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1.  Prediction and diagnosis of colorectal anastomotic leakage: A systematic review of literature 
Although many studies have focused on the preoperative risk factors of anastomotic leakage after colorectal surgery (CAL), postoperative delay in diagnosis is common and harmful. This review provides a systematic overview of all available literature on diagnostic tools used for CAL. A systematic search of literature was undertaken using Medline, Embase, Cochrane and Web-of-Science libraries. Articles were selected when a diagnostic or prediction tool for CAL was described and tested. Two reviewers separately assessed the eligibility and level of evidence of the papers. Sixty-nine articles were selected (clinical methods: 11, laboratory tests: 12, drain fluid analysis: 12, intraoperative techniques: 22, radiology: 16). Clinical scoring leads to early awareness of probability of CAL and reduces delay of diagnosis. C-reactive protein measurement at postoperative day 3-4 is helpful. CAL patients are characterized by elevated cytokine levels in drain fluid in the very early postoperative phase in CAL patients. Intraoperative testing using the air leak test allows intraoperative repair of the anastomosis. Routine contrast enema is not recommended. If CAL is clinically suspected, rectal contrast-computer tomography is recommended by a few studies. In many studies a “no-test” control group was lacking, furthermore no golden standard for CAL is available. These two factors contributed to a relatively low level of evidence in the majority of the papers. This paper provides a systematic overview of literature on the available tools for diagnosing CAL. The study shows that colorectal surgery patients could benefit from some diagnostic interventions that can easily be performed in daily postoperative care.
doi:10.4240/wjgs.v6.i2.14
PMCID: PMC3942535  PMID: 24600507
Colorectal; Anastomosis; Leakage; Diagnosis; Prediction
2.  Force Sensing in Surgical Sutures 
PLoS ONE  2013;8(12):e84466.
The tension in a suture is an important factor in the process of wound healing. If there is too much tension in the suture, the blood flow is restricted and necrosis can occur. If the tension is too low, the incision opens up and cannot heal properly. The purpose of this paper is to describe the design and evaluation of the Stitch Force (SF) sensor and the Hook-In Force (HIF) sensor. These sensors were developed to measure the force on a tensioned suture inside a closed incision and to measure the pulling force used to close the incision. The accuracy of both sensors is high enough to determine the relation between the force in the thread of a stitch and the pulling force applied on the suture by the physician. In a pilot study, a continuous suture of 7 stitches was applied on the fascia of the abdominal wall of multiple pigs to study this relationship. The results show that the max force in the thread of the second stitch drops from 3 (SD 1.2) to 1 (SD 0.3) newton after the 4th stitch was placed. During placement of the 5th, 6th and 7th stitch, the force in the 2nd stitch was not influenced anymore. This study indicates that in a continuous suture the force in the thread remains constant up to more than 3 stiches away from the pulled loose end of the suture. When a force feedback tool is developed specially for suturing in surgery on patients, the proposed sensors can be used to determine safety threshold for different types of tissue and sutures.
doi:10.1371/journal.pone.0084466
PMCID: PMC3871579  PMID: 24376812
3.  A double blind randomized controlled trial comparing primary suture closure with mesh augmented closure to reduce incisional hernia incidence 
BMC Surgery  2013;13:48.
Background
Incisional hernia is the most frequently seen long term complication after laparotomy causing much morbidity and even mortality. The overall incidence remains 11-20%, despite studies attempting to optimize closing techniques. Two patient groups, patients with abdominal aortic aneurysm and obese patients, have a risk for incisional hernia after laparotomy of more than 30%. These patients might benefit from mesh augmented midline closure as a means to reduce incisional hernia incidence.
Methods/design
The PRImary Mesh Closure of Abdominal Midline Wound (PRIMA) trial is a double-blinded international multicenter randomized controlled trial comparing running slowly absorbable suture closure with the same closure augmented with a sublay or onlay mesh. Primary endpoint will be incisional hernia incidence 2 years postoperatively. Secondary outcomes will be postoperative complications, pain, quality of life and cost effectiveness.
A total of 460 patients will be included in three arms of the study and randomized between running suture closure, onlay mesh closure or sublay mesh closure. Follow-up will be at 1, 3, 12 and 24 months with ultrasound imaging performed at 6 and 24 months to objectify the presence of incisional hernia. Patients, investigators and radiologists will be blinded throughout the whole follow up.
Disccusion
The use of prosthetic mesh has proven effective and safe in incisional hernia surgery however its use in a prophylactic manner has yet to be properly investigated. The PRIMA trial will provide level 1b evidence whether mesh augmented midline abdominal closure reduces incisional hernia incidence in high risk groups.
Trial registration
Clinical trial.gov NCT00761475.
doi:10.1186/1471-2482-13-48
PMCID: PMC3840708  PMID: 24499111
4.  Good brace compliance reduced curve progression and surgical rates in patients with idiopathic scoliosis 
European Spine Journal  2012;21(10):1957-1963.
Purpose
To examine the association between brace compliance and outcome.
Patients and methods
495 (457 females) patients with late onset juvenile and adolescent idiopathic scoliosis were examined prospectively before bracing and at least 2 years after brace weaning. One spine surgeon examined all patients. 381 (353 females) answered a standardised questionnaire and 355 had radiological examination after median 24 years. Compliance was defined as brace wear >20 h daily until weaning. Main outcomes were curve progression and surgery.
Results
At weaning, 76/389 compliers and 59/106 non-compliers had curve progression ≥6° (OR 5.2, 95 % CI 3.3–8.2). At long-term the numbers were 68/284 and 46/71 (OR 5.8, 95 % CI 3.3–10.2), 10/284 versus 17/71 had been operated (OR 8.6, 95 % CI 3.7–19.9).
Conclusion
We conclude that the risk for curve progression and surgery are reduced in patients with good brace compliance.
doi:10.1007/s00586-012-2386-9
PMCID: PMC3463688  PMID: 22661234
Idiopathic scoliosis; Bracing; Compliance; Curve progression; Surgery
5.  The INCH-Trial: a multicentre randomized controlled trial comparing the efficacy of conventional open surgery and laparoscopic surgery for incisional hernia repair 
BMC Surgery  2013;13:18.
Background
Annually approximately 100.000 patients undergo a laparotomy in the Netherlands. About 15,000 of these patients will develop an incisional hernia. Both open and laparoscopic surgical repair have been proven to be safe. However, the most effective treatment of incisional hernias remains unclear. This study, the ‘INCH-trial’, comparing cost-effectiveness of open and laparoscopic incisional hernia repair, is therefore needed.
Methods/Design
A randomized multi-center clinical trial comparing cost-effectiveness of open and laparoscopic repair of incisional hernias. Patients with a symptomatic incisional hernia, eligible for laparoscopic and open incisional hernia repair. Only surgeons, experienced in both open and laparoscopic incisional hernia repair, will participate in the INCH trial. During incisional hernia repair, a mesh is placed under or on top of the fascia, with a minimal overlap of 5 cm. Primary endpoint is length of hospital stay after an incisional hernia repair. Secondary endpoints are time to full recovery within three months after index surgery, post-operative complications, recurrences, mortality and quality of life.
Our hypothesis is that laparoscopic incisional hernia repair comes with a significant shorter hospital stay compared to open incisional hernia repair. A difference of two days is considered significant. One-hunderd-and-thirty-five patients are enrolled in each treatment arm. The economic evaluation will be performed from a societal perspective. Primary outcomes are costs per patient related to time-to-recovery and quality of life.
The main goal of the trial is to establish whether laparoscopic incisional hernia repair is superior to conventional open incisional hernia repair in terms of cost-effectiveness. This is measured through length of hospital stay and quality of life. Secondary endpoints are re-operation rate due to post-operative complications or recurrences, mortality and quality of life.
Discussion
The difference in time to full recovery between the two treatment strategies is thought to be in favor of laparoscopic incisional hernia repair. Laparoscopic incisional hernia repair is therefore expected to be a more cost-effective approach.
Trial registration
Netherlands Trial register: NTR2808
doi:10.1186/1471-2482-13-18
PMCID: PMC3680330  PMID: 24499061
6.  Colorectal anastomotic leakage: Aspects of prevention, detection and treatment 
All colorectal surgeons are faced from time to time with anastomotic leakage after colorectal surgery. This complication has been studied extensively without a significant reduction of incidence over the last 30 years. New techniques of prevention, by innovative anastomotic techniques should improve results in the future, but standardization and “teachability” should be guaranteed. Risk scoring enables intra-operative decision-making whether to restore continuity or deviate. Early detection can lead to reduction in delay of diagnosis as long as a standard system is used. For treatment options, no firm evidence is available, but future studies could focus on repair and saving of the anastomosis on the one hand or anastomotical breakdown and definitive colostomy on the other hand.
doi:10.3748/wjg.v19.i15.2293
PMCID: PMC3631979  PMID: 23613621
Colorectal surgery; Complications; Postoperative care; Anastomotic leakage; Prevention
7.  Training in laparoscopic colorectal surgery: a new educational model using specially embalmed human anatomical specimen 
Surgical Endoscopy  2012;26(8):2189-2194.
Background
With an increasing percentage of colorectal resections performed laparoscopically nowadays, there is more emphasis on training “before the job” on operative skills, including the comprehension of specific laparoscopic surgical anatomy. As integration of technical skills with correct interpretation of the anatomical image must be incorporated in laparoscopic training, a human specimen training model with special emphasis on surgical anatomy was developed.
Methods
The new embalming method Anubifix™ combines long-term high-quality embalming of human bodies with almost normal flexibility and plasticity, and the body can be kept operational as long as conventionally embalmed human specimens. A colorectal training model was created in a specimen in which anatomical landmarks of colorectal anatomy were permanently colored to explore laparoscopic colorectal anatomy in a skills training setting. Airtight closure of the abdominal wall permits the creation of pneumoperitoneum. Residents were asked to test the model by mobilizing the small and large bowels and expose the central vessels and ureters. Afterward they were asked to fill out an eight-item questionnaire about the model.
Results
Eleven surgical residents in their first and second year of training participated. Responses to the questionnaire showed that a majority of residents considered the model to be representative of the real situation and superior to animal models or virtual reality simulators, and helped to improve the knowledge of three-dimensional anatomy and laparoscopic skills.
Conclusion
The new training model for laparoscopic colorectal surgery proved to be a high-quality tool, concentrating on laparoscopic colorectal anatomy in a skills training setting. We believe it may be a valuable adjunct to residency training programs based on the principle of “training before the job.”
doi:10.1007/s00464-012-2158-y
PMCID: PMC3392504  PMID: 22286275
Abdominal; Laparoscopic education; Training; Colorectal surgery; Gastrointestinal
8.  Long-term results after Boston brace treatment in late-onset juvenile and adolescent idiopathic scoliosis 
Scoliosis  2011;6:18.
Background
It is recommended that research in patients with idiopathic scoliosis should focus on short- and long-term patient-centred outcome. The aim of the present study was to evaluate outcome in patients with late-onset juvenile or adolescent idiopathic scoliosis 16 years or more after Boston brace treatment.
Methods
272 (78%) of 360 patients, 251 (92%) women, responded to follow-up examination at a mean of 24.7 (range 16 - 32) years after Boston brace treatment. Fifty-eight (21%) patients had late-onset juvenile and 214 had adolescent idiopathic scoliosis. All patients had clinical and radiological examination and answered a standardised questionnaire including work status, demographics, General Function Score (GFS) (100 - worst possible) and Oswestry Disability Index (ODI) (100 - worst possible), EuroQol (EQ-5D) (1 - best possible), EQ-VAS (100 - best possible), and Scoliosis Research Society - 22 (SRS - 22) (5 - best possible).
Results
The mean age at follow-up was 40.4 (31-48) years. The prebrace major curve was in average 33.2 (20 - 57)°. At weaning and at the last follow-up the corresponding values were 28.3 (1 - 58)° and 32.5 (7 - 80)°, respectively. Curve development was similar in patients with late-onset juvenile and adolescent start. The prebrace curve increased > 5° in 31% and decreased > 5° in 26%. Twenty-five patients had surgery. Those who did not attend follow-up (n = 88) had a lower mean curve at weaning: 25.4 (6-53)°. Work status was 76% full-time and 10% part-time. Eighty-seven percent had delivered a baby, 50% had pain in pregnancy. The mean (SD) GFS was 7.4 (10.8), ODI 9.3 (11.0), EQ-5D 0.82 (0.2), EQ-VAS 77.6 (17.8), SRS-22: pain 4.1 (0.8), mental health 4.1 (0.6), self-image 3.7 (0.7), function 4.0 (0.6), satisfaction with treatment 3.7 (1.0). Surgical patients had significantly reduced scores for SRS-physical function and self-image, and patients with curves ≥ 45° had reduced self-image.
Conclusion
Long-term results were satisfactory in most braced patients and similar in late-onset juvenile and idiopathic adolescent scoliosis.
doi:10.1186/1748-7161-6-18
PMCID: PMC3189160  PMID: 21880123
9.  A multicenter randomized controlled trial evaluating the effect of small stitches on the incidence of incisional hernia in midline incisions 
BMC Surgery  2011;11:20.
Background
The median laparotomy is frequently used by abdominal surgeons to gain rapid and wide access to the abdominal cavity with minimal damage to nerves, vascular structures and muscles of the abdominal wall. However, incisional hernia remains the most common complication after median laparotomy, with reported incidences varying between 2-20%. Recent clinical and experimental data showed a continuous suture technique with many small tissue bites in the aponeurosis only, is possibly more effective in the prevention of incisional hernia when compared to the common used large bite technique or mass closure.
Methods/Design
The STITCH trial is a double-blinded multicenter randomized controlled trial designed to compare a standardized large bite technique with a standardized small bites technique. The main objective is to compare both suture techniques for incidence of incisional hernia after one year. Secondary outcomes will include postoperative complications, direct costs, indirect costs and quality of life.
A total of 576 patients will be randomized between a standardized small bites or large bites technique. At least 10 departments of general surgery and two departments of oncological gynaecology will participate in this trial. Both techniques have a standardized amount of stitches per cm wound length and suture length wound length ratio's are calculated in each patient. Follow up will be at 1 month for wound infection and 1 year for incisional hernia. Ultrasound examinations will be performed at both time points to measure the distance between the rectus muscles (at 3 points) and to objectify presence or absence of incisional hernia. Patients, investigators and radiologists will be blinded during follow up, although the surgeon can not be blinded during the surgical procedure.
Conclusion
The STITCH trial will provide level 1b evidence to support the preference for either a continuous suture technique with many small tissue bites in the aponeurosis only or for the commonly used large bites technique.
Trial registration
Clinicaltrials.gov NCT01132209
doi:10.1186/1471-2482-11-20
PMCID: PMC3182877  PMID: 21871072
11.  High tie versus low tie in rectal surgery: comparison of anastomotic perfusion 
Purpose
Both “high tie” (HT) and “low tie” (LT) are well-known strategies in rectal surgery. The aim of this study was to compare colonic perfusion after HT to colonic perfusion after LT.
Methods
Patients undergoing rectal resection for malignancy were included. Colonic perfusion was measured with laser Doppler flowmetry, immediately after laparotomy on the antimesenterial side of the colon segment that was to become the afferent loop (measurement A). This measurement was repeated after rectal resection (measurement B). The blood flow ratios (B/A) were compared between the HT group and the LT group.
Results
Blood flow was measured in 33 patients, 16 undergoing HT and 17 undergoing LT. Colonic blood flow slightly decreased in the HT group whereas the flow increased in the LT group. The blood flow ratio was significantly higher in the LT group (1.48 vs. 0.91; p = 0.04), independent of the blood pressure.
Conclusion
This study shows the blood flow ratio to be higher in the LT group. This suggests that anastomoses may benefit from better perfusion when LT is performed.
doi:10.1007/s00384-011-1188-6
PMCID: PMC3140934  PMID: 21445553
High tie; Low tie; Perfusion; Colorectal surgery; Anastomosis
12.  The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitisA and Hartmann's procedure or resection with primary anastomosis for purulent or faecal peritonitisB in perforated diverticulitis (NTR2037) 
BMC Surgery  2010;10:29.
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
doi:10.1186/1471-2482-10-29
PMCID: PMC2974662  PMID: 20955571
13.  A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial) 
BMC Surgery  2010;10:23.
Background
Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects.
Methods
A randomized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis. I) A conservative strategy with antibiotics: hospital admission, supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral, if tolerated (for a total duration of antibiotic treatment of 10 days). II) A liberal strategy without antibiotics: admission only if needed on clinical grounds, supportive measures only. Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging. Only patients with stages 1a and 1b according to Hinchey's classification or "mild" diverticulitis according to the Ambrosetti criteria are included. The primary endpoint is time-to-full recovery within a 6-month follow-up period. Full recovery is defined as being discharged from the hospital, with a return to pre-illness activities, and VAS score below 4 without the use of daily pain medication. Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention, morbidity, costs, health-related quality of life, readmission rate and acute diverticulitis recurrence rate. In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85% and a confidence level of 95%. With an estimated one percent of patients lost to follow up, a total of 533 patients will be included.
Conclusion
A clinically relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected. The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach.
Trial registration
Trial registration number: NCT01111253
doi:10.1186/1471-2482-10-23
PMCID: PMC2919453  PMID: 20646266
14.  Avoiding or Reversing Hartmann’s Procedure Provides Improved Quality of Life After Perforated Diverticulitis 
Introduction
The existing literature regarding acute perforated diverticulitis only reports about short-term outcome; long-term following outcomes have not been assessed before. The aim of this study was to assess long-term quality of life (QOL) after emergency surgery for perforated diverticulitis.
Patients and Methods
Validated QOL questionnaires (EQ-VAS, EQ-5D index, QLQ-C30, and QLQ-CR38) were sent to all eligible patients who had undergone emergency surgery for perforated diverticulitis in five teaching hospitals between 1990 and 2005. Differences were compared between patients that had undergone Hartmann’s procedure (HP) or resection with primary anastomosis (PA) and also compared to a sex- and age-matched sample of healthy subjects.
Results
Of a total of 340 patients, only 150 patients (44%) were found still alive in July 2007 (median follow-up 71 months). The response rate was 87%. In patients with PA, QOL was similar to the general population, whereas QOL after HP was significantly lower. The presence of a stoma was found to be an independent factor related to worse QOL. The deterioration in QOL was mainly due to problems in physical function and body image.
Conclusions
Survivors after perforated diverticulitis had a worse QOL than the general population, which was mainly due to the presence of an end colostomy. QOL may improve if these stomas are reversed or not be performed in the first place.
doi:10.1007/s11605-010-1155-5
PMCID: PMC2836251  PMID: 20127201
Perforated diverticulitis; Quality of life; Hartmann’s procedure; Primary anastomosis
15.  Evaluation of Operative Notes Concerning Laparoscopic Cholecystectomy: Are Standards Being Met? 
World Journal of Surgery  2010;34(5):903-909.
Background
Laparoscopic cholecystectomy (LC) is the most performed minimal invasive surgical procedure and has a relatively high complication rate. As complications are often revealed postoperatively, clear, accurate, and timely written operative notes are important in order to recall the procedure and start follow-up treatment as soon as possible. In addition, the surgeon’s operative notes are important to assure surgical quality and communication with other healthcare providers. The aim of the present study was to assess compliance with the Dutch guidelines for writing operative notes for LC.
Methods
Nine hospitals were asked to send 20 successive LC operative notes. All notes were compared to the Dutch guideline by two reviewers and double-checked by a third reviewer. Statistical analyses on the “not described” items were performed.
Results
All hospitals participated. Most notes complied with the Dutch guideline (52–69%); 19–30% of items did not comply. Negative scores for all hospitals were found, mainly for lacking a description of the patient’s posture (average 69%), bandage (94%), blood loss (98%), name of the scrub nurse (87%), postoperative conclusion (65%), and postoperative instructions (78%). Furthermore, notes from one community hospital and two teaching hospitals complied significantly less with the guidelines.
Conclusions
Operative notes do not always fully comply with the standards set forth in the guidelines published in the Netherlands. This could influence adjuvant treatment and future patient treatment, and it may make operative notes less suitable background for other purposes. Therefore operative note writing should be taught as part of surgical training, definitions should be provided, and procedure-specific guidelines should be established to improve the quality of the operative notes and their use to improve patient safety.
doi:10.1007/s00268-010-0422-7
PMCID: PMC2848728  PMID: 20112020
16.  Treatment of Perforated Diverticulitis with Generalized Peritonitis: Past, Present, and Future 
World Journal of Surgery  2010;34(3):587-593.
Background
The supposed optimal treatment of perforated diverticulitis with generalized peritonitis has changed several times during the last century, but at present is still unclear.
Methods/results
The first cases of complicated perforated diverticulitis of the colon were reported in the beginning of the twentieth century. At that time the first therapeutic guidelines were postulated in which an initial nonresectional procedure was provided to be the safest plan of management. After many years in which resection had become standard practice, today, one century later, again (laparoscopic) nonresectional surgery is presented as a safe and promising alternative in treatment of complicated perforated diverticulitis. The question rises what had happened to close the circle?
Conclusions
This paper includes a historic summary of changing patterns in surgical strategies in perforated diverticulitis complicated by generalized peritonitis.
doi:10.1007/s00268-009-0372-0
PMCID: PMC2816807  PMID: 20052468
17.  Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature 
Surgical Endoscopy  2009;24(6):1231-1239.
Background
Perforated peptic ulcer (PPU), despite antiulcer medication and Helicobacter eradication, is still the most common indication for emergency gastric surgery associated with high morbidity and mortality. Outcome might be improved by performing this procedure laparoscopically, but there is no consensus on whether the benefits of laparoscopic closure of perforated peptic ulcer outweigh the disadvantages such as prolonged surgery time and greater expense.
Methods
An electronic literature search was done by using PubMed and EMBASE databases. Relevant papers written between January 1989 and May 2009 were selected and scored according to Effective Public Health Practice Project guidelines.
Results
Data were extracted from 56 papers, as summarized in Tables 1–7. The overall conversion rate for laparoscopic correction of perforated peptic ulcer was 12.4%, with main reason for conversion being the diameter of perforation. Patients presenting with PPU were predominantly men (79%), with an average age of 48 years. One-third had a history of peptic ulcer disease, and one-fifth took nonsteroidal anti-inflammatory drugs (NSAIDs). Only 7% presented with shock at admission. There seems to be no consensus on the perfect setup for surgery and/or operating technique. In the laparoscopic groups, operating time was significant longer and incidence of recurrent leakage at the repair site was higher. Nonetheless there was significant less postoperative pain, lower morbidity, less mortality, and shorter hospital stay.
Conclusion
There are good arguments that laparoscopic correction of PPU should be first treatment of choice. A Boey score of 3, age over 70 years, and symptoms persisting longer than 24 h are associated with higher morbidity and mortality and should be considered contraindications for laparoscopic intervention.
doi:10.1007/s00464-009-0765-z
PMCID: PMC2869436  PMID: 20033725
Laparoscopic surgery; Perforated peptic ulcer; Omentoplasty; Review
18.  Abdominal Wound Dehiscence in Adults: Development and Validation of a Risk Model 
World Journal of Surgery  2009;34(1):20-27.
Background
Several studies have been performed to identify risk factors for abdominal wound dehiscence. No risk model had yet been developed for the general surgical population. The objective of the present study was to identify independent risk factors for abdominal wound dehiscence and to develop a risk model to recognize high-risk patients. Identification of high-risk patients offers opportunities for intervention strategies.
Methods
Medical registers from January 1985 to December 2005 were searched. Patients who had primarily undergone appendectomies or nonsurgical (e.g., urological) operations were excluded. Each patient with abdominal wound dehiscence was matched with three controls by systematic random sampling. Putative relevant patient-related, operation-related, and postoperative variables were evaluated in univariate analysis and subsequently entered in multivariate stepwise logistic regression models to delineate major independent predictors of abdominal wound dehiscence. A risk model was developed, which was validated in a population of patients who had undergone operation between January and December 2006.
Results
A total of 363 cases and 1,089 controls were analyzed. Major independent risk factors were age, gender, chronic pulmonary disease, ascites, jaundice, anemia, emergency surgery, type of surgery, postoperative coughing, and wound infection. In the validation population, risk scores were significantly higher (P < 0.001) for patients with abdominal wound dehiscence (n = 19) compared to those without (n = 677). Resulting scores ranged from 0 to 8.5, and the risk for abdominal wound dehiscence over this range increased exponentially from 0.02% to 70.1%.
Conclusions
The validated risk model shows high predictive value for abdominal wound dehiscence and may help to identify patients at increased risk.
doi:10.1007/s00268-009-0277-y
PMCID: PMC2795859  PMID: 19898894
19.  Level of arterial ligation in total mesorectal excision (TME): an anatomical study 
Introduction
High-tie ligation is a common practice in rectal cancer surgery. However, it compromises perfusion of the proximal limb of the anastomosis. This anatomical study was designed to assess the value of low-tie ligation in order to obtain a tension-free anastomosis.
Materials and methods
Consecutive high- and low-tie resections were performed on 15 formalin-fixed specimens, with or without splenic flexure mobilization. If the proximal colon limb could reach the superior aspect of the symphysis pubis with more than 3 cm, the limb would be long enough for a tension-free colorectal anastomosis.
Results
In 80% of cases, it was not necessary to perform high-tie ligation as sufficient length was gained with low-tie ligation. The descending branch of the left colic artery was the limiting factor in the other 20% of cases. Resecting half the sigmoid resulted in four times as many tension-free anastomoses after low-tie resection.
Conclusion
In the majority of cases, it was not necessary to perform high-tie ligation in order to create a tension-free anastomosis. Low-tie ligation was applicable in 80% of cases and might prevent anastomotic leakage due to insufficient blood supply of the proximal colon limb.
doi:10.1007/s00384-009-0761-8
PMCID: PMC2758382  PMID: 19609537
Vascular anatomy; Anastomosis; Inferior mesenteric artery; Rectal cancer
20.  Comparison of Closure of Gastric Perforation Ulcers With Biodegradable Lactide-Glycolide-Caprolactone or Omental Patches 
Results of both methods of gastric closure (omental and biodegradable patch) were similar suggesting that a biodegradable patch glued to the outside of the stomach may be a viable alternative for closure of perforations of the digestive tract.
Background:
The current treatment of perforated peptic ulcers is primary closure, supported by the application of an omental patch. It is difficult and time consuming to perform this procedure by laparoscopic surgery, largely because of the required suturing. It was our aim to develop and test a new method of closure for gastric perforation that is similar in efficacy and safety to a traditional repair. This technique could have utility in laparoscopic repair, as it does not require sutures or mobilization of the omentum.
Method:
The new method, called the “stamp” method consists of closure of the perforation by gluing a biodegradable patch made of lactide-glycolide-caprolacton (LGC, Polyganics, B.V. Groningen, The Netherlands) on the outside of the stomach. It was compared with the omental patch procedure. Perforations were made in the stomach of 20 rats and closed by either method (10 rats in each group). The rats were followed for 10 weeks.
Results:
No complications were seen in any of the rats. In both groups, histological degradation of the patch by giant cells started at week 2. No signs of inflammation existed in either group. Signs of closure of the mucosa were seen after 2 weeks, and the muscular layer started to regenerate after 8 weeks in both groups.
Conclusion:
Results of both methods were similar, which means that treatment of a gastric perforation through the application of a biodegradable patch to the outside of the stomach is a feasible option and might even be an interesting technique for closure of other perforations in the digestive tract.
doi:10.4293/108680809X12589998404362
PMCID: PMC3030790  PMID: 20202396
Gastric perforation; Laparoscopy; Biodegradable patch
21.  Long-term results after Boston brace treatment in adolescent idiopathic scoliosis 
Scoliosis  2009;4:17.
Background
Few studies have evaluated long-term outcome after bracing using validated health related quality of life outcome measures. The aim of the present study was to evaluate the long-term outcome in adolescent idiopathic scoliosis (AIS) 12 years or more after treatment with the Boston brace.
Methods
109 (80%) of 135 patients (7 men) with AIS treated with the Boston brace at a mean of 19.2 (range 12–28) years previously responded to long-term follow-up examination.
All patients (n = 109) answered a standardised questionnaire including demographics, work status, treatment, Global Back Disability Question, Oswestry Disability Index (ODI) (100-worst possible), General Function Score (GFS) (100 – worst possible), EuroQol (EQ-5D) (1 – best possible), EQ-VAS (100 – best possible)) and Scoliosis Research Society -22 (SRS – 22) (5 – best possible). Clinical and radiological examination was obtained in 86 patients.
Results
The magnitude of the primary prebrace major curve was in average 33.4° (range 20 – 52). At weaning and at the last follow-up the corresponding values were 28.3° (9–56) and 34.2° (8 – 87), respectively. The mean age at follow-up was 35 (27 – 46) years. Work status was: full time (80%), on sick-leave (3%), on rehabilitation (4%), disability pension (4%), homemaker (7%), students (2%), 7% had changed their job because of back pain. 88% had had delivered a baby, 55% of them had pain in pregnancy. Global back status was excellent or good in 81%. The mean (standard deviation) ODI was 6.4 (9.8), GFS 5.4 (10.5), EQ-5D 0.84 (0.2), SRS-22: pain 4.2 (0.8), mental health 4.2 (0.7), self-image 3.9 (0.7), function 4.1 (0.6), satisfaction with treatment 3.7 (1.0). 28% had taken physiotherapy for back pain the last year and 12% had visited a doctor.
Conclusion
Long-term results were satisfactory in most patients with AIS treated with the Boston brace.
doi:10.1186/1748-7161-4-17
PMCID: PMC2743640  PMID: 19709435
22.  Risk Factors for Abdominal Wound Dehiscence in Children: A Case-Control Study 
World Journal of Surgery  2009;33(7):1509-1513.
Background
In the limited literature concerning abdominal wound dehiscence after laparotomy in children, reported incidences range between 0.2–1.2% with associated mortality rates of 8–45%. The goal of this retrospective case-control study was to identify major risk factors for abdominal wound dehiscence in the pediatric population.
Methods
Patients younger than aged 18 years who developed abdominal wound dehiscence in three pediatric surgical centers during the period 1985–2005 were identified. For each patient with abdominal wound dehiscence, four controls were selected by systematic random sampling. Patients with (a history of) open abdomen treatment or abdominal wound dehiscence were excluded as control subjects. Putative relevant patient-related, operation-related, and postoperative variables for both cases and control subjects were evaluated in univariate analyses and subsequently entered in multivariate stepwise logistic regression models to identify major independent predictors of abdominal wound dehiscence.
Results
A total number of 63 patients with abdominal wound dehiscence and 252 control subjects were analyzed. Mean presentation of abdominal wound dehiscence was at postoperative day 5 (range, 1–15) and overall mortality was 11%. Hospital stay was significantly longer (p < 0.001) in the case group (median, 42 vs. 10 days). Major independent risk factors for abdominal wound dehiscence were younger than aged 1 year, wound infection, median incision, and emergency surgery. Incisional hernia was reported in 12% of the patients with abdominal wound dehiscence versus 3% in the control group (p = 0.001).
Conclusions
Abdominal wound dehiscence is a serious complication with high morbidity and mortality. Median incisions should be avoided whenever possible.
doi:10.1007/s00268-009-0058-7
PMCID: PMC2691929  PMID: 19418094
23.  Randomized Clinical Trial of Laparoscopic Versus Open Repair of the Perforated Peptic Ulcer: The LAMA Trial 
World Journal of Surgery  2009;33(7):1368-1373.
Background
Laparoscopic surgery has become popular during the last decade, mainly because it is associated with fewer postoperative complications than the conventional open approach. It remains unclear, however, if this benefit is observed after laparoscopic correction of perforated peptic ulcer (PPU). The goal of the present study was to evaluate whether laparoscopic closure of a PPU is as safe as conventional open correction.
Methods
The study was based on a randomized controlled trial in which nine medical centers from the Netherlands participated. A total of 109 patients with symptoms of PPU and evidence of air under the diaphragm were scheduled to receive a PPU repair. After exclusion of 8 patients during the operation, outcomes were analyzed for laparotomy (n = 49) and for the laparoscopic procedure (n = 52).
Results
Operating time in the laparoscopy group was significantly longer than in the open group (75 min versus 50 min). Differences regarding postoperative dosage of opiates and the visual analog scale (VAS) for pain scoring system were in favor of the laparoscopic procedure. The VAS score on postoperative days 1, 3, and 7 was significant lower (P < 0.05) in the laparoscopic group. Complications were equally distributed. Hospital stay was also comparable: 6.5 days in the laparoscopic group versus 8.0 days in the open group (P = 0.235).
Conclusions
Laparoscopic repair of PPU is a safe procedure compared with open repair. The results considering postoperative pain favor the laparoscopic procedure.
doi:10.1007/s00268-009-0054-y
PMCID: PMC2691927  PMID: 19430829
24.  After-hours colorectal surgery: a risk factor for anastomotic leakage 
Purpose
This study aims to increase knowledge of colorectal anastomotic leakage by performing an incidence study and risk factor analysis with new potential risk factors in a Dutch tertiary referral center.
Methods
All patients whom received a primary colorectal anastomosis between 1997 and 2007 were selected by means of operation codes. Patient records were studied for population description and risk factor analysis.
Results
In total 739 patients were included. Anastomotic leakage (AL) occurred in 64 (8.7%) patients of whom nine (14.1%) died. Median interval between operation and diagnosis was 8 days. The risk for AL was higher as the anastomoses were constructed more distally (p = 0.019). Univariate analysis showed duration of surgery (p = 0.038), BMI (p = 0.001), time of surgery (p = 0.029), prophylactic drainage (p = 0.006) and time under anesthesia (p = 0.012) to be associated to AL. Multivariate analysis showed BMI greater than 30 kg/m2 (p = 0.006; OR 2.6 CI 1.3–5.2) and “after hours” construction of an anastomosis (p = 0.030; OR 2.2 CI 1.1–4.5) to be independent risk factors.
Conclusion
BMI greater than 30 kg/m2 and “after hours” construction of an anastomosis were independent risk factors for colorectal anastomotic leakage.
doi:10.1007/s00384-009-0692-4
PMCID: PMC2689358  PMID: 19301016
After-hours; Colorectal surgery; Anastomotic leakage; Body mass index
25.  Laparoscopic ileocolic resection versus infliximab treatment of distal ileitis in Crohn's disease: a randomized multicenter trial (LIR!C-trial) 
BMC Surgery  2008;8:15.
Background
With the availability of infliximab, nowadays recurrent Crohn's disease, defined as disease refractory to immunomodulatory agents that has been treated with steroids, is generally treated with infliximab. Infliximab is an effective but expensive treatment and once started it is unclear when therapy can be discontinued. Surgical resection has been the golden standard in recurrent Crohn's disease. Laparoscopic ileocolic resection proved to be safe and is characterized by a quick symptom reduction.
The objective of this study is to compare infliximab treatment with laparoscopic ileocolic resection in patients with recurrent Crohn's disease of the distal ileum with respect to quality of life and costs.
Methods/design
The study is designed as a multicenter randomized clinical trial including patients with Crohn's disease located in the terminal ileum that require infliximab treatment following recent consensus statements on inflammatory bowel disease treatment: moderate to severe disease activity in patients that fail to respond to steroid therapy or immunomodulatory therapy. Patients will be randomized to receive either infliximab or undergo a laparoscopic ileocolic resection. Primary outcomes are quality of life and costs. Secondary outcomes are hospital stay, early and late morbidity, sick leave and surgical recurrence. In order to detect an effect size of 0.5 on the Inflammatory Bowel Disease Questionnaire at a 5% two sided significance level with a power of 80%, a sample size of 65 patients per treatment group can be calculated. An economic evaluation will be performed by assessing the marginal direct medical, non-medical and time costs and the costs per Quality Adjusted Life Year (QALY) will be calculated. For both treatment strategies a cost-utility ratio will be calculated. Patients will be included from December 2007.
Discussion
The LIR!C-trial is a randomized multicenter trial that will provide evidence whether infliximab treatment or surgery is the best treatment for recurrent distal ileitis in Crohn's disease.
Trial registration
Nederlands Trial Register NTR1150
doi:10.1186/1471-2482-8-15
PMCID: PMC2533646  PMID: 18721465

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