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Contains fulltext : 229543.pdf (Publisher’s version ) (Closed access), OBJECTIVE: To determine the yield of preoperative screening for COVID-19 with chest CT and RT-PCR in patients without COVID-19 symptoms. SUMMARY OF BACKGROUND DATA: Many centers are currently screening surgical patients for COVID-19 using either chest CT, RT-PCR or both, due to the risk for worsened surgical outcomes and nosocomial spread. The optimal design and yield of such a strategy are currently unknown. METHODS: This multicenter study included consecutive adult patients without COVID-19 symptoms who underwent preoperative screening using chest CT and RT-PCR before elective or emergency surgery under general anesthesia. RESULTS: A total of 2093 patients without COVID-19 symptoms were included in 14 participating centers; 1224 were screened by CT and RT-PCR and 869 by chest CT only. The positive yield of screening using a combination of chest CT and RT-PCR was 1.5% [95% confidence interval (CI): 0.8-2.1]. Individual yields were 0.7% (95% CI: 0.2-1.1) for chest CT and 1.1% (95% CI: 0.6-1.7) for RT-PCR; the incremental yield of chest CT was 0.4%. In relation to COVID-19 community prevalence, up to approximately 6% positive RT-PCR was found for a daily hospital admission rate >1.5 per 100,000 inhabitants, and around 1.0% for lower prevalence. CONCLUSIONS: One in every 100 patients without COVID-19 symptoms tested positive for SARS-CoV-2 with RT-PCR; this yield increased in conjunction with community prevalence. The added value of chest CT was limited. Preoperative screening allowed us to take adequate precautions for SARS-CoV-2 positive patients in a surgical population, whereas negative patients needed only routine procedures.

Contains fulltext : 220002.pdf (Publisher’s version ) (Open Access), PURPOSE: A substantial part (21-35%) of defunctioning stomas created during resection for colorectal cancer will never be reversed. Known risk factors for non-closure are age, peri- or postoperative complications, comorbidity, and tumor stage. However, studies performed to identify these risk factors mostly focus on rectal cancer and include both preoperative and postoperative factors. This study aims to identify preoperative risk factors for non-reversal of intended temporary stomas created during acute resection of left-sided obstructive colon cancer (LSOCC) with primary anastomosis. METHODS: All patients who underwent emergency resection for LSOCC with primary anastomosis and a defunctioning stoma between 2009 and 2016 were selected from the Dutch ColoRectal Audit, and additional data were collected in the local centers. Multivariable analysis was performed to identify independent preoperative factors for non-closure of the stoma. RESULTS: A total of 155 patients underwent acute resection for LSOCC with primary anastomosis and a defunctioning stoma. Of these, 51 patients (32.9%) did not have their stoma reversed after a median of 53 (range 7-104) months of follow-up. In multivariable analysis, hemoglobin < 7.5 mmol/L (odds ratio (OR) 4.79, 95% confidence interval (95% CI) 1.60-14.38, p = 0.005), estimated glomerular filtration rate (eGFR) ≤ 45 mL/min/1.73 m(2) (OR 4.64, 95% CI 1.41-15.10, p = 0.011), and metastatic disease (OR 6.12, 95% CI 2.35-15.94, p < 0.001) revealed to be independent predictors of non-closure. CONCLUSIONS: Anemia, impaired renal function, and metastatic disease at presentation were found to be independent predictors for non-reversal of intended temporary stomas in patients who underwent acute resection for LSOCC. In patients who have an increased risk of non-reversal, the surgeon should consider a Hartmann's procedure.

Contains fulltext : 168316.pdf (publisher's version ) (Closed access), BACKGROUND & AIMS: Although colonic diverticulitis is a common disorder, there is no clear treatment strategy for patients with recurrent episodes of diverticulitis. We investigated whether colonic resection or conservative or medical treatments have the greatest effects on quality-adjusted life-years (QALYs). METHODS: A Markov model simulating patients with 2 episodes of non-surgically treated diverticulitis was used to simulate all relevant outcomes of each treatment strategy. A 1-year cycle length with 10-year follow-up period was used to allow for chance of recurrent diverticulitis. Primary outcome was QALYs gained from each strategy. Factors considered were morbidity, mortality, chance of colostomy formation, risk of recurrence, and persistence of abdominal pain. The probabilities of clinical events were determined by using the best available published data. RESULTS: A strategy in which colonic resection was performed after 2 episodes of diverticulitis was associated with the lowest quality-adjusted survival (a gain of 8.66 QALYs) and highest chance of stoma formation (1.1%) but the lowest chance of a mild (3.5%) or severe (1.1%) recurrence. The strategies of colonic resection or conservative or medical treatment after the third episode of diverticulitis were comparable in terms of quality-adjusted survival, providing 8.78, 8.76, and 8.74 QALYs, respectively. Probabilistic sensitivity analysis did not change these results. Persistent abdominal complaints were lowest in the medical treatment strategy. CONCLUSIONS: Elective surgery after 2 episodes of diverticulitis should be questioned in terms of QALYs. After the third episode of diverticulitis, surgical or conservative or medical treatments provide similar QALYs, but rates of abdominal symptoms are lower with the medical treatment strategy. This Markov decision model has limitations when the individual patient and physician face a complex decision weighing early and long-term risks and benefits of elective sur

Item does not contain fulltext, BACKGROUND: The preperitoneal mesh position seems preferable to reduce the number of patients with postoperative chronic pain after inguinal hernia surgery. The transrectus sheath preperitoneal mesh repair (TREPP) is gaining popularity. Teaching a new technique requires a standardized approach to achieve an optimal learning curve. The aim of this paper was to provide a step-by-step teaching module for hernia surgeons learning the TREPP. METHODS: Literature was critically reviewed and the forthcoming nine surgical steps of the new TREPP technique and its rationale are described in this article. The TREPP hernia repair technique is illustrated with an online education video and three photos of the anatomical landmarks and the proposed mesh position of TREPP. RESULTS: The nine steps of TREPP are described extensively and the critical steps are presented in a standardized way for surgical educational purposes. Also the rationale and technical considerations of inguinal hernia experts are presented. DISCUSSION: TREPP may be a promising technique for groin hernia surgery. To date there have been no major complications with the TREPP repair which is currently the subject of a RCT. The learning curve of TREPP is being investigated and teaching of this technique requires standardization for trainee surgeons. CONCLUSION: TREPP potentially merges the advantages of a preperitoneal positioned mesh with an open technique. Initial results are promising and TREPP seems to be applicable in different hospitals in the Netherlands. Since the start of an active teaching program, TREPP has been introduced and accepted well by dedicated hernia surgeons in other hospitals in the Netherlands and Europe.

Item does not contain fulltext, BACKGROUND & AIMS: Patients with diverticulitis develop recurrences and chronic abdominal symptoms. Recurrent diverticulitis is seldom complicated, which has led to a conservative treatment approach. However, some studies suggest that surgical intervention reduces recurrence and chronic abdominal problems. We conducted a systematic review and meta-analysis of quality of life (QOL) and other patient-reported outcomes (PROs) after conservative vs surgical treatment of uncomplicated diverticulitis. METHODS: We searched the CENTRAL, MEDLINE, EMBASE, and PsycInfo databases for randomized trials and cohort studies reporting on QOL or other PROs after conservative or operative treatment for uncomplicated diverticulitis from January 1990 through May 2014. Eight PROs were defined and graded according to their clinical relevance. Risk of bias was assessed by using the Cochrane Collaboration tool. Subgroup and sensitivity analyses were performed to test the robustness of the results. The review protocol was registered through PROSPERO (CRD42013005854). RESULTS: We analyzed data from 21 studies that comprised 1858 patients; all studies had a high risk of bias. There were no head-to-head comparisons of gastrointestinal symptoms or general QOL between elective surgical vs conservative treatment of recurrent diverticulitis. On the basis of Short-Form 36 scores, patients had higher QOL scores after elective laparoscopic resection (73.4; 95% confidence interval [CI], 65.7-81.1) than conservative treatment (58.1; 95% CI, 47.2-69.1). A lower proportion of patients had gastrointestinal symptoms after laparoscopic surgery (9%; 95% CI, 4%-14%) than conservative treatment (36%; 95% CI, 27%-45%) in all cohorts and in 1 trial comparing these treatments (odds ratio, 0.35; 95% CI, 0.16-0.7). The proportion of patients with chronic abdominal pain after elective laparoscopy was 11% (95% CI, 1%-21%) compared with 38% (95% CI, 19%-56%) after conservative treatment. CONCLUSIONS: On the basis of a

Radboud Universiteit Nijmegen, 30 april 2015, Promotores : Goor, H. van, Bleichrodt, R.P., Contains fulltext : 140192.pdf (publisher's version ) (Open Access)

Contains fulltext : 138014.pdf (publisher's version ) (Closed access), AIM: External validation and comparison of the diagnostic accuracy of two predictive tools, the emergency department triad and the clinical scoring tool in diagnosing acute diverticulitis. METHODS: Two derivation datasets were used crosswise for external validation. In addition, both tools were validated in a third independent cohort. Predictive values were reassessed and the Area Under the Curve expressed discriminatory capacity. Performance was compared by calculating positive predictive values of the emergency department triad in the validation cohorts and with a cut-off analysis for the clinical scoring tool at a positive predictive value of 90%. RESULTS: Predictive value of the emergency department triad was comparable to the clinical scoring tool. The positive predictive value of the emergency department triad (97%) decreased in the clinical scoring tool cohort (81%) and was excellent in the independent cohort (100%), identifying 24%, 20% and 14% of the patients. A smaller proportion of patients with diverticulitis could be identified with the clinical scoring tool (6%, 19% and 9%). CONCLUSION: The emergency department triad as well as the clinical scoring tool have significant predictive value in external cohorts of patients suspected of diverticulitis. These tools can be used to select patients in whom additional imaging to diagnose acute diverticulitis may be omitted.

Contains fulltext : 137109.pdf (publisher's version ) (Closed access), Background. The lack of pathognomonic findings and the chance of complicated disease have resulted in the widespread use of additional imaging to diagnose acute colonic diverticulitis (ACD). The added value of additional imaging in the diagnostic workup of patients suspected of ACD is not well defined. Aims. The aim of this study was to systematically review the literature of the accuracy of the clinical evaluation and diagnostic modalities for patients with suspected ACD, to come to an evidence-based approach to diagnose ACD. Methods. A systematic review and meta-analysis of studies that reported diagnostic accuracy of the clinical diagnosis and diagnostic modalities in patients with suspected diverticulitis were performed. Study quality was assessed with the STARD checklist. True-positive, true-negative, false-positive, and false-negative findings were extracted and pooled estimates of sensitivity and specificity per diagnostic test were calculated, if applicable. Results. The overall quality of the studies reporting the diagnostic accuracy of the clinical diagnosis, contrast enema and magnetic resonance imaging (MRI) were moderate to poor and not suitable for meta-analysis. Sensitivity of the clinical diagnosis varied between 64% and 68%. Ultrasound (US) and computed tomography (CT) studies were eligible for meta-analysis. Summary sensitivity estimates for US were 90% (95% CI: 76-98%) versus 95% (95% CI: 91-97%) for CT (p = 0.86). Summary specificity estimates for US were 90% (95% CI: 86-94%) versus 96% (95% CI: 90-100%) for CT (p = 0.04). Sensitivity for MRI was 98% and specificity varied between 70% and 78%. Sensitivity of contrast enema studies varied between 80% and 83%. Conclusion. In two-thirds of the patients, the diagnosis of ACD can be made based on clinical evaluation alone. In one-third of the patients, additional imaging is a necessity to establish the diagnosis. US and CT are comparable in diagnosing diverticulitis and superior to other moda

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1 juni 2012, Item does not contain fulltext, INTRODUCTION: Laparoscopic and endoscopic hernia repair popularized the preperitoneal mesh position due to promising results concerning less chronic pain. However, considerable proportions of severe adverse events, learning curves, or added costs have to be taken into account. Therefore, open preperitoneal mesh techniques may have more advantages. The open approach to the preperitoneal space (PPS) according to transrectus sheath preperitoneal (TREPP) mesh repair is through the sheath of the rectus abdominus muscle. This technique provides an excellent view of the PPS and facilitates elective or acute hernia reduction and mesh positioning under direct vision. In concordance with the promising transinguinal preperitoneal inguinal hernia repair experiences in the literature, we investigated the feasibility of TREPP. METHODS: A rationale description of the surgical technique, available level of evidence for thoughts behind technical considerations. Furthermore, a descriptive report of the clinical outcomes of our pilot case series including 50 patients undergoing the TREPP mesh repair. RESULTS: A consecutive group of our first 50 patients were operated with the TREPP technique. No technical problems were experienced during the development of this technique. No conversions to Lichtenstein repair were necessary. No recurrences and no chronic pain after a mean follow-up of 2 years were notable findings. CONCLUSION: This description of the technique shows that the TREPP mesh repair might be a promising method because of the complete preperitoneal view, the short learning curve, and the stay-away-from-the-nerves principle. The rationale of the TREPP repair is discussed in detail.

Item does not contain fulltext, OBJECTIVE: The aim of this study was to assess and compare the diagnostic value of elements of the disease history, physical examination, and routine laboratory tests in patients with suspected acute left-sided colonic diverticulitis (ALCD). BACKGROUND: Misdiagnosis rates for diverticulitis vary in literature between 34% and 68% which needs improvement. Because of the frequent misdiagnosis, liberal use of imaging has been recommended. Before making a plea for routine imaging, the diagnostic accuracy of different variables of disease history, physical examination, and routine laboratory tests needs to be specified. METHODS: All patients seen on the emergency department because of acute abdominal pain suspected of ALCD in whom an abdominal computed tomography was performed, between January 2002 and March 2006, were studied. Univariate logistic regression was used to study differences in patients' characteristics and symptoms, findings at physical examination and routine laboratory tests between patients with and without ALCD. Independent predictors to the risk of ALCD were identified using multivariate logistic regression and used to create a clinical scoring system. RESULTS: Of 1290 patients with acute abdominal pain, 287 patients were eligible for analysis. Acute left-sided colonic diverticulitis was the final diagnosis in 124 patients (43%). Age, 1 or more previous episodes, localization of symptoms in the lower left abdomen, aggravation of pain on movement, the absence of vomiting, localization of abdominal tenderness in the lower left abdomen, and C-reactive protein 50 or more were found to be independent predictors of ALCD. A nomogram was constructed based on these independent predictors with a diagnostic accuracy of 86%. CONCLUSIONS: This study showed that the clinical diagnosis of diverticulitis is difficult to make but can be improved using a clinical scoring system. In case of a high chance of ALCD based on the nomogram, additional imaging may not be needed.

Contains fulltext : 69776.pdf (publisher's version ) (Closed access), BACKGROUND: Diverticular disease is a common problem in Western countries. Rationale for elective surgery is to prevent recurrent complicated diverticulitis and to reduce emergency procedures. Recurrent diverticulitis occurs in about 10% after resection. The pathogenesis for recurrence is not completely understood. We studied the incidence and risk factors for recurrence and the overall morbidity and mortality of surgical therapy for diverticular disease. METHODS: Medical records of 183 consecutive patients with pathology-proven diverticulitis were eligible for evaluation. Mean duration of follow-up was 7.2 years. Number of preoperative episodes, emergency or elective surgeries, type of operation, level of anastomosis, postoperative complications, persistent postoperative pain, complications associated with colostomy reversal, and recurrent diverticulitis were noted. The Kaplan-Meier method was used to calculate the cumulative probability of recurrence. Cox regression was used to identify possible risk factors for recurrence. RESULTS: The incidence of recurrence was 8.7%, with an estimated risk of recurrence over a 15-year period of 16%. Risk factors associated with recurrence were (younger) age (p < 0.02) and the persistence of postoperative pain (p < 0.005). Persistent abdominal pain after surgery was present in 22%. Eighty percent of patients who needed emergency surgery for acute diverticulitis had no manifestation of diverticular disease prior to surgery. In addition, recurrent diverticulitis was not associated with a higher percentage of emergency procedures. CONCLUSION: Estimated risk of recurrence is high and abdominal complaints after surgical therapy for diverticulitis are frequent. Younger age and persistence of postoperative symptoms predict recurrent diverticulitis after resection. The clinical implication of these findings needs further investigation. The results of this study support the careful selection of patients for surgery for diverticulitis.

Contains fulltext : 53058.pdf (publisher's version ) (Closed access), A 23-year-old man presented with a left-sided non-healing small preauricular wound, which existed for several months after an operation for an infected suspected 'epidermal cyst'. At operation a preauricular sinus with fistula was excised.