What are we waiting for? Factors influencing completion times in an academic and peripheral emergency department.

BACKGROUND: A long completion time in the Emergency Department (ED) is associated with higher morbidity and in-hospital mortality. A completion time of more than four hours is a frequently used cut-off point. Mostly, older and sicker patients exceed a completion time of four hours on the ED. The primary aim was to examine which factors currently contribute to overcrowding and a time to completion of more than four hours on the EDs of two different hospitals, namely: the VU Medical Center (VUmc), an academic level 1 trauma centre and the St. Antonius Hospital, a large community hospital in Nieuwegein. In addition, we compared the differences between these hospitals. METHODS: In this observational study, the time steps in the process of diagnosing and treatment of all patients visiting the EDs of the two hospitals were measured for four weeks. Patients triaged as Emergency Severity Index (ESI) category 2/3 or Manchester Triage System (MTS) orange/yellow were followed more closely and prospectively by researchers for detailed information in the same period from 12.00-23.00 hrs. RESULTS: In the VUmc, 89% of the patients had a completion time of less than four hours. The average completion time (n = 2262) was 2:10 hours, (median 1:51 hours, range: 0:05-12:08). In the St. Antonius Hospital, 77% of patients had a completion time shorter than four hours (n = 1656). The average completion time in hours was 2:49 (n = 1655, median 2:34, range: 0:08-11:04). In the VUmc, a larger percentage of ESI 1, 2 and 3 patients did not achieve the 4-hour target (14%, 20% and 19%) compared with ESI 4 and 5 patients (2.7% and 0%), p < 0.001. At the St. Antonius Hospital, a greater percentage of orange and yellow categorised patients exceeded four hours on the ED (32% and 28%) compared with red (8%) and green/blue (13%), p < 0.001. For both hospitals there was a significant dependency between exceeding four hours on the ED and the following: whether a consultation was performed (p < 0.001), the number of radiology tests performed (p < 0.001), and an age above 65 years. CONCLUSION: Factors leading to ED stagnation were similar in both hospitals, namely old age, treatment by more than one speciality and undergoing radiological tests. Uniform remedial measures should be taken on a nationwide level to deal with these factors to reduce stagnation in the EDs.

[Internal and external haemorrhoids]. / Interne en externe hemorroïden.

In this article, we present 3 cases of patients with different types of haemorrhoidal disease. The first patient is a 27-year-old woman who had been experiencing incidental rectal blood loss without pain during defecation for 3 months. The second patient is a 76-year-old woman who had been bothered by varying degrees of pain from a swelling nearby the anus for 1 year. The third case involves a 31-year-old man who had had continuous severe pain in the anal area for 3 consecutive days. The first patient appeared to have internal hemorrhoids, whereas different forms of external hemorrhoids affected the patients in the other 2 cases. Internal haemorrhoids develop from the intraluminal corpus cavernosum recti; external haemorrhoids from the perianal marginal veins. Patients with internal haemorrhoids present with symptoms that include blood loss and prolaps feeling during defecation. In patients with external haemorrhoids pain is the prominent symptom. Internal haemorrhoids are treated either conservatively or surgically, depending upon their severity. Considering external haemorrhoidal disease surgical treatment provides the most rapid and persistent relief of symptoms.

Single-dose antibiotic prophylaxis for urinary catheter removal does not reduce the risk of urinary tract infection in surgical patients: a randomized double-blind placebo-controlled trial.

We conducted a double-blind, placebo-controlled randomized trial to assess the effect of single-dose prophylaxis using co-trimoxazole (960 mg) (n = 46) or ciprofloxacin (500 mg) (n = 43) vs. placebo (n = 51) before urinary catheter removal on significant bacteriuria (SBU) (primary outcome) and urinary tract infection (UTI) in surgical patients with scheduled bladder drainage for 3-14 days. SBU was determined directly after catheter removal, and UTI 12-14 days after catheter removal. After 12-14 days, incidences of SBU were 19%, 19% and 33% for patients receiving ciprofloxacin, co-trimoxazole and placebo, respectively (p ns), and incidences of UTI were 3%, 0% and 3% for patients receiving ciprofloxacin, co-trimoxazole and placebo, respectively (p ns).

Anatomical branches of the superior rectal artery in the distal rectum.

OBJECTIVE: The aim of this experimental study was to study the arterial supply of the corpus cavernosum recti in the inner wall of the distal rectum in relation to haemorrhoidal ligation therapy. METHOD: In 10 nonfixed human cadavers, the arterial vasculature of the rectum was studied using the Araldite casting method. Subsequently, the specimens were treated with methylbenzoate in order to obtain semitransparent specimens in which the corpus cavernosum recti could be studied. RESULTS: Specimens were obtained permitting study of the arterial vasculature of the rectum and corpus cavernosum recti at all levels. The superior rectal artery was found to supply the corpus cavernosum recti which consisted of a variable number of equally spaced twisting arteries. CONCLUSION: The distal rectum is supplied by the superior rectal artery. The supplying arteries of the corpus cavernosum recti are not confined to the strict locations described in the literature. This finding is of importance in surgical treatment of haemorrhoidal disease.

[Symptomatic gallstone disease: an indication for surgery]. / Symptomatisch galsteenlijden: een operatie-indicatie.

Three patients, men in the ages of 58, 66 and 56 years, respectively, had experienced 'warning colics' a considerable time before gallstone complications or severe recurrent colic. Ultrasonographically proven gallstones had not led to cholecystectomy. The 58-year-old man died of sepsis due to infected pancreatic necrosis; the other men underwent laparoscopic cholecystectomy, after which they recovered fully. Approximately 10-5% of the adult Dutch population have gallstones, but only 10% will develop symptoms. The annual risk for developing complicated gallstone disease is 1-2% in asymptomatic gallstone carriers. Of patients admitted with complicated gallstone disease, 58% have had prior 'warning colics'. Complicated gallstone disease can be prevented by timely treatment after recognition of warning colics. Cholecystectomy is indicated in patients with intermittent upper-abdominal pain and proven gallstones or sludge.

What is next in inguinal hernia surgery?

Traditionally, the inguinal hernia repair is performed through an incision in the groin. Different kinds of operations are suggested as best repairs by using the patient's own tissue, or use of prosthetic mesh to reinforce the abdominal wall. The advent of the laparoscopic repair that also uses prosthetic mesh, made it even more complex to determine the best repair. Using the Evidence Based Medicine (EBM) principles, endpoints of the treatment are not only based on recurrence rates, but also on complications, patient satisfaction, convalescence, and costs. Several meta-analyses concluded that use of mesh is superior to the non-mesh operations. More difficult to determine is which mesh repair, open or laparoscopically, is the best. The laparoscopic repair is difficult and less suitable for general practice, but the open-mesh repair results in a higher percentage of chronic postoperative pain. Further research should be focused on making the laparoscopic repair less complicated, and development of new meshes for open surgery that reduce the amount of persistent postoperative pain.

[Proximal femur fractures in the elderly in The Netherlands during the period 1991-2004: incidence, mortality, length of hospital stay and an estimate of the care capacity needed in the future]. / Proximale femurfracturen bij ouderen in Nederland in de periode 1991-2004: incidentie, sterfte, opnameduur en schatting van de in de toekomst benodigde zorgcapaciteit.

OBJECTIVE: To assess the incidence of operations for neck and pertrochanteric femur fractures during the last 15 years and to estimate the future demand for such operations in The Netherlands. DESIGN: Retrospective. METHOD: For the years 1991, 1995, 2000 and 2004, the following anonymised data were collected in the National Medical Registry of Prismant for all patients admitted to Dutch hospitals for a hip fracture: age-group, gender, length of pre- and postoperative hospital stay, destination after discharge and hospital mortality. These data were related to demographic data for the Dutch population from Statistics Netherlands (CBCS) and to estimates for the Dutch population in the future from Primos Prognostic Data. RESULTS: The average absolute increase in the period 1991-2004 was linear, with 230 fractures per year. Women were operated for a hip fracture 1.5-2 times as often as men in the same age range. The age-specific incidence remained constant over the years but the absolute number of elderly persons per age group increased. The average length of pre- and postoperative hospital stay was reduced by half during the period under investigation. The postoperative hospital mortality decreased from 8.1% in 1991 to 5.6% in 2004, and was 1.5 times as high for men aged 70 years or over as for women of the same age group. In 2004 as compared to 1991, 2.5 times as many patients were discharged to a nursing home. In view of the increasing age of the population, the total number of operated hip fractures can be expected to be 20,200 in the year 2010 and 23,900 in the year 2020. CONCLUSION: In the period 1991-2004 there was an annual increase of 230 operations for proximal femur fractures that was closely related to the ageing of the Dutch population. During the years under investigation, the incidence in the same age range was higher in women, but men had a higher hospital mortality. It is estimated that the decreasing hospital mortality and the decrease in the length of hospital stay will increase the need for nursing-home care for this category of patients.

[The 'Inguinal Hernia' guideline of the Association of Surgeons of the Netherlands]. / Richtlijn 'Liesbreuk' van de Nederlandse Vereniging voor Heelkunde.

The 'Inguinal hernia' guideline was written over a period of two years by nine surgeons (including one epidemiologist) from all regions of the Netherlands with demonstrable clinical and scientific expertise in the area of inguinal surgery after a training course on 'The development of evidence-based guidelines'. A draft of the guideline was on the website of the Association of Surgeons of the Netherlands for a period of three months, during which time the members of the society could comment on its contents interactively. The guideline comprises chapters on risk factors and prevention, diagnostics, indications for treatment, treatment, day surgery, antibiotics, thrombosis prophylaxis, training, anaesthesia, postoperative pain control, complications, costs, aftercare, and specific aspects of inguinal hernia in children. For the treatment of adult patients a mesh technique is recommended. The Lichtenstein technique is recommended as the first choice for uncomplicated primary inguinal hernia. Laparo-endoscopic techniques can be used by trained teams for specific indications. Other techniques have not been compared with the current methods of treatment sufficiently. It is recommended that the operations be carried out in daycare and that the use of local anaesthesia should be considered more often. The diagnosis of inguinal hernia in a child is based on the physical examination. It is recommended that the surgeon should not rely solely on the history but confirm the presence of a hernia personally. The treatment of a paediatric inguinal hernia is always operative. Generally, the younger the child, the more urgent the operation because of the increased risk of incarceration in infants, particularly premature babies. There is no indication for routine exploration of the contralateral groin. If an incarcerated hernia cannot be reduced, emergency operation is necessary and referral to a paediatric surgical centre must be considered. The implementation and effectiveness of the guideline will be measured by taking an inventory of all inguinal hernia operations performed in the Netherlands before and after its publication.

Laparoscopic techniques versus open techniques for inguinal hernia repair.

BACKGROUND: Inguinal hernia repair is the most frequently performed operation in general surgery. The standard method for inguinal hernia repair had changed little over a hundred years until the introduction of synthetic mesh. This mesh can be placed by either using an open approach or by using a minimal access laparoscopic technique. Although many studies have explored the relative merits and potential risks of laparoscopic surgery for the repair of inguinal hernia, most individual trials have been too small to show clear benefits of one type of surgical repair over another. OBJECTIVES: The objective of this review was to compare minimal access laparoscopic mesh techniques with open techniques. Comparisons of open mesh techniques versus open non-mesh techniques have been considered in a separate Cochrane review. SEARCH STRATEGY: We searched MEDLINE, EMBASE, and The Cochrane Central Controlled Trials Registry for relevant randomised controlled trials. The reference list of identified trials, journal supplements, relevant book chapters and conference proceedings were searched for further relevant trials. Through the EU Hernia Trialists Collaboration (EUHTC) communication took place with authors of identified randomised controlled trials to ask for information on any other recent and ongoing trials known to them. Specialists involved in research on the repair of inguinal hernia were contacted to ask for information about any further completed and ongoing trials. The world wide web was also searched. SELECTION CRITERIA: All published and unpublished randomised controlled trials and quasi-randomised controlled trials comparing laparoscopic groin hernia repair with open groin hernia repair were eligible for inclusion. Trials were included irrespective of the language in which they were reported. DATA COLLECTION AND ANALYSIS: Individual patient data were obtained, where possible, from the responsible trialist for all eligible studies. All reanalyses were cross-checked by the reviewers and verified by the trialists before inclusion. Where IPD were unavailable additional aggregate data were sought from trialists and published aggregate data checked and verified by the trialists. IPD were available for 25 trials, additional aggregated data for seven and published data only for nine. Where possible, time to event analysis for hernia recurrence and return to usual activities were performed on an intention to treat principle. The main analyses were based on all trials. Sensitivity analyses based on the data source and trial quality were also performed. Pre-defined subgroup analyses based on recurrent hernias, bilateral hernias and femoral hernias were also carried out. MAIN RESULTS: 41 published reports of eligible trials were included involving 7161 participants. Sample sizes ranged from 38 to 994, with follow-up from 6 weeks to 36 months. Duration of operation was longer in the laparoscopic groups (WMD 14.81 minutes, 95% CI 13.98 to 15.64; p<0001). Operative complications were uncommon for both methods but more frequent in the laparoscopic group for visceral (Overall 8/2315 versus 1/2599) and vascular (Overall 7/2498 versus 5/2758) injuries. Length of hospital stay did not differ between groups (WMD -0.04 days, 95% CI -0.08 to 0.00; p=0.05, but return to usual activity was earlier for laparoscopic groups (HR 0.56, 95%CI 0.51 to 0.61; p<0.0001 - equivalent to 7 days). The data available showed less persisting pain (Overall 290/2101 versus 459/2399; Peto OR 0.54, 95% CI 0.46 to 0.64; p<0.0001), and less persisting numbness (Overall 102/1419 versus 217/1624; Peto OR 0.38, 95% CI 0.4286 to 0.49; p<0.0001) in the laparoscopic groups. In total, 86 recurrences were reported amongst 3138 allocated laparoscopic repair and 109 amongst 3504 allocated to open repair (Peto OR 0.81, 95% CI 0.61 to 1.08; p = 0.16). The use of mesh during laparoscopic hernia repair is associated with a reduction in the risk of hernia recurrence, significantly so for the transabdominal preperitoneal repair (TAPP) versus open non-mesh repair (overall 26/1440 versus preperitoneal repair (TAPP) versus open non-mesh repair (overall 26/1440 versus 47/1119; Peto OR 0.45, 95% CI 0.28 to 0.72; p=0.0009). However, no difference was detected when comparing laparoscopic methods with open mesh methods of hernia repair. REVIEWER'S CONCLUSIONS: The use of mesh during laparoscopic hernia repair is associated with a relative reduction in the risk of hernia recurrence of around 30-50%. However, there is no apparent difference in recurrence between laparoscopic and open mesh methods of hernia repair. The data suggests less persisting pain and numbness following laparoscopic repair. Return to usual activities is faster. However, operation times are longer and there appears to be a higher risk of serious complication rate in respect of visceral (especially bladder) and vascular injuries.

Time-action analysis of instrument positioners in laparoscopic cholecystectomy.

BACKGROUND: Instrument positioners can position and lock a laparoscopic instrument. This study uses time-action analysis to evaluate objectively whether IPs can substitute for a surgical assistant efficiently and safely. METHODS: In four hospitals, 78 laparoscopic cholecystectomies were randomly assisted by a surgical assistant or an instrument positioner (AESOP and PASSIST) The efficiency and safety of laparoscopic cholecystectomies were analyzed with respect to time, number and type of actions, positioning accuracy, and peroperative complications. A questionnaire evaluated the difficulties for each operation and the comfort of instrument positioner use. RESULTS: The PASSIST and AESOP were able to replace the surgical assistant during laparoscopic cholecystectomies without significantly changing either the efficiency or the safety of the operation. The questionnaire showed that the surgeons preferred to operate with an instrument positioner. CONCLUSION: This study assessed objectively that instrument positioners can substitute for a surgical assistant efficiently and safely in elective laparoscopic cholecystectomies.

Open mesh versus non-mesh for repair of femoral and inguinal hernia.

BACKGROUND: Inguinal hernia repair is the most frequent operation in general surgery. Until recently the standard procedure has been open musculo-aponeurotic repair using sutures under tension to close the defect but 'tension-free' repair using prosthetic mesh is becoming increasingly common in many countries. OBJECTIVES: The purpose of this review is to evaluate open mesh techniques in comparison with open non-mesh techniques for the surgical repair of groin hernia. SEARCH STRATEGY: Electronic databases were searched and further trials were sought from the reference lists of reports of known trials. Through the EU Hernia Trialists Collaboration authors of identified randomised controlled trials were asked for information on any other trials known to them. There was no language restriction. SELECTION CRITERIA: Studies were eligible for inclusion if they were randomised or quasi-randomised trials comparing either a) open mesh with open non-mesh repair of groin hernia or b) open flat mesh repair with plug and mesh repair of groin hernia. DATA COLLECTION AND ANALYSIS: For each outcome the results were derived using data from the best available source. The majority of data for this review came from individual patient data (IPD) supplied by the trialists. When these were unavailable data came from additional aggregated information or from published trial reports. All trials were analysed using the 'intention to treat' principle. MAIN RESULTS: Twenty trials comparing open mesh with open non-mesh repair were identified. Open mesh methods, on average, took 7-10 minutes less to perform than Shouldice procedures, but took 1-4 minutes longer than other non-mesh methods. There were no clear differences between mesh and non-mesh groups for haematomas, seromas or wound/superficial infections. Three serious operative complications were reported after open mesh repair and three following non-mesh repair. Overall, those in the mesh groups had a shorter length of hospital stay and quicker return to usual activities, but this pattern was not observed for all trials. There was a suggestion that persisting pain was less frequent after mesh repair than after non-mesh repair but this result was dependent on one trial and data were not available for 11 trials. There was no evidence of a difference between the groups with respect to persisting numbness. Fewer hernia recurrences were reported after mesh repair (Peto OR: 0.37, 95% CI: 0.26 to 0.51). There were too few data to reliably address differential effects for patients with recurrent, bilateral or femoral hernias. Two trials comparing flat mesh with plug and mesh were identified. There was no clear evidence of differences between the groups. REVIEWER'S CONCLUSIONS: There is evidence that the use of open mesh repair is associated with a reduction in the risk of recurrence of between 50% and 75%. Although the trials were heterogeneous there is also some evidence of quicker return to work and of lower rates of persisting pain following mesh repair.

Timing of adoption of laparoscopic cholecystectomy in Denmark and in The Netherlands: a comparative study.

Laparoscopic cholecystectomy (LC) has diffused rapidly in most industrialised countries. The aim of this study has been to analyse the impact of different hospital characteristics on the hospital adoption of LC in Denmark and The Netherlands. Data on the timing of the adoption of LC and hospital characteristics (hospital size, teaching status and location) were retrieved in both countries. Proportional hazard regression was used to analyse different multivariate models. A total of 59 Danish and 109 Dutch hospitals adopting LC were identified. The multivariate analyses showed that increased hospital size was associated with relatively early adoption of LC in Denmark. Neither this nor other hospital characteristics influenced the timing of adoption in The Netherlands. As in other countries studied, hospital size is identified as an important factor in hospital adoption, whereas teaching status and location play a more limited role. The study shows that a multivariate method, such as the proportional hazard regression, can be used to elucidate differences among countries of the impact of different factors on the adoption of medium-ticket technologies like LC. Such multinational comparisons provide valuable information for health policy and planning.

[Ambulatory laparoscopic cholecystectomy is as effective as hospitalization and from a social perspective less expensive: a randomized study]. / Laparoscopische cholecystectomie in dagbehandeling even effectief als tijdens klinische opname en vanuit maatschappelijk perspectief goedkoper; een gerandomiseerd onderzoek.

OBJECTIVE: To compare the effects and costs of an ambulatory treatment versus an overnight stay for laparoscopic cholecystectomy. DESIGN: Prospective, randomised. METHOD: In the St Antonius hospital, Nieuwegein, the Netherlands, 86 patients with symptomatic cholelithiasis without comorbidity underwent either ambulatory (AM: 42 patients: 8 men and 36 women; mean age: 48.9 years (SD: 11.9)) or overnight stay (OS: 44 patients: 10 men and 32 women; mean age: 44.9 years (SD: 11.8)) laparoscopic cholecystectomy in the period 1 November 1997-30 September 1999. The following were registered: operative time, complications, hospital stay and readmissions, as well as reported pain, nausea, activity resumption, quality of life and patient satisfaction. The cost analysis was performed from a societal and hospital perspective. RESULTS: In the OS group one laparoscopic procedure was converted to open cholecystectomy, two relaparotomies were performed due to intra-abdominal haemorrhage and 1 patient had a catheter inserted due to urine retention. Two patients were readmitted, one for postoperative pancreatitis and the other for a retained bile duct stone. In the AM group one laparoscopic procedure was converted to open cholecystectomy, in 1 patient a wound abscess was treated with drainage in the outpatient clinic, in 1 patient there was peroperative stone loss without further complications and in 1 patient a catheter was placed to drain peroperative bile and blood loss. In the AM group 11 (26%) patients were kept overnight due to nausea and/or pain (n = 7) or one of the aforementioned complications (n = 4). Two patients were readmitted within 24 hours of being discharged due to abdominal pain. The average hospital stay was 3.1 (OS) versus 1.7 (AM) days. The quality of life, pain, nausea and activity resumption were comparable for both groups. Due to the difference in hospital stay, costs for the ambulatory procedure were lower. CONCLUSION: Laparoscopic cholecystectomy was successfully performed as an ambulatory surgery procedure in 69% of the patients. The quality of life, patient satisfaction and resumption of activities in both groups were comparable. The ambulatory treatment was less expensive.

Preoperative and postoperative assessment of laparoscopic inguinal hernia repair by dynamic MRI.

RATIONALE AND OBJECTIVES: To determine the value of dynamic MRI for seroma detection, hernia recurrence, and mesh placement in patients after laparoscopic inguinal hernia repair. METHODS: Thirteen inguinal hernias in 10 consecutive patients were evaluated before and after surgery by using an MRI protocol consisting of coronal T1-weighted (fast field echo) and T2-weighted (turbo spin-echo) images and two sequences obtained during straining (turbo field echo gradient technique). All patients underwent a transabdominal preperitoneal laparoscopic inguinal hernia repair. MRI scans were reviewed for the presence of postoperative fluid collections, recurrent hernia, and mesh localization. RESULTS: In all patients, an inguinal hernia was identified on the preoperative MRI and was absent on the postoperative MRI. In all patients treated laparoscopically, the mesh and its position were clearly identified. Three small fluid collections were found on the postoperative MRI scans. CONCLUSIONS: Dynamic MRI can demonstrate small, postoperative fluid collections and a sufficient hernioplasty by showing the proper position of the mesh and the absence of a hernia.