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Syndesmotic screw removal following acute syndesmotic injury is a commonly performed procedure. However, recent studies suggest that the removal does not result in improved patient reported outcome, while the procedure has proved not to be without complications. The aim of this study was to present a health-economic evaluation of on-demand removal (ODR) compared to routine removal (RR) of the syndesmotic screw.Data were collected from the RODEO trial, a randomized controlled non-inferiority trial comparing functional outcome of ODR with RR. Economic evaluation resulted in total costs, costs (in Euro) per quality adjusted life year (QALY) and costs per point improvement on the Olerud Molander Ankle Score (OMAS). This included both direct and indirect costs.Total costs for ODR were significantly lower with a mean difference of 3160 euro compared to RR (p 0.001). The difference in QALY was not significant. The difference in OMAS at 12 months was 1.79 with an incremental cost-effectiveness ratio (ICER) of €-1763 (p = 0.512). The ICER was well below the willingness to pay. Although unit costs might vary between hospitals and countries, these results provide relevant data of cost-effectiveness.The clinical effectiveness of both ODR and RR can be considered equal. The costs are lower for patients treated with ODR, which leads to the conclusion that ODR is cost-effective.

The introduction of enhanced recovery after surgery (ERAS) has resulted in a decrease in length of hospital stay of patients after bariatric surgery. The general length of hospital stay is 1 day. Some bariatric patients stay longer after an uncomplicated procedure or are readmitted for varying reasons. The aim of the present study is to identify risk factors associated with prolonged hospital stay and readmissions. A retrospective study of all patients who underwent a primary procedure (i.e. Roux-en-Y gastric bypass or sleeve gastrectomy) between January 2016 and January 2019 was performed. A total of 1669 patients who underwent primary laparoscopic Roux-en-Y gastric bypass (70.7%) or sleeve gastrectomy (29.3%) were included. The median length of stay was 1 day (range 1–69 days). In 138 patients (8.3%), a postoperative complication was diagnosed and 89 patients were readmitted (5.3%) within 30 days after discharge. Overall, 348 patients (20.9%) stayed longer than 1 day. Univariable analysis showed that depression, ASA III, sleeve gastrectomy and a perioperative and/or postoperative complication were significantly (p value

Introduction The importance of routine follow-up of several relatively simple stable injuries (SSIs) is questionable. Multiple studies show that direct discharge (DD) of patients with SSIs from the Emergency Department results in patient outcomes and experiences comparable to ‘standard care’ with outpatient follow-up. The purpose of this study was to evaluate to which extent DD of SSIs has been adopted amongst trauma and orthopedic surgeons internationally, and to assess the variation in the management of these common injuries. Methods An online survey was sent to members of an international trauma- and orthopaedic surgery collaboration. Participants, all trauma- or orthopaedic surgeons, were presented with eleven hypothetical cases of patients with simple stable injuries in which they were asked to outline their treatment plan regarding number of follow-up appointments and radiographs, physiotherapy and when to start functional movement. The primary outcome was the proportion of surgeons selecting direct discharge (i.e. zero scheduled appointments), per injury. Secondary outcomes included clinical agreement (>80% of respondents answering similarly) on total number of follow-up appointments (0, 1 or ≥2), radiographs (0, 1 or ≥2), routine physiotherapy referral (yes/no) and when to start functional movement (weeks). Results 138 of 667 (20.7%) surgeons completed the survey. Adoption of direct discharge ranged from 4-45% of case examples. In 10 out of 11 cases, less than 25% of surgeons selected direct discharge. Clinical agreement regarding number of appointments and when to start functional movement was not reached for any of the injuries. There was clinical agreement on number of radiographs for one injury and for four injuries regarding routine referral to a physiotherapist. Discussion Despite available evidence, DD of SSIs has not been widely adopted worldwide. Practice variation still exists even for these common injuries. This variation suggests inefficiency and consequently unnecessarily high healthcare costs. (Orthopaedic) trauma surgeons are encouraged to evaluate their current treatment protocols of SSIs.

In the originally published version of this protocol [1], the sample size calculation of the subgroups for age should have been phrased differently. The actual sample size of each subgroup (routine removal 60 years old, routine removal 60 years old, on demand removal 60 years old and on demand removal 60 years old) should be 44, making a total of 176 (unchanged), which would come to a required number of included patients of 196 when incorporating a loss to follow up of 10%.

The length of hospital stay after bariatric surgery has decreased rapidly in recent years to an average of 1 day (one midnight). The transition from a controlled hospital environment to home environment may be a big step for patients. For these patients, home monitoring can be a substitute.A pilot study of 84 morbidly obese patients undergoing either laparoscopic Roux-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LGS) was performed. Home monitoring consisted of daily contact via video consultation and measurement of vital signs at home. The primary outcome was feasibility of home monitoring. Secondary outcomes were complications and patient satisfaction measured with a questionnaire (PSQ-18).In 77 of the 84 patients (92%), videoconference was possible on day 1, 74 patients (88%) on day 2 and 76 patients (90%) on day 3. Four patients (5%) were never reached. On day 1, 52 patients (62%) performed all instructed measurements, on day 2, 49 patients (58%) and on day 3, 63 patients (75%). Only 47 out of 84 patients (56%) measured the instructed amount of times on all 3 days. High satisfaction rates were reported in the patients receiving home monitoring.Our first experience with home monitoring was disappointing since home monitoring of vital signs had poor compliance and not all patients were able to use the application. Further refinement of the home monitoring tool is needed to increase compliance and utility of the tool.

The introduction of enhanced recovery after surgery (ERAS) has resulted in a decrease in length of hospital stay of patients after bariatric surgery. The general length of hospital stay is 1 day. Some bariatric patients stay longer after an uncomplicated procedure or are readmitted for varying reasons.The aim of the present study is to identify risk factors associated with prolonged hospital stay and readmissions.A retrospective study of all patients who underwent a primary procedure (i.e. Roux-en-Y gastric bypass or sleeve gastrectomy) between January 2016 and January 2019 was performed.A total of 1669 patients who underwent primary laparoscopic Roux-en-Y gastric bypass (70.7%) or sleeve gastrectomy (29.3%) were included. The median length of stay was 1 day (range 1-69 days). In 138 patients (8.3%), a postoperative complication was diagnosed and 89 patients were readmitted (5.3%) within 30 days after discharge. Overall, 348 patients (20.9%) stayed longer than 1 day. Univariable analysis showed that depression, ASA III, sleeve gastrectomy and a perioperative and/or postoperative complication were significantly (p value 0.05) associated with a prolonged stay. In the multivariable model depression, sleeve gastrectomy and postoperative complication were independent risk factors for prolonged stay. Univariable analysis of risk factors associated with readmission identified depression and perioperative and postoperative complications. Multivariable analysis for readmission demonstrated only presence of a postoperative complication was an independent risk factor.Depression, sleeve gastrectomy and postoperative complications were independent risk factors for prolonged stay. Postoperative complication was an independent risk factor for readmission.

The optimal diagnostics and treatment of acute appendicitis continues to be a challenge. We evaluated the implementation of the guideline “diagnostics and treatment in acute appendicitis” in 2010. This guideline states that, in every patient with clinically suspected acute appendicitis, an ultrasonography or CT scan is advised to confirm the diagnosis before surgery. We selected all consecutive patients with acute appendicitis in our hospital in the years 2008 and 2011. We compared the use of imaging and the operation results in both years. In 2008, 228 patients were treated for acute appendicitis. In 43 %, imaging was performed. In 2011, 238 patients were treated; in 99 % of the cases, imaging was performed. A decrease in patients with negative appendectomy was seen from 19 % in 2008 to 5 % in 2011. Financial analysis showed a reduction in costs favoring 2011. The increased use of pre-operative imaging in patients with suspected acute appendicitis resulted in a cost-effective way to decrease the number of patients with negative appendectomies.

Objective: The objective of the study was to determine the long-term effect of the use of a hyaluronic acid-carboxymethylcellulose membrane (Seprafilm) on the incidence of adhesions and subsequent small-bowel obstruction and chronic abdominal complaints after colorectal surgery (Hartmann's procedure). Background: Adhesions occur frequently after abdominal surgery and are the most common cause of bowel obstruction, chronic abdominal pain, and infertility. The risk for adhesion-related readmission in the first 10 years after colorectal surgery is as high as 30%. To reduce the formation of adhesions, a mechanical barrier composed of hyaluronic acid and carboxymethylcellulose was developed, to prevent adherence of tissues after abdominal surgery. Longterm results concerning the incidence of small-bowel obstruction and chronic abdominal pain are lacking. Methods: Between April 1996 and September 1998, 71 patients requiring Hartmann's procedure for sigmoid diverticulitis or obstructed rectosigmoid were randomized to either intraperitoneal placement of Seprafilm under the midline and in the pelvis or as a control. Direct visual evaluation of the incidence and severity of adhesions was performed laparoscopically in 42 patients at second-stage surgery for restoration of the continuity of the colon. The results of this study were published in 2002. In 2006, the patients' general practitioners were interviewed by means of a questionnaire concerning their patients' health. The patients who were still alive were interviewed and asked to fill out 2 questionnaires concerning pain and quality of life (VAS-pain score, EQ-5D, and SF-36). In 2009, the medical records of the patients were evaluated for adhesion-related hospital re-admissions. Results: Of the 42 evaluated patients, 35 (16 in the Seprafilm group, 19 in the control group) could be enrolled in the long-term follow-up. Median follow-up was 126 months (range 41-148) for the Seprafilm group and 128 months (range 49-149) months for the control group. Incidence of chronic (3 months or longer existing) abdominal complaints was significantly lower in the Seprafilm group compared with controls (35.3% vs. 77.8%, respectively; P = 0.018). Incidence of small-bowel obstruction showed no significant difference in favor of the Seprafilm group; no small-bowel obstructions occurred in the Seprafilm group, whereas in the control group 2 cases of small-bowel obstruction were found to have occurred. Evaluation of the quality of life questionnaires did not reveal significant differences between the 2 groups. Conclusions: In Hartmann's procedure, Seprafilm placement does not provide protection against small-bowel obstruction. Incidence of chronic abdominal complaints is significantly lower after use of Seprafilm.

Background Inguinal hernias are a common entity with nearly 31,000 repairs annually in The Netherlands and over 800,000 in the USA. The aim of the present study is to determine whether a laparoscopically diagnosed patent processus vaginalis (PPV) is a risk factor for the development of groin hernia. Methods The study population was originally composed of 599 consecutive cases (189 male, 32%) of laparoscopic transperitoneal surgery for different indications performed in 4 teaching hospitals in The Netherlands between November 1998 and February 2002. During laparoscopy, the deep inguinal ring was inspected bilaterally. The PPV group was compared with the obliterative processus vaginalis (OPV) group. Results After a mean follow-up of 5.5 years, the studied population consisted of 337 cases (94 male, 28%). In this study 12% of the studied population appeared to have PPV in adult life. The percentage PPV of our study group is much higher than the percentage of hernia repairs performed in the Dutch population. A greater proportion (12%) of hernia repairs in the PPV group was found as compared with the OPV group (3%). The chance of developing an inguinal hernia within 5.3 years is four times higher in the group with PPV. No significant correlation between age and the prevalence of PPV was observed. Conclusion This study demonstrates that PPV is an etiologic factor and a risk factor for acquiring an indirect inguinal hernia in adults.

Background Peroperative identification and subsequent division or preservation of the inguinal nerves during open hernia repair may influence the incidence of chronic postoperative pain. Methods A systematic literature review was performed to identify studies investigating the influence of different types of nerve management. Results Based on three randomized studies the pooled mean percentage of patients with chronic pain after identification and division of the ilioinguinal nerve was similar to that after identification and preservation of the ilioinguinal nerve. Two cohort studies suggested that the incidence of chronic pain was significantly lower after identification of all inguinal nerves compared with no identification of any nerve. Another cohort study reported a significant difference in the incidence of chronic pain in favour of identification and facultative pragmatic division of the genital branch of the genitofemoral nerve compared with no identification at all. Conclusion The nerves should probably be identified during open hernia repair. Division of and preservation of the ilioinguinal nerve show similar results.

Background: Hartmann's gallbladder pouch was the subject of an article in The Lancet 60 years ago. It has regained new interest in view of laparoscopic cholecystectomy. However, different opinions exist with regard to its incidence and nature. To elucidate these discrepancies, a descriptive study was performed with regard to the incidence and morphology of Hartmann's pouch. Methods: Gallbladders were obtained after elective laparoscopic cholecystectomy. In addition, gallbladders were obtained during routine postmortem examination. The gallbladders were divided in two groups: those with Hartmann's pouch and those without Hartmann's pouch. All the gallbladders were examined macroscopically and microscopically. Fisher's Exact Probability Test (p < 0.05, two-tailed) was used to analyze the data. Results: A total of 98 gallbladders were examined: 49 obtained after laparoscopic or open cholecystectomy and 49 obtained after postmortem examination. Among the gallbladders with Hartmann's pouch (n = 51), 65% contained stones and 35% had no stones. Among the gallbladders without Hartmann's pouch, 43% contained stones and 57% had no stones. Macroscopically, in all the gallbladders with Hartmann's pouch, the pouch was observed to result from adhesions between the cystic duct and the neck of the gallbladder. After cleavage of these adhesions, the phenomenon of Hartmann's pouch was abolished in all cases. Conclusions: Hartmann's gallbladder pouch is a frequent but inconstant feature of normal and pathologic human gallbladders. There is a significant association between the presence of Hartmann's pouch and stones (p < 0.05). Adhesions between the cystic duct and the neck of the gallbladder are responsible for Hartmann's pouch. Consequently, Hartmann's gallbladder pouch is a morphologic rather than an anatomic entity.

Chronic groin pain, especially in professional sportsmen, is a difficult clinical problem. From January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 ± 4.5 years; range, 17–36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement. Incipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation. A TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain.

Background: Although a large number of surgeons currently perform endoscopic hernia surgery using a total extraperitoneal (TEP) approach, reviews published to date are based mainly on trials that compare laparoscopic transabdominal preperitoneal (TAPP) repair with various types of open inguinal hernia repair. Methods: A qualitative analysis of randomized trials comparing TEP with open mesh or sutured repair. Results: In this review, 4,231 patients were included in 23 trials. In 10 of 15 trials, TEP repair was associated with longer surgery time than open repair. A shorter postoperative hospital stay after TEP repair than after open repair was reported in 6 of 11 trials. In 8 of 9 trials, the time until return to work was significantly shorter after TEP repair. Hospital costs were significantly higher for TEP than for open repair in all four trials that included an economic evaluation. Most trials (n = 14) reported no differences in subsequent recurrence rates between TEP and open repair. Conclusions: The findings showed that endoscopic TEP repair is associated with longer surgery time, shorter postoperative hospital stay, earlier return to work, and recurrence rates similar to those for open inguinal hernia repair. The procedure involves greater expenses for hospitals, but appears to be cost effective from a societal perspective. The TEP technique is a serious option for mesh repair of primary hernias.