Long-term follow-up after umbilical hernia repair: are there risk factors for recurrence after simple and mesh repair.

Adult umbilical hernia is a common surgical condition mainly encountered in the fifth and sixth decade of life. Despite the high frequency of the umbilical hernia repair procedure, disappointingly high recurrence rates, up to 54% for simple suture repair, are reported. Since both mesh and suture techniques are used in our clinic we set out to investigate the respective recurrence rates and associated complications, retrospectively. Patients who were treated between January 1998 and December 2002 were identified from our hospital database and invited to attend the outpatient department for an extra follow-up, history taking and physical examination. The use of prosthetic material, occurrence of surgical site infection, body mass and height as well as recurrence were recorded at the time of this survey. In total, 131 consecutive patients underwent operative repair of an umbilical hernia. Twenty-eight percent of the patients were female (n = 37). In 12 patients (11%) umbilical hernia repair was achieved with mesh implantation. Fourteen umbilical hernia recurrences were noted (13%); none had been repaired using mesh. No relationship was found between wound infection or obesity and umbilical hernia recurrence. In the light of these results it is necessary to re-evaluate our clinical "guidelines" on mesh placement in umbilical hernia repair: apparently not every umbilical fascial defect needs mesh repair. Research should focus on establishing risk factors for hernia recurrence.

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.

[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.

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.

Extramedullary plasmacytoma of the breast simulating breast cancer.

A patient with a palpable mass in the breast suggestive of carcinoma underwent radical modified mastectomy. Surprisingly, histology of the tumor revealed an extramedullary plasmacytoma. Further diagnostic work up showed no evidence of underlying multiple myeloma. Among neoplastic lesions of the breast, although rare, malignancy of mesenchymal or lymphoproliferative origin should always be considered.

Dysphagia lusoria: clinical aspects, manometric findings, diagnosis, and therapy.

OBJECTIVE: The lusorian artery is a rare anomaly of the right subclavian artery. This artery arises from the aortic arch distal of the left subclavian artery, crossing the midline behind the esophagus. Normally this anomaly causes no symptoms. Sometimes dysphagia first appears above the age of 40 yr. METHODS: In the period of 1992-1997, the diagnosis of an aberrant right subclavian artery was made in five patients with dysphagia who were referred to a small community hospital. A sixth patient had a right-sided aorta with an aberrant left subclavian artery. RESULTS: Endoscopy revealed a pulsating impression in the esophagus of three patients. Four patients had coexisting esophageal abnormalities. Barium contrast examination of the esophagus showed a characteristic diagonal impression at the level of the fourth thoracic vertebra in all patients. Computed tomography and angiography confirmed the diagnosis and excluded aneurysms. Manometric investigation of the esophagus revealed nonspecific abnormalities in five patients. Drug treatment was sufficient in three patients (mean follow-up, 6.2 yr). Three patients were operated upon because of persistent dysphagia. Through a cervical approach the artery was ligated near its root and connected with the right carotid artery. Postoperatively two patients became symptom-free, the other patient still has intermittent dysphagia. CONCLUSION: Dysphagia can be caused by a rare anomaly of the subclavian artery. The diagnosis can be overlooked at endoscopy, but barium contrast study of the esophagus will reveal the abnormality. In patients with coexisting esophageal abnormalities the finding may be incidental and specific conservative treatment may be sufficient. Manometry cannot be used to diagnose this condition or to predict surgical outcome. When the symptoms are intractable, surgical correction should be considered even if coexisting esophageal abnormalities are present.

[Free air below the diaphragm: not always an acute surgical problem]. / Vrije lucht onder het diafragma: niet altijd een acuut chirurgisch probleem.

In three patients, two males aged 66 and 67 years with among other disorders chronic obstructive pulmonary disease (COPD) and one woman aged 24 years with a history of intestinal surgery and current abdominal pain, the chest X-ray showed free air below the diaphragm. The two males had no major abdominal symptoms, but they did have pneumonia. All were treated conservatively. Of the males, one died from pneumonia, the other recovered. The woman presented recurrent symptoms and was subjected to extensive diagnostic examinations. This revealed a marked sigmoid perforation which was repaired, after which the symptoms did not recur. Pneumoperitoneum indicates rupture or perforation of a hollow viscus in up to 90%. In these cases, prompt surgical management is the therapy of choice. In at least 10% free air under the diaphragm is due to causes which do not require surgical treatment. These causes can be divided into intra-abdominal, intrathoracic, gynaecological and iatrogenic diseases. Conservative management should only be considered if followed by frequent and intensive evaluation of the patient's condition.

Late recurrence of liposarcoma simulating adenoma of the duodenum.

A large pedunculated, polypoid mass in the duodenum of a patient with asymptomatic anaemia, with mucosal biopsies indicating a villous adenoma, turned out to be a liposarcoma during laparotomy. The patient had had a completely resected retroperitoneal liposarcoma 8 years before. Liposarcoma recurrence should be highly suspected even in case of atypical presentation and long disease free interval.

Infections and bacteriological data after laparoscopic and open gallbladder surgery.

In two hospitals 637 patients undergoing cholecystectomy between June 1989 and June 1993 were entered into a prospective audit. The aim of this study was to determine the incidence of postoperative infections, especially wound infections, after open and laparoscopic biliary surgery and to assess the bacteriological data on these patients. The incidence of minor wound infection was 10.4% (66/637), of major wound infection 3.6% (23/637) and the overall incidence was 14% (89/637). The incidence of wound infection after laparoscopic cholecystectomy was 5.3% (10/189) and all were minor. Significant specific risk factors for developing a wound infection after laparoscopic cholecystectomy were emergency of the operation (P = 0.046) and acute cholecystitis (P = 0.014). Overall, bile cultures were positive in 22%. There were 85 patients (13.3%) with positive bile from the gallbladder. From the laparoscopically operated patients 2.8% had a positive bile culture. The predominant micro-organisms from gallbladder bile were Escherichia coli (56 isolates), Klebsiella spp. (20 isolates) and Streptococcus spp. (16 isolates). There was no relationship between positive gallbladder cultures and wound infection. The consequences of wound infections can be serious and this study showed a morbidity rate comparable with the literature. The incisions used in laparoscopic gallbladder surgery are less susceptible to major problems. This combined with the significantly lower incidence of wound infections after laparoscopic cholecystectomy suggests that routine antibiotic prophylaxis as recommended for biliary surgery in general is now questionable.

Severe slow-transit constipation following radical hysterectomy.

Two patients with severe invalidating "slow-transit constipation" after radical hysterectomy are described. Both underwent a left-sided hemicolectomy with dramatic improvement of their symptoms.

[Disabling constipation following Wertheim's radical hysterectomy]. / Invaliderende obstipatie na radicale hysterectomie volgens Wertheim.

The prognosis of patients after a radical hysterectomy according to Wertheim because of a carcinoma of the cervix is good, yet the long-term morbidity is considerable. In a retrospective investigation regarding constipation, a questionnaire was sent to 48 patients who had undergone hysterectomy in the period 1975-1990 in the Ikazia Hospital, Rotterdam. The response rate was 83%. Of the 40 respondents, 18% acquired constipation after the operation (< 3 times defaecation per week), and 33% needed prolonged straining; 13% had abdominal cramps, 20% had started to use laxatives, 48% had an increased consistency of the faeces, and 40% had to assist defaecation with the fingers. The incidence of chronic constipation after radical hysterectomy according to Wertheim is more than 20%; this kind of morbidity is insufficiently recognised. Operative treatment of these constipated patients can be successful.

The late complications of aorto-ilio-femoral Dacron prostheses: dilatation and anastomotic aneurysm formation.

Dilated prosthetic grafts and anastomotic aneurysms are recognised as a long-term complication of aorto-ilio-femoral reconstruction. In the literature an incidence of 1-24% for anastomotic aneurysms and a mean dilatation of 85.7% for Dacron aortic prostheses is reported. In our own clinic the frequency of these complications was not known, and we started a follow-up study in order to establish: the mean dilatation of the prosthetic grafts, the actual incidence of anastomotic aneurysms and the relationship between these two. All patients (n = 61) who underwent aorto-ilio-femoral reconstruction between 1980 and 1985 were retrospectively studied. During the mean 8 years follow-up period 16 patients died (26%). Complete data were available from 36 patients, who underwent physical examination and ultrasonography. In the whole series the degree of dilatation varied from 0 to 44% with an average of 5.9% at the aortic level and 8.9% at the distal level. The diameters of 25 grafts remained unchanged, and the maximum dilatation observed was 44%. The incidence of anastomotic aneurysms in these patients was 13.8%. The anastomotic aneurysms were located at the following anatomical sites: aortic anastomoses 5.9%, iliac anastomoses 0 and 30.4% for the femoral anastomoses. There was no relationship between the dilated grafts and anastomotic aneurysms. In our clinic the degree of dilatation and the incidence of anastomotic aneurysms seems to be low, especially if we compare these results with the results reported by other investigators. None of the patients who underwent aorto-ilio-femoral reconstruction between 1980 and 1985 died or had to undergo emergency surgery because of graft failure or a ruptured anastomotic aneurysm.

Local thrombolytic therapy for axillary-subclavian vein thrombosis.

Thrombosis of the axillary-subclavian vein can be primary and secondary. The case histories of three patients with spontaneous idiopathic thrombosis of the axillary vein are presented. Successful treatment with low-dose local streptokinase infusion could be confirmed by daily venography. Instead of weeks of heparine infusions, the patients could leave the hospital after a couple of days (range 10 to 12 days), long-term follow-up (4 months) showed no recurrence.

Haemorrhagic shock due to primary aortoduodenal fistula.

The case history is presented of a 68-year-old man with a primary aortoduodenal fistula. Primary aortoduodenal fistulas are a rare complication of aortic aneurysms. Given a high degree of suspicion, this otherwise lethal disease can successfully be treated by surgery. The so-called herald bleed usually allows time for investigation and diagnosis. In emergency operations, a primary repair of the duodenum and replacement of the aortic aneurysm with a Dacron prosthesis is advised. Decompression of the duodenum, protection of the graft with an omentum flap and prolonged antibiotics can minimize the risk of postoperative complications. The diagnostic and therapeutic approach is reviewed.