The influence of mechanical bowel preparation in elective colorectal surgery for diverticulitis.

BACKGROUND: Mechanical bowel preparation (MBP) has been shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in elective surgery in combination with an inflammatory component such as diverticulitis is yet unclear. This study evaluates the effects of MBP on anastomotic leakage and other septic complications in 190 patients who underwent elective surgery for colonic diverticulitis. METHODS: A subgroup analysis was performed in a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP in elective colorectal surgery. Primary endpoint was the occurrence of anastomotic leakage in patients operated on for diverticulitis, and secondary endpoints were septic complications and mortality. RESULTS: Out of a total of 1,354 patients, 190 underwent elective colorectal surgery (resection with primary anastomosis) for (recurrent or stenotic) diverticulitis. One hundred and three patients underwent MBP prior to surgery and 87 did not. Anastomotic leakage occurred in 7.8 % of patients treated with MBP and in 5.7 % of patients not treated with MBP (p = 0.79). There were no significant differences between the groups in septic complications and mortality. CONCLUSION: Mechanical bowel preparation has no influence on the incidence of anastomotic leakage, or other septic complications, and may be safely omitted in case of elective colorectal surgery for diverticulitis.

Long-term survival after perforated diverticulitis.

AIM: Short-term survival after emergency surgery for perforated diverticulitis is poor. Less is known about long-term survival. The aims of this study were to evaluate long-term survival after discharge from hospital and to identify factors associated with prognosis. METHOD: All patients who underwent emergency surgery for perforated diverticulitis in five hospitals in Rotterdam, the Netherlands, between 1990 and 2005, were included. The association between type of surgery (Hartmann's procedure or primary anastomosis) and long-term survival was analysed using multivariate Cox regression analysis, taking into account age American Society of Anesthesiology (ASA) classification, Hinchey score, Mannheim Peritonitis Index (MPI) and surgeon's experience. In addition, survival of the patients was compared with that of the matched general Dutch population. RESULTS: Of 340 patients included in the study, 250 were discharged alive from hospital. The overall 5-year survival was 53%. Survival was significantly impaired compared with the expected matched gender-, age- and calendar time-specific survival. Overall survival was significantly related to age and ASA classification. Hinchey score, MPI, number of re-interventions, the surgeon's experience and type of procedure did not influence long-term survival, although a trend was found for Hartmann's procedure to be a risk factor for poorer survival compared with primary anastomosis (hazard ratio for mortality: 1.88; 95% confidence interval, 0.96-3.67; P = 0.07). CONCLUSION: Long-term survival of patients after perforated diverticulitis is limited and mainly caused by the poor general condition of the patients, rather than by the severity of the primary disease or calendar-time and type of procedure.

Long-term follow-up evaluation of chronic pain after endoscopic total extraperitoneal repair of primary and recurrent inguinal hernia.

BACKGROUND: Long-term data on chronic pain after endoscopic total extraperitoneal (TEP) hernia repair are hardly available. METHODS: Between January 1997 and December 1998, 416 patients with consecutive primary and recurrent inguinal hernia underwent endoscopic TEP hernia repair. Long-term follow-up evaluation was carried out from June 2007 to June 2008. The primary outcome measure was persistent pain and discomfort interfering with daily activity. RESULTS: The overall response rate was 66% (273 of 416 patients). Of the 416 patients, 85 (20%) had died of causes unrelated to hernia repair and 58 (14%) were lost to follow-up. A total of 177 patients were physically examined in the outpatient clinic. Because 96 patients were not able to visit the outpatient' clinic, they completed the survey by telephone. The median follow-up period was 10 years (range, 9-11 years). After TEP repair, 16 patients (6%) reported chronic groin pain, and 10 patients (4%) still experience pain at this writing after the 10-year follow-up period. One of the patients has experienced persistent pain and discomfort interfering with daily activity. Patients with preoperative pain have reported significantly more chronic pain (P = 0.03). CONCLUSIONS: Chronic groin pain after TEP repair of primary and recurrent inguinal hernia seems to have a low incidence after a 10-year follow-up period.

Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure?

OBJECTIVE: Hartmann's procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis. METHOD: All 158 patients who had survived emergency surgery for acute perforated diverticulitis in five teaching hospitals in The Netherlands between 1995 and 2005 and underwent HP or PA with DI were retrospectively studied. Age, gender, ASA-classification, severity of primary disease, delay of stoma reversal, surgeon's experience, surgical procedure and type of anastomosis were analysed in relation to outcome after stoma reversal. RESULTS: Of the 158 patients, 139 had undergone HP and 19 PA with DI. The reversal-rate was higher in patients with DI (14/19; 74%) compared to HP (63/139; 45%) (P = 0.027) Delay between primary surgery and stoma reversal was shorter after PA with DI compared with HP (3.9 vs 9.1 months; P < 0.001). Cumulative postreversal morbidity after HP was 44%. Early surgical complications occurred in 22 of 63 patients. Morbidity after DI reversal was 15% (P < 0.001). Three patients died after HP reversal, none died after DI reversal. Anastomotic leakage was observed in 10 patients after HP reversal. This was less frequently observed when the operation was performed by a specialist colorectal surgeon (10%vs 33%; P = 0.049) and when a stapled anastomosis was performed (4%vs 24%; P = 0.037). CONCLUSIONS: Reversal of HP should only be performed by an experienced colorectal surgeon, preferably performing a stapled anastomosis, or probably not be performed at all, as it is accompanied by high postoperative morbidity and even mortality. It is important that these findings are taken in account for when performing primary emergency surgery for acute perforated diverticulitis.

A 10-year follow-up study on endoscopic total extraperitoneal repair of primary and recurrent inguinal hernia.

BACKGROUND: To determine whether endoscopic repair is favorable in the long term, follow-up recurrence rates after 10 years need to be assessed. METHODS: Between January 1995 and January 1996, 306 consecutive patients underwent total extraperitoneal (TEP) inguinal hernia repair. Long-term follow-up assessment occurred from January 2006 to May 2006. RESULTS: After a 10-year follow-up period, six (4%) recurrences were found in the primary inguinal hernia group and three recurrences (11%) in the recurrent inguinal hernia group. Age, experience, hospital stay, and operating time were not significantly correlated with recurrences. CONCLUSION: The long-term results of TEP primary inguinal hernia repair demonstrate it to be an effective and safe procedure with an acceptable recurrence rate. Recurrence rates may be underestimated because the findings show that recurrences continue to occur for as long as 10 years.

Totally extraperitoneal repair for bilateral inguinal hernia: does mesh configuration matter?

BACKGROUND: The endoscopic preperitoneal approach has numerous advantages for the reconstruction of bilateral inguinal hernias. Repair may be achieved using either one large or two small meshes. The aim of this study was to investigate whether one of the techniques was superior in terms of recurrence and complication rate. METHODS: Data obtained from 113 patients who underwent surgery between January 1998 and December 2001 was reviewed. For the sake of this study, 86% of all patients were examined for hernia recurrence at an additional outpatient visit. RESULTS: The findings showed recurrence rates, of 3.5% for single mesh and 3.7% for double mesh. This difference was not significant. Complication rates did not differ significantly between the groups. CONCLUSIONS: Endoscopic preperitoneal bilateral hernia repair is a safe and reliable technique in the hands of experienced surgeons. The rate of hernia recurrence and complications is low and independent of the mesh configuration (single or double). Mesh configuration based on personal preference is permissible.

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.

Long-term results after modified Gallie technique for incisional hernia repair: results in 19 patients.

BACKGROUND: A modified forgotten technique for repairing large incisional hernias is described together with its long-term results in 19 patients. A synthetic mesh with 1-cm wide spokes radiating from the mesh is placed preperitioneally, overlapping the fascial defect. The spokes are pulled through rectus sheaths and muscle and sutured ventrally, thereby creating a solid reconstruction withstanding shrinking of the mesh. METHOD: Nineteen patients were operated on (13 primary incisional hernia, minimal fascial defect 10 cm). Notes on patients were reviewed, and the patients were contacted for follow-up examination. RESULTS: No major complications occurred. After a median of 49 months, 17 patients were reviewed at the outpatient clinic. Two possible recurrences were detected, of which one was operated on. This proved to be bulging of the mesh, resulting in a recurrence of 1 out of 17 (6%). CONCLUSION: From these results, it is concluded that Gallie's technique using synthetic mesh is a safe and effective repair for incisional hernia and deserves more attention, especially for large fascial defects.

Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy.

BACKGROUND: Although the recurrence rate for endoscopic herniography is low (0-3%), it is still debatable whether these recurrences should be corrected laparoscopically or by the conventional method. The aim of this study was to investigate whether these recurrences can be repaired by means of the laparoscopic approach with acceptable complication and recurrence rates. METHODS: From October 1992 to December 1997, 34 patients with recurrent inguinal hernias at physical examination underwent surgery at our institutions. All the recurrences occurred following endoscopic inguinal hernia repair with mesh prostheses. The recurrences were repaired endoscopically using a transabdominal approach. Depending on the size of the defect, a new polypropylene mesh was used. RESULTS: Mean surgery time was 69 min. There were no conversions to the anterior approach. After a mean follow-up of 35 months, no recurrences had been diagnosed. CONCLUSION: The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy.

Endoscopic totally extraperitoneal repair of bilateral inguinal hernias.

BACKGROUND: Recurrence rates associated with bilateral inguinal hernia repair with a giant prosthesis (Stoppa procedure) are low. Endoscopic totally extraperitoneal bilateral inguinal hernia repair with a giant prosthesis combines the low recurrence rate of the Stoppa repair and the advantages of minimally invasive surgery. The aim of this retrospective study was to investigate whether extraperitoneal bilateral inguinal hernia repair could be performed by the minimally invasive, totally extraperitoneal approach. METHODS: From February 1993 to January 1998, 98 patients with bilateral inguinal hernias underwent surgery. A polypropylene 30 x 10 cm rectangular mesh or a 30 x 10/15 cm 'slipmesh' was used. Follow-up, including a physical examination, of 96 per cent of patients was performed. RESULTS: Median operative time was 60 min. Mostly minor intraoperative complications occurred. Conversion was required for two patients. Apart from one patient with a necrotic fasciitis who died from respiratory failure, only minor postoperative complications (10 per cent) occurred. Median hospital stay was 1 (range 1-21) days. Median recuperation time was 5 (range 1-22) days. Median follow-up (96 per cent) was 32 (range 7-57) months; there were six recurrences among 34 hernias in the group of 17 patients treated with 10 x 30 cm mesh and two (1 per cent) in the group that received 30 x 10/15 cm mesh (162 hernias in 81 patients). CONCLUSION: The endoscopic approach for the Stoppa procedure for bilateral inguinal hernia repair is a reliable method with minor complications. It ensures a short recuperation time and the recurrence rate is low owing to adequate overlap of the hernial defect when a 'slipmesh' is used.

Endoscopic total extraperitoneal repair of primary and recurrent inguinal hernias.

BACKGROUND: In most reports different techniques have been described for combinations of primary and recurrent hernias. The aim of this study was to investigate and compare the results of endoscopic total extraperitoneal repair (TEP) of primary and recurrent inguinal hernias. METHODS: From January 1993 to July 1995, 221 patients with an unilateral inguinal hernia (186 primary and 35 recurrent) underwent TEP repair. Follow-up, including physical examination, was performed at regular 3-month intervals. RESULTS: The mean operation time was 37.6 min. Minor perioperative complications occurred in 23 cases. Conversion was required for 16 patients (7.2%). Postoperative complications were reported for 11.7% of the patients. Hospital stay was short. Mean follow-up was 40.4 months. The recurrence rate was 3. 2% for primary hernias and 20% for recurrent hernias. CONCLUSIONS: This study confirms the preliminary success of TEP for primary inguinal hernia repair, as previously reported. The high recurrence rate after endoscopic repair of recurrent hernias needs to be studied further.

CD44 splice variants as prognostic markers in colorectal cancer.

BACKGROUND: Splice variants of CD44 play a causal role in the metastatic spread of pancreatic carcinoma in the rat. In previous studies we have shown that homologues of these CD44 isoforms (CD44v6) are overexpressed during colorectal tumorigenesis in man and that CD44v6 overexpression is associated with an unfavorable prognosis in this disease. In the present study we have assessed the prognostic significance of CD44 variants containing exon v5. In addition, we have used a panel of different antibodies against CD44v6 and applied a combined scoring system to improve its value as prognosticator. METHODS: Expression of CD44 variants was studied by immunohistochemistry on frozen tissue sections, and the prognostic value of the CD44 variant expression was assessed using univariate and multivariate analysis. RESULTS: Our studies show that expression of CD44v6, but not CD44v5, has significant prognostic value. Analysis of CD44v6 expression by means of a combined scoring system, on the basis of a panel of three different monoclonal antibodies (mAbs), makes CD44v6 a highly significant prognostic marker that is independent of Dukes stage, tumor grade, or tumor localization. CONCLUSION: Assessment of CD44v6 expression by a combination of mAbs yields an independent prognosticator that may be of value in identifying patients with a high propensity to develop distant metastasis.

Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair.

BACKGROUND: Inguinal hernias can be repaired by laparoscopic techniques, which have had better results than open surgery in several small studies. METHODS: We performed a randomized, multicenter trial in which 487 patients with inguinal hernias were treated by extraperitoneal laparoscopic repair and 507 patients were treated by conventional anterior repair. We recorded information about postoperative recovery and complications and examined the patients for recurrences one and six weeks, six months, and one and two years after surgery. RESULTS: Six patients in the open-surgery group but none in the laparoscopic-surgery group had wound abscesses (P=0.03), and the patients in the laparoscopic-surgery group had a more rapid recovery (median time to the resumption of normal daily activity, 6 vs. 10 days; time to the return to work, 14 vs. 21 days; and time to the resumption of athletic activities, 24 vs. 36 days; P<0.001 for all comparisons). With a median follow-up of 607 days, 31 patients (6 percent) in the open-surgery group had recurrences, as compared with 17 patients (3 percent) in the laparoscopic-surgery group (P=0.05). All but three of the recurrences in the latter group were within one year after surgery and were caused by surgeon-related errors. In the open-surgery group, 15 patients had recurrences during the first year, and 16 during the second year. Follow-up was complete for 97 percent of the patients. CONCLUSIONS: Patients with inguinal hernias who undergo laparoscopic repair recover more rapidly and have fewer recurrences than those who undergo open surgical repair.

The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair.

BACKGROUND: Several laparoscopic techniques have been introduced to re pair inguinal hernia, the newest and most promising being a totally extraperitoneal approach. Nevertheless, the surgeon may encounter several complications and technical difficulties associated with the transition from the conventional anterior operation. METHODS: In late 1993 and 1994, 120 patients were operated on for inguinal hernia using the totally extraperitoneal approach by four laparoscopic surgeons inexperienced in this new technique in a secondary referral setting. Their learning curve was assessed through operation time, perioperative and postoperative complications, and technical difficulties. RESULTS: Median operative time decreased significantly (P = 0.0003) when going through the learning curve. During the initial part of the learning curve, conversion to another technique was necessary in 10 (8%) cases, and in 6 of these cases, conversion was needed for a peritoneal tear (relative risk for conversion if peritoneal tear was present: 4.0; 95% confidence interval 1.2 to 13.1, P = 0.025). The median operative time for Nyhus type IIIb and IVb hernias was significantly longer than for other types (70 versus 55 minutes, P = 0.003). Median postoperative stay was 2 days (range 0 to 7). There were 10 recurrences within 6 months due to technical or judgement errors. CONCLUSIONS: For surgeons, the learning curve for totally extraperitoneal laparoscopic hernia repair can be overcome; however, the presence of an experienced surgeon during the procedure is vital, as this may prevent unnecessary recurrences.

Difference in expression of CD44 splice variants between proximal and distal adenocarcinoma of the large bowel.

To help determine whether adenocarcinomas of the proximal and distal large bowel reflect distinct entities, the expression of two splice variants of the metastasis-associated cell adhesion molecule CD44, carrying exons v5 and v6 respectively, was investigated retrospectively in fresh frozen samples of 23 proximal and 41 distal carcinomas by immunohistochemical staining with specific anti-CD44v5 monoclonal antibody VFF8 and anti-CD44v6 monoclonal antibodies VFF4 and VFF7. Tumours were staged as: Dukes A, 0; Dukes B, 27; Dukes C, 31; and Dukes 'D', six. Compared with distal tumours, proximal lesions expressed significantly more CD44v5 (96 versus 87 per cent, P = 0.02) and CD44v6 (83 versus 61 per cent, P = 0.01). CD44v5 and CD44v6 are considered markers for tumour progression and aggressive behaviour. Their high expression in proximal carcinomas seems to contrast with the general belief that these tumours show less aggressive behaviour than left-sided lesions. Further study of the biological significance of the expression of CD44 splice variants is therefore needed.

Colorectal cancer prognosis and expression of exon-v6-containing CD44 proteins.

CD44 variants containing v6 confer metastatic potential to rat carcinoma cell-lines. In man, CD44v6 is increasingly expressed during colorectal tumour progression. In 68 colorectal carcinoma patients, survival analysis showed that CD44v6 expression in the tumours was associated with tumour-related death. In patients who had an apparently radical resection of their primary tumour, CD44v6 expression had prognostic value independent of Dukes' stage. CD44v6 expression may reflect propensity for metastasis after apparently curative surgery, making adjuvant therapy an option in these patients.

Initial experience with laparoscopic fundoplication in The Netherlands and comparison with an established technique (Belsey Mark IV).

Since the introduction of laparoscopic cholecystectomy as an alternative for conventional cholecystectomy, the number of cholecystectomies per year is showing an increased tendency, suggesting that indications for surgery have broadened now that the morbidity of the procedure has decreased so much. For gastro-oesophageal reflux disease (GORD) the current number of operations performed per year in The Netherlands is small compared with the calculated prevalence of complicated GORD. If the data on epidemiology of GORD by Richter are extrapolated to the population of The Netherlands, there must be at least 4,500 potential candidates for antireflux surgery currently available and only 250 operations are performed per year. Laparoscopic Nissen fundoplication is practised with acceptable results. If with this new development the same tendency as for laparoscopic cholecystectomy arises, this may mean either that too many patients will undergo antireflux surgery or that the potential candidates will now get their chance to have an effective operation with the prospect of low procedure-related morbidity. In The Netherlands, 62 laparoscopic Nissen fundoplications have been performed. There have been no deaths and in 5 patients the laparoscopic procedure had to be converted into a laparotomy. Forty-two of these 62 patients were treated according to a protocol and were included in the follow-up. At one month, 38 out of 42 patients were available for follow-up. At one month after surgery, 38 patients felt that their reflux symptoms had improved. Surgery-induced symptoms were present in 19 out of 38 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Granular cell tumor of the breast.

Three cases of granular cell tumor of the breast are reported. Granular cell tumor of the breast is a rare benign tumor with a malignant appearance both clinically, radiologically and macroscopically. The cytology is quite characteristic although the tumor clinically often resembles a carcinoma. Frozen section can be misinterpreted, unnecessary mastectomy or axillary dissection can be prevented by careful cytological examination.

Peri-operative blood transfusions in colorectal cancer.

Clinical studies report reduced recurrence-free survival and increased cancer-related death after surgical treatment for cancer, when peri-operative blood transfusions were given. In this study we collected transfusion data of 212 patients who participated in a prospective study of two different resection techniques for colorectal cancer. One hundred and fifty-eight patients were transfused and 54 were not. The follow-up period for almost all patients was 5 years. The 5-year survival rate was 52% both for the transfused patients and the nontransfused patients. For subgroups of patients with Dukes' B and Dukes' C tumours no statistically significant differences were found. In the group of patients that were transfused the number of transfusions did not affect survival. In this study we could not confirm the deleterious effect of peri-operative blood transfusions on survival.

Proximal femoral fractures in conjunction with hemiarthroplasty according to Moore.

During a period of six years, 245 hemiarthroplasties according to Moore were implanted for fractures with dislocation of the femoral neck. In five patients (2%) proximal ipsilateral fractures of the femur occurred in the postoperative phase. All fractures were located near the tip of the prosthesis. Four were spiral fractures, one was a communitive fracture. Four patients were treated with plating, one with screw fixation. Two patients were unable to walk, two patients were able to walk with help and one walked without help. Classification of fractures distal to an endoprosthesis and operative modalities are discussed.