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Contains fulltext : 232906.pdf (Publisher’s version ) (Open Access) BACKGROUND: Preoperative differentiation between neoplastic and nonneoplastic gallbladder polyps, and the subsequent indication for cholecystectomy remains a clinical dilemma. The current 1 cm size threshold for neoplasia is unspecific. The aim of this study was to improve diagnostic work-up for gallbladder polyps using sonographic and MRI characteristics of neoplastic and nonneoplastic polyps. METHODS: A prospective, exploratory study including patients undergoing cholecystectomy for gallbladder polyp(s) was conducted. Patients underwent targeted transabdominal ultrasound (TAUS) and MRI. Outcomes were sensitivity and specificity for polyp diagnosis, and the radiological characteristics of neoplastic and nonneoplastic polyp types. Histopathology after cholecystectomy was used as reference standard. RESULTS: Histopathology demonstrated gallbladder polyps in 20/27 patients (74%): 14 cholesterol polyps, three adenomyomatosis, two adenomas and one gastric heterotopia. Sensitivity of polyp identification were 72% (routine TAUS) and 86% (targeted TAUS and MRI). Both adenomas were identified as neoplastic on targeted TAUS and MRI. Sonographic presentation as multiple, pedunculated polyps, either heterogeneous or with hyperechoic foci, or as single polyps containing cysts were limited to nonneoplastic polyps. On MRI hyperintense polyps on T1-weighted image were cholesterol polyps. An adenoma with high-grade dysplasia showed foci of decreased ADC values. We propose a checklist for polyp evaluation by targeted TAUS and a flowchart for radiological work-up of gallbladder polyps. CONCLUSIONS: The presented checklist and flowchart could aid diagnostic work-up for gallbladder polyps compared to current routine ultrasound, by elimination of nonneoplastic polyps and ultimately improve treatment decision for patients with gallbladder polyps.

Background: A Bochdalek hernia is one of the most frequently occurring congenital diaphragmatic hernias, and it occurs in 1 out of 2,500 births. Clinical cases of adults with symptomatic Bochdalek hernias are very rare. We describe a patient with an incarcerated Bochdalek hernia who underwent emergency surgery and presented with a recurrence after three years. Comparable cases in the literature were reviewed. Case Presentation: A 56-year-old woman presented to the emergency department with acute dyspnea and pain in the epigastrium shortly after gastroscopy. A CT scan showed right sided intrathoracic herniation of the ascending colon and signs of perforation of a hollow viscus. During the operation, a suture repair of a cecal perforation as well as of a diagrammatic lesion was performed. The thorax and abdomen were lavaged and drained. The postoperative course was uneventful. After 3 years, the patient presented with colic pain in the upper abdominal quadrants. A small recurrence of the Bochdalek hernia was observed on a computed tomography scan and was managed with watchful waiting. A systematic search of comparable acute cases of Bochdalek hernias was performed. Conclusion: An incarcerated right colon with a perforation in a Bochdalek hernia is extremely rare; only 11 comparable cases of right sided Bochdalek hernia with acute symptoms are described in the literature. Recurrent Bochdalek hernias are even rarer. As a delay in the diagnosis or a missed diagnosis can ultimately lead to death, adequate imaging is warranted when considering a recurrence of a Bochdalek hernia.

Background The component separation technique (CST) is considered an excellent technique for complex ventral hernia repair. However, postoperative infectious complications and reherniation rates are significant. Risk factor analysis for postoperative complication and reherniation has focused mostly on patient history and co-morbidity and shows equivocal results. The use of abdominal morphometrics derived from CT scans to assist in risk assessment seems promising. The aim of this study is to determine the predictability of reherniation and surgical site infections (SSI) using pre-operative CT measurements. Methods Electronic patient records were searched for patients who underwent CST between 2000 and 2013 and had a pre-operative CT scan available. Visceral fat volume (VFV), subcutaneous fat volume (SFV), loss of domain (LOD), rectus thickness and width (RT, RW), abdominal volume, hernia sac volume, total fat volume (TFV), sagittal distance (SD) and waist circumference (WC) were measured or calculated. Relevant variables were entered in multivariate regression analysis to determine their effect on reherniation and SSI as separate outcomes. Results Sixty-five patients were included. VFV (p = 0.025, OR = 1.65) was a significant predictor regarding reherniation. Hernia sac volume (p = 0.020, OR = 2.10) and SFV per 1000 cm3 (p = 0.034, OR = 0.26) were significant predictors of SSI. Conclusion Visceral fat volume, subcutaneous fat volume and hernia sac volume derived from CT scan measurements may be used to predict reherniation and SSI in patients undergoing complex ventral hernia repair using CST. These findings may aid in optimizing patient-tailored preoperative risk assessment.

Background The surgical treatment of patients with complex ventral hernias is challenging. The aim of this study was to present an international overview of expert opinions on current practice. Methods A survey questionnaire was designed to investigate preoperative risk management, surgical approach and mesh choice in patients undergoing complex hernias repair, and treatment strategies for infected meshes. Geographical location of practice, experience and annual volumes of the surgeons were compared. Results Of 408 surgeons, 234 (57.4 per cent) were practising in the USA, 116 (28.4 per cent) in Europe, and 58 (14.2 per cent) in other countries. Some 412 of 418 surgeons (98.6 per cent) performed open repair and 322 of 416 (77.4 per cent) performed laparoscopic repair. Most recommended preoperative work-up/lifestyle changes such as smoking cessation (319 of 398, 80.2 per cent) and weight loss (254 of 399, 63.7 per cent), but the consequences of these strategies varied. American surgeons and less experienced surgeons were stricter. Antibiotics were given at least 1 h before surgery by 295 of 414 respondents (71.3 per cent). Synthetic and biological meshes were used equally in contaminated primary hernia repair, whereas for recurrent hernia repair synthetic mesh was used in a clean environment and biological or no mesh in a contaminated environment. American surgeons and surgeons with less experience preferred biological mesh in contaminated environments significantly more often. Percutaneous drainage and antibiotics were the first steps recommended in treating mesh infection. In the presence of sepsis, most surgeons favoured synthetic mesh explantation and further repair with biological mesh. Conclusion There remains a paucity of good-quality evidence in dealing with these hernias, leading to variations in management. Patient optimization and issues related to mesh choice and infections require well designed prospective studies., This manuscript displays a good overview of current practice among difficult subjects in ventral hernia repair on which limited guidelines exist in two continents (Europe and USA). Based on our findings we would recommend that more attention should be paid on pre-operative optimization and specifically pre-operative diabetic control and adequate administration of antibiotic prophylaxis. Prehabilitation programs should be implemented together with patient education on the importance of risk reduction and the impact of complications. Reaching goals set to optimize patients before hernia surgery should be a quality control parameter. The use of biologic mesh in ventral hernia repair should be critically appraised. To improve adherence to guidelines and protocol decision tools, guideline training, easy ways of data sharing, feedback loops and apps may be helpful. Since there is a gap in knowledge concerning mesh infection (abscess) a standardized animal model needs to be developed to assess different treatment options and analyze different meshes for their susceptibility to infection and the ability to clear an infection. Lack of high quality evidence This survey provided a good overview of current practice among difficult subjects in ventral hernia repair on which limited guidelines exist in two continents (Europe and USA). Based on the findings, the authors recommend that more attention should be paid to preoperative optimization, specifically preoperative diabetic control and adequate antibiotic prophylaxis. Prehabilitation programmes should be implemented together with patient education on the importance of risk reduction and the impact of complications. Reaching goals set to optimize patients before hernia surgery should be a quality control parameter. The use of biological mesh in ventral hernia repair should be appraised critically. To improve adherence to guidelines and protocol decision tools, guideline training, easy ways of data-sharing, feedback loops and apps may be helpful.

Contains fulltext : 181803.pdf (Publisher’s version ) (Open Access)

Summary Background International guidelines advise laparoscopic cholecystectomy to treat symptomatic, uncomplicated gallstones. Usual care regarding cholecystectomy is associated with practice variation and persistent post-cholecystectomy pain in 10–41% of patients. We aimed to compare the non-inferiority of a restrictive strategy with stepwise selection with usual care to assess (in)efficient use of cholecystectomy. Methods We did a multicentre, randomised, parallel-arm, non-inferiority study in 24 academic and non-academic hospitals in the Netherlands. We enrolled patients aged 18–95 years with abdominal pain and ultrasound-proven gallstones or sludge. Patients were randomly assigned (1:1) to either usual care in which selection for cholecystectomy was left to the discretion of the surgeon, or a restrictive strategy with stepwise selection for cholecystectomy. For the restrictive strategy, cholecystectomy was advised for patients who fulfilled all five pre-specified criteria of the triage instrument: 1) severe pain attacks, 2) pain lasting 15–30 min or longer, 3) pain located in epigastrium or right upper quadrant, 4) pain radiating to the back, and 5) a positive pain response to simple analgesics. Randomisation was done with an online program, implemented into a web-based application using blocks of variable sizes, and stratified for centre (academic versus non-academic and a high vs low number of patients), sex, and body-mass index. Physicians and patients were masked for study-arm allocation until after completion of the triage instrument. The primary, non-inferiority, patient-reported endpoint was the proportion of patients who were pain-free at 12 months' follow-up, analysed by intention to treat and per protocol. A 5% non-inferiority margin was chosen, based on the estimated clinically relevant difference. Safety analyses were also done in the intention-to treat population. This trial is registered at the Netherlands National Trial Register, number NTR4022. Findings Between Feb 5, 2014, and April 25, 2017, we included 1067 patients for analysis: 537 assigned to usual care and 530 to the restrictive strategy. At 12 months' follow-up 298 patients (56%; 95% CI, 52·0–60·4) were pain-free in the restrictive strategy group, compared with 321 patients (60%, 55·6–63·8) in usual care. Non-inferiority was not shown (difference 3·6%; one-sided 95% lower CI −8·6%; pnon-inferiority=0·316). According to a secondary endpoint analysis, the restrictive strategy resulted in significantly fewer cholecystectomies than usual care (358 [68%] of 529 vs 404 [75%] of 536; p=0·01). There were no between-group differences in trial-related gallstone complications (40 patients [8%] of 529 in usual care vs 38 [7%] of 536 in restrictive strategy; p=0·16) and surgical complications (74 [21%] of 358 vs 88 [22%] of 404, p=0·77), or in non-trial-related serious adverse events (27 [5%] of 529 vs 29 [5%] of 526). Interpretation Suboptimal pain reduction in patients with gallstones and abdominal pain was noted with both usual care and following a restrictive strategy for selection for cholecystectomy. However, the restrictive strategy was associated with fewer cholecystectomies. The findings should encourage physicians involved in the care of patients with gallstones to rethink cholecystectomy, and to be more careful in advising a surgical approach in patients with gallstones and abdominal symptoms. Funding The Netherlands Organization for Health Research and Development, and CZ healthcare insurance.

International audience; Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients.The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance.The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria.An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

© The Author(s). The original article [1] contains an error whereby a co-author, Boris Sakakushev has their family name spelt incorrectly as 'Sakakhushev'. The authors would therefore like it known that the correct spelling of the family name is 'Sakakushev'.

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs., 0, SCOPUS: ar.j, info:eu-repo/semantics/published

The original article [1] contains an error whereby a co-author, Boris Sakakushev has their family name spelt incorrectly as 'Sakakhushev'. The authors would therefore like it known that the correct spelling of the family name is 'Sakakushev'. © The Author(s).

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

© 2016 The Author(s). Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Contains fulltext : 89798.pdf (Publisher’s version ) (Closed access) BACKGROUND: The study aimed to analyze if peritoneal cytokine levels can predict survival in an experimental model for peritonitis. Early identification of patients most at risk for adverse outcomes would facilitate the decision for aggressive therapy in order to maximally exploit their chance for survival. STUDY DESIGN: Peritonitis was induced by intraperitoneal injection of a feces/bacteria mixture in 175 rats. Surgical debridement was performed after 1 hour. Abdominal fluid samples were taken after 24 and 72 hours for the measurement of interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-alpha. Surviving animals were sacrificed after 5 days and correlations between cytokine levels and survival were analyzed. RESULTS: Altogether, 60 animals died prematurely, 12 before the first sampling of cytokines. So, 48 nonsurvivors and 115 survivors were analyzed. Peritoneal cytokine levels were much higher (p < 0.0001) in nonsurvivors than in survivors. At 24 hours there were strong correlations between cytokine levels, especially between IL-6 and IL-10 (r = 0.93). Peritoneal cytokines at 24 hours also discriminated between animals dying within the next 24 hours and those dying later. A strongly (p < 0.0001) increased mortality was observed if IL-6, IL-10, or TNF-alpha levels exceeded 2, 1, or 0.2 ng/mL, respectively. Receiver operating characteristic curves were promising for all 3, but IL-10 showed the best characteristics, with an area under the curve of 0.94 and 67% sensitivity at 95% specificity, obtained at a cut-off value of 1.26 ng/mL. CONCLUSIONS: These data should generate renewed interest to examine the peritoneal cytokines as early markers for adverse outcomes in patients with secondary peritonitis. Possibly, combinations of peritoneal cytokines with other markers can lead to much needed, reliable early prediction of disease severity. 01 augustus 2010

Contains fulltext : 81116.pdf (Publisher’s version ) (Closed access) Early administration of fibrinolytics after surgical treatment of peritonitis in the rat reduces abscess formation. The current study investigates the effect of various treatment protocols using intraperitoneal recombinant tissue plasminogen activator (rtPA). Peritonitis was induced in rats and surgical debridement was performed after 1 hour. Animals were treated with rtPA at different time points. Abdominal fluid samples were taken at 24, 72, and 120 hours for cytokine measurements and cell counts. After 5 days the abdomen was inspected for abscesses. Early administration of rtPA significantly reduced the number of rats with abscesses and the abscess load per rat. Delayed treatment significantly reduced abscess load but not the incidence of abscesses. No meaningful differences in the local inflammatory response were found. rtPA was most effective when applied early and continued for 72 hours, although mortality increased after prolonged treatment. rtPA consistently reduces intra-abdominal abscess formation, and a clinical study seems warranted.

Contains fulltext : 81121.pdf (Publisher’s version ) (Closed access) BACKGROUND: Intra-abdominal application of recombinant tissue-type plasminogen activator (rtPA) can decrease the rate of abscess formation in a rat peritonitis model. Before using rtPA clinically, its effects on healing of bowel anastomoses and laparotomy wounds should be investigated. METHODS: Peritonitis was induced in 148 male Wistar rats via intra-abdominal injection of a feces/bacteria mixture. Laparotomy, operative debridement and construction of a colo-colostomy after a limited colectomy or ileo-ileostomy after a limited ileal resection were performed after 1 hour. All animals received antibiotics (ceftriaxone plus metronidazole). In addition to untreated controls, other animals received rtPA in 1 of 3 dosing schemes, starting immediately after operation or 24 hour afterwards. Wound strength and hydroxyproline content of the wound were analyzed after 3 or 7 days. RESULTS: Mortality was 2% and manifestations of excessive bleeding were virtually absent. RtPA significantly decreased the rate of abscess formation. Neither bursting pressure nor breaking strength of the anastomoses was affected by any of the rtPA protocols. The same was true for wound strength in the abdominal fascia. Additionally, wound hydroxyproline content and architecture remained unchanged after rtPA administration. CONCLUSION: Intraperitoneal rtPA administration consistently and significantly decreased the rate of abscess formation, but did not affect wound healing. Clinical studies investigating its potential as an adjunct in the treatment of secondary peritonitis may be warranted.

Background Intra-abdominal abscesses are sources of recurrent or ongoing abdominal sepsis. They are an important target for prevention and treatment during or after surgical treatment of peritonitis. Experimental data suggest that fibrinolytic therapy may be effective when antibiotics are not. Methods Peritonitis was induced via intra-abdominal injection of a faeces and bacteria mixture in male Wistar rats. Surgical debridement was performed after 1 h. Next to untreated controls, animals were treated with antibiotics (ceftriaxone plus metronidazole), recombinant tissue plasminogen activator (rtPA) or both. Abdominal fluid samples were taken at 24, 72 and 120 h for interleukin 6, interleukin 10 and tumour necrosis factor α measurements and cell counts. After 5 days the abdomen was inspected for the presence of abscesses. Results Antibiotics did not significantly affect abscess formation. However, giving rtPA significantly reduced the number of rats with abscesses and the abscess load per rat, both in the absence and presence of concomitant antibiotic therapy. No adverse side-effects were observed and no meaningful differences in the local inflammatory response were found. Conclusion In this rat model, rtPA consistently reduced abscess formation after surgical treatment of secondary peritonitis. It therefore represents a promising adjuvant to conventional therapy.

Intra-abdominal abscesses are a potential source of recurrent or residual infection after surgical intervention for secondary peritonitis. The development of therapies requires a model which combines low mortality with the formation of persisting abscesses and which is also suitable to study the local inflammatory response. Male Wistar rats were injected intraperitoneally with a mixture of sterile rat faeces, increasing doses of E. coli (10(4)-10(8) cfu/ml) and a fixed dose of B. Fragilis (10(4) cfu/ml). After one h a laparotomy was performed and the peritoneal cavity was debrided. Blood samples were taken under anaesthesia after 6 and 24 h. Abdominal fluid samples were collected (by laparotomy) after 24 and 72 h. The rats were killed after 5 days and the abdomen was inspected for abscesses. Mortality was 90% in the two groups with the highest doses of E. coli and 30% in those with the two lowest doses. In the latter groups all surviving rats but one showed intraabdominal abscesses and bacteremia was encountered frequently, especially after 24 h in the 10(5) cfu E. coli group. The groups receiving 10(4)-10(6) cfu E. coli showed similar plasma IL-6 concentrations after 6 h which were lowered significantly after 24 h. No circulating TNF-alpha was found. Considerable concentrations of TNF-alpha, IL-6, IL-1beta, and IL-10, were found in the peritoneal fluid after 24 h but no differences were observed between the contro groups and those receiving 10(4)-10(6) cfu E. coli. At 72 h cytokine levels were reduced significantly and remained the highest in the animals dosed with 10(6) cfu E. coli. The present model is suitable to study the mechanisms involved in, and prevention of, intra-abdominal abscess formation after surgical treatment of generalized peritonitis.

Trials 13, 54 (2012). doi:10.1186/1745-6215-13-54, Published by BioMed Central, London

Contains fulltext : 109648.pdf (Publisher’s version ) (Closed access) BACKGROUND: Parastomal hernias are a frequent complication of enterostomies that require surgical treatment in approximately half of patients. This systematic review aimed to evaluate and compare the safety and effectiveness of the surgical techniques available for parastomal hernia repair. METHODS: Systematic review was performed in accordance with PRISMA. Assessment of methodological quality and selection of studies of parastomal hernia repair was done with a modified MINORS. Subgroups were formed for each surgical technique. Primary outcome was recurrence after at least 1-year follow-up. Secondary outcomes were mortality and postoperative morbidity. Outcomes were analyzed using weighted pooled proportions and logistic regression. RESULTS: Thirty studies were included with the majority retrospective. Suture repair resulted in a significantly increased recurrence rate when compared with mesh repair (odds ratio [OR] 8.9, 95% confidence interval [CI] 5.2-15.1; P < 0.0001). Recurrence rates for mesh repair ranged from 6.9% to 17% and did not differ significantly. In the laparoscopic repair group, the Sugarbaker technique had less recurrences than the keyhole technique (OR 2.3, 95% CI 1.2-4.6; P = 0.016). Morbidity did not differ between techniques. The overall rate of mesh infections was low (3%, 95% CI 2) and comparable for each type of mesh repair. CONCLUSIONS: Suture repair of parastomal hernia should be abandoned because of increased recurrence rates. The use of mesh in parastomal hernia repair significantly reduces recurrence rates and is safe with a low overall rate of mesh infection. In laparoscopic repair, the Sugarbaker technique is superior over the keyhole technique showing fewer recurrences. 01 april 2012

Contains fulltext : 98303.pdf (Publisher’s version ) (Open Access) BACKGROUND: Biologic grafts are increasingly used instead of synthetic mesh for parastomal hernia repair due to concerns of synthetic mesh-related complications. This systematic review was designed to evaluate the use of these collagen-based scaffolds for the repair of parastomal hernias. METHODS: Studies were retrieved after searching the electronic databases MEDLINE, EMBASE and Cochrane CENTRAL. The search terms 'paracolostomy', 'paraileostomy', 'parastomal', 'colostomy', 'ileostomy', 'hernia', 'defect', 'closure', 'repair' and 'reconstruction' were used. Selection of studies and assessment of methodological quality were performed with a modified MINORS index. All reports on repair of parastomal hernias using a collagen-based biologic scaffold to reinforce or bridge the defect were included. Outcomes were recurrence rate, mortality and morbidity. RESULTS: Four retrospective studies with a combined enrolment of 57 patients were included. Recurrence occurred in 15.7% (95% confidence interval [CI] 7.8-25.9) of patients and wound-related complications in 26.2% (95% CI 14.7-39.5). No mortality or graft infections were reported. CONCLUSIONS: The use of reinforcing or bridging biologic grafts during parastomal hernia repair results in acceptable rates of recurrence and complications. However, given the similar rates of recurrence and complications achieved using synthetic mesh in this scenario, the evidence does not support use of biologic grafts.

Contains fulltext : 74420.pdf (Publisher’s version ) (Open Access) RU Radboud Universiteit Nijmegen, 22 juni 2009 Promotor : Bleichrodt, R.P. Co-promotores : Hendriks, T., Goor, H. van 152 p.

Contains fulltext : 69538.pdf (Publisher’s version ) (Open Access) BACKGROUND: In the presence of severe maxillofacial trauma, management of the airway is important because this condition poses a significant threat to airway patency. That securing the airway is not always straightforward is described and illustrated in this paper. CASE: We present the case of a 23-year-old patient who sustained severe maxillofacial injury for which airway control was necessary. A wire-guided percutaneous dilation cricothyrotomy was performed, which was most probably the cause of an acute loss of airway patency. The literature regarding the role of percutaneous techniques in an elective and emergency setting is reviewed.