[An abdominal wall bulging: consider a neurological cause]. / Een uitstulping van de buik.

A patient with a swelling of the abdominal wall is a regular occurrence in general practice and hospital. The diagnosis can often be made with a thorough history and physical examination. An abdominal wall hernia is characterized by an increase in swelling on standing physical examination and Valsalva maneuver, which is often reducible, and a hernia defect is palpable. If no interruption of the abdominal wall is palpable and there is hypoesthesia, there may be an abdominal wall paresis because of thoracic paramedian hernia nuclei pulposi (HNP). Where an abdominal wall hernia is treated surgically in case of symptoms, this is conservatively treated with an HNP.

Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial.

BACKGROUND: Surgical resection is regarded as the only curative option for resectable oesophageal cancer, but pulmonary complications occurring in more than half of patients after open oesophagectomy are a great concern. We assessed whether minimally invasive oesophagectomy reduces morbidity compared with open oesophagectomy. METHODS: We did a multicentre, open-label, randomised controlled trial at five study centres in three countries between June 1, 2009, and March 31, 2011. Patients aged 18-75 years with resectable cancer of the oesophagus or gastro-oesophageal junction were randomly assigned via a computer-generated randomisation sequence to receive either open transthoracic or minimally invasive transthoracic oesophagectomy. Randomisation was stratified by centre. Patients, and investigators undertaking interventions, assessing outcomes, and analysing data, were not masked to group assignment. The primary outcome was pulmonary infection within the first 2 weeks after surgery and during the whole stay in hospital. Analysis was by intention to treat. This trial is registered with the Netherlands Trial Register, NTR TC 2452. FINDINGS: We randomly assigned 56 patients to the open oesophagectomy group and 59 to the minimally invasive oesophagectomy group. 16 (29%) patients in the open oesophagectomy group had pulmonary infection in the first 2 weeks compared with five (9%) in the minimally invasive group (relative risk [RR] 0·30, 95% CI 0·12-0·76; p=0·005). 19 (34%) patients in the open oesophagectomy group had pulmonary infection in-hospital compared with seven (12%) in the minimally invasive group (0·35, 0·16-0·78; p=0·005). For in-hospital mortality, one patient in the open oesophagectomy group died from anastomotic leakage and two in the minimally invasive group from aspiration and mediastinitis after anastomotic leakage. INTERPRETATION: These findings provide evidence for the short-term benefits of minimally invasive oesophagectomy for patients with resectable oesophageal cancer. FUNDING: Digestive Surgery Foundation of the Unit of Digestive Surgery of the VU University Medical Centre.

Laparoscopic versus open transhiatal esophagectomy for distal and junction cancer.

BACKGROUND: the only curative treatment for esophageal cancer is surgical resection. This treatment is associated with a high morbidity rate and long in-hospital recovery period. Both transthoracic and transhiatal esophagectomies are performed worldwide. The transhiatal approach may reduce the respiratory infection rate in compromised patients with distal esophageal and gastro-esophageal (GE) cancers. Minimally invasive esophagectomy could further improve post-operative outcome. Two cohorts of laparoscopic and open transhiatal esophagectomy for cancer were compared for short- and long-term outcome. METHODS: from January 2001 through December 2004, 50 patients who underwent laparoscopic transhiatal esophagectomy were compared to a historical group of 50 patients who had undergone open transhiatal esophagectomy between January 1998 and December 2000. Post-operative management was identical in both groups. RESULTS: no significant differences were seen between the two groups with regard to baseline characteristics and oncological parameters including resection margin (R0 82 vs. 74%, p = 0.334) and 5-year survival. Operation time did not differ significantly between the groups. (300 vs. 280 min, p = 0.110). Median hospital stay and intensive care unit stay were significantly shorter in the laparoscopic group (13 vs. 16 days, p = 0.001 and 1 vs. 3 days, p = 0.000 respectively). CONCLUSION: minimally invasive transhiatal esophagectomy is feasible and has the same oncological outcome as open transhiatal esophagectomy. Faster recovery without a significant longer operation time could be the major benefit of the laparoscopic transhiatal approach. To our knowledge, this is the largest comparative study in literature comparing laparoscopic transhiatal with open transhiatal esophagectomy for cancers of distal and GE junction. Randomized trials are needed to further clarify the role of laparoscopic transhiatal approach for esophageal cancer.

[Non-metastasized oesophageal cancer]. / Niet-gemetastaseerd slokdarmcarcinoom: de chirurgische behandeling.

Recently the incidence of oesophageal carcinoma has increased predominantly due to a rise in the incidence of adenocarcinoma. A relationship with the increasing prevalence of Barrett's oesophagus plays an important role. Diagnosis and staging should include oesophago-gastro-duodenoscopy, transoesophageal endo-echography and computer tomography. A higher sensitivity and specificity for distant metastases may possibly be achieved by adding positron emission tomography. In patients with adenocarcinoma neoadjuvant chemoradiotherapy followed by surgery has been associated with better survival. This effect is less convincing in squamous cell carcinomas. Distal and gastro-oesophageal tumours are particularly suitable for a transhiatal approach. Intrathoracic tumours are suitable for a transthoracic resection. There is no difference in survival after the transhiatal or the transthoracic approach, despite the less extensive lymph node dissection in the transhiatal procedure. Minimally invasive oesophagectomy seems to be associated with a lower morbidity and a shorter hospital stay. Randomized trials are needed to substantiate these results.

An unusual case of polydactyly.

Polydactyly is defined as a congenital anomaly of the hand or foot with the presence of supernumerary digits. The frequency of polydactyly varies widely among populations. It can occur as an isolated condition or as a feature of a congenital condition. In the literature, the condition is commonly described in combination with an apparent congenital deformity. We describe a case of polydactyly with no other obvious, macroscopically visible anomaly. A 21-year-old man presented with a sprained left ankle. On examination, a slightly irregularly shaped fifth digit of the left foot that appeared like a tailor's bunion was observed. The patient reported slight weight-bearing pain and tenderness over the navicular bone. No fractures were seen on radiographs, but they revealed an os tibiale externum, an extra metatarsal bone conjoined distally with the fifth metatarsal, and an extra hypoplastic proximal phalanx. No obvious signs of deformity were present. A bunionette, which was an extra hypoplastic proximal phalanx, was observed at the base of the fifth toe. Few published reports have described isolated polymetatarsia, and none of those describe supernumeral digits. A comprehensive search of the literature found no cases identical to ours.