Search

Background: Mechanical bowel preparation (MBP) has been shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in elective surgery in combination with an inflammatory component such as diverticulitis is yet unclear. This study evaluates the effects of MBP on anastomotic leakage and other septic complications in 190 patients who underwent elective surgery for colonic diverticulitis., Methods: A subgroup analysis was performed in a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP in elective colorectal surgery. Primary endpoint was the occurrence of anastomotic leakage in patients operated on for diverticulitis, and secondary endpoints were septic complications and mortality., Results: Out of a total of 1,354 patients, 190 underwent elective colorectal surgery (resection with primary anastomosis) for (recurrent or stenotic) diverticulitis. One hundred and three patients underwent MBP prior to surgery and 87 did not. Anastomotic leakage occurred in 7.8 % of patients treated with MBP and in 5.7 % of patients not treated with MBP (p = 0.79). There were no significant differences between the groups in septic complications and mortality., Conclusion: Mechanical bowel preparation has no influence on the incidence of anastomotic leakage, or other septic complications, and may be safely omitted in case of elective colorectal surgery for diverticulitis.

Background: A previous multicenter randomized trial demonstrated that mechanical bowel preparation (MBP) does not guard against anastomotic leakage in elective colorectal surgery. The aim of this complementary study was to evaluate the effects of MBP on morbidity and mortality after anastomotic leakage in elective colorectal surgery., Methods: A subgroup analysis was performed of a randomized trial comparing the incidence of anastomotic leakage and septic complications with and without MBP in patients undergoing elective colorectal surgery., Results: Elective colorectal surgery was performed in 1,433 patients with primary anastomoses, of whom 63 patients developed anastomotic leakage. Twenty-eight patients (44%) received MBP and 35 patients (56%) did not. Mortality rate, initial need for surgical reintervention, and extent of bowel contamination did not differ between groups (29% vs 40%; P = .497, P = .667, and P = .998, respectively)., Conclusions: No benefit of MBP was found regarding morbidity and mortality after anastomotic leakage in elective colorectal surgery., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Aim: Short-term survival after emergency surgery for perforated diverticulitis is poor. Less is known about long-term survival. The aims of this study were to evaluate long-term survival after discharge from hospital and to identify factors associated with prognosis., Method: All patients who underwent emergency surgery for perforated diverticulitis in five hospitals in Rotterdam, the Netherlands, between 1990 and 2005, were included. The association between type of surgery (Hartmann's procedure or primary anastomosis) and long-term survival was analysed using multivariate Cox regression analysis, taking into account age American Society of Anesthesiology (ASA) classification, Hinchey score, Mannheim Peritonitis Index (MPI) and surgeon's experience. In addition, survival of the patients was compared with that of the matched general Dutch population., Results: Of 340 patients included in the study, 250 were discharged alive from hospital. The overall 5-year survival was 53%. Survival was significantly impaired compared with the expected matched gender-, age- and calendar time-specific survival. Overall survival was significantly related to age and ASA classification. Hinchey score, MPI, number of re-interventions, the surgeon's experience and type of procedure did not influence long-term survival, although a trend was found for Hartmann's procedure to be a risk factor for poorer survival compared with primary anastomosis (hazard ratio for mortality: 1.88; 95% confidence interval, 0.96-3.67; P = 0.07)., Conclusion: Long-term survival of patients after perforated diverticulitis is limited and mainly caused by the poor general condition of the patients, rather than by the severity of the primary disease or calendar-time and type of procedure., (© 2010 The Authors. Colorectal Disease © 2010 The Association of Coloproctology of Great Britain and Ireland.)

Background: Recently, excellent results are reported on laparoscopic lavage in patients with purulent perforated diverticulitis as an alternative for sigmoidectomy and ostomy.The objective of this study is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis)., Methods/design: In this multicentre randomised trial all patients with perforated diverticulitis are included. Upon laparoscopy, patients with purulent peritonitis are treated with laparoscopic lavage and drainage, Hartmann's procedure or sigmoidectomy with primary anastomosis in a ratio of 2:1:1 (LOLA-arm). Patients with faecal peritonitis will be randomised 1:1 between Hartmann's procedure and resection with primary anastomosis (DIVA-arm). The primary combined endpoint of the LOLA-arm is major morbidity and mortality. A sample size of 132:66:66 patients will be able to detect a difference in the primary endpoint from 25% in resectional groups compared to 10% in the laparoscopic lavage group (two sided alpha = 5%, power = 90%). Endpoint of the DIVA-arm is stoma free survival one year after initial surgery. In this arm 212 patients are needed to significantly demonstrate a difference of 30% (log rank test two sided alpha = 5% and power = 90%) in favour of the patients with resection with primary anastomosis. Secondary endpoints for both arms are the number of days alive and outside the hospital, health related quality of life, health care utilisation and associated costs., Discussion: The Ladies trial is a nationwide multicentre randomised trial on perforated diverticulitis that will provide evidence on the merits of laparoscopic lavage and drainage for purulent generalised peritonitis and on the optimal resectional strategy for both purulent and faecal generalised peritonitis., Trial Registration: Nederlands Trial Register NTR2037.

Background: Long-term data on chronic pain after endoscopic total extraperitoneal (TEP) hernia repair are hardly available., Methods: Between January 1997 and December 1998, 416 patients with consecutive primary and recurrent inguinal hernia underwent endoscopic TEP hernia repair. Long-term follow-up evaluation was carried out from June 2007 to June 2008. The primary outcome measure was persistent pain and discomfort interfering with daily activity., Results: The overall response rate was 66% (273 of 416 patients). Of the 416 patients, 85 (20%) had died of causes unrelated to hernia repair and 58 (14%) were lost to follow-up. A total of 177 patients were physically examined in the outpatient clinic. Because 96 patients were not able to visit the outpatient' clinic, they completed the survey by telephone. The median follow-up period was 10 years (range, 9-11 years). After TEP repair, 16 patients (6%) reported chronic groin pain, and 10 patients (4%) still experience pain at this writing after the 10-year follow-up period. One of the patients has experienced persistent pain and discomfort interfering with daily activity. Patients with preoperative pain have reported significantly more chronic pain (P = 0.03)., Conclusions: Chronic groin pain after TEP repair of primary and recurrent inguinal hernia seems to have a low incidence after a 10-year follow-up period.

Background: This randomized controlled trial was designed to compare the most common technique for open mesh repair (Lichtenstein) with the currently preferred minimally invasive technique (total extra peritoneal, TEP) for the surgical correction of inguinal hernia., Methods: A total of 660 patients were randomized to Lichtenstein or TEP procedure. Primary outcomes were postoperative pain, length of hospital stay, period until complete recovery, and quality of life (QOL). Recurrences, operating time, complications, chronic pain, and costs were secondary endpoints. This study was registered at www.clinicaltrials.gov and carries the ID: NCT00788554., Results: About 336 patients were randomized to TEP, and 324 to Lichtenstein repair. TEP was associated with less postoperative pain until 6 weeks postoperatively (P=0.01). Chronic pain was comparable (25% vs. 29%). Less impairment of inguinal sensibility was seen after TEP (7% vs. 30%, P=0.01). Mean operating time for a unilateral hernia with TEP was longer (54 vs. 49 minutes, P=0.03) but comparable for bilateral hernias. Incidence of adverse events during surgery was higher with TEP (5.8% vs. 1.6%, P<0.004), but postoperative complications (33% vs. 33%), hospital stay and QOL were similar. After TEP, patients had a faster recovery of daily activities (ADL) and less absence from work (P=0.01). After a mean follow-up of 49 months, recurrences (3.8% vs. 3.0%, P=0.64) and total costs (euro3.096 vs. euro3.198) were similar., Conclusion: TEP procedure was associated with more adverse events during surgery but less postoperative pain, faster recovery of daily activities, quicker return to work, and less impairment of sensibility after 1 year. Recurrence rates and chronic pain were comparable. TEP is recommended in experienced hands.

Objective: This study evaluates the effects of mechanical bowel preparation (MBP) on anastomosis below the peritoneal verge and questions the influence of MBP on anastomotic leakage in combination with a diverting ileostomy in lower colorectal surgery., Summary Background Data: In a previous large multicenter randomized controlled trial MBP has shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in lower colorectal surgery with or without a diverting ileostomy remains unclear., Methods: This study is a subgroup analysis of a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP. Primary end point was the occurrence of anastomotic leakage and secondary endpoints were septic complications and mortality., Results: Total of 449 Patients underwent a low anterior resection with a primary anastomosis below the peritoneal verge. The incidence of anastomotic leakage was 7.6% for patients who received MBP and 6.6% for patients who did not. Significant risk factors for anastomotic leakage were the American Society of Anesthesiologists-classification (P = 0.005) and male gender (P = 0.007). Of total, 48 patients received a diverting ileostomy during initial surgery; 27 patients received MBP and 21 patients did not. There were no significant differences regarding septic complications and mortality between both groups., Conclusion: MBP has no influence on the incidence of anastomotic leakage in low colorectal surgery. Furthermore, omitting MBP in combination with a diverting ileostomy has no influence on the incidence of anastomotic leakage, septic complications, and mortality rate.

Objective: Hartmann's procedure (HP) still remains the most frequently performed procedure in acute perforated diverticulitis, but it results in a end colostomy. Primary anastomosis (PA) with or without defunctioning loop ileostomy (DI) seems a good alternative. The aim of this study was to assess differences in the rate of stomal reversal after HP and PA with DI and to evaluate factors associated with postreversal morbidity in patients operated for acute perforated diverticulitis., Method: All 158 patients who had survived emergency surgery for acute perforated diverticulitis in five teaching hospitals in The Netherlands between 1995 and 2005 and underwent HP or PA with DI were retrospectively studied. Age, gender, ASA-classification, severity of primary disease, delay of stoma reversal, surgeon's experience, surgical procedure and type of anastomosis were analysed in relation to outcome after stoma reversal., Results: Of the 158 patients, 139 had undergone HP and 19 PA with DI. The reversal-rate was higher in patients with DI (14/19; 74%) compared to HP (63/139; 45%) (P = 0.027) Delay between primary surgery and stoma reversal was shorter after PA with DI compared with HP (3.9 vs 9.1 months; P < 0.001). Cumulative postreversal morbidity after HP was 44%. Early surgical complications occurred in 22 of 63 patients. Morbidity after DI reversal was 15% (P < 0.001). Three patients died after HP reversal, none died after DI reversal. Anastomotic leakage was observed in 10 patients after HP reversal. This was less frequently observed when the operation was performed by a specialist colorectal surgeon (10%vs 33%; P = 0.049) and when a stapled anastomosis was performed (4%vs 24%; P = 0.037)., Conclusions: Reversal of HP should only be performed by an experienced colorectal surgeon, preferably performing a stapled anastomosis, or probably not be performed at all, as it is accompanied by high postoperative morbidity and even mortality. It is important that these findings are taken in account for when performing primary emergency surgery for acute perforated diverticulitis.

Objective: To assess which factors predict in-hospital mortality after emergency surgery for acute perforated diverticulitis., Design: Multicenter retrospective study., Method: From 1995-2005 a total of 291 patients underwent surgery to treat perforated diverticulitis in five teaching hospitals in Rotterdam, the Netherlands. The relation to postoperative mortality of patient-related risk factors such as age, gender and classification according to the American Society of Anesthesiologists (ASA); disease severity factors such as Hinchey score and Mannheim peritonitis index (MPI); surgery-related risk factors, such as type of surgery, e.g. Hartmann’s procedure (HP) or resection with primary anastomosis; surgeon, and time of operation were evaluated using multivariate analysis., Results: The total postoperative in-hospital mortality was 29%. HP was performed 211 times and primary anastomosis was performed 75 times. HP was significantly more frequently performed in patients with higher values of age, ASA, Hinchey and MPI (all: p < 0.01). Multiple logistic regression analysis showed that age, ASA classification, Hinchey score, MPI and the absence of a specialist gastrointestinal surgeon during surgery, were important prognostic factors of mortality. Surgical technique was not related to postoperative mortality (adjusted odds ratio for mortality (HP versus primary anastomosis): 1.3; 95% CI: 0.6-2.9; p = 0.54)., Conclusion: The type of surgery did not appear to be a risk factor for high postoperative mortality. As well as patient-related risk factors, including age, ASA and severity of disease scores, such as Hinchey score and MPI, the absence of a specialist gastrointestinal surgeon during surgery was found to be a factor associated with high mortality risk.

Background: To determine whether endoscopic repair is favorable in the long term, follow-up recurrence rates after 10 years need to be assessed., Methods: Between January 1995 and January 1996, 306 consecutive patients underwent total extraperitoneal (TEP) inguinal hernia repair. Long-term follow-up assessment occurred from January 2006 to May 2006., Results: After a 10-year follow-up period, six (4%) recurrences were found in the primary inguinal hernia group and three recurrences (11%) in the recurrent inguinal hernia group. Age, experience, hospital stay, and operating time were not significantly correlated with recurrences., Conclusion: The long-term results of TEP primary inguinal hernia repair demonstrate it to be an effective and safe procedure with an acceptable recurrence rate. Recurrence rates may be underestimated because the findings show that recurrences continue to occur for as long as 10 years.

Background: Mortality and morbidity rates of acute perforated diverticulitis remain high. The ideal treatment is still controversial. The object of this study was to compare patients with perforated diverticulitis treated either by resection with primary anastomosis (PA) or Hartmann's procedure (HP)., Methods: A multicenter study was carried out on 200 consecutive patients with acute perforated diverticulitis who were presented in the surgical units of four affiliated teaching hospitals in Rotterdam, The Netherlands, between 1995 and 2005. Mortality and morbidity were compared in relation to type of surgery, ASA classification, age, gender, Mannheim Peritonitis Index (MPI), Hinchey score, surgeon's experience, and the time of operation., Results: There was a tendency for more severely affected patients (Hinchey, MPI, ASA and age) to undergo HP. Multivariate logistic regression analysis showed no significant difference in mortality between HP and PA. After HP, more patients needed one or more reinterventions to treat postoperative complications compared to PA. Besides, HP resulted in a longer total hospital and intensive care unit stay. Specialist colorectal surgeons performed significantly more frequently a PA instead of a HP and had fewer postoperative complications than general surgeons. The time of operation did not influence the choice of surgical procedure., Conclusion: Selected patients with perforated diverticulitis can be managed well by PA, as it does not seem to be inferior to HP in terms of severe postoperative complications that need surgical or radiological reintervention and mortality. This decision should be made while taking into account the patient's concomitant diseases, response on preoperative resuscitation and the availability of a surgeon experienced in colorectal surgery.

Adult umbilical hernia is a common surgical condition mainly encountered in the fifth and sixth decade of life. Despite the high frequency of the umbilical hernia repair procedure, disappointingly high recurrence rates, up to 54% for simple suture repair, are reported. Since both mesh and suture techniques are used in our clinic we set out to investigate the respective recurrence rates and associated complications, retrospectively. Patients who were treated between January 1998 and December 2002 were identified from our hospital database and invited to attend the outpatient department for an extra follow-up, history taking and physical examination. The use of prosthetic material, occurrence of surgical site infection, body mass and height as well as recurrence were recorded at the time of this survey. In total, 131 consecutive patients underwent operative repair of an umbilical hernia. Twenty-eight percent of the patients were female (n = 37). In 12 patients (11%) umbilical hernia repair was achieved with mesh implantation. Fourteen umbilical hernia recurrences were noted (13%); none had been repaired using mesh. No relationship was found between wound infection or obesity and umbilical hernia recurrence. In the light of these results it is necessary to re-evaluate our clinical "guidelines" on mesh placement in umbilical hernia repair: apparently not every umbilical fascial defect needs mesh repair. Research should focus on establishing risk factors for hernia recurrence.

Background: The endoscopic preperitoneal approach has numerous advantages for the reconstruction of bilateral inguinal hernias. Repair may be achieved using either one large or two small meshes. The aim of this study was to investigate whether one of the techniques was superior in terms of recurrence and complication rate., Methods: Data obtained from 113 patients who underwent surgery between January 1998 and December 2001 was reviewed. For the sake of this study, 86% of all patients were examined for hernia recurrence at an additional outpatient visit., Results: The findings showed recurrence rates, of 3.5% for single mesh and 3.7% for double mesh. This difference was not significant. Complication rates did not differ significantly between the groups., Conclusions: Endoscopic preperitoneal bilateral hernia repair is a safe and reliable technique in the hands of experienced surgeons. The rate of hernia recurrence and complications is low and independent of the mesh configuration (single or double). Mesh configuration based on personal preference is permissible.

Background: A modified forgotten technique for repairing large incisional hernias is described together with its long-term results in 19 patients. A synthetic mesh with 1-cm wide spokes radiating from the mesh is placed preperitioneally, overlapping the fascial defect. The spokes are pulled through rectus sheaths and muscle and sutured ventrally, thereby creating a solid reconstruction withstanding shrinking of the mesh., Method: Nineteen patients were operated on (13 primary incisional hernia, minimal fascial defect 10 cm). Notes on patients were reviewed, and the patients were contacted for follow-up examination., Results: No major complications occurred. After a median of 49 months, 17 patients were reviewed at the outpatient clinic. Two possible recurrences were detected, of which one was operated on. This proved to be bulging of the mesh, resulting in a recurrence of 1 out of 17 (6%)., Conclusion: From these results, it is concluded that Gallie's technique using synthetic mesh is a safe and effective repair for incisional hernia and deserves more attention, especially for large fascial defects.

Background: Although the recurrence rate for endoscopic herniography is low (0-3%), it is still debatable whether these recurrences should be corrected laparoscopically or by the conventional method. The aim of this study was to investigate whether these recurrences can be repaired by means of the laparoscopic approach with acceptable complication and recurrence rates., Methods: From October 1992 to December 1997, 34 patients with recurrent inguinal hernias at physical examination underwent surgery at our institutions. All the recurrences occurred following endoscopic inguinal hernia repair with mesh prostheses. The recurrences were repaired endoscopically using a transabdominal approach. Depending on the size of the defect, a new polypropylene mesh was used., Results: Mean surgery time was 69 min. There were no conversions to the anterior approach. After a mean follow-up of 35 months, no recurrences had been diagnosed., Conclusion: The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy.

Background: Recurrence rates associated with bilateral inguinal hernia repair with a giant prosthesis (Stoppa procedure) are low. Endoscopic totally extraperitoneal bilateral inguinal hernia repair with a giant prosthesis combines the low recurrence rate of the Stoppa repair and the advantages of minimally invasive surgery. The aim of this retrospective study was to investigate whether extraperitoneal bilateral inguinal hernia repair could be performed by the minimally invasive, totally extraperitoneal approach., Methods: From February 1993 to January 1998, 98 patients with bilateral inguinal hernias underwent surgery. A polypropylene 30 x 10 cm rectangular mesh or a 30 x 10/15 cm 'slipmesh' was used. Follow-up, including a physical examination, of 96 per cent of patients was performed., Results: Median operative time was 60 min. Mostly minor intraoperative complications occurred. Conversion was required for two patients. Apart from one patient with a necrotic fasciitis who died from respiratory failure, only minor postoperative complications (10 per cent) occurred. Median hospital stay was 1 (range 1-21) days. Median recuperation time was 5 (range 1-22) days. Median follow-up (96 per cent) was 32 (range 7-57) months; there were six recurrences among 34 hernias in the group of 17 patients treated with 10 x 30 cm mesh and two (1 per cent) in the group that received 30 x 10/15 cm mesh (162 hernias in 81 patients)., Conclusion: The endoscopic approach for the Stoppa procedure for bilateral inguinal hernia repair is a reliable method with minor complications. It ensures a short recuperation time and the recurrence rate is low owing to adequate overlap of the hernial defect when a 'slipmesh' is used.

Background: In most reports different techniques have been described for combinations of primary and recurrent hernias. The aim of this study was to investigate and compare the results of endoscopic total extraperitoneal repair (TEP) of primary and recurrent inguinal hernias., Methods: From January 1993 to July 1995, 221 patients with an unilateral inguinal hernia (186 primary and 35 recurrent) underwent TEP repair. Follow-up, including physical examination, was performed at regular 3-month intervals., Results: The mean operation time was 37.6 min. Minor perioperative complications occurred in 23 cases. Conversion was required for 16 patients (7.2%). Postoperative complications were reported for 11.7% of the patients. Hospital stay was short. Mean follow-up was 40.4 months. The recurrence rate was 3. 2% for primary hernias and 20% for recurrent hernias., Conclusions: This study confirms the preliminary success of TEP for primary inguinal hernia repair, as previously reported. The high recurrence rate after endoscopic repair of recurrent hernias needs to be studied further.

Background: Splice variants of CD44 play a causal role in the metastatic spread of pancreatic carcinoma in the rat. In previous studies we have shown that homologues of these CD44 isoforms (CD44v6) are overexpressed during colorectal tumorigenesis in man and that CD44v6 overexpression is associated with an unfavorable prognosis in this disease. In the present study we have assessed the prognostic significance of CD44 variants containing exon v5. In addition, we have used a panel of different antibodies against CD44v6 and applied a combined scoring system to improve its value as prognosticator., Methods: Expression of CD44 variants was studied by immunohistochemistry on frozen tissue sections, and the prognostic value of the CD44 variant expression was assessed using univariate and multivariate analysis., Results: Our studies show that expression of CD44v6, but not CD44v5, has significant prognostic value. Analysis of CD44v6 expression by means of a combined scoring system, on the basis of a panel of three different monoclonal antibodies (mAbs), makes CD44v6 a highly significant prognostic marker that is independent of Dukes stage, tumor grade, or tumor localization., Conclusion: Assessment of CD44v6 expression by a combination of mAbs yields an independent prognosticator that may be of value in identifying patients with a high propensity to develop distant metastasis.

Background: Inguinal hernias can be repaired by laparoscopic techniques, which have had better results than open surgery in several small studies., Methods: We performed a randomized, multicenter trial in which 487 patients with inguinal hernias were treated by extraperitoneal laparoscopic repair and 507 patients were treated by conventional anterior repair. We recorded information about postoperative recovery and complications and examined the patients for recurrences one and six weeks, six months, and one and two years after surgery., Results: Six patients in the open-surgery group but none in the laparoscopic-surgery group had wound abscesses (P=0.03), and the patients in the laparoscopic-surgery group had a more rapid recovery (median time to the resumption of normal daily activity, 6 vs. 10 days; time to the return to work, 14 vs. 21 days; and time to the resumption of athletic activities, 24 vs. 36 days; P<0.001 for all comparisons). With a median follow-up of 607 days, 31 patients (6 percent) in the open-surgery group had recurrences, as compared with 17 patients (3 percent) in the laparoscopic-surgery group (P=0.05). All but three of the recurrences in the latter group were within one year after surgery and were caused by surgeon-related errors. In the open-surgery group, 15 patients had recurrences during the first year, and 16 during the second year. Follow-up was complete for 97 percent of the patients., Conclusions: Patients with inguinal hernias who undergo laparoscopic repair recover more rapidly and have fewer recurrences than those who undergo open surgical repair.

Background: Several laparoscopic techniques have been introduced to re pair inguinal hernia, the newest and most promising being a totally extraperitoneal approach. Nevertheless, the surgeon may encounter several complications and technical difficulties associated with the transition from the conventional anterior operation., Methods: In late 1993 and 1994, 120 patients were operated on for inguinal hernia using the totally extraperitoneal approach by four laparoscopic surgeons inexperienced in this new technique in a secondary referral setting. Their learning curve was assessed through operation time, perioperative and postoperative complications, and technical difficulties., Results: Median operative time decreased significantly (P = 0.0003) when going through the learning curve. During the initial part of the learning curve, conversion to another technique was necessary in 10 (8%) cases, and in 6 of these cases, conversion was needed for a peritoneal tear (relative risk for conversion if peritoneal tear was present: 4.0; 95% confidence interval 1.2 to 13.1, P = 0.025). The median operative time for Nyhus type IIIb and IVb hernias was significantly longer than for other types (70 versus 55 minutes, P = 0.003). Median postoperative stay was 2 days (range 0 to 7). There were 10 recurrences within 6 months due to technical or judgement errors., Conclusions: For surgeons, the learning curve for totally extraperitoneal laparoscopic hernia repair can be overcome; however, the presence of an experienced surgeon during the procedure is vital, as this may prevent unnecessary recurrences.

To help determine whether adenocarcinomas of the proximal and distal large bowel reflect distinct entities, the expression of two splice variants of the metastasis-associated cell adhesion molecule CD44, carrying exons v5 and v6 respectively, was investigated retrospectively in fresh frozen samples of 23 proximal and 41 distal carcinomas by immunohistochemical staining with specific anti-CD44v5 monoclonal antibody VFF8 and anti-CD44v6 monoclonal antibodies VFF4 and VFF7. Tumours were staged as: Dukes A, 0; Dukes B, 27; Dukes C, 31; and Dukes 'D', six. Compared with distal tumours, proximal lesions expressed significantly more CD44v5 (96 versus 87 per cent, P = 0.02) and CD44v6 (83 versus 61 per cent, P = 0.01). CD44v5 and CD44v6 are considered markers for tumour progression and aggressive behaviour. Their high expression in proximal carcinomas seems to contrast with the general belief that these tumours show less aggressive behaviour than left-sided lesions. Further study of the biological significance of the expression of CD44 splice variants is therefore needed.

Since the introduction of laparoscopic cholecystectomy as an alternative for conventional cholecystectomy, the number of cholecystectomies per year is showing an increased tendency, suggesting that indications for surgery have broadened now that the morbidity of the procedure has decreased so much. For gastro-oesophageal reflux disease (GORD) the current number of operations performed per year in The Netherlands is small compared with the calculated prevalence of complicated GORD. If the data on epidemiology of GORD by Richter are extrapolated to the population of The Netherlands, there must be at least 4,500 potential candidates for antireflux surgery currently available and only 250 operations are performed per year. Laparoscopic Nissen fundoplication is practised with acceptable results. If with this new development the same tendency as for laparoscopic cholecystectomy arises, this may mean either that too many patients will undergo antireflux surgery or that the potential candidates will now get their chance to have an effective operation with the prospect of low procedure-related morbidity. In The Netherlands, 62 laparoscopic Nissen fundoplications have been performed. There have been no deaths and in 5 patients the laparoscopic procedure had to be converted into a laparotomy. Forty-two of these 62 patients were treated according to a protocol and were included in the follow-up. At one month, 38 out of 42 patients were available for follow-up. At one month after surgery, 38 patients felt that their reflux symptoms had improved. Surgery-induced symptoms were present in 19 out of 38 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of three current types of preoperative large bowel preparation on the microbial flora and the colonization resistance (CR) was investigated in 15 volunteers. In the first group a whole gut irrigation was performed without administration of antibiotics (group WGI). In the second group 0.5 g/l metronidazole and 1 g/l neomycin was added to the irrigation fluid (group WGI + AB). A whole gut irrigation with prior oral administration of 1 l mannitol 10% was performed in the third group. The antibiotic prophylaxis in this group consisted of two doses of 80 mg gentamicin i.v. and 500 mg metronidazole orally 24 h after lavage (group Mann + AB). One hour after the mechanical cleansing procedure was finished all volunteers were orally contaminated with one dose of an Escherichia coli test strain. The aerobic faecal reduction due to the cleansing procedure was 2-3 logs, while for the anaerobes it was 4-5 logs. The anaerobic flora in group WGI recovered within 24 h, while the aerobes showed a transient 'overgrowth' for the period of 2 days. The overgrowth of aerobes in group WGI + AB was observed for more than a week and the total numbers of aerobes started gradually to decline after the anaerobic flora had reached pretreatment levels at day three or four. Despite the normal numbers of anaerobes present 24 h after treatment, overgrowth of E. coli was seen in the group Mann + AB, probably due to residual mannitol left in the intestinal tract. The test strain of E. coli was excreted for a period of 1 week by the volunteers in the groups WGI and Mann + AB, but it was isolated for more than 10 weeks in the group WGI + AB. It is thought that all three methods of preoperative large bowel preparation decreased the CR of the gastrointestinal tract because of a disturbance of the interaction between aerobic and anaerobic microorganisms and alterations of the colonic wall. The anaerobic microflora, however, appeared to be primarily responsible for the maintenance of the CR. Antimicrobial prophylaxis should consist of a high dose, short term, systemic antibiotic regimen, not only because an adequate serum level of an appropriate drug at the time of operation substantially decreases the incidence of postoperative septic complications but also because a systemic regimen scarcely influences the CR of the gastrointestinal tract. beta-Aspartylglycine appeared to be a specific but not very sensitive marker for decreased CR.

Clinical studies report reduced recurrence-free survival and increased cancer-related death after surgical treatment for cancer, when peri-operative blood transfusions were given. In this study we collected transfusion data of 212 patients who participated in a prospective study of two different resection techniques for colorectal cancer. One hundred and fifty-eight patients were transfused and 54 were not. The follow-up period for almost all patients was 5 years. The 5-year survival rate was 52% both for the transfused patients and the nontransfused patients. For subgroups of patients with Dukes' B and Dukes' C tumours no statistically significant differences were found. In the group of patients that were transfused the number of transfusions did not affect survival. In this study we could not confirm the deleterious effect of peri-operative blood transfusions on survival.

During a period of six years, 245 hemiarthroplasties according to Moore were implanted for fractures with dislocation of the femoral neck. In five patients (2%) proximal ipsilateral fractures of the femur occurred in the postoperative phase. All fractures were located near the tip of the prosthesis. Four were spiral fractures, one was a communitive fracture. Four patients were treated with plating, one with screw fixation. Two patients were unable to walk, two patients were able to walk with help and one walked without help. Classification of fractures distal to an endoprosthesis and operative modalities are discussed.

It has been suggested that relative depolarization of the cell membrane occurs during carcinogenesis. A study was undertaken to determine the effect on the colonic transmural potential difference in CF1 mice following the administration of a carcinogen, a cytotoxic agent, and bile acids. Depolarization of the distal colonic mucosa was seen in mice treated with the carcinogen but not with the cytotoxic agent, and bile acids caused further depolarization of the mucosa. These experiments support the hypothesis that epithelial depolarization is a putative mechanism in carcinogenesis, which could have important implications for the early detection of colon cancer.

An unprecedented fatal case of pseudomembranous colitis (PMC) is described, associated with the use of topical antibiotics (neomycin and erythromycin base) during whole gut irrigation. This case was one of a cluster of five, occurring within a period of 4 months in 1978. These observations tend to support the hypothesis that disturbances in bacterial flora give rise to PMC and furthermore that the short-term use of antibiotics does not prevent the occurrence of PMC.

Three cases of granular cell tumor of the breast are reported. Granular cell tumor of the breast is a rare benign tumor with a malignant appearance both clinically, radiologically and macroscopically. The cytology is quite characteristic although the tumor clinically often resembles a carcinoma. Frozen section can be misinterpreted, unnecessary mastectomy or axillary dissection can be prevented by careful cytological examination.

In a prospective randomized trial, systemic antimicrobial prophylaxis with metronidazole and gentamicin was compared to the administration of metronidazole alone in elective colorectal surgery. In both groups, an identical mechanical large-bowel preparation was performed. In order to reduce the duration of the whole-gut irrigation, a 10% mannitol solution was administered before the irrigation procedure. Although no serious infections were observed in either group, the incidence of superficial wound infections was relatively high: 19% in the group with metronidazole and gentamicin prophylaxis and 25% in the other group. From all these wounds E. coli was isolated, and no obligate anaerobic bacteria were cultured. This high rate of wound infections is most likely caused by an overgrowth of E. coli after irrigation, due to the residues of mannitol in the colon, which serve as a nutrient for E. coli. It is concluded that mannitol should not be used in the preoperative mechanical preparation of the large bowel before elective colorectal surgery.

The acute effects of cholic acid ingestion on methylazoxymethanol acetate [(MAM) CAS: 592-62-1]-treated conventional and germfree rats were investigated. Male SD rats were divided into 4 treatment groups. The first group received control chow; the second group, control chow plus 0.5% cholic acid; the third group, control chow plus MAM; and the fourth group, control chow plus 0.5% cholic acid plus MAM. Fecal bile acids, cholesterol, cholesteral degradation products, and neutral sterols, as well as labeling indices and numbers of epithelial cells per crypt column, were measured after 6 weeks of treatment. The administration of MAM to germfree groups diminished both fecal bulk and the amount of fecal water. MAM did not affect the fecal bile acid composition. Analysis of the fecal bile acids in conventional rats fed cholic acid demonstrated that half of the bile acids were in a form of deoxycholic acid. In the germfree groups fed cholic acid, 90% of the bile acids appeared unaltered in the feces. Neither in the germfree nor in the conventional groups was an effect seen of MAM on the output of fecal neutral sterols. The addition of cholic acid to the food decreased the output of neutral sterols both in the conventional (P less than .001) and in the germfree (P less than .02) animals. The germfree animals showed a reduced amount of neutral steroid excretion (P less than .01) when compared to the findings for the conventional groups. MAM had no influence on the fecal cholesterol or coprostanol output. The consumption of 0.5% cholic acid decreased the total output of cholesterol (P less than .05). The excretion of coprostanol was significantly diminished in the conventional rats fed cholic acid (P less than .001). No difference in labeling indices was observed between conventional and germfree rats, whether treated with cholic acid, MAM, or cholic acid plus MAM. However, all germfree groups showed less epithelial cells per crypt column (P less than .001) than did conventional animals.

Following 4 weeks of s.c. injections of 1,2-dimethylhydrazine, a carcinogen that produces colon cancer in CF1 mice, an increase in the unidirectional mucosal to serosal flux and net absorption of sodium was observed in the distal colon. This increase in sodium transport was amiloride sensitive. 1,2-Dimethylhydrazine treatment had no effect on sodium transport in the distal colon of DBA/2 mice, a strain which does not develop colonic malignant transformation. Although stimulation of sodium transport has been observed in cultured cell systems exposed to growth factors, similar changes in sodium transport have not previously been demonstrated in an intact epithelium at an early stage of carcinogenesis. The present study in mouse distal colon demonstrates that sodium transport is altered in 1,2-dimethylhydrazine-induced malignant transformation of the large bowel.