Five-year results of inguinal hernia treatment with the Prolene Hernia System in a regional training hospital.

PURPOSE: Long-term results of inguinal hernia repair with the Prolene Hernia System (PHS) in our regional training hospital were retrospectively analysed. Research was conducted in an identical cohort of patients previously investigated for short-term results. METHODS: One-hundred and fifty-eight patients (217 inguinal hernias) treated with the PHS were traced and included. Patients were invited to visit the outpatient clinic for a brief history, physical examination and ultrasound. A quality of life questionnaire was completed by all patients. The primary endpoint was recurrence rate. Testis atrophy, chronic pain and hypaesthesia were secondary endpoints. RESULTS: The mean age of the population (n = 187) was 62.2 years (range 28-92), with a male:female ratio of 15:1 (175:12). The median follow-up was 5.5 years (range 3.9-6.8). One-hundred and forty-five patients visited the outpatient clinic, while 13 patients were included by telephone interview. Twenty-one patients died during follow-up and eight others were lost to follow-up. The resulting follow-up rate was 85% (158/187). In our initial study, we found four recurrences (1.8%) and seven patients with persisting pain (3.2%) after 32 months. During current follow-up, five patients were diagnosed with recurrent herniation (2.3%, 5/217) and only four patients (1.8%) suffered from persisting pain. Three patients (1.4%) were diagnosed with testicular atrophy, while ten patients (4.4%) experienced hypaesthesia. CONCLUSION: In a regional training hospital, the recurrence rate and long-term complications of patients treated for inguinal hernia with the PHS are acceptable after a follow-up of 5.5 years. The number of patients experiencing persistent pain seems to decrease over time.

Management of hepatic trauma: a 9-year experience in 's-Hertogenbosch.

BACKGROUND: In patients who sustain abdominal trauma the liver is the most frequently injured organ. Although treatment for haemodynamically unstable patients remains urgent surgery, there has been a shift of management in haemodynamacally stable patients towards non-operative management. We performed an outcome assessment of traumatic hepatic injury. METHODS: A retrospective study was performed to assess incidence, mechanisms, management and outcome of traumatic liver injury in the region of 's-Hertogenbosch, The Netherlands, in the period 1999-2007. RESULTS: A total of 47 patients were identified. Thirty-six patients had blunt hepatic trauma, eleven sustained penetrating hepatic injury. In 67% (n = 24) of the blunt hepatic trauma patients the initial intention was to treat non-operatively. Yet, two patients underwent explorative laparotomy after one and two days. In the penetrating liver trauma patients, 91% (n = 10) underwent urgent surgery. In total, 31 of 47 patients were treated conservatively. CONCLUSION: Blunt hepatic trauma is the most common cause of hepatic trauma. Most patients sustaining hepatic trauma can be managed conservatively at a dedicated ICU and/or surgical trauma ward.

[Delirium after a fractured hip in more than one-third of the patients]. / Delier na een heupfractuur bij ruim een derde van de patiënten.

OBJECTIVE: Inventarisation and evaluation of the incidence, risk factors, and prognosis of postoperative delirium in patients with a fractured hip admitted to a surgical ward. DESIGN: Descriptive study of patient records. METHOD: All patients with a fractured hip admitted to the surgical ward of the Jeroen Bosch Hospital, Den Bosch, the Netherlands, in 2004 were included and evaluated. Active multidisciplinary interventions for the recognition and treatment of delirium by non-pharmacological and pharmacological means take place in this surgical ward. The records of all patients from the surgical and geriatric wards were evaluated and the data were analysed statistically by means of univariate and multivariate logistic 'step-forward' regression analysis. RESULTS: 114 patients were included. The incidence of postoperative delirium was 37%. Older age was a significant risk factor for the development of delirium in both the univariate and the multivariate analysis after correcting for overestimation (p < 0.01). Several other factors, including sex, type of surgery, and medical history, had no effect on the risk of delirium. CONCLUSION: Delirium after a hip fracture is not rare; the most important risk factor is older age.

Inguinal hernia treatment with the Prolene Hernia System in a Dutch regional training hospital.

INTRODUCTION: In this retrospective study results from inguinal hernia repair with the Prolene Hernia System (PHS) in a regional training hospital were analysed. PATIENTS AND METHODS: One-hundred and seventy-eight primary inguinal hernias and thirty-nine recurrent hernias (initial non-mesh repair) were treated with the PHS. The primary endpoint was the recurrence rate. Secondary endpoints were short-term and long-term complications. Pain was evaluated by use of a visual analog scale (VAS, 0-100), and a short-form 36-item questionnaire was used to assess postoperation quality of life. All patients visited the outpatient clinic for a physical examination (100% follow-up). RESULTS: After a median follow-up of 32 months four patients were diagnosed with recurrent herniation (1.8%), three after primary hernia repair (1.6%) and one after recurrent hernia repair (2.6%). Three superficial wound infections (1.3%), three haematomas needing surgical evacuation (1.3%), and two lesions of the spermatic cord (0.9%) were diagnosed. Seven patients (3.2%) suffered from persistent pain (VAS > 40). Average VAS score was 13 (0-80) >24 months after surgery. CONCLUSION: In a regional training hospital, primary and recurrent inguinal hernias were treated with low recurrence and few complications by use of the PHS.

Resuming driving after a fracture of the lower extremity: a survey among Dutch (orthopaedic) surgeons.

BACKGROUND: Patients with a fracture of the lower extremity often ask their physician during their rehabilitation when they can resume driving. Since no guidelines exist and only scarce literature is available with varying advices the physician has to rely on his own clinical experience and judgment. The Dutch legislation also fails to provide rules when driving can be resumed after a temporary invalidity, it relies on the physician to judge when driving can be assumed to be safe. With this study, we investigated the need for specific guidelines concerning driving after fractures of the lower extremity among Dutch (orthopaedic) surgeons. METHODS: A survey was conducted among Dutch (orthopaedic) surgeons consisting of four parts; the first part contains questions about how the physician handles with patients who suffered from a lower extremity fracture. The second part of the survey is about which criteria are used to judge whether driving can be resumed. The third part contains true/false/do not know questions about the legal context on participation in motorized traffic with a (temporary) disability. The fourth and last part is a series of examples of fractures with a description of how the fracture was treated in which we asked how long it should normally take before a patient can resume driving again safely per case. A final question is about the need for specific guidelines on this topic. RESULTS: One third of the surgeons do not advise their patients regarding driving. A wide range of criteria is used to consider whether driving is safe, however the possibility of full weight bearing is considered the most important. The legal knowledge of the surgeons on this subject is poor; up to 10% believe that driving with a plaster on the right leg is allowed. Seventy-nine percent of the questioned surgeons believe that guidelines concerning driving after a fracture should be developed. CONCLUSIONS: Our study shows that there is a great demand for guidelines concerning car driving after a fracture of the lower extremity.

Traumatic retropharyngeal haematoma treated by embolization of the thyrocervical trunk.

Trauma involving the retropharyngeal space is relatively infrequent. Upper airway obstruction due to a retropharyngeal haematoma can be life threatening and requires immediate intervention. We present a well-documented case that illustrates the unexpected clinical course of such a haematoma and its management.

[Necrotising pancreatitis as an unexpected complication in seriously ill patients]. / Necrotiserende pancreatitis als onverwachte complicatie bij ernstig zieke patiënten.

Three patients, two men aged 70 and 73 years, respectively, who underwent surgery due to an abdominal aortic aneurysm, and a woman aged 75 years, who was operated on due to acute arterial embolic occlusion of both legs, developed abdominal complaints post-operatively. These were found to be caused by necrotising pancreatitis. The accompanying fluid accumulation was drained percutaneously. Two patients recovered; the 73-year-old man died suddenly, possibly as a result of burst aortic sutures. In patients with a serious condition, necrotising pancreatitis should be considered in the case of a generalised inflammatory reaction and abdominal symptoms. Percutaneous drainage of infected necrotic tissue can sometimes improve the patient's condition, making surgery possible at a later stage.

[Dyspnea or confusion after trauma? Consider fat embolism syndrome]. / Benauwde of verwarde patiënt na trauma? Denk aan het vetemboliesyndroom.

Three patients, 2 women aged 26 and 19 years and a 65-year-old man, underwent surgical fracture treatment after a motor vehicle accident with fractures of the lower extremity. They developed respiratory distress from fat embolism syndrome. After maximal support in the ICU 2 of them died and 1 recovered. Fat embolism syndrome is a clinical condition mostly seen after long bone fractures. The main features are respiratory distress, cerebral confusion and a petechial rash. Usually the presentation is quite benign, but severe morbidity and even mortality can occur in some cases. It is caused by a combination of a mechanical and a biochemical pathway. Therapeutic options consist of respiratory and haemodynamic support. Preventive measures are rapid fracture fixating, good analgesia, adequate fluid infusion and tissue oxygenation.

A device to facilitate donning and cleaning of a roll-on socket in a trans-tibial amputee with a non-functional arm.

Rehabilitation of a person with a non-functional arm and a trans-tibial amputation with a short stump with fragile skin, multiple scars and a limited knee function presents a considerable problem. The best prosthesis was considered to be one with a roll-on socket. Donning and cleaning of the socket however could not be done by the patient himself and it was therefore necessary to develop a device to permit the patient to perform these tasks independently. A case history is presented and the new device described.

Predictors of recurrence of fulminant bacterial peritonitis after discontinuation of antibiotics in open management of the abdomen.

OBJECTIVE: To assess a scoring system for predicting recurrence of fulminant bacterial peritonitis after discontinuation of antimicrobial treatment in patients being treated by open management of the abdomen for persistent bacterial peritonitis after perforation of the digestive tract, anastomotic disruption, or necrotising pancreatitis. DESIGN: Retrospective study. SETTING: University Hospital, The Netherlands. SUBJECTS: 58 consecutive patients. MAIN OUTCOME MEASUREMENTS: Recurrence of fulminant bacterial peritonitis and survival. RESULTS: 13 of the 58 patients (22%) died during the initial course of antimicrobial drugs. 14 of the remaining 45 patients had a recurrence of fulminant bacterial peritonitis after discontinuation of antimicrobial drugs, 4 of whom died. Predictive criteria included raised white cell count (WCC) (p = 0.02), duration of initial antibiotic treatment (p = 0.05), and deterioration in Simplified Acute Physiology Score (p = 0.05). Using the WCC and the duration of initial antimicrobial treatment together with other variables that showed a predictive trend (body temperature, percentage band cells, underlying disease, and use of inotropic agents), in a new scoring system (0-12), fulminant bacterial peritonitis did not recur when the score was 0-3, but in 9 of 11 patients with a score of 6 or more it did (p < 0.001). CONCLUSION: Patients at increased risk of recurrence of fulminant bacterial peritonitis during open management of the abdomen can be identified at the time of discontinuation of antimicrobial treatment by a new scoring system; antimicrobial treatment should not be discontinued in patients with a score of 6 or more.