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.

Dimethylhydrazine-induced colonic neoplasia: dissociation from endogenous gastrin levels.

The potential tropic effect of gastrin in promoting colonic carcinogenesis was tested in rats (n = 133) with 6- to 16-fold variations in endogenous gastrin resulting from antrectomy or fundectomy, followed by 12 injections of 1,2-dimethylhydrazine (10 mg/kg). The incidence and grade of differentiation of resulting tumors, as well as the thickness, content of nucleic acids, and specific activity of DNA in colonic mucosa, were similar in both high-gastrin and low-gastrin animals and were unchanged from data in unoperated control animals receiving only the carcinogen. Long-term changes in endogenous gastrin concentration are not followed by colonic mucosal tropic effects, and gastrin does not act as a cofactor in dimethylhydrazine-induced carcinogenesis at this dosage.

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.

Timing of surgery for acute biliary pancreatitis.

Twenty-five patients with acute biliary pancreatitis were classified according to the severity of disease as determined by Ranson's signs. A significant correlation was found between the severity of pancreatitis estimated in this way and the observed postoperative mortality. Early operation was performed in 15 patients, whereas 10 patients received conservative management for a certain period before operation. The choice of treatment was based on clinical considerations. No significant difference was found in mortality between the two groups. We conclude that early operation does not harm patients with mild pancreatitis whereas patients with severe pancreatitis may benefit from it.

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.

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.

[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 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.

[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.

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.

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.

Gastro-intestinal bleeding and malignancy of the testis.

Three cases of gastro-intestinal bleeding caused by metastasis of a testicular tumour to the duodenum are described. The report illustrates that, particularly in young patients, the possibility of a primary tumour in the testis should be considered when a tumour mass is found in the upper abdomen, even if other symptoms suggestive of primary gastro-intestinal disorders, such as melaena and haematemesis, are also present. As primary malignancies of the small intestine are rare, a presumptive diagnosis of anaplastic duodenal carcinoma should always arouse the suspicion of metastatic rather than primary growth.

Treatment of intussusception in children operative treatment versus hydrostatic reduction.

Intestinal intussusception is a serious abdominal emergency in infancy and childhood, with a high mortality-rate if not diagnosed and treated early. Since the management of intussusception in children is still controversial, the pro's and con's for barium enema reduction and for surgical treatment are discussed. The results of our own series of 19 patients primarily treated by barium-enema reduction compare favourably with a previous series of 14 patients treated by primary surgery.