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The risk for intraabdominal abscess (IAA) after laparoscopic appendectomy (LA) is still a matter of debate. The aim of the present study was to evaluate postoperative complications after open (OA) and laparoscopic appendectomy, in particular in perforated appendicitis (PA).In the period 1999-2002, 331 appendectomies were performed for histological proven appendicitis, 144 by the open and 187 by the laparoscopic technique. Parameters were conversion rate, perforation, wound infection, and IAA.Conversion to OA was done in 20 cases (10.7%). Perforated appendicitis led more frequently to conversion than simple appendicitis (23.5 vs 7.8%; p = 0.007). Perforated appendicitis was equally seen in the open and laparoscopic technique (15 vs 18%). Wound infections after OA, converted and LA for acute appendicitis were 3 of 144 (2.1%), 1 of 20 (5.0%) and 1 of 167 (0.6%), respectively (NS). IAA formation did not differ among the three procedures (3.5 vs 0 vs 3.6%). In PA the rate of IAA formation was increased. However, the risk was not influenced by the technique: Two patients after the OA, none after a converted procedure, and two patients after LA formed an abscess (9.5 vs 0 vs 7.7% [NS]).LA does not lead to more intraabdominal abscesses than the open technique; even for perforated appendicitis the laparoscopic technique can be used safely.

Case report about a minimally invasive technique for removal of a femoral antegrade nail (FAN). Femoral nails are introduced by minimally invasive techniques, but are often removed with more invasive surgery. Four cases of young patients are described in whom the femoral nail was removed after consolidation by a minimally invasive extraction technique at the trochanteric site. By using a threaded wire for locating the proximal entrance of the femoral nail followed by reaming over the wire, the entrance of the nail in the trochanteric region is freed. Then the extraction bolt can be placed over the wire and the nail can be extracted through the same incision as it was inserted in, without enlarging the incision. This case report discusses a technique for minimally invasive femoral nail extraction, not the necessity of removing nails. Leaving out the endcap at the initial operation is the only preoperative condition, since the endcap blocks the entrance of the nail. This operation is done with fluoroscopic guidance. The difficult part is the reaming. The reamer must not be damaged when approaching the nail entrance. This minimally invasive femoral nail extraction technique is applicable for various types of femoral nails. Minimally invasive extraction of femoral nails is possible and needs more attention. The level of evidence is a level IV case series.

BACKGROUND: A retrospective study was done to determine whether laparoscopic adhesiolysis benefits patients with chronic abdominal pain. Factors that influence complications and feasibility of laparoscopic adhesiolysis were evaluated. METHODS: 174 consecutive operations in 157 patients were retrospectively analyzed for factors which might influence the complication rate and the feasibility of laparoscopic adhesiolysis. RESULTS: In 128 out of 174 procedures a complete adhesiolysis was performed. We had to accept an incomplete adhesiolysis in 39 other patients and in 7 patients a primary conversion was needed. We noticed 16 major complications. Two patients died. Relief of pain was recorded in 80% of patients after short follow-up. The number of previous abdominal operations and patient age significantly affected the outcome of surgery. CONCLUSION: Laparoscopic adhesiolysis in patients with chronic abdominal pain seems to be a feasible and effective operation with considerable risk.

To give an overview of the trends and variation in breast-conserving surgery in patients with a breast tumouror = 2 cm (pT1) or2 andor = 5 cm (pT2), treated in general hospitals in the southeast and east of the Netherlands.Descriptive.Data from the regional cancer registries of the Comprehensive Cancer Centre South (CS) and the Comprehensive Cancer Centre Stedendriehoek Twente (CST) were used to study trends and variations in the use of breast-conserving surgery in 12,985 pT1 tumours and 8,893 pT2 tumours in the period 1990-2002.The mean percentage of patients that underwent breast-conserving surgery from 1990-2002 was 54 in the CS region and 43 in the CST region. In patients50 years old with a pT1 tumour a decrease in the percentage of breast-conserving surgery from 73 to 64 was seen in the CS region, and in the CST region this percentage decreased from 72 to 51. In pT2 tumours a decrease from 47 to 37 was seen in the CS region and from 34 to 31 in the CST region. In patients of 50 to 69 years of age with a pT1 tumour, the percentage of breast-conserving surgery increased in the CS region from 67 to 74 and in the CST region from 54 to 61. In pT2 tumours it increased from 40 to 44 and from 25 to 37. In patientsor = 70 years the percentage of breast-conserving surgery in pT1 tumours increased from 37 to 59 in the CS region and in the CST region from 42 to 50. In pT2 tumours it increased from 20 to 31 in the CS region whereas it remained 17 in the CST region. The variation in breast-conserving surgery between hospitals in the period 1999-2002 was large. The percentage of breast-conserving surgery in patients with pT1 tumours varied between 47 and 86 in the hospitals in the CS region and between 54 and 71 in the CST region. In patients with a pT2 tumour the percentages varied between 25 and 43 in the CST region and between 16 and 64 in the CS region.More than 20 years after the introduction of breast-conserving surgery a large regional variation still exists in the use of this treatment, in the CS region in particular. There is also wide inter-hospital variation.

In addition to reducing breast cancer mortality, breast cancer screening programmes are expected to increase the proportion of patients who can undergo breast-conserving surgery. Trends in the use of breast-conserving surgery (BCS) in Southeast Netherlands between 1990 and 1998 were studied in relation to the gradual introduction of mammographical screening for women 50-69 years of age between 1992 and 1996. The characteristics of the tumours detected by the screening programme or outside of the programme were compared, to see whether this might clarify the observed trends. In the period 1990-1998, 4788 patients were diagnosed with invasive, operable breast cancer, of whom 2341 were 50-69 years of age. Although the screening programme resulted in a larger proportion of patients with small tumours and more favourable tumour characteristics, no increase was observed in the use of BCS for patients 50-69 years of age in the period 1990-1998 (64% in 1990 and 1998). Patients with a screening-detected tumour, however, were more likely to undergo breast conservation compared with those presenting clinically (68% versus 54%; P0.0001). In conclusion, no increase in the proportion of breast-conserving surgical procedures was observed in Southeast Netherlands among patients 50-69 years of age in the period 1990-1998, during the introduction of mass mammographical screening for this group. Screening, however, resulted in a larger proportion of patients with small tumours with more favourable characteristics, who are better candidates for breast conservation.

To analyse the incidence and treatment of ductal carcinoma in situ (DCIS) of the breast in the population.Retrospective, descriptive.The incidence of DCIS in the period 1975-1997 in 8 hospitals in southeastern North Brabant and northern Limburg, the Netherlands, was analysed, using data from the Eindhoven Cancer Registry. Changes in the treatment of DCIS in the period 1984-1997 were studied, using information from the Breast Cancer Documentation Project.Between 1975 and 1997, 448 cases of DCIS were detected in 442 women. After adjustment for age according to the European Standard Population, the incidence rate of DCIS increased from 0.3 per 100,000 in 1975 to 13.4 in 1997. Of the 87 patients with DCIS between 50 and 69 years of age in 1996 and 1997, 68% was detected by the screening programme. The proportion of patients with DCIS undergoing ablation of the breast was 53% during the period 1984-1989, and varied around 45% thereafter. The other patients underwent local excision. The proportion of patients receiving radiotherapy after local excision decreased from 78% in the period 1984-1989 to 24% in the period 1994-1995 and rose to 41% during the last few years. Substantial differences in the treatment of DCIS were observed between the 8 hospitals.

A woman aged 38 displayed colicky pains and melaena two weeks after a laparoscopic cholecystectomy. The haemoglobin level was decreased, the serum hepatic enzyme levels were slightly increased. Diagnostic imaging examinations and finally, because of recurrent symptoms, an emergency laparotomy revealed a bleeding from a pseudoaneurysm of the proper hepatic artery next to the choledochus. The aneurysm was ligated. Seven months later the patient had no more symptoms. The possibility of haemobilia should be considered in every case of gastrointestinal bleeding after laparoscopic cholecystectomy.

A retrospective study was done to determine whether laparoscopic adhesiolysis benefits patients with chronic abdominal pain. Factors that influence complications and feasibility of laparoscopic adhesiolysis were evaluated.174 consecutive operations in 157 patients were retrospectively analyzed for factors which might influence the complication rate and the feasibility of laparoscopic adhesiolysis.In 128 out of 174 procedures a complete adhesiolysis was performed. We had to accept an incomplete adhesiolysis in 39 other patients and in 7 patients a primary conversion was needed. We noticed 16 major complications. Two patients died. Relief of pain was recorded in 80% of patients after short follow-up. The number of previous abdominal operations and patient age significantly affected the outcome of surgery.Laparoscopic adhesiolysis in patients with chronic abdominal pain seems to be a feasible and effective operation with considerable risk.

To assess the effect of oestrogen (ER) and progesterone (PgR) receptors on the prognosis of patients with operable breast cancer and the decision to treat these patients with adjuvant tamoxifen.Retrospective.Eight community hospitals in the Southeast Netherlands.Using the registry of the Comprehensive Cancer Centre South, 2862 breast cancer patients were identified with stage I, II or IIIA tumours, treated during the period 1984-1992.ER and PgR status were known for 2393 (84%) and 1761 (62%) patients respectively. From 1991, over 80% of the postmenopausal, lymph node positive patients had received tamoxifen, irrespective of the steroid receptor status. Of all lymph node negative patients fewer than 3% received adjuvant systemic treatment. Among the lymph node negative patients the steroid receptor status was not a significant predictor of survival. Among the lymph node positive patients whose tumours were both ER-negative and PgR-negative, a 2.8-fold increased risk of death was found during the first four years after primary treatment. The risk of death was not increased if only the ER or only the PgR status was negative.This study shows that ER and PgR receptors are significant prognostic factors for survival in breast cancer patients with involved axillary lymph nodes. The prognostic effect appeared to be restricted to the first four years after primary treatment. Selection of patients for endocrine treatment should be based on the steroid receptor status, considering the importance of the steroid receptors for predicting the response to endocrine treatment.

To evaluate the treatment and prognosis of 82 patients with local relapse in the breast as the first event after breast-conserving therapy of operable breast cancer.Descriptive and retrospective.17 general hospitals in southeast North-Brabant and North-Limburg.Using the registries of the Comprehensive Cancer Centre South in Eindhoven (1981-1990) and the Bernard Verbeeten Institute in Tilburg (1981-1987), 82 patients were identified who had developed local recurrence after breast-conserving therapy.The mean age of the 82 patients at the time of detection of local recurrence was 51 years. 46 recurrences (56%) were localized at or near the site of the original tumour, 14 (17%) were detected elsewhere in the breast, 15 (18%) showed diffuse spread through the breast and seven (9%) were completely or partly localized in the skin. Nine recurrences (11%) were non-invasive. Of the 82 patients four received adjuvant systemic therapy only and no surgery. Of the 78 patients treated with surgery 72 underwent mastectomy, 6 local excision. After treatment, the actuarial five-year overall survival, distant recurrence-free survival and disease-free survival rates were 60%, 43% and 31% respectively. Local control, defined as survival without second local recurrence and without local progression of the disease, was 57% after five years.The five-year distant recurrence-free and disease-free survival rates for patients with local recurrence after breast conserving-therapy were low. The high proportion of second local recurrences and local progression of disease in this study underlines the difficulty of obtaining local control after treatment of local recurrence.

We studied changes in staging and treatment of patients with early breast cancer (TNM stage I and II) in eight community hospitals in southeast Netherlands between 1984 and 1991 and related these changes to the guidelines for the management of breast cancer drawn up by the regional Breast Cancer Study Group. Since 1984, the proportion of patients that underwent breast-conserving therapy (local tumour excision, axillary dissection, and irradiation of the breast) increased from 26% to 53%. Although the mean number of axillary lymph nodes examined by the pathologists increased significantly, the proportion of patients with positive lymph nodes remained unchanged. The proportion of patients with involved axillary nodes receiving any form of adjuvant systemic therapy increased from 49% to 82%. Therapeutic policy initially varied significantly from one hospital to another but gradually became more uniform. We conclude that, except for elderly patients, treatment of early breast cancer corresponded increasingly to the guidelines of the regional Breast Cancer Study Group.

Background The present phase II study aimed to assess the feasibility and efficacy of a new paclitaxel-based neoadjuvant chemoradiation regimen followed by surgery in patients with stage II–III esophageal cancer. Methods From January 2002 to November 2004, 50 patients with a potentially resectable stage II–III esophageal cancer received chemotherapy with paclitaxel, carboplatin, and 5-FU in combination with radiotherapy 45 Gy in 25 fractions. Surgery followed 6–8 weeks after completion of neoadjuvant treatment. Results Patient characteristics: male/female: 44/6, median age 60 years (34–75), median WHO 1 (0–2), adenocarcinoma (n = 42), squamous cell carcinoma (n = 8). Toxicity was mild, and 84 % of the patients completed the whole regimen. Forty-seven patients underwent surgery with a curative intention (transhiatal n = 44, transthoracic n = 3). Pathologic complete tumor regression was achieved in 18 of 47 operated patients (38%). R0 resection was achieved in 45 of 47 operated patients (96%). There were four postoperative deaths (8.5). Postoperative complications were comparable with other studies. After a median follow-up of 41.5 months (21–59) estimated 3- and 5-year survival on an intention-to-treat basis was 56 and 48%. Estimated 3-year survival in responders was 61%, in nonresponders 33%. Conclusion This novel neoadjuvant chemoradiation regimen for treatment of patients with stage II–III esophageal cancer is feasible. Results are encouraging with a high pathologic complete tumor regression and R0 resection rate and an acceptable morbidity and mortality. Preliminary survival data are very promising.

Postoperative blood losses after open-heart surgery for Tetralogy of Fallot made re-operation imperative in 15 out of 44 patients (34%, Series A). A surgical bleeding point proved to be the causative factor in only 2 cases; the others were believed to be caused by disturbances of the haemostatic mechanism, particularly by low platelet counts, apparently due to extracorporeal circulation. Administration of a platelet suspension after disconnection of the extracorporeal circuit diminished the number of bleeding complications significantly: in a series of 58 patients (Series B), 8 re-operations (14%) were necessary. In 3 of these cases, technical reasons could be found for the blood losses. Haemodilution was carried out routinely in both series. However, the diluent contained a pasteurised protein solution in Series A and fresh frozen plasma in Series B in order to minimize the deficit of coagulation factors as much as possible.

Sixty consecutive patients (66 legs) underwent surgical lumbar sympathectomy as the only therapy for severe lower limb ischaemia (pain at rest and/or frank gangrene) caused by arteriosclerosis in the period 1977 to 1982. After six months results were good, as defined by absence of pain at rest, healing of ischaemic lesions and no major amputation, in 48% of limbs and bad in all other limbs. Patients with rest pain only fared much better than those with gangrene: after six months a major amputation had to be performed in 14% and 45% respectively. The presence or absence of diabetes mellitus and palpable pulsations at knee level and the angiographic patterns were of no help in the prediction of the results of lumbar sympathectomy. Doppler ankle/arm indices did have predictive value, since in all limbs with Doppler indices lower than 0.30 a major amputation had to be performed. Lumbar sympathectomy still remains a useful procedure in the treatment of selected patients with severe lower limb ischaemia in which reconstructive surgery is not feasible. But it is only advocated in the presence of ankle/arm indices above 0.30 and in the absence of gangrenous lesions.

Subcutaneously implanted venous access devices allow prolonged access with a minimum of discomfort for patients with inadequate peripheral veins or chemotherapy-induced recurrent thrombophlebitis. In 45 cancer patients, 49 venous access devices (Port-A-Cath) were implanted subcutaneously by means of a venous cut-down technique to avoid the risk of pneumothorax. Most catheters were implanted in the deltapectoral groove under local anaesthesia with lidocaine 0.5% and guided by fluoroscopy. The cumulative function time was 22.6 patient years (1177 weeks), the mean function time 24 weeks (range 0-98 weeks). No serious complications were seen. There were two local infections and four occlusions. The patency could be restored in three of these four. Surgical implantation of venous access devices, under local anaesthesia, is a safe method to establish central venous access in cancer patients. The complication rate is low in comparison with percutaneous catheters or AV-fistulas.