Quality of life and health status before and after ileal pouch-anal anastomosis for ulcerative colitis.

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is considered the surgical treatment of choice for patients with ulcerative colitis. Quality of life (QoL) and health status are the most important patient-related outcomes. Studies investigating QoL are often cross-sectional and focus on health status. This longitudinal study evaluated QoL and health status after IPAA for ulcerative colitis and compared these with reference data from a healthy population. METHODS: Patients with ulcerative colitis who underwent a pouch operation between 2003 and 2008 completed validated questionnaires for QoL and health status. Questionnaires were completed before pouch surgery, and 6, 12, 24 and 36 months after operation. The effect of IPAA on QoL and health status was analysed, and data were compared with reference values from the healthy Dutch population. RESULTS: Data were obtained for 30 of the 32 patients. Six months after IPAA, QoL was at least comparable with that of the reference population in four of six domains. Twelve months after IPAA, overall QoL had improved, supported by findings in three QoL domains. Six months after IPAA, health status was comparable to that of the reference population in three of eight dimensions, and after 3 years it was at least comparable in five dimensions. CONCLUSION: QoL and health status increased after IPAA and reached levels comparable with those of the healthy reference population in a majority of domains and dimensions. QoL was restored first after IPAA, followed by health status.

Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm.

OBJECTIVE: Boerhaave's syndrome is a spontaneous rupture of the oesophagus with a lack of diagnostic and treatment consistency in the literature. Therefore, we reviewed all published literature in order to design a treatment algorithm based on the literature. STUDY DESIGN: A systematic literature review written in the English language since 1975. RESULTS: We reviewed all known literature. Treatment of the Boerhaave syndrome was divided into three categories: conservative, endoscopic and surgical approach. The survival rate of all treatments was 75, 100 and 81%, respectively. CONCLUSION: Boerhaave's syndrome should be treated endoscopically when diagnosed within 48 h and when there are no signs of sepsis. However, when a patient is diagnosed within 48 h and has a septic profile, thoracotomy with hemifundoplication and pleural/mediastinal drainage should be performed; and in case of intra-abdominal leakage, a laparotomy for local repair should be performed. When a patient is diagnosed after 48 h, conservative treatment should be followed and only when a patient gets a septic profile is surgical treatment indicated.

[Non-incarcerated inguinal hernia in children: operation within 7 days not necessary]. / Niet-beklemde liesbreuken bij kinderen: opereren binnen 7 dagen niet noodzakelijk.

OBJECTIVE: To assess the necessity to operate on non-incarcerated inguinal hernia in children within 7 days of diagnosis. DESIGN: Retrospective. METHOD: Data on 360 children, 0-10 years old (104 girls and 256 boys) who were operated on for inguinal hernia between 1 January 1993-31 December 2001 at the St. Elisabeth Hospital in Tilburg, the Netherlands, were collected from the medical records. These data included sex, age, interval between diagnosis and repair, recurrence, incarceration, length of hospitalisation and complications. RESULTS: In the group of 113 children 0-1 years old, 137 inguinal hernias were repaired, ofwhich 16 were incarcerated on presentation. The interval between diagnosis and repair was known in 93 of 121 cases: 37 hernias were repaired within 7 days and 56 at a later stage. In the latter group, there was one case of secondary incarceration (1.8%; 95% CI: 0-5.4). The number needed to treat was 56. In the group of 247 children 1-10 years old, 269 inguinal hernias were repaired, of which 8 were primarily incarcerated. The interval between diagnosis and repair was known in 208 of 261 cases: 34 hernias were repaired within 7 days and 174 at a later stage. In the latter group, 3 hernias incarcerated secondarily (1.7%; 95% CI: 0-3.7). The number needed to treat was 58. In the group of non-incarcerated hernias 1 complication occurred, in the group of incarcerated hernias none. The mean length of hospitalisation of children with non-incarcerated hernia was 0.85 days, and of children with incarcerated hernia 2.4 days. CONCLUSION: In children with a non-incarcerated inguinal hernia who are waiting for an operation, the risk of secondary incarceration and complications is 2% which we do not think is enough reason to carry out an elective hernia-repair procedure within 7 days.

Management of common bile duct stones: selective endoscopic retrograde cholangiography and endoscopic sphincterotomy: short- and long-term results.

BACKGROUND: Common bile duct stones are still a frequent problem. Although new diagnostic and therapeutic techniques are continually being development, they remain poorly defined. Therefore, we decided to evaluate our standard method of diagnosing and treating common bile duct stones. The aim of the study was to determine the short- and long-term results of this method. METHODS: Between 1985 and 1995, 552 consecutive patients (200 men and 352 women; median age, 69 years) underwent endoscopic retrograde cholangiography (ERC) because of suspected common bile duct stones. If stones were detected, they were treated endoscopically, if possible. The results and complications of this policy were recorded. Patients were followed 1-13 years after undergoing ERC and endoscopic sphincterotomy (ES). Long-term results and complications during this period were also recorded. RESULTS: ERC was attempted in 552 patients and succeeded in 510 patients (92%): ES was attempted in 315 patients and failed in five (98%). Duct clearance was done in 271 patients; in 26 of these patients, symptoms disappeared spontaneously. Ten patients underwent common bile duct exploration. Complications occurred in 46 patients (8.3%). Mortality was 0.4%, hemorrhage occurred in 3.6%, pancreatitis in 1.4%, sepsis and cholangitis also in 1.4%, and the lithotripter basket became impacted in four patients (0.8%), necessitating to common bile duct exploration. During follow-up, 45 patients (8%) returned, 35 with recurrent stones, five with cholangitis, two with stenosis of the papilla of Vater, and one with biliary pancreatitis. In 35 cases, complications were treated endoscopically, common bile duct exploration was performed in five cases, and symptoms disappeared spontaneously in five cases. CONCLUSIONS: ERC is a safe and reliable way of diagnosing common bile duct stones, and ES is a very efficient way of treating them. Morbidity and mortality are low, and the long-term results are very good.

Injuries of the acetabular triradiate cartilage and sacroiliac joint.

Four patients with injuries of the acetabular triradiate cartilage are presented. In three of them premature fusion of the cartilage occurred; two of these developed acetabular deformity and subluxation of the hip. In all patients the sacroiliac joint also was injured; in two, the joint was completely disrupted, leading to fusion and growth disturbance of the ilium. As injury of the triradiate cartilage is easily missed on the initial radiograph, it is advised that all patients with pelvic trauma should be followed clinically and radiographically for at least one year.

[Differentiated protocol for the conservative/surgical treatment of ankle fractures in adults]. / Gedifferentieerd protocol voor de conservatieve/chirurgische behandeling van enkelfracturen bij volwassenen.

OBJECTIVE: Evaluation of the long-term results of protocol treatment of adult patients with ankle fractures. SETTING: St Elisabeth Hospital, Tilburg, the Netherlands. DESIGN: Retrospective long-term follow-up study. METHOD: All patients (n = 579) with an ankle fracture (580 fractures) in the period 1985-1989, who had not died soon after the injury and in whom the morbidity was not caused mainly by other conditions (n = 30) were treated according to a protocol which specified the indications for conservative or surgical therapy depending on the particular fracture type. After a median follow-up period of 5 years (range: 2.25-8.17 years) the treatment results could be evaluated in 92% of the patients. RESULTS: Clinically "good' or "excellent' results ranging from 79-90.5% types A, B and C fractures (according to the Swiss Arbeitsgemeinschaft für Osteosynthesefragen) were achieved. CONCLUSIONS: A broad indication for conservative, even functional (tape bandaging) treatment and restricted use of implants during osteosynthesis appear justified considering the results obtained.

[Favorable results of the surgical treatment of intra-articular crush fractures of the distal femur]. / Gunstige resultaten van operatieve behandeling van intra-articulaire verbrijzelingsfracturen van het distale deel van het femur.

Severely comminuted intra-articular femoral fractures are usually associated with major soft-tissue damage as a part of serious multiple injuries. Surgical treatment should aim at exact anatomical restoration of the articular surface. Internal fixation should be stable so that functional after-treatment is possible, a condition of achieving an optimal result. In a period of over 7 years, 24 patients with 26 intra-articular comminuted fractures were operated on. Twenty patients had multiple injuries (ISS > 18), 11 fractures were complicated. Postoperatively, impaired wound healing occurred in three elderly patients; in two of these amputation was necessary. Considering the severity of the injury, the long-term results were good: ten of the 16 patients examined with 18 fractures recovered completely, in the other cases the functional result wa adequate to good. Surgical treatment of comminuted intra-articular fractures of the distal femur is to be adapted to the individual case; depending on the fracture type and the associated damage a selection is to be made from various implants and techniques. With consistent, individually adapted application of the current AO techniques good results can be obtained.

[External fixation of unstable wrist fractures]. / Behandeling van instabiele polsfracturen met de 'fixateur externe'.

The results of external fixation of 66 unstable distal radial fractures were evaluated. In the majority, the radiological results were excellent or good. There was a clear correlation between an excellent or good clinical score and the subsequent radiological result. Upper limb dystrophy which caused a considerable morbidity was found in every third patient. Unstable distal radial fractures with severe initial displacement predispose to reflex dystrophy. External fixation obviously cannot prevent this severe complication, it is even possible that tension on soft tissues, capsules and ligaments caused by ligamentotaxis might induce reflex dystrophy. Therefore, the indication for using external fixation of unstable distal radial fractures has to be defined with due caution.

[The value of roentgen studies in supination injuries of ankle and foot]. / De waarde van röntgenonderzoek bij supinatieletsels van enkel en voet.

In 523 consecutive patients with inversion injuries of ankle and foot, X-ray examination revealed 52 fractures. The majority of these fractures could be treated symptomatically. On the basis of clinical examination as the diagnostic tool for these ankle injuries, the need for radiological assessment was decided. All important fractures were recognized. The patient's ability to bear weight on the injured ankle, the presence of lateral malleolar tenderness and advanced age were important clinical variables. Careful physical examination can lead to a selective radiological assessment of acute ankle injuries. Superfluous X-ray procedures can be eliminated which will greatly reduce costs without detriment to patient care.

[Early functional treatment of humerus shaft fractures by the Sarmiento method]. / Die frühfunktionelle Behandlung der Humerusschaftfrakturen nach Sarmiento.

The functional treatment of humerus shaft fractures with a brace according to Sarmiento is described. Reported are the results of the functional treatment of 47 humerus shaft fractures. Every humerus shaft fracture normally treated conservatively, including the humerus shaft fractures in polytraumatised patients and those patients with a primary radial nerve injury, can be treated in this way. The functional treatment of humerus shaft fractures results in a quick and uneventful healing of the fracture with a good function and cosmetic aspect.

The transinguinal preperitoneal hernia correction vs Lichtenstein's technique; is TIPP top?

BACKGROUND: Chronic pain is the main drawback of the Lichtenstein procedure for inguinal hernia repair, with a reported incidence of 15-40%. The transinguinal pre-peritoneal (TIPP) technique seems to be associated with less chronic pain, comparable to the total extra peritoneal (TEP) technique. The aim of this study was to evaluate 3 years of TIPP and Lichtenstein experience since the start of our Hernia Center Brabant in January 2006. METHODS: Patient records of unilateral primary inguinal anterior hernia corrections (TIPP and Lichtenstein) performed since the opening of Hernia Center Brabant (2006-2008) were evaluated in a retrospective study. ASA class 4 and 5, <18 years, recurrences and bilateral hernias were excluded. In the TIPP technique, a Polysoft™ Hernia Patch was placed into the preperitoneal space using an anterior protocol led approach. The Lichtenstein technique was performed as described by Amid [Amid et al (1996) Eur J Surg 162:447-453] and modified with a soft mesh. One of the hernia surgeons decided peroperatively which technique to perform. Baseline characteristics and postoperative complications were assessed retrospectively. The attempted follow up period was 6 months. Chronic pain was assessed in both groups as mild (VAS 1-3), moderate (VAS 4-6) or severe (VAS 7-10). Chronic pain was defined in both groups as any pain sensation lasting longer than 3 months postoperatively, or when local injection of analgesia was necessary. Patients who did not come back because of chronic pain after regular follow up were regarded as free of pain. RESULTS: A total of 496 patients were included in this study; 225 TIPP and 271 Lichtenstein anterior inguinal hernia operations were analyzed. Data from one TIPP-patient were lost. Both groups were comparable with regard to baseline characteristics regarding age (p = 0.059), gender (p = 0.478) and ASA-classification (p = 0.104). TIPP: mean age 52.7 years, ASA-classification I: 54%, II: 36% and III: 5.3%. A total of 7.6% complications were assessed; recurrence (n = 1), bleeding (and re-operation) (n = 4); 10 patients (4.4%) experienced chronic pain. Persisting sensation loss occurred in 0.9%. Lichtenstein: mean age 57.3 years, ASA-classification I: 51%, II: 38% and III: 11%. A total of 8.5% complications were assessed; recurrence (n = 3), bleeding (and re-operation) (n = 3); 11 Lichtenstein patients (4.1%) experienced chronic pain. Persisting sensation loss occurred in 2.2%. Limitations of this retrospective study were incomplete follow up (31.3% had only one post operative visit 14 days after surgery) and these patients were further regarded as free of pain. Therefore, possible under-reporting of chronic pain could be present. The study was not double blind. CONCLUSION: This retrospective study design revealed no significantly better results for the TIPP procedure as compared to the Lichtenstein technique. The incidence of chronic pain reported in this retrospective study has been low in both groups since the opening of the Hernia Center Brabant. These results form the basis for a prospective randomized clinical trial comparing the TIPP and Lichtenstein techniques.

The ileo neo rectal anastomosis (INRA) in patients with familial adenomatous polyposis: clinical results at two years.

BACKGROUND: Ileo neo rectal anastomosis (INRA) is a promising alternative for patients with familial adenomatous polyposis (FAP) to restorative proctocolectomy with its morbidity and unpredictable functional outcome to colectomy with ileo rectal anastomosis (IRA) with the continuing risk of rectal cancer. The aims of the present study were to evaluate the function of the neorectum, to assess the morbidity and complications of the operation and to determine the incidence of neorectal polyps. METHODS: Data of all patients having INRA, including bowel function and complications, were prospectively recorded. The reservoir capacity was determined repeatedly by physiologic tests. The anal sphincter complex was assessed by manometry and ultrasound examination. Evaluation of the neorectal mucosa was performed by endoscopy. RESULTS: Six patients underwent the INRA procedure for FAP. Median defaecation frequency two years postoperatively was 5.5/24 h (range 4-7) including 1/night (range 0-2). Endoscopic examination showed normal mucosa and no evidence of polyp formation in all patients. CONCLUSION: INRA affords a good functional reservoir and is accompanied by few reservoir-related complications. At a minimum follow up period of two years, no growth of polyps in the neorectum occurred.

Femoral hernia: is a conservative policy justified?

OBJECTIVE: To find out the incidence of complications among patients who present with femoral hernias and whether they are preventable. DESIGN: Retrospective study. SETTING: Teaching hospital, The Netherlands. SUBJECTS: 111 patients whose femoral hernias were operated on between 1 January 1983 and 31 June 1994. INTERVENTIONS: Emergency (n = 33) and elective repair (n = 78). MAIN OUTCOME MEASURES: Morbidity and mortality, and associated factors. RESULTS: Patients who underwent emergency repair were significantly older (median age 77 years, range 28-106 compared with 54, range 19-85, p < 0.001), were more likely to have cardiopulmonary disease (14/33 compared with 6/78, p < 0.001), and were more likely to need a bowel resection (9/33 compared with 0/78, p < 0.001). Three patients died in the emergency group compared with none in the elective group. CONCLUSION: An initial conservative policy led to higher subsequent morbidity and mortality because of the relatively high incidence of strangulation in older patients and those with cardiopulmonary disease. We therefore recommend elective repair as the treatment of choice.

Conservative treatment of acetabular fractures: the role of the weight-bearing dome and anatomic reduction in the ultimate results.

A retrospective study of 57 conservatively treated acetabular fractures with an average followup of 7.9 years is presented. The overall functional result was satisfactory in 75%. The least satisfactory results were seen in fractures crossing the weight-bearing dome of the acetabulum in which congruency could not be achieved (N = 11, nine patients had fair or poor results). However, fractures crossing the weight-bearing dome which could be reduced by traction to less than 2 mm (N = 8) gave good or excellent results in seven patients. It is concluded that conservative treatment of acetabular fractures can be very successful, even in fractures crossing the weight-bearing dome, provided that congruence is preserved during the period of traction.

Anterior lesser curve seromyotomy with posterior truncal vagotomy versus proximal gastric vagotomy.

In a prospective randomized trial anterior lesser curve seromyotomy with posterior truncal vagotomy (ASPTV, n = 48) has been compared with proximal gastric vagotomy (PGV, n = 43). Eighty-eight and eighty-three patients were available for follow-up studies at 1 year and 2 years, respectively. Six months postoperatively the mean reduction in pentagastrin-stimulated peak acid output (PAO) was 48.5 per cent (s.d. 26.3) after PGV and 50.5 per cent (s.d. 23.3) after ASPTV. Two years after the operation satisfactory clinical results (Visick I + II) were found in 84.2 per cent of the patients after PGV and in 88.9 per cent after ASPTV. There was a significant difference in the duration of surgery. No serious postoperative gastric sequelae were encountered after either operation. Up till January 1987, eight endoscopically proven, symptomatic recurrent ulcers have been diagnosed: four in the PGV group (9.3 per cent) and four in the ASPTV group (8.7 per cent). The results of this randomized study suggest that ASPTV is as good as PGV in the surgical treatment of chronic duodenal ulcers.