[Widespread preoperative hair removal in the southwest of The Netherlands despite an evidence-based guideline discouraging this practice]. / Wijdverbreide preoperatieve ontharing in Zuidwest-Nederland ondanks evidence-based ontmoediging.

OBJECTIVE: To determine whether the 1993 guideline from the Dutch Institute for Healthcare Improvement (CBO) is followed in the Southwest region of the Netherlands. The guideline states that preoperative hair removal serves no purpose in preventing wound infection. DESIGN: Inventory. METHOD: All surgical short-stay departments in the Southwest region of The Netherlands received a structured questionnaire on their management of preoperative hair removal. Questions included whether or not they had a hair removing protocol, which methods they used for removing hair and the timeframe within which preoperative hair removal usually was carried out. RESULTS: The response was 100% (24/24). The majority of surgical short-stay departments did practice preoperative hair removal (88%). Less than half of the hospitals use a hair removal protocol. Hair clippers were used for preoperative hair removal in most hospitals (86%) and in 71% the procedure was carried out within 2 hours of the planned operation and mostly by nursing staff (71%). No difference was found in hair removal management in hospitals with or without a protocol. CONCLUSION: Despite the existence of a published guideline that states that preoperative hair removal serves no purpose in preventing wound infection, the majority of hospitals in the Southwest region of the Netherlands do still carry out the practice as a routine action. The policy of hair removal management appears to depend on subjective feelings of individual surgeons. The existence ofan evidenced-based guideline does not appear to have much effect on this management.

[Submucosal lipoma of the colon: abdominal cramps with rectal bleeding and weight loss]. / Submucosaal lipoom in het colon: buikkrampen met rectaal bloedverlies en gewichtsverlies.

An 81-year-old woman had abdominal cramps, rectal bleeding since 2 weeks and weight loss. Colonoscopy showed an ulcerating tumour of about 4 cm in the transverse colon. Pathological examination of biopsies taken during colonoscopy indicated moderately active chronic colitis. Based on the colonoscopy findings, the tumour appeared to be malignant and laparotomy was performed and the transverse colon was resected. Pathological examination of the resected lesion revealed a submucosal lipoma. The patient recovered fully. Lipomas account for 4% of benign gastrointestinal tumours and 90% of lipomas are submucosal. Their presentation is often similar to malignant tumours. The naked fat sign after biopsy and the elasticity of the lesion are typical features encountered during colonoscopy. Given the high fat content of these lesions, they are easily discernible with CT and MRI. Lipomas with a diameter < 2 cm can be safely removed endoscopically. Larger lesions should be removed by segment resection.

[The surgical treatment of Graves' disease]. / Chirurgische behandeling van de ziekte van Graves.

A man aged 80 and three women aged 66, 26, and 39 years respectively, underwent surgery for Graves' disease. The first woman had pneumonia and experienced thyrotoxic storm. Euthyroidism was restored with antithyroid drugs (ATD) and thyroidectomy was performed as ablative treatment for hyperthyroidism. The man presented with thyrotoxicosis and had severe Graves' ophthalmopathy. After euthyroidism was restored with ATD, he underwent subtotal thyroidectomy. The second woman presented with severe thyrotoxicosis but was allergic to ATD. She was treated with iodine and beta-blockers after which subtotal thyroidectomy was done as an ablative procedure. Medical treatment for hyperthyroidism failed in the last patient and, as she had experienced severe psychological disturbances during a previous relapse, she too chose surgery as a definitive treatment option. In two patients the postoperative course was complicated by early hypocalcaemia and one of these patients experienced temporary recurrent laryngeal nerve paralysis. Surgery has a limited role in the treatment of Graves' disease. In pregnant women with severe ATD-resistant thyrotoxicosis, surgery is the only treatment option, while in patients with Graves' orbitopathy surgery may be preferable because of its neutral and perhaps even beneficial effects on eye symptoms. Large goitre size and thyroid nodules are concomitant reasons for choosing surgery, as are allergy to ATD and patients' preference. Lastly, in patients who have suffered from severe thyrotoxicosis, surgery provides rapid and definitive treatment. Early morbidity following surgery is common and should be discussed with the patient.