Biomedical subjects

D J Gouma

Publications and source records attributed to D J Gouma.

At least 37 records · Page 2Linked to original sources

PubMed2005

[Relaparotomy in secondary peritonitis Planned relaparotomy or relaparotomy on demand?].

Secondary peritonitis is associated with serious morbidity and a persistent high mortality in recent decades, this despite improvement in antibiotic, intensive care and surgical treatment. The available literature regarding the surgical treatment of secondary peritonitis was searched through Pubmed (1966- January 2005) as well as a hand search of references of retrieved articles. Definitions, pathophysiology and classification of secondary peritonitis are discussed, as well as the scientific rationale for the surgical treatment in secondary peritonitis. The historical development and the scientific foundation of present-day relaparotomy strategies in secondary peritonitis are evaluated, with an emphasis on two frequently applied surgical treatment strategies: planned relaparotomy and relaparotomy on demand. Criteria for relaparotomy after the initial laparotomy and potential areas for further research to reduce both morbidity and mortality are discussed. Furthermore, the care of patients with secondary peritonitis is evolving from a surgical entity to a more multidisciplinary challenge uniting surgeons, intensivists, radiologists and microbiologists. Research needs to be expanded into novel fields to further decrease morbidity and mortality.

Hospital Mortality↗

PubMed2005

The café fire on New Year's Eve in Volendam, the Netherlands: description of events.

AIM OF STUDY: The café fire at Volendam occurred shortly after midnight on the first of January 2001 and resulted in one of the worst mass burn incidents in recent Dutch history. The aim of this study was to provide insight into medical and organisational requirements of a major burns incident. METHODS: Shortly after the fire, two university hospitals and a burn center in the region of the accident developed a plan for evaluation of medical care given during and after this major burn incident. A multidisciplinary research group investigated the management of victims at the scene, in the emergency departments (ED) and during admission in the hospitals. All 245 casualties were included in this study. RESULTS: A brief severe fire occurred in a crowded cafe with around 350 young visitors on a small embankment of a relatively isolated town, resulting in a unusually high number of severely injured burn victims. Four died immediately. The ensuing rescue effort was hampered by poor access and chaotic circumstances. At the scene of the incident, mobile medical teams ensured orderly transport and treatment priority for the injured. There were 245 victims with a median total body surface area burned of 12%. Inhalation injury was present in 96 patients. A total of 182 victims were admitted, with 112 to intensive care. Ten patients died in the hospital. Seventy-eight patients were secondarily transported, many to specialised centers in the Netherlands and abroad. In total, 36 hospitals in three countries participated. CONCLUSION: An incident with high numbers of burn victims poses a challenge to any health care system. The difficult circumstances at the site demonstrated the need for robust organisational structures. The primary and secondary distribution of patients required coordination, general hospitals were able to provide initial medical care to these major burn casualties.

Adolescent↗

PubMed2005

Medical management after indoor fires: a review.

UNLABELLED: Fires involving mass burn casualties require extreme efforts and flexibility from the regular health care system. The café fire in Volendam, which occurred shortly after midnight on the first of January 2001, resulted in the worst indoor mass burns incident in Dutch history. During the extensive medical evaluation of this disaster, it became obvious that information on similar incidents is relatively scarce in the literature. This article systematically reviews the existing information in the medical literature on indoor fires and provides findings and knowledge used in the evaluation of the medical management after indoor fires and for future mass burn casualty preparedness, mitigation and response. METHODS: A literature review was undertaken for burn disasters with characteristics similar to the indoor Volendam fire disaster. In all fires, the following aspects were investigated: characteristics of the fire; the initial emergency response; triage and on-site treatment; primary and secondary distribution; hospital admission; severity of the sustained injuries and mortality. RESULTS: A total of nine similar indoor fires were selected. The number of people involved was reported in seven fires (range 137-6000). All reports provided the mortality rate (range 1.4% to over 50%). Data regarding the emergency response could be collected in half of the studies. On-scene triage was performed in five fires. The number of hospitals participating in the primary distribution ranged from 1 to 19. Except for the Volendam fire, all patients were primarily distributed to general hospitals. CONCLUSION: Characteristics of indoor fires, which are relevant for disaster preparedness, mitigation and response are not frequently reported in medical literature. The current articles on indoor fires, mainly report on numbers of casualties and the mortality. Limited data are available to provide insight in the characteristics of management and medical treatment and to come up with suggestions for improvement of future burn incidents management. The evaluation of disasters should be based on uniform methods and structured reports and effective record keeping is essential to achieve this.

Burns↗

PubMed2005

Outcome of regional and local ablative therapies for hepatocellular carcinoma: a collective review.

BACKGROUND: Transcatheter arterial (chemo) embolization (TACE), cryoablation (CA) and percutaneous ethanol injection (PEI) were the first regional and local ablative techniques that came into use for irresectable HCC. Radiofrequency ablation (RFA) and interstitial laser coagulation (ILC) followed and have now evolved rapidly. It would not be ethical to compare resection with ablation in patients well enough to undergo major surgery. Therefore, hepatic resection and hepatic transplantation remain the only curative treatment options for HCC. METHODS: On the basis of a Medline literature search and the authors' experiences, the principles, current status and prospects of TACE and local ablative techniques in HCC are reviewed. RESULTS: Complete tumour necrosis can be achieved in 60-100% of patients treated with PEI (70-100%), cryoablation (60-85%), RFA (80-90%) or ILC (70-97%). After TACE significant tumour response is achieved in 17-61.9% but complete tumour response is rare (0-4.8%) as viable tumour cells remain after TACE. Five-year survival rates are available for TACE (1-8%), PEI (0-70%) and cryoablation (40%). Only PEI and RFA were compared in one RCT. RFA was associated with fewer treatment sessions and a higher complete necrosis rate. Furthermore, all techniques are associated with low morbidity and mortality, but cryoablation seems to be associated with a higher morbidity rate. CONCLUSION: TACE has shown to be a valuable therapy with survival benefits in strictly selected patients with unresectable HCC. RFA and PEI are now considered as the local ablative techniques of choice for the treatment of, preferably small, HCC. When tumours are located close to bile ducts or large vessels, PEI remains a valuable therapy. Completeness of ablation can be more easily monitored during cryoablation and another advantage of cryoablation is the possibility of edge freezing. The results of ILC are comparable to RFA with only few side effects and high tumour response rates.

Carcinoma, Hepatocellular↗

PubMed2005

Palliative management of hilar cholangiocarcinoma.

Around 80% of the patients with hilar cholangiocarcinoma are candidates for palliative management due to extensive co-morbidity for major surgery, metastases or advanced loco-regional disease. The primary aim of treatment is to provide biliary drainage with long-term relief from pruritus, cholangitis, pain and jaundice. Endoscopically placed self-expanding metallic biliary stent has low procedure-related complications and is probably the modality of choice for patients with unresectable tumour on preoperative assessment. Percutaneous biliary drainage has comparable results and is an alternative when endoscopic expertise is not available or has failed or there are multiple isolated segments with cholangitis. Surgical cholangiojejunostomy provides lasting biliary drainage but has limitations of associated morbidity and mortality. In the absence of high-quality studies, comparing these modalities the choice of biliary drainage procedure should be guided by the available local expertise. Other modalities of treatment like radiotherapy, chemotherapy and photodynamic therapy currently remain investigational.

Bile↗

PubMed2005

Fenestrations in the jaws of laparoscopic graspers.

Laparoscopic graspers used for manipulating delicate tissue generally possess jaws with fenestrations (windows). The fenestrations should enhance the grip on the tissue; however, fenestrations reduce the contact area between jaws and tissue, leading to higher local pressures and possibly tissue damage. Experiments were performed to determine the effect of a fenestration on the pinch force needed to prevent slip of tissue and on the pinch force leading to tissue damage. In addition, the size and position of the fenestration were determined. Fenestrated jaws resulted in increased tissue damage, without affecting the pinch force needed to prevent slip. These negative effects increased with increasing fenestration size and when the fenestration was located toward the tip of the jaws. Therefore, fenestrated jaws had a smaller safe working range than the jaws without fenestrations.

Journal Article↗

PubMed2005

Comparison of the novel quantitative ARMS assay and an enriched PCR-ASO assay for K-ras mutations with conventional cytology on endobiliary brush cytology from 312 consecutive extrahepatic biliary stenoses.

BACKGROUND: Extrahepatic biliary stenosis (EBS) has malignant and benign causes. Patients with EBS are at risk of having or developing malignancy. Accurate diagnostic tests for early detection and surveillance are needed. The sensitivity of biliary cytology for malignancy is low. K-ras mutation analysis on brush cytology is a valuable adjunct, but specificity is low. A quantitative test for K-ras mutations has been developed: the amplification refractory mutation system (ARMS). AIM: To assess the test characteristics and additional value of ARMS in diagnosing the cause of EBS. METHODS: Brush samples from endoscopic retrograde cholangiopancreatography were collected from 312 patients with EBS. K-ras mutation analysis was performed using ARMS-allele specific amplification was coupled with real time fluorescent detection of PCR products. Results were compared with conventional cytology and K-ras mutation analysis using allele specific oligonucleotide (ASO) hybridisation, and evaluated in view of the final diagnosis. RESULTS: The test characteristics of ARMS and ASO largely agreed. Sensitivity for detecting malignancy was 49% and 42%, specificity 93% and 88%, and positive predictive value (PPV) 96% and 91%, respectively. The sensitivity of ARMS and cytology combined was 71%, and PPV was 93%. The specificity of ARMS could be increased to 100% by setting limits for the false positives, but reduced sensitivity from 49% to 43%. CONCLUSIONS: ARMS can be considered supplementary to conventional cytology, and comparable to ASO in diagnosing malignant EBS. A specificity of 100% can be achieved with ARMS, which should be considered in the surveillance of patients at risk for pancreatic cancer.

Adult↗

PubMed2004

Hernia surgery changes in the Amsterdam region 1994-2001: decrease in operations for recurrent hernia.

Inguinal hernia (IH) surgery has changed substantially in the past decade. Conventional (nonmesh) techniques have largely given way to prostheses. This study's aim was to analyse whether changes in technique used for IH repair influenced the operation rate for recurrence. A retrospective study was performed on all adult males who had undergone IH surgery in the Amsterdam region during the calendar years of 1994, 1996, 1999, and 2001. Data were obtained for 3,649 subjects and included patient demographics, hernia type, and surgical technique. We observed a decrease in the use of conventional techniques and a significant increase (P<0.05) in the use of prosthetic materials. The number of operations performed for recurrent hernia decreased from 19.5% (216/1,108) in 1994, to 16.8% 197/1,170) in 1996, to 14.0% (152/1,088) in 1999, and to 14.1% (40/283) in 2001. When comparing 1999 and 2001 with 1994, there was a significant decrease in operations performed for recurrent hernia (P=0.005). There was also a significant increase in supervision of the surgical resident by a surgeon.

Adolescent↗

PubMed2004

[Diagnostic modalities in diagnosis of adult patients with acute abdominal pain].

In order to provide an accurate diagnosis and management strategy for adult patients with acute abdominal pain and peritoneal irritation, it is important to understand the value of various forms of diagnostics modalities. History, physical examination and laboratory results can generally differentiate between an acutely serious and a less serious abdominal problem. Patients with acute abdominal pain and no increase in either the leukocyte count or the concentration of C-reactive protein should be re-evaluated after 12 hours. If laboratory values are increased, then diagnostic imaging is necessary. For patients with diffuse abdominal pain and for patients with signs of shock or respiratory insufficiency, a CT-scan is the imaging method of choice. If symptoms are located in the left upper quadrant, an upright chest radiograph or a plain abdominal film are recommended. If symptoms are located in the right upper quadrant, ultrasonography will be preferred. If the diagnosis is still uncertain, a CT-scan will be performed. A CT-scan is indicated for lower abdominal pain in women with increased inflammatory parameters and in men aged 50 years or older with increased inflammatory parameters. If the cause of the abdominal pain is still unclear following a CT-scan, then diagnostic laparoscopy may be considered for fertile women of childbearing age and for men aged less than 50 years with signs of appendicitis.

Abdominal Pain↗

PubMed2004

The optimal mechanical efficiency of laparoscopic forceps.

BACKGROUND: Laparoscopic forceps have a large amount of friction in the mechanism, leading to a limited mechanical efficiency, which impairs the pinch force feedback. The advantage of a small amount of friction is that it is easier to maintain a constant pinch force on the tissue. Therefore, to obtain the optimal mechanical efficiency of the forceps, the influence of mechanical efficiency on the performance of several static and dynamic operative tasks, such as grasping tissue and estimating pressure, is quantified. METHODS: A grasper with adjustable mechanical efficiency and a load cell to measure the pinch force on the tissue was developed. Using this grasper, subjects performed several tasks on pig bowel tissue and simulation tissue: grasping tissue, reproducing a requested constant or variable pinch forces, and estimating the pressure in a tube. RESULTS: With increasing mechanical efficiency, a variable pinch force could be reproduced more accurately (deviation from the requested pinch force decreased from 34.4 to 24.9%, p = 0.016). The performance on the grasping tissue, reproducing a constant pinch force, and estimating pressure tasks did not improve with increased mechanical efficiency. CONCLUSIONS: The optimal mechanical efficiency of laparoscopic forceps is dependent on the task that is performed. For tasks requiring little movement of the forceps, such as grasping and holding tissue, a low mechanical efficiency is sufficient, whereas for tasks requiring repeated movement of the forceps to feel tissue, a high mechanical efficiency is required.

Animals↗

PubMed2004

[Obstructive jaundice after surgery of the biliary tract, a benign stricture or not?].

Obstructive jaundice occurred in 3 patients, 2 women, aged 44 and 60 years, and one man aged 62 years: 17 years after choledochojejunostomy following a complicated cholecystectomy, 8 years after hepatojejunostomy following choledochal cyst removal, and 1 year after laparoscopic cholecystectomy. Percutaneous or endoscopic stent placement was performed in all patients to relieve biliary obstruction. However, stent dysfunction repeatedly resulted in re-stenting of the obstruction. Imaging techniques, as well as endoscopic brush pathology could not distinguish between a benign or malignant stenosis. Explorative laparotomy showed a new growth in all 3 patients, of which 2 were malignant. When obstructive jaundice occurs after surgery of the biliary tract for benign disease, the most likely cause is a benign stenosis. Percutaneous or endoscopic stenting is the treatment of choice. In case of unexpected and/or repeated stent failure, when a diagnosis cannot be made due to inconclusive imaging or pathology of the stenosis exploratory surgery should be considered, as malignant stenosis may be present.

Adult↗

PubMed2004

[Bile duct injury after cholecystectomy: risk of mortality substantially higher].

Previous studies showed that bile duct injury after cholecystectomy is associated with substantial morbidity and a negative effect on Quality of Life. In a recent study, patients with a bile duct injury after cholecystectomy exhibited a 3-fold increase in mortality during a follow-up period of nine years compared to patients without injury. This is the first study to demonstrate a negative impact of bile duct injury on survival. Repair by a less experienced surgeon leads to an 11% higher mortality during follow-up. Cholangiography should probably be performed routinely during cholecystectomy. A bile duct lesion should be suspected when the patient has not recovered within 48 hours. Endoscopic or percutaneous treatment of stenoses or leakage is usually successful, even after several weeks.

Bile Ducts↗

PubMed2004

Slip and damage properties of jaws of laparoscopic graspers.

BACKGROUND: The optimal jaws of laparoscopic graspers can be used to manipulate the tissue properly with minimal damage. The criteria jaws should satisfy are investigated. METHODS: The cecum of pigs was clamped between 13 pairs of jaws differing in size and profile. Various pinch and pull forces were applied. At 5 N pull force, the minimally required pinch force to prevent slip and the pinch force that is maximally allowable without causing damage were obtained. RESULTS: With increasing size of the jaws, the contact area with the tissue increases. With increasing contact area, the pinch force leading to tissue damage was increased from 15 to 37 N. A profile of the jaws decreased the pinch force needed to prevent slip of tissue from 22 to 3 N. CONCLUSION: An optimal jaw possesses a large contact area to prevent tissue damage and a slight profile to prevent tissue slip.

Animals↗

PubMed2004

The influence of force feedback and visual feedback in grasping tissue laparoscopically.

BACKGROUND: Due to the limited force feedback provided by laparoscopic instruments, surgeons may have difficulty in applying the appropriate force on the tissue. The aim of this study was to determine the influence of force feedback and visual feedback on the exerted pinch force. METHODS: A grasper with a force sensor in the jaws was developed. Subjects with and without laparoscopic experience grasped and pulled pig bowel with a force of 5 N. The applied pinch force was measured during tasks of 1-s and 1-min duration. Visual feedback was provided in half the measurements. Force feedback was adjusted by changing the mechanical efficiency of the forceps from 30% to 90%. RESULTS: The mean pinch force applied was 6.8 N (+/-0.5), whereas the force to prevent slippage was 3.0 N (+/-0.4). Improving the mechanical efficiency had no effect on the pinch force for the 1-s measurements. The amount of excessive pinch force when holding tissue for 1 min was lower at 30% mechanical efficiency compared with 90% (105% vs 131%, p = 0.04). The tissue slipped more often when the subject had no visual feedback (2% vs 8%, p = 0.02). CONCLUSION: Force feedback and visual feedback play a more limited role than expected in the task of grasping tissue with laparoscopic forceps.

Animals↗

PubMed2004

Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial.

PURPOSE: The extent of lymph node dissection appropriate for gastric cancer is still under debate. We have conducted a randomized trial to compare the results of a limited (D1) and extended (D2) lymph node dissection in terms of morbidity, mortality, long-term survival and cumulative risk of relapse. We have reviewed the results of our trial after follow-up of more than 10 years. PATIENTS AND METHODS: Between August 1989 and June 1993, 1,078 patients with gastric adenocarcinoma were randomly assigned to undergo a D1 or D2 lymph node dissection. Data were collected prospectively, and patients were followed for more than 10 years. RESULTS: A total of 711 patients (380 in the D1 group and 331 in the D2 group) were treated with curative intent. Morbidity (25% v 43%; P <.001) and mortality (4% v 10%; P =.004) were significantly higher in the D2 dissection group. After 11 years there is no overall difference in survival (30% v 35%; P =.53). Of all subgroups analyzed, only patients with N2 disease may benefit of a D2 dissection. The relative risk ratio for morbidity and mortality is significantly higher than one for D2 dissections, splenectomy, pancreatectomy, and age older than 70 years. CONCLUSION: Overall, extended lymph node dissection as defined in this study generated no long-term survival benefit. The associated higher postoperative mortality offsets its long-term effect in survival. For patients with N2 disease an extended lymph node dissection may offer cure, but it remains difficult to identify patients who have N2 disease. Morbidity and mortality are greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age. Extended lymph node dissections may be of benefit if morbidity and mortality can be avoided.

Adenocarcinoma↗

PubMed2004

[Cystadenomas with ovarian stroma in liver and pancreas: indications of embryonic migration of the gonadal epithelium].

OBJECTIVE: To provide an embryological explanation for the presence of ovarian stroma in cystadenomas of the liver and pancreas. DESIGN: Investigation of patients and embryos. METHOD: From 1997 to 2001 in the Academic Medical Centre, Amsterdam, the Netherlands, nine women were treated for a cystadenoma with ovarian stroma, six of which were situated in the liver and three in the tail of pancreas. In one patient with a cystadenoma in the liver, malignant changes had taken place. In embryos at 5-8 weeks development, the regional differences in the morphology of the epithelium of the peritoneal cavity and the position of the gonads in relation to the embryonic liver, pancreas and spleen were examined. RESULTS: In the foetal period before the gonads begin to descend, they are situated directly dorsal to the liver, tail of pancreas and spleen, but are separated from these by the peritoneal cavity. The cells that cover the urogenital folds distinguish themselves from those elsewhere in the peritoneal cavity as they are bulging in shape as opposed to flattened. This activated morphology suggests that on physical contact with a neighbouring organ the cells covering the gonads may become detached and lodge in that organ. CONCLUSION: It is likely that cystadenomas of the liver and pancreas have their origin in the cells that cover the embryonic gonads. The anomalous morphology of these covering cells in fact suggests that they are relatively easily mobilized. They are probably comparable with inoculation metastasis in the coelomic cavity. Taking the chance of malignant transformation of a cystadenoma into account, the treatment of choice is radical resection of the abnormality.

Cystadenoma↗

PubMed2004

Hand-assisted laparoscopic surgery (HALS): a report of 150 procedures.

BACKGROUND: This study was performed to evaluate the (long-term) morbidity associated with hand-assisted laparoscopic surgery (HALS) for various indications. METHODS: HALS procedures for various indications were evaluated prospectively from 1995 to 2002. The primary outcome parameters were postsurgical complications and the development of incisional hernias. RESULTS: Twenty-six splenectomies, 51 hand-assisted laparoscopic donor nephrectomies (HLDN), 34 segmental bowel resections, 29 proctocolectomies, and 10 emergency colectomies were evaluated. A Küstner or Pfannenstiel incision was used for handport placement. Minor complications (i.e., wound complications, urinary tract infection) occurred in 15%, 12%, 26%, 7%, and 33% of the patients after, respectively, splenectomy, HLDN, bowel resection, proctocolectomy, and emergency colectomy. Major complications (i.e., hemorrhage, anastomotic leakage) occurred in 15% and 12% of the patients after, respectively, bowel resection and proctocolectomy. Incisional hernias occurred in six patients (4%), all after a wound complication in the Küstner incision. CONCLUSION: HALS is fast, safe, and feasible for various indications, especially HLDN and (procto-)colectomies. Little advantage can be expected when HALS is applied in splenectomy and segmental bowel (sigmoid) resection.

Adult↗

PubMed2004

Robot-assisted laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: a comparative study.

BACKGROUND: The efficacy of conventional laparoscopic cholecystectomy (CLC) was compared with robot-assisted laparoscopic cholecystectomy (RLC). Surgical trainees performed the LC to avoid the surgeon's experience bias. METHODS: Two surgical trainees performed 10 CLCs and 10 RLCs at random with a Zeus-Aesop Surgical Robotic System. The primary efficacy parameters were the total time and the number of actions involved in the procedure. The secondary parameters were setup and dissection times, and the number of grasping and dissection actions. Surgical complications were evaluated. RESULTS: For CLC and RLC, respectively, the total times were 95.4 +/- 28 min and 123.5 +/- 33.3 min and the total actions were 420 +/- 176.3 and 363.5 +/- 158.2. For CLC, the times required for setup (21 +/- 10.4 min) and dissection (50.2 +/- 17.7 min) were less than for RLC (33.8 +/- 11.3 min and 72 +/- 24.3 min, respectively). The numbers of grasping and dissection actions were not significantly different: 41.4 +/- 26.5 and 378 +/- 173.7, respectively, for CLC versus 48.9 +/- 27 and 314.6 +/- 141.9, respectively, for RLC. CONCLUSION: Although feasible, RLC requires significantly more time than CLC because of slower performed actions.

Adult↗