social life, the patients' satisfaction was high. CONCLUSION: The continent ileostomy should be considered a good alternative to a terminal ileostomy, notably for patients in whom resection of a dysfunctioning ileoanal pouch will be performed. Continence can be preserved in this way, which is of great importance to the patient.

Transphrenic dissemination of actinomycosis.

Thoracic actinomycosis is an uncommon disease and often presents difficulty in diagnosis. Two cases are presented in which thoracic actinomycosis produced fistulae between the thoracic and abdominal cavities. Surgical drainage and high dose penicillin for at least 4-6 months was the treatment of choice.

Primary inguinal hernia repair in The Netherlands.

OBJECTIVE: To assess the operative methods used in Dutch surgical practice to repair the inguinal floor of the primary hernia. DESIGN: Survey by questionnaire. SETTING: University department of Surgery, The Netherlands. SUBJECTS: All Dutch Surgeons. OUTCOME MEASURES: Answers to questions about the methods of repair used, specific surgical options, and materials. Comparison of training hospitals and district hospitals. RESULTS: Replies were received from 145/155 departments (94%), but from only 448/774 individual surgeons (58%). 192 (43%) used one method alone (Bassini 71, Shouldice 49, McVay 36, Griffith 24 and others 12) and 256 (57%) of surgeons used combinations of 11 different methods. Only 9 used a prosthetic mesh and 7 laparoscopic repair. The Shouldice method was significantly more popular in training hospitals compared with non-training hospitals (36%) (71/199) compared with (20%) (48/249) (p < 0.05). There were many modifications to accepted methods. Only 78% (94/121) of surgeons who said that they did a standard shouldice repair incised the transversalis fascia. 64% (287) of surgeons said that they modified their technique to suit individual patients. CONCLUSION: In the Netherlands there is no standard technique of inguinal hernia repair.

[Leiomyosarcoma of the small intestine: a rare cause of gastrointestinal blood loss]. / Leiomyosarcoom van de dunne darm: een zeldzame oorzaak van gastro-intestinaal bloedverlies.

A 61-year old man is described with recurrent gastrointestinal bleeding, due to a metastatic jejunal leiomyosarcoma. Because of the low incidence and the aspecific symptoms, a long delay occurred until the bleeding tumour and its metastases were demonstrated at radionuclide scanning and mesenteric angiography. The tumour-bearing segment could be removed by simple surgical excision.

[Dieulafoy's exulceratio simplex, a life-threatening gastric hemorrhage]. / Exulceratio simplex Dieulafoy, een levensbedreigende maagbloeding.

The 'exulceratio simplex Dieulafoy' is an uncommon and probably underdiagnosed cause of upper gastrointestinal haemorrhage. The bleeding is intermittent and even endoscopically often missed. In this article the pathogenesis, diagnostic methods, clinical presentation and therapy are discussed. We present one case treated in our hospital.

Longitudinal myotomy of ileum for bladder replacement in dogs.

To evaluate the application of longitudinal myotomy of ileum for bladder replacement, pressure/volume characteristics of myotomized ileal segments were studied in dogs after incorporation in the urinary tract. In five dogs a 12 cm. long myotomized ileal segment was incorporated in the left urinary system as a ureteral substitute. These ileal segments did not dilate. In another six animals total cystectomy was carried out and the bladder was replaced by a 12 cm. long myotomized ileal segment. Urodynamic and radiological studies demonstrated early dilatation of these segments, leading to a four-to-five-fold increase in volume after six weeks. During filling the intraluminar pressure remained below 20 cm. H2O up to two-thirds of the maximal volume and gradually rose when filling was continued. High pressure waves were not observed. This study demonstrates that in experimental dogs longitudinal myotomy of a short length of ileum results in a high volume/low pressure urinary reservoir. This technique is easy to perform, requires less bowel compared to current reservoir techniques and leads to satisfactory reservoir function.

Epidemiology of the Bacteroides fragilis group in the colonic flora in 10 patients with colonic cancer.

We report the relative frequencies of members of the Bacteroides fragilis group in the faeces, in colon lavage fluid obtained pre-operatively, and in colonic tissue specimens obtained at operation from 10 patients with colonic cancer. B. vulgatus was the most and B. fragilis and B. ovatus were the least frequently isolated Bacteroides spp. in the faeces of the 10 subjects. B. uniformis and B. thetaiotaomicron ranked second and third in the faeces. The relative frequencies of all species except B. fragilis were lower in the lavage fluid and in cultures of mucosa. The relative frequency of B. fragilis increased from 4% in faeces to 39% in the final lavage fluid and to 42% in the colonic mucosa culture. Our results suggest that B. fragilis has a more intimate association with the gut mucosa than other members of the B. fragilis group, which might be one explanation for the high incidence of this species in gut-associated intra-abdominal infections.