A prospective cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track multimodal management, for surgical patients with colon carcinomas (TAPAS study).

BACKGROUND: The present developments in colon surgery are characterized by two innovations: the introduction of the laparoscopic operation technique and fast recovery programs such as the Enhanced Recovery After Surgery (ERAS) recovery program. The Tapas-study was conceived to determine which of the three treatment programs: open conventional surgery, open 'ERAS' surgery or laparoscopic 'ERAS' surgery for patients with colon carcinomas is most cost minimizing? METHOD/DESIGN: The Tapas-study is a three-arm multicenter prospective cohort study. All patients with colon carcinoma, eligible for surgical treatment within the study period in four general teaching hospitals and one university hospital will be included. This design produces three cohorts: Conventional open surgery is the control exposure (cohort 1). Open surgery with ERAS recovery (cohort 2) and laparoscopic surgery with ERAS recovery (cohort 3) are the alternative exposures. Three separate time periods are used in order to prevent attrition bias. Primary outcome parameters are the two main cost factors: direct medical costs (real cost price calculation) and the indirect non medical costs (friction method). Secondary outcome parameters are mortality, complications, surgical-oncological resection margins, hospital stay, readmission rates, time back to work/recovery, health status and quality of life. Based on an estimated difference in direct medical costs (highest cost factor) of 38% between open and laparoscopic surgery (alfa = 0.01, beta = 0.05), a group size of 3 x 40 = 120 patients is calculated. DISCUSSION: The Tapas-study is three-arm multicenter cohort study that will provide a cost evaluation of three treatment programs for patients with colon carcinoma, which may serve as a guideline for choice of treatment and investment strategies in hospitals. TRIAL REGISTRATION: ISRCTN44649165.

Simultaneous occurrence of Meckel's diverticulum and patent urachus.

The simultaneous occurrence of a Meckel's diverticulum and a patent urachus is very uncommon. We describe the occurrence and surgical treatment of Meckel's diverticulum and an urachal anomaly in a 1-year-old boy. The patient had intermittent production of clear fluid from the patent urachus, which disappeared after surgical resection.

Gastric pneumatosis in a small-for-gestational-age neonate.

We describe a dysmature (small-for-gestational-age) neonate born at term with multiple congenital defects, who presented with bloody diarrhoea. The abdominal X-ray showed gastric pneumatosis. The patient was treated conservatively with intravenous fluids and antibiotics, and recovered uneventfully. The patient underwent genetic investigation, and was diagnosed with Cornelia de Lange syndrome. Gastric pneumatosis is rare, and may be the result of neonatal sepsis, gastritis, pyloric stenosis, necrotising enterocolitis of the stomach, misplacement of nasogastric tubes, or non-invasive positive pressure ventilation. Furthermore, it is speculated that gastric pneumatosis might more frequently occur with congenital, cardiac or genetic disorders.

Acute acalculous cholecystitis after abdominal wall repair (Rives-Stoppa).

Acute acalculous cholecystitis (AAC) is a rare condition normally occurring in critically ill patients. Compared to acute calculous cholecystitis, AAC is associated with complications and has a worse outcome. Hence, knowledge of this condition is very important. We describe a case of a 31-year-old man who developed AAC after abdominal wall repair with mesh (Rives-Stoppa procedure) 1 day after discharge from the hospital. To the best of our knowledge, this is the first paper to report AAC after abdominal incisional hernia repair. Although it is known to be more common in critically ill patients, AAC can also occur postoperatively in outpatients. Early recognition and treatment of AAC may improve outcome.

[Primary torsion of the omentum majus]. / Primaire torsie van het omentum majus.

BACKGROUND: Primary torsion of the omentum majus is a rare condition. The clinical picture can mimic other causes of acute abdominal pain. The condition is therefore often not recognised and the diagnosis is made only perioperatively. CASE DESCRIPTION: A 32-year-old man visited the emergency department with acute abdominal pain. During surgery, the pain turned out to be caused by an ischaemic segment of the omentum majus, resulting in torsion. In retrospect, the patient had been suffering from recurrent attacks of similar abdominal pain for years without a satisfactory diagnosis. CONCLUSION: In any patient with episodes of recurrent, localised, stabbing abdominal pain, possibly related to exercise and without any other clear diagnosis, the diagnosis 'torsion of the omentum majus' should be considered.

The Volkmann Ischemic Contracture of the Forearm is Preventable.

The acute compartment syndrome of the forearm is rare and may therefore be easily missed. Although many clinicians will not see such a patient during their entire career, profound knowledge of the symptoms is required to recognize the syndrome in time. Besides immediate identification of the compartment syndrome early surgical treatment is mandatory to avoid its devastating consequences. Then the functional results can be good, but if the correct diagnosis is missed a Volkmann's ischemic contracture will invariably develop. This paper aims to attend the reader to this diagnostic pitfall. Two patients with a compartment syndrome of the forearm are described to illustrate both ends of this diagnostic challenge. Pathophysiological, anatomical and clinical aspects, classification and therapeutic modalities are reviewed.