Biomedical subjects

D J Gouma

Publications and source records attributed to D J Gouma.

At least 55 records · Page 3Linked to original sources

PubMed2004

Mortality and morbidity of planned relaparotomy versus relaparotomy on demand for secondary peritonitis.

BACKGROUND: Planned relaparotomy (PR) and relaparotomy on demand (ROD) are both frequently used in the treatment of secondary peritonitis. The aim of this study was to evaluate the mortality, morbidity and long-term outcome associated with PR compared with ROD in patients with secondary peritonitis admitted to a university hospital. METHOD: This retrospective study included 278 consecutive patients who underwent emergency laparotomy for secondary peritonitis between January 1994 and January 2000. Outcome was analysed based on the decision made by the surgeon during the first operation to perform either ROD (197 patients) or PR (81). RESULTS: The Acute Physiology And Chronic Health Evaluation II score was comparable in ROD and PR groups (10.8 versus 11.7; P = 0.222). The in-hospital mortality rate was significantly lower with ROD than PR (21.8 versus 36 per cent; P = 0.016). Two-year survival(s.e.) was 65.8(3.4) per cent in the ROD group and 55.5(5.5) per cent in the PR group (P = 0.031). CONCLUSION: The in-hospital and long-term survival rates were higher in patients with secondary peritonitis treated by ROD than in those with disease of comparable severity treated by PR. Choice of treatment strategy was an independent predictor of survival.

Aged↗

PubMed2004

Bowel injury as a complication of laparoscopy.

BACKGROUND: Bowel injury is a rare but serious complication of laparoscopic surgery. This review examines the incidence, location, time of diagnosis, causative instruments, management and mortality of laparoscopy-induced bowel injury. METHODS: The review was carried out using the MeSH browser within PubMed. The keywords used were 'laparoscopy/adverse effects' and 'bowel perforation'. Additional articles were sourced from references within the studies found in the PubMed search. RESULTS: The incidence of laparoscopy-induced gastrointestinal injury was 0.13 per cent (430 of 329 935) and of bowel perforation 0.22 per cent (66 of 29 532). The small intestine was most frequently injured (55.8 per cent), followed by the large intestine (38.6 per cent). In at least 66.8 per cent of bowel injuries the diagnosis was made during the laparoscopy or within 24 h thereafter. A trocar or Veress needle caused the most bowel injuries (41.8 per cent), followed by a coagulator or laser (25.6 per cent). In 68.9 per cent of instances of bowel injury, adhesions or a previous laparotomy were noted. Management was mainly by laparotomy (78.6 per cent). The mortality rate associated with laparoscopy-induced bowel injury was 3.6 per cent. CONCLUSION: At 0.13 per cent, the incidence of laparoscopy-induced bowel injury is small and such injury is usually discovered during the operation. Nevertheless, laparoscopy-induced bowel injury is associated with a high mortality rate of 3.6 per cent.

Humans↗

PubMed2004

Endoscopic and surgical management of bile duct injury after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the first choice of management for symptomatic cholecystolithiasis. While it is associated with decreased postoperative morbidity and mortality, bile duct injuries are reported to be more severe and more common (0-2.7%), when compared to open cholecystectomy (0.2-0.5%) [New Engl. J. Med. 234 (1991) 1073; Am. J. Surg. 165 (1993) 9; Surg. Clin. N Am. 80 (2000) 1127]. These bile duct injuries include leaks, strictures, transection and removal of (part of) the duct, with or without vascular damage. Bile duct injury might be due to misidentification of the biliary tract anatomy due to acute cholecystitis, large impacted stones, short cystic duct, anatomical variations, but also due to technical errors leading to bleeding with subsequent clipping and coagulation trauma [Ann. Surg. 237 (2003) 460]. Early recognition and adequate multidisciplinary approach is the cornerstone for the optimal final outcome. Suboptimal management of injuries often leads to more extensive damage to the biliary tree and its vasculature with as consequences biliary peritonitis, sepsis, abscesses, multiple organ failure, a more difficult (proximal) reconstruction and in the long run, secondary biliary cirrhosis, and liver failure. Despite increasing experience in performing laparoscopic cholecystectomy, the frequency of bile duct injuries has not decreased [Ann. Surg. 234 (2001) 549]. Therapy encompasses endoscopic stenting, percutaneous transhepatic dilatation (PTCD) and surgical reconstruction.

Bile Ducts↗

PubMed2004

Management of bleeding and leakage after pancreatic surgery.

Pancreatic surgery has advanced considerably during the past decades. Recent studies report reduced morbidity rates and virtually no mortality after resection. However, postoperative complications are still a formidable menace. In this chapter we discuss the management of postoperative bleeding and leakages which are considered the most feared complications, and discuss the advent of minimal invasive methods for management of these complications. Patients who develop postoperative bleeding almost always present with septic complications and a sentinel bleed before onset of bleeding. These patients should undergo early diagnostic angiography followed by embolisation. If this does control the bleeding an emergency laparotomy should be performed as last resort. Patients who develop pancreatic leakage are generally managed conservatively by means of percutaneous drainage. Aggressive surgery should be performed at the first sign of severe sepsis. The condition of the pancreatic remant found during reoperation dictates the type of surgical intervention best performed.

Crohn Disease↗

PubMed2004

Surgical treatment of pancreatic adenocarcinoma; actual survival and prognostic factors in 343 patients.

Survival data of patients with pancreatic carcinoma are often overestimated because of incomplete follow-up. Therefore, the aim of this study was to approach complete follow-up and to analyse survival and prognostic factors of patients who underwent surgical treatment for pancreatic adenocarcinoma. Between 1992 and 2002, 343 patients underwent surgical treatment for pancreatic adenocarcinoma. One hundred and sixty patients underwent a resection with a curative intention and 183 patients underwent bypass surgery for palliation. Follow-up was complete for 93% of patients. Median survival after resection and bypass was 17.0 and 7.5 months, and 5-year survival was 8% and 0, respectively. In multivariate analysis, tumour-positive lymph nodes, non-radical surgery, poor tumour differentiation, and tumour size were independent prognostic factors for survival after resection. For patients treated with bypass surgery, metastatic disease and tumour size independently predicted survival. In conclusion, actual survival of patients with pancreatic adenocarcinoma is disappointing compared with the actuarial survival rates reported in the literature. The independent prognostic factors for survival of patients who underwent surgical treatment for pancreatic adenocarcinoma are tumour-related.

Adenocarcinoma↗

PubMed2004

Limitation of diagnostic laparoscopy for patients with a periampullary carcinoma.

BACKGROUND: Diagnostic laparoscopy has been generally accepted in staging of patients with a periampullary malignancy. In our institution diagnostic laparoscopy was routinely used since 1992. However, in 1998 it was eliminated from the protocol since in a prospective study a yield of only 13% was found with a histologically proven accuracy of 60% for distant metastases. The effect of implementation of the new protocol on the occurrence of unnecessary laparotomies and the outcome after bypass surgery was assessed. METHODS: Between January 1999 and December 2001, 186 consecutive patients with a potentially resectable periampullary carcinoma after radiological staging without diagnostic laparoscopy underwent explorative laparotomy with the intention to perform a curative pancreatoduodenectomy. Incidence of unresectability and outcome of palliative surgery were assessed. RESULTS: Resection could not be performed in 65 patients who underwent laparotomy because of metastatic disease (29 patients) and loco-regional tumour ingrowth (34 patients). These patients underwent a bypass procedure with a median survival of 216 days. CONCLUSION: At laparotomy distant metastases were detected in 16% of the patients. Considering the fact that the detection rate of diagnostic laparoscopy is lower than 100%, the use of staging laparotomy is too limited to justify it as a routine procedure.

Adult↗

PubMed2004

Which children could benefit from additional diagnostic tools in case of suspected appendicitis?

BACKGROUND: New diagnostic tools such as ultrasound scan, computed tomography (CT) scan, and diagnostic laparoscopy, have become available for children with suspected appendicitis but should be reserved for equivocal cases. The aim of this study was to develop a scoring system to identify this subgroup of children. METHODS: Patients from 2 different periods (period 1, 99 consecutive children [group 1] and period 2, 62 consecutive children [group 2] with suspected appendicitis) were prospectively evaluated. Variables predicting appendicitis were obtained from group 1. By means of a regression analysis, a scoring system was created and applied to the patients of group 2. Missed appendicitis and negative appendectomy rates obtained by clinical practice were compared with the results that would have been accomplished based on the scoring system. Thereafter, the scoring system was externally validated in a group of children presented at another hospital (group 3, n = 114). RESULTS: The variables, leukocyte count > or = 10.10(9)/L (2 points); rebound tenderness (2 points); and temperature > or = 38 degrees C (1 point) correlated significantly with appendicitis. The scoring system was used to categorize patients into 3 groups: appendicitis unlikely, doubtful appendicitis, and suspected appendicitis. The specificity and sensitivity of the scoring system were, respectively, 85% and 89%. Applying the scoring system would lead to comparable negative appendectomy rates of 8% versus 6% using clinical judgement and a comparable number of performed laparoscopies (26% v 31%). However, it could lead to a lower missed appendicitis rate (1% v 6%) and a lower perforation rate (0% v 11%). External validation showed comparable performed laparoscopies (32%) and missed appendicitis (2%) rates but a higher negative appendectomy rate (19%), probably owing to a lower percentage of appendicitis in hospital (2, 47%) compared with hospital (1, 71%). CONCLUSIONS: Children can be observed if leukocyte count is less than 10.10(9)/L and rebound tenderness is absent; a diagnostic laparoscopy should be performed if one of these is present, and if both are present one could perform an appendectomy.

Abdominal Pain↗

PubMed2004

Surgical management of neoplasms of the ampulla of Vater: local resection or pancreatoduodenectomy and prognostic factors for survival.

BACKGROUND: Neoplasms of the ampulla of Vater have a better 5-year survival than pancreatic and bile duct neoplasms after resection. This study was performed to analyze the outcome after local resection and pancreatoduodenectomy (PD) and to identify predictive factors for survival. METHODS: We used a prospective database to evaluate 145 patients (1992-2002) with a neoplasm of the ampulla of Vater. RESULTS: The median age of the entire cohort was 66 years. Agreement between preoperative biopsies and definite resection specimen was 58% for invasive adenocarcinoma. Local resection was performed in 25 patients, but the operation was adequate therapy in only 16 patients (64%). Subsequent PD (n=9) was performed in the remaining patients because of an R1 resection. Other patients (n=120) underwent an elective PD. Hospital mortality was 4.0% (1/25) after local resection and 5.0% (6/120) after PD. Multivariate analysis revealed that advanced invasion and nodal status were independent predictive factors for survival. The overall 5-year actuarial survival of patients with adenocarcinoma after PD was 37%. CONCLUSIONS: Preoperative biopsies have a poor diagnostic accuracy. Local resection is an adequate surgical treatment for adenomas. In experienced hands, PD is the preferred treatment for patients with adenocarcinoma.

Actuarial Analysis↗

PubMed2004

Long-term outcomes and quality of life after laparoscopic adhesiolysis for chronic abdominal pain.

STUDY OBJECTIVE: To evaluate clinical outcome in terms of pain and quality of life after laparoscopic adhesiolysis. DESIGN: Prospective observational study (Canadian Task Force II-3). SETTING: University-affiliated medical center. PATIENTS: Twenty-three patients (22 women). INTERVENTION: Laparoscopic adhesiolysis for chronic abdominal pain. MEASUREMENTS AND MAIN RESULTS: Pain was assessed by validated McGill score. Patients with an intraindividual decrease in pain score of 5 points or more were considered successes. Quality of life was assessed by the SF-36 and gastrointestinal quality of life index. Patients were evaluated before and at intervals until 2 years after adhesiolysis. The mean pain score before adhesiolysis was 30.5 (range: 17-40). At 2 years of follow-up, 10 (45%) of 22 patients (95% CI 0.244-0.678) were considered successes. They reported significant improvement in quality of life on scales physical, role physical, and social function, and fewer gastrointestinal symptoms. Twelve women (55%) had a complete relapse, and most were not motivated to visit the pain clinic after 6 months. CONCLUSION: Laparoscopic adhesiolysis for chronic abdominal pain was successful in only 45% of patients.

Abdomen↗

PubMed2004

Restorative proctectomy after emergency laparoscopic colectomy for ulcerative colitis: a case-matched study.

OBJECTIVE: The aim of the study was to evaluate feasibility and safety of restorative proctectomy with ileal pouch anal anastomosis (IPAA) through a Pfannenstiel incision after prior laparoscopic colectomy. METHODS: Seventeen patients who underwent restorative proctectomy after laparoscopic emergency colectomy for ulcerative colitis (UC) were prospectively evaluated. Results were compared with results of a group of 21 case matched patients that had restorative proctectomy and IPAA via a midline incision in the same period. RESULTS: Median operation time was longer, although not significantly, in patients who had a restorative proctectomy through a pfannenstiel (186 min) compared to a restorative proctectomy through a midline incision (158 min). Procedure related complications were comparable between the groups, respectively, 1 of 17 patients in the pfannenstiel group and 3 of 21 patients in the median laparotomy group. Median hospital stay in the pfannenstiel group was 10 days and in the midline group 12 days. CONCLUSIONS: After laparoscopic assisted emergency colectomy for ulcerative colitis, restorative proctectomy is feasible and can be performed safely through a Pfannenstiel incision.

Adult↗

PubMed2004

Diagnostic laparoscopy for primary and secondary liver malignancies: impact of improved imaging and changed criteria for resection.

BACKGROUND: Diagnostic laparoscopy (DL) combined with laparoscopic ultrasonography (LUS) has previously shown positive results as a staging modality for liver malignancies. Recent improvements in noninvasive diagnostic imaging techniques such as multiphasic spiral computed tomography, together with the policy that bilobar disease or the number of lesions is no longer considered an absolute exclusion criterion for curative resection, could reduce the additional value of DL. This study retrospectively analyzed the efficacy of DL combined with LUS for liver malignancies to assess the effect of improved imaging and changed criteria for resection. METHODS: All patients with primary or metachronous secondary liver malignancy eligible for resection in 1997 to 2002 were included. RESULTS: DL combined with LUS was performed in 84 consecutive patients (56 men and 28 women; mean age, 59 years) with primary (n = 33) or secondary (n = 51) liver malignancies. DL showed unresectability in 13 patients (39%) with primary malignancy. Exploratory laparotomy showed that an additional 5 (25%) of the remaining 20 patients had unresectable disease. DL showed unresectability in 5 patients (12%) with colorectal liver metastasis (n = 43). At laparotomy, another 7 (18%) of the remaining 38 patients had unresectable disease. In five patients (13%) from the latter group, LUS could not be performed because of adhesions from previous surgery. CONCLUSIONS: DL combined with LUS is an adequate staging modality for primary liver malignancies. For colorectal liver metastasis, more liberal resection criteria, a high failure rate due to adhesions from previous surgery, and better preoperative imaging probably resulted in a lower efficacy.

Aged↗

PubMed2004

Surgical palliation in pancreatic cancer.

The prognosis of patients with pancreatic carcinoma is poor. At the time of diagnosis, approximately 80% of patients are found to have an unresectable tumour, because of local spread or metastatic disease. Therefore, most patients will undergo palliative treatment, which is aimed at the improvement of the quality of life and the prevention of symptoms. The most important symptoms which are associated with advanced pancreatic cancer are pain, obstructive jaundice and gastric outlet obstruction. Controversy remains on the question whether these symptoms should be treated surgically or non-surgically. This review describes the best evidence (if possible randomised controlled trials) in recent literature on the palliation of most important symptoms and focuses on surgical palliative treatment options.

Abdominal Pain↗

PubMed2003

Inter- and intraindividual variabilities of perforation forces of human and pig bowel tissue.

BACKGROUND: A laparoscopic bowel grasper should be suitable for safely grasping the bowel in a wide variety of patients. Therefore, the inter- and intraindividual variabilities in the strength of bowel tissue to resist perforation force should be analyzed. METHODS: The large and small bowels of pigs ( n = 14) and the human small bowel ( n = 7) were clamped between two hemispheres 1.5 mm in diameter. The pinch force was increased until the tissue was perforated. RESULTS: The perforation force for the pig large bowel was higher than for the small bowel (13.5 +/- 3.7 vs 11.0 +/- 2.5 N; p = 0.014). No difference was found between the human and pig small bowel (10.3 +/- 2.9 vs 11.0 +/- 2.5 N). The intercoefficient of variation varied between 22% and 28%, and the intracoefficient of variation varied between 14% and 18%. CONCLUSIONS: The strength of the pig bowel is approximately comparable to the strength of the human bowel, and, therefore, testing of graspers on pig bowel is justified. However, due to the large interindividual variation, large safety margins should be taken into account.

Adult↗

PubMed2003

Experimental model of obstructive, chronic pancreatitis in pigs.

BACKGROUND: We aimed to develop a reproducible, experimental model of obstructive pancreatitis for future analysis of surgical interventions, and characterized this model using functional, histological and biochemical parameters. ANIMALS AND METHODS: In 10 female pigs the pancreatic duct (PD) was ligated. After 4, 6 or 8 weeks the animals were sacrificed. Before and after ligation, glucose tolerance and intraductal pressure were measured, and pancreatic juice was collected after stimulation with cholecystokinin and secretin. Amylase and lipase activities were analyzed in plasma and juice. Pancreatic tissue was collected for histochemical analysis. RESULTS: Within 4 weeks of ligation, the pancreas appeared atrophic. Intraductal pressure had risen significantly. Acinar-to-ductal metaplasia was accompanied by strong proliferation of stellate cells and increased collagen deposition. Islets of Langerhans appeared smaller and more numerous. Blood amylase and lipase levels were normal and glucose tolerance was unaffected. Pancreatic juice volume and amylase and lipase activities were significantly lower. CONCLUSION: Ligation of the PD in pigs resulted in a marked fibrosing obstructive pancreatitis within 4 weeks, similar to human chronic pancreatitis in regard to clinical, functional, histological and biochemical parameters.

Animals↗

PubMed2003

[Pleural fluid in chronic pancreatitis].

In three patients, a 44-year-old schizophrenic woman and two men aged 54 and 42, who presented with dyspnoea, a pancreaticopleural fistula was diagnosed as a complication of pancreatitis, i.e. a fistulous tract between the pancreas and the pleural cavity. In general, these fistulas have a good prognosis; however, delay in finding the correct diagnosis influences the prognosis. This is often due to unfamiliarity with the disease and the non-specific presentation of patients with pleural effusion. The initial presentation usually comprises respiratory (dyspnoea, coughing due to pleural effusion) and occasional abdominal symptoms (epigastric pain). A definitive diagnosis is made when elevated pleural effusion amylase levels are demonstrated. Surgical treatment is only indicated if conservative or endoscopic treatment fails, and consists of resection of the fistula and drainage of the pancreatic duct via a lateral pancreaticojejunostomy or resection of the part of the pancreas where the fistula originates. In the first patient, surgical drainage of the fluid accumulation was applied, but she died of aspiration pneumonia after she had removed the feeding tube and had refused further treatment. Pancreatic resection resulted in recovery in the two men.

Adult↗

PubMed2003

[The registration of complications of medical treatment].

The National Surgical Adverse Event Registration (LHCR) software has been fully implemented in 25 (18.7%) departments of surgery in the Netherlands. This is a relatively low percentage considering that 92.5% of all hospitals are already using a local registration system for complications. Software difficulties in creating a link between the LHCR and local systems is suggested to be the main impeding factor. There are still a number of questions, notably concerning the validity of the system for registration of all complications versus a selected group of (severe) complications, the issue of the implications of the registration system in terms of quality control and subsequent regulation or centralization of procedures, and the importance for other specialists, in particular those performing invasive procedures, to introduce a complication registration system to establish a quality control system in those areas as well.

General Surgery↗

PubMed2003

The effect of suprapubic catheterization versus transurethral catheterization after abdominal surgery on urinary tract infection: a randomized controlled trial.

BACKGROUND/AIM: Transurethral catheterization is generally associated with a higher incidence of urinary tract infections than suprapubic catheterization; however, suprapubic catheterization is associated with other disadvantages such as higher costs and a more difficult technique, and at the moment there is no consensus about the use of both catheter systems. Therefore, a prospective randomized study was performed to investigate the effects of suprapubic catheterization and transurethral catheterization in patients undergoing surgery on the incidence of urinary tract infections and patient satisfaction. METHODS: Patients who underwent an elective laparotomy were randomized and received a suprapubic or transurethral catheter. The primary end point was urinary tract infection. Other parameters of urinary tract infection, as well as duration of catheterization, hospital stay, and number of recatheterizations and of relaparotomies were monitored. Treatment 'per protocol' was also analyzed after exclusion of patients receiving another catheter than randomized for. Patients were asked for their satisfaction with the catheters and complaints during and after catheterization. RESULTS: 165 patients were eligible, of whom 19 patients had to be excluded. 75 patients were allocated to receive the suprapubic catheter and 71 the transurethral catheter. There was no difference in the incidence of a urinary tract infection between the suprapubic group (n = 9/75; 12%) and the transurethral group (n = 8/71; 11%). Most patients (6/9) who developed a urinary tract infection in the suprapubic group, however, underwent recatheterization because of postoperative complications/sepsis and relaparotomy. The incidence of urinary tract infections in patients who received a suprapubic catheter and not a transurethral catheter was 3/59 (5%). The patients did not differ with respect to satisfaction and complaints. Being a men, recatheterization and duration of catheterization are risk factors. CONCLUSIONS: The incidence of a urinary tract infection between a suprapubic catheter and a transurethral catheter in patients undergoing major surgery was not different. A potential advantage of the suprapubic catheter (reduction of urinary tract infections) is probably partly negated, because transurethral catheters were used if recatheterization was indicated during the postoperative stay or due to complications.

Adult↗

PubMed2003

[Laparoscopic cholecystectomy in day care; implementation of a guideline for clinical practice].

OBJECTIVE: To evaluate the extent to which the guideline to perform laparoscopic cholecystectomy in day care was followed in the institute where the guideline was developed and in the other hospitals in the Netherlands. DESIGN: Retrospective, descriptive. METHOD: For the patients who underwent a laparoscopic cholecystectomy in the Amsterdam University Medical Centre (AMC) during the period 1 January 1998-31 December 2000, data were collected from medical records on how the intervention was performed: in day care or during a hospital admission. The national figures were obtained from SIG Zorginformatie in Utrecht. RESULTS: A total of 262 patients underwent a laparoscopic cholecystectomy at the AMC: 60 men and 202 women, with an average age of 43 years (range: 2-86). A total of 163 (62%) patients were eligible for treatment in day care. Laparoscopic cholecystectomy was performed in day care in the years 1998, 1999 and 2000 in 80%, 92% and 93% of patients respectively (n = 144). Of these 144 patients, 129 (90%) were discharged to home the same day. For the same years, these figures for the whole of the Netherlands were 0.8%, 1.3% and 1.7% respectively. CONCLUSION: The clinical guideline for performing laparoscopic cholecystectomy in day care has been implemented to a large extent in the AMC but has scarcely been implemented at the national level. At the AMC, day care treatment could be carried out for 90% of the patients for whom this had been planned.

Adolescent↗