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Background: Residents’ well-being is essential for both the individual physician and the quality of patient care they deliver. Therefore, it is important to maintain or possibly enhance residents’ well-being. We investigated (i) the influence of mind fitness training (MFT) on quality of care-related well-being characteristics: work engagement, empathy, work satisfaction and stress perception and explored (ii) residents’ perceptions of MFT., Methods: A multicenter study was conducted in eight Dutch teaching hospitals, from September 2012 to February 2014, using mixed methods—that is, quantitative and qualitative approaches to data collection and analysis. Eighty-nine surgical residents were invited to participate in pre- and post-intervention questionnaire surveys. Twenty-two residents participated in MFT and were additionally invited to evaluate the training by post-intervention interviews including open questions., Results: At baseline 22 (100%) residents in intervention group and 47 (70.2%) residents in control group, and postintervention 20 (90.9 %) residents in intervention group and 41 (66.1%) residents in control group completed the questionnaires. In intervention-group, residents’ specialty satisfaction increased by 0.23 point on 5-point Likert scale (95% CI 0.23–0.24, P < 0.001) while stress scores decreased by -0.94 point on 10-point scale (95% CI -1.77 to -0.12, P = 0.026). No substantial changes were observed in control group. Participation in MFT was positively associated with residents’ empathy (b = 7.22; 95% CI 4.33–10.11; P < 0.001) and specialty satisfaction scores (b = 0.42; 95% CI 0.18–0.65; P = 0.001). Residents positively evaluated MFT with median scores of 6.80 for training design and 7.21 for outcome (10-point scale). Residents perceived improvement in focusing skills and reported being more aware of their own state of mind and feeling calmer and more in control., Conclusion: Mind fitness training could improve residents’ empathy, specialty satisfaction, stress perception, and focusing skills, and was positively received by surgical residents.

Background: Incisional hernia is one of the most frequent postoperative complications after abdominal surgery. Patients with an abdominal aortic aneurysm and patients with a body mass index of 27 or higher have an increased risk to develop incisional hernia. Primary mesh augmentation is a method in which the abdominal wall is strengthened to reduce incisional hernia incidence. This study focused on the short-term results of the PRImary Mesh Closure of Abdominal Midline Wounds trial, a multicenter double blind randomized controlled trial., Methods: Between 2009 and 2012 patients were included if they were operated via midline laparotomy, and had an abdominal aortic aneurysm or a body mass index of 27 or higher. Patients were randomly assigned to either receive primary suture, onlay mesh augmentation (OMA), or sublay mesh augmentation., Results: Outcomes represent results after 1-month follow-up. A total of 480 patients were randomized. During analysis, significantly (P = 0.002) more seromas were detected after OMA (n = 34, 18.1%) compared with primary suture (n = 5, 4.7%) and sublay mesh augmentation (n = 13, 7%). No differences were discovered in any of the other outcomes such as surgical site infection, hematoma, reintervention, or readmission. Multivariable analysis revealed an increase in seroma formation after OMA with an odds ratio of 4.3 (P = 0.004) compared with primary suture and an odds ratio of 2.9 (P = 0.003) compared with sublay mesh augmentation., Conclusions: On the basis of these short-term results, primary mesh augmentation can be considered a safe procedure with only an increase in seroma formation after OMA, but without an increased risk of surgical site infection.

Music and other forms of art are increasingly being integrated into hospitals. As well as the aesthetic value of art, more and more attention is being paid to its contribution to the healing of the patient. Scientific research indicates the possible benefits of specific art in healthcare facilities. Using this knowledge of the role and employability of surroundings and art in the healing of patients may be complementary to the high quality of care in the Netherlands. By means of proper, methodologically correct research, it is possible to investigate the use of different aspects of the patient's environment as simple, safe and low-cost measures in improving health and well-being of patients.

Background: Faculty members rely on residents' feedback about their teaching performance. The influence of residents' characteristics on evaluations of faculty is relatively unexplored. We aimed to evaluate the levels of work engagement and empathy among residents and the association of both characteristics with their evaluation of the faculty's teaching performance., Methods: A multicenter questionnaire study among 271 surgery and gynecology residents was performed from September 2012 to February 2013. Residents' ratings of the faculty's teaching performance were collected using the system for evaluation of teaching quality (SETQ). Residents were also invited to fill out standardized measures of work engagement and empathy using the short Utrecht Work Engagement Scale and the Jefferson Scale of Physician Empathy, respectively. Linear regression analysis using generalized estimating equations to evaluate the association of residents' engagement and empathy with residents' evaluations of teaching performance., Results: Overall, 204 (75.3 %) residents completed 1814 SETQ evaluations of 302 faculty, and 143 (52.8 %) and 140 (51.7 %) residents, respectively, completed the engagement and empathy measurements. The median scores of residents' engagement and empathy were 4.56 (scale 0-6) and 5.55 (scale 1-7), respectively. Higher levels of residents' engagement (regression coefficient b = 0.128; 95 % confidence interval (CI) 0.072-0.184; p < 0.001) and empathy (b = 0.113; 95 % CI 0.063-0.164; p < 0.001) were associated with higher faculty teaching performance scores., Conclusions: Residents' engagement and empathy appear to be positively associated with their evaluation of the faculty's performance. A possible explanation is that residents who are more engaged and can understand and share others' perspectives stimulate and experience faculty's teaching better than others.

Background: The aim was to study which dressing material was best for healing donor-site wounds (DSWs) after split-skin grafting as there is wide variation in existing methods, ranging from classical gauze dressings to modern silicone dressings., Methods: This 14-centre, six-armed randomized clinical trial (stratified by centre) compared six wound dressing materials in adult patients with DSWs larger than 10 cm(2) . Primary outcomes were time to complete re-epithelialization and pain scores measured on a visual analogue scale (VAS) over 4 weeks. Secondary outcomes included itching (VAS, over 4 weeks), adverse events and scarring after 12 weeks rated using the Patient and Observer Scar Assessment Scale (POSAS)., Results: Between October 2009 and December 2011, 289 patients were randomized (of whom 288 were analysed) to either alginate (45), film (49), gauze (50), hydrocolloid (49), hydrofibre (47) or silicone (48) dressings. Time to complete re-epithelialization using hydrocolloid dressings was 7 days shorter than when any other dressing was used (median 16 versus 23 days; P < 0·001). Overall pain scores were low, and slightly lower with use of film dressings (P = 0·038). The infection rate among patients treated with gauze was twice as high as in those who had other dressings (18 versus 7·6 per cent; relative risk 2·38, 95 per cent confidence interval 1·14 to 4·99). Patients who had a film dressing were least satisfied with overall scar quality., Conclusion: This trial showed that use of hydrocolloid dressings led to the speediest healing of DSWs. Gauze dressing should be discontinued as they caused more infections., Registration Number: NTR1849 (http://www.trialregister.nl)., (© 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd.)

A patient with an umbilical hernia presenting with collateral veins in the abdominal wall and umbilicus is a case that every hernia surgeon has to deal with occasionally. Several underlying diseases have been described to provoke collateral veins in the abdominal wall. However, the treatment strategy should be uniform. We herein report a case of a successful laparoscopic umbilical hernia repair in a patient with collateral veins in the abdominal wall and umbilicus. A 63-year-old man was referred to the surgical outpatient clinic with a large symptomatic umbilical hernia and collateral veins in the abdominal wall, secondary to an occlusion of both common iliac veins. Because of collateral veins in the umbilicus and the size of the hernial defect, he was offered laparoscopic hernia repair without compromising these veins. Because of the extensive abdominal wall collaterals, duplex sonography vein mapping was performed preoperatively to mark a safe collateral-free area for trocar introduction. The defect was repaired by mesh prosthesis.

Background: Abdominal surgery is a major oxidative stress effector. The increase in oxidative stress has been related to postoperative complications. Oxidative stress leads to the formation and accumulation of oxidation protein end products, which exhibit autofluorescence (AF) and induce inflammatory reactions., Methods: Skin AF was assessed perioperatively in 40 consecutive colorectal surgery patients until discharge. Duration of surgery, estimated blood loss, and urinary production per hour were analyzed as measures of surgical stress. The clinical occurrence of anastomotic leakage, systemic infections, and cardiopulmonary complications within 30 days of surgery were analyzed., Results: A perioperative increase in skin AF of 19 ± .2% was observed. Duration of operation and blood loss were independently associated with the perioperative increase in skin AF. Skin AF correlated with C-reactive protein levels postoperatively. American Society of Anesthesiologists classification, duration of operation, and preoperative and perioperative increases in AF were independently associated with postoperative complications., Conclusions: This is the first study to demonstrate an association between skin AF and surgical stress and outcomes, which may rate the condition of a patient after operation., (Copyright © 2011 Elsevier Inc. All rights reserved.)

In recent decades, numerous prospective randomized surgical trials have been performed in the Netherlands. Due to the unexpected high mortality rate in the PROPATRIA-trial, legislation pertaining to research involving human subjects has recently been changed. The resulting considerable legal and administrative burdens and financial consequences now necessitate a different way of organising clinical research in non-academic hospitals.

Background: Long-term results of laparoscopically assisted versus open ileocolic resection for Crohn's disease were evaluated in a randomized trial., Methods: Sixty patients who underwent ileocolic resection between 1999 and 2003 were followed prospectively. Primary outcomes were reoperation, readmission and repeat resection rates for recurrent Crohn's disease. Secondary outcomes were quality of life (QOL), body image and cosmesis., Results: Five patients were lost to follow-up. Median follow-up was 6.7 (interquartile range 5.7-7.9) years. Sixteen of 29 and 16 of 26 patients remained relapse free after ileocolic resection in the laparoscopic and open groups respectively (risk difference 6 (95 per cent confidence interval - 20 to 32) per cent). Resection of recurrent Crohn's disease was necessary in two of 29 versus three of 26 patients (risk difference 5 (-11 to 20) per cent). Overall reoperation rates for recurrent Crohn's disease, incisional hernia and adhesion-related problems were two of 29 versus six of 26 (risk difference 16 (-3 to 35) per cent). QOL was similar, whereas body image and cosmesis scores were significantly higher after laparoscopy (P = 0.029 and P < 0.001 respectively)., Conclusion: Laparoscopically assisted ileocolic resection results in better body image and cosmesis, whereas open surgery is more likely to produce incisional hernia and obstruction., (Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Laparoscopic cholecystectomy (LC) after an endoscopic retrograde cholangiography (ERC) has higher rates for complications and conversion caused by unpredictable adhesions. The risk factors for an adverse outcome of LC after an ERC were analyzed., Methods: Variables from patients treated by LC after ERC for cholelithiasis in two clinics from 1996 to 2003 were retrospectively stored in a database. Complications and conversions were recorded., Results: A total of 140 patients underwent LC after ERC (83 from clinic A and 57 from clinic B), 31% (44/140) of whom were men. Peri- or postoperative complications occurred for 28 patients (20%). For 19 patients (14%), a conversion was necessary. Significant variables associated with complications and conversions were an elevated level of C-reactive protein (CRP) at the time of LC (odds ratio [OR], 10.2; 95% confidence interval [CI], 1.1-91, P = 0.037 for both) and severe adhesions during laparoscopy (OR, 3.6; 95% CI, 1.5-8.6; P = 0.003 and OR, 5.2; 95% CI, 1.9-14.4; P = 0.002, respectively). Male gender (OR, 2.8; 95% CI, 1.1-7.6; P = 0.037) and serum bilirubin level at the time of ERC (OR, 3.7; 95% CI, 1.24-11; P = 0.014) were associated with conversion only. Time after ERC (LC within 1 week vs. >1 week or < or = 2 weeks vs. 2-6 weeks vs. >6 weeks or < or = 6 weeks vs. >6 weeks) was not associated with complications or conversion. Multivariate regression analysis showed a pre-LC CRP exceeding 6 to be predictive of complications (OR, 10.5; 95% CI, 1.1-95; P = 0.040) and conversion (OR, 10.6; 95% CI, 1.1-99; P = 0.034)., Conclusion: Male gender, bilirubin levels during ERC, severe adhesions during LC, and pre-LC CRP levels were associated with an adverse outcome for an LC after endoscopic cholangiography. The time between LC and ERC failed to be a significant risk factor in this larger series.

AN EXAMPLE FOR THE PRESENT DAY: The current requirement for explicit quality standards and examination of surgeons is an opportunity to contemplate surgical training from a historical perspective by looking at the regulations of the Amsterdam Surgeons' Guild (1461-1736). At that time Amsterdam surgeons usually trained for five years in a master-apprentice relationship under the guidance of a master surgeon in a surgeon's shop. An important part of the surgical training took place in the botanical gardens and anatomical theatre, where, during the weekly lessons, the praelector anatomiae would also demonstrate anatomy on the bodies of the deceased. Surgical training was complete after the trainee had passed the 'meesterproef' (master's exam), in which the manufacturing of lancets, blood-letting and performing a trepanation on a skull played a major part. However, over the course of time the final master's exam as the ultimate test of capability at the end of surgical training has disappeared. From the perspective of renewed interest in explicit quality standards and examination of surgeons, the reintroduction of a modern master's exam should perhaps be considered.

Background: Publications in peer-reviewed journals are the main determinants of research rating and funding. The present study assesses worldwide scientific contributions in the field of surgical research., Methods: Fifteen major surgical journals were selected for a bibliometric search in Medline/PubMed over a 6-year period (2000-2005). All articles with abstracts were totalled according to country of corresponding author. Publications (total and corrected for population size) and journal impact factor were assessed according to country., Results: A total of 18,717 articles were identified. Fifteen countries generated 88.8 per cent of these: the USA produced 42.1 per cent, Japan 9.1 per cent and the UK 7.6 per cent. When corrected for population size, the Netherlands, Sweden and Switzerland topped the ranking; the USA was sixth. Ireland and Switzerland scored the highest mean impact factor., Conclusion: The USA is the most productive country in terms of absolute number of surgical publications in the selected journals. However, when population size is taken into consideration, certain smaller European countries were more prolific., (Copyright (c) 2006 British Journal of Surgery Society Ltd.)

Objective: The aim of the study was to compare laparoscopic-assisted and open ileocolic resection for primary Crohn's disease in a randomized controlled trial., Methods: Sixty patients were randomized for laparoscopic-assisted or open surgery. Primary outcome parameter was postoperative quality of life (QoL) during 3 months of follow-up, measured by SF-36 and GIQLI questionnaire. Secondary parameters were operating time, morbidity, hospital stay, postoperative morphine requirement, pain, and costs., Results: Patient characteristics were not different. Conversion rate was 10% (n=3). Median operating time was longer in laparoscopic compared with open surgery (115 versus 90 minutes; P<0.003). Hospital stay was shorter in the laparoscopic group (5 versus 7 days; P=0.008). The number of patients with postoperative morbidity within the first 30 days differed between the laparoscopic and open group (10% versus 33%; P=0.028). There was no statistically significant difference in QoL between the groups during follow-up. Significant time effects were found on all scales of the SF-36 (P<0.001) and the GIQLI score (P<0.001). QoL declined in the first week, returned to baseline levels after 2 weeks, and was improved 4 weeks and 3 months after surgery. Median overall costs during the 3 months follow-up were significantly different: euro6412 for laparoscopic and euro8196 for open surgery (P=0.042)., Conclusions: Although QoL measured by SF-36 and GIQLI questionnaires was not different for laparoscopic-assisted compared with the open ileocolic resection, morbidity, hospital stay, and costs were significantly lower.

Background: Preceding endoscopic retrograde cholangiography (ERC) in patients with choledochocystolithiasis impedes laparoscopic cholecystectomy (LC) and increases risk of conversion. We studied the influence of time interval between ERC and LC on the course of LC., Methods: All patients treated for choledochocystolithiasis with ERC and LC during 1996-2001 were studied retrospectively, comparing the course of LC in three time interval groups; LC < 2, 2-6, and > 6 weeks after ERC., Primary Outcomes: adhesions, bile duct injury, operating time, and conversion-rate., Results: Eighty-three patients were studied (group 1, n = 23; group 2, n = 15; group 3, n = 45). Adhesions, operation time, and bile duct damage did not significantly differ between the groups. The conversion rate in group 2 is significantly higher compared to group 1 (p = 0.027, OR 11 (1.13-106.8)) CONCLUSIONS: A higher conversion rate of LC is found 2-6 weeks after ERC compared to LC within 2 weeks. However, further research is needed to gain more reliable data on whether this is caused by timing.

Background: Several methods for skin closure are used, i.e. sutures, adhesive papertape and tissue adhesives. Little is known about the efficacy of these techniques in laparoscopic surgery. This study was performed to analyse the efficacy of octylcyanoacrylate, a new tissue adhesive, adhesive papertape and poliglecaprone for wound closure in laparoscopy., Methods: From May 2000 to September 2001, 140 patients were included in a prospective randomized trial. Wounds were closed with octylcyanoacrylate (n = 48), adhesive papertape (n = 42) or poliglecaprone (n = 50). Closing time, wound infection, cosmetic results and costs were evaluated. A time-motion analysis was also performed., Results: The patients in the three groups were well matched for age, gender and body mass index. Closing times per wound were 26, 33 and 65 s respectively for adhesive papertape, octylcyanoacrylate and poliglecaprone (P < 0.001). Cosmetic results, as scored by the patients, were no different. The number of actions required to close each wound was 5.7, 8.3 and 21.0 for octylcyanoacrylate, adhesive papertape (P = 0.05 versus octylcyanoacrylate) and poliglecaprone (P < 0.01 versus octylcyanoacrylate and adhesive papertape) respectively. Octylcyanoacrylate was significantly more expensive than poliglecaprone and adhesive papertape., Conclusion: Closure with adhesive papertape was the fastest method. The smallest number of actions required to close a wound was with octylcyanoacrylate. Adhesive papertape was the most cost-effective.

Two patients, premenopausal women aged 48 years and 37 years, who were treated with tamoxifen following a mammary carcinoma operation, experienced abdominal complaints, hot flushes, vaginal discharge, an irregular menstrual cycle and/or concern about the increased risk of ovarian carcinoma. Transvaginal ultrasonography of the ovaries and laboratory tests indicated ovarian overstimulation. Both patients temporarily stopped using tamoxifen; in one of the patients both ovaries were ablated. The range of indications for treatment with tamoxifen has in recent years been extended to premenopausal patient groups and the length of treatment has been increased from two to five years. We recommend more extensive checks when prescribing tamoxifen to premenopausal patients in view of the possible adverse effects of ovarian stimulation associated with this treatment.

Purpose: Subfascial division of incompetent perforating veins seems to be a successful treatment for patients with venous leg ulceration (CEAP 6). For postoperative wound complications, endoscopic techniques are more common than open subfascial division of incompetent perforating veins (Linton procedure). We investigated the long-term results of ulcer healing and recurrence rates and compared them with preoperative and postoperative duplex findings., Methods: Patients with venous ulceration on the medial side of the lower leg were randomly allocated to endoscopic exploration or open exploration by means of the modified Linton approach. Ulcer healing and recurrence rates were documented., Results: Thirty-nine patients were randomly allocated to exploration, 19 patients to open subfascial division of incompetent perforating veins (Linton group), and 20 patients to subfascial endoscopic division of incompetent perforating veins (SEPS group). During the follow-up period, four patients in the SEPS group died, all of causes other than the venous leg ulcer. Because of a squamous cell carcinoma that had developed in the venous ulcer, one patient in the SEPS group underwent a below-knee amputation. In a mean follow-up period of 50.6 months, the venous ulceration of all 18 patients in the Linton group who were available for follow-up initially healed. The recurrence rate in this group was 22% (4 patients). In the SEPS group, the mean follow-up period for 19 patients was 46.1 months, with the ulceration healing in 17 patients and a recurrence rate of 12% (2 patients). The presence of deep venous incompetence (DVI) did not influence the recurrence rates (P =.044, Fisher exact test), but it significantly influenced the development of new incompetent perforating veins (3 of 10 without DVI; 7 of 10 with DVI; P =.011, binomial test)., Conclusion: The long-term follow-up results of the endoscopic division of perforating veins are comparable with those of the open division of perforating veins (modified Linton procedure).

Objective: To determine how the influx of patients in an emergency room (ER) is spread over the week and what factors play a part., Design: Prospective., Method: The ER contacts in the De Weezenlanden Hospital of Zwolle, the Netherlands, were recorded on standardized forms during the period 1 May-14 June 1997 (6 weeks)., Results: 1995 ER contacts were recorded: 47% were referred by the GP and 8% by the municipal ambulance service, while 45% came at their own initiative. Injuries to the locomotor apparatus and wounds accounted for at least 50% of all contacts and were more frequent among patients attending at their own initiative (73%) or delivered by the ambulance service (49%) than among those referred by the GP (31%). Patients with various diseases, on the other hand, were mostly referred by the GPs (62%). 76% of all contacts occurred between 8 a.m. and 8 p.m. There was no Friday afternoon peak. The differences between the number of contacts during the week and in the weekend were not significant. Of the patients referred by the GP or delivered by the ambulance service more than half were admitted to the hospital, as against 18% of the patients attending at their own initiative., Conclusion: In the ER examined there were not more new patients on the Friday afternoon than during the rest of the week.

Purpose: Subfascial division of incompetent perforating veins plays an important role in the surgical treatment of patients with venous ulceration of the lower leg. To minimize the high incidence of postoperative wound complications after open exploration, endoscopic approaches have recently been developed. We carried out a prospective, randomized comparison of open and endoscopic treatment of these patients that was aimed at ulcer healing and postoperative wound complications., Methods: Patients with current venous ulceration on the medial side of the lower leg were randomly allocated to open exploration by the modified Linton approach or endoscopic exploration by use of a mediastinoscope., Results: Thirty-nine patients were randomized, 19 to open exploration and 20 to endoscopic exploration. The incidence of wound infections after open exploration was 53%, compared with 0% in the endoscopic group (p < 0.001). Patients in the open group needed longer hospital stays (mean, 7 days; range, 3 to 39 days) than patients in the endoscopic group (mean, 4 days; range, 2 to 6 days; p = 0.001). Four months after operation, the ulcers of 17 patients (90%) in the open group and 17 patients (85%) in the endoscopic group had healed. During a mean follow-up of 21 months (range, 16 to 29 months), no recurrences were noticed in either group., Conclusions: Endoscopic division of incompetent perforating veins is equally as effective as open surgical exploration for the treatment of venous ulceration of the lower leg but leads to significantly fewer wound healing complications. Endoscopic division is therefore the preferred method.

Purpose: The purpose of this study was to investigate the efficacy of subfascial endoscopy by use of a mediastinoscope in the identification and ligation of incompetent perforating veins in patients with venous ulceration of the lower leg., Methods: All patients who underwent subfascial endoscopy for venous ulceration between Jan. 1, 1994, and Mar. 1, 1995, at the Sint Franciscus Gasthuis in Rotterdam underwent duplex ultrasound scans of the lower leg before and 6 weeks after operation. The number and localization of the perforating veins on the mediodorsal side were compared with the findings during subfascial endoscopy., Results: In 20 patients, preoperative duplex examination showed 46 incompetent and six competent perforating veins. During operation the site of 43 incompetent and all competent perforating veins was confirmed. Five additional perforating veins were found at operation (false-negatives). Postoperative duplex ultrasound scans showed six incompetent perforating veins (four persisting and two recurring perforating veins) in four patients, of which the ulcers did not heal in three. The ulcers of the other 17 patients healed., Conclusions: Subfascial endoscopy is an efficient technique in identifying incompetent perforating veins in patients with chronic ulceration of the lower leg. The persistence of incompetent perforating veins is related to failure of ulcer healing.

Purpose: Incompetent perforating veins play an important role in the etiologic mechanism of venous ulceration and recurrent varicose veins. The anatomic and functional status of the venous system can be evaluated by duplex ultrasonography. To determine the value of this technique in the identification of competent and incompetent perforating veins, a prospective study was performed., Methods: In patients who underwent subfascial exploration for venous ulceration of the lower leg, the preoperative findings of duplex ultrasonography were compared with the findings at surgical exploration., Results: In 20 consecutive patients, 42 incompetent and 8 competent perforating veins were detected by duplex ultrasonography. During operation the location of all 50 perforating veins appeared to be predicted correctly. Eleven additional perforating veins that had not been detected by duplex ultrasonography were found during operation. The sensitivity and specificity of duplex ultrasonography in predicting the site of perforating veins at the medial side of the lower leg in our study were 79.2% and 100%, respectively, for incompetent perforating veins and 82% and 100%, respectively, for competent and incompetent perforating veins., Conclusion: These figures indicate that duplex-guided local exploration of the lower leg in patients with venous ulceration as a result of incompetent perforating veins would miss a substantial number of perforating veins, possibly leading to incomplete healing or recurrent ulceration.

Objectives: To assess the technique of subfascial endoscopic ligation of incompetent perforatory veins by use of a mediastinoscope., Design: Prospective open clinic study., Setting: Two Departments of Surgery., Materials and Methods: Thirty-eight consecutive patients (40 legs) with recurrent or protracted venous ulceration of the lower leg were treated. Through a short, transverse incision of the skin and fascia in the proximal 1/3 of the lower leg a mediastinoscope (length 18 cm, diameter 12 mm) is inserted after which the perforating veins are ligated by haemoclips under direct vision., Main Results: All legs showed signs of incompetent perforating veins by clinical examination, confirmed with continuous wave ultrasonography and in 31 legs there was associated deep vein incompetence. Sixteen patients had active ulceration at the moment of operation and 22 had a history of recent or recurrent ulceration. One patient developed an inflammatory reaction at the wound and in two legs a subfascial infection occurred, necessitating surgical drainage. No postoperative mortality was seen. All 16 ulcers healed within 2 months (mean: 34 days; range: 21-55 days). During a mean follow-up of 3.9 (range: 2-5) years only one out of 38 patients (2.5%) developed a recurrent ulcer., Conclusions: Subfascial endoscopic ligation of incompetent perforating veins by use of a mediastinoscope is a relatively simple technique with a low postoperative complication rate and a low recurrent ulcer rate which makes it a valuable method for treating incompetent perforating veins.

Extracorporeal shock wave lithotripsy has become an accepted alternative for the management of nephrolithiasis and cholelithiasis. Direct impact of shock waves cause tear and shear forces at transition sites between tissues with divergent acoustic impedances leading to stone fragmentation. The aim of this study was to determine whether shock waves can cause cortical bone damage at all and, if so, what the relationship is, if any, between the energy density of the shock waves, the number of shock waves applied, and the resulting cortical bone damage. With the Siemens Lithostar Plus with overhead module, electromagnetic shock waves, generated under water with energy densities of 0.23, 0.33, 0.42, or 0.54 mJ/mm2, corresponding with power settings 2, 4, 6, and 8, were applied to bone specimens, i.e., of rabbit femurs and tibiae. Prior to exposure to the shock waves, the bones were mounted on a specially constructed perspex holder which could be placed in a water-filled test basin with an elastic membrane in the front through which the shock waves propagate without loss of energy. This setup made it possible not only to induce complete fractures, but also to detect the existence of a linear relationship with a Spearman rank correlation coefficient of -0.72 (P < or = 0.01) between the energy level of the shock waves and the severity of the cortical bone defects. The latter findings are especially of great importance because this means that the process can be controlled and that the cortical effects will be predictable and reproducible. This study should be considered a preliminary test concerning the effects of high energy shock wave on bone.(ABSTRACT TRUNCATED AT 250 WORDS)