Biomedical subjects
Publications and source records attributed to P M Go.
This technical note describes the use of dynamic MRI in the diagnosis of groin herniations. A review of the anatomy of the groin is presented and 4 representative cases are described. This paper indicates that dynamic MRI can be used to confirm the diagnosis in patients with clinically evident groin herniations.
A cost-effectiveness (CE) analysis was performed of Bassini versus laparoscopic repair for primary inguinal hernia. Incremental costs per 1-year recurrence-free patient were calculated for the societal and hospital perspective. From the hospital perspective, the incremental CE ratio of laparoscopic repair is 5.348 guilders. From the societal perspective, laparoscopic repair is both less costly and more effective than Bassini repair. Results were sensitive to assumptions about recurrence rates, laparoscopic operating time, and return to work. Laparoscopic repair should replace Bassini repair in order to benefit society. From the hospital perspective, the decision to accept laparoscopic repair depends on the willingness to pay.
OBJECTIVE: To compare the effectiveness of open and laparoscopic primary inguinal hernia repair. DESIGN: Randomised controlled trial. SETTING: University hospital, The Netherlands. SUBJECTS: 87 patients had 103 open repairs and 88 patients had 114 laparoscopic repairs between November 1993 and July 1995. INTERVENTIONS: Laparoscopic repair by the transabdominal preperitoneal (TAPP) technique and open repair by the Bassini technique. MAIN OUTCOME MEASURES: Recurrence, morbidity, pain, and duration of convalescence. RESULTS: Operating time was longer for laparoscopy (mean (SD): 82 (28) compared with 45 (15) minutes p < 0.001). Patients in the Bassini group had higher postoperative pain scores (mean (SD)VAS: 2.9 (1.6) compared with 2.0 (1.6) p=0.002), used more analgesics (median total intake: 2 (0-54) compared with 0 tablets (0-42) p=0.008), and needed a longer convalescence time (mean (SD) time to return to work: 22 (12.6) compared with 14 (10.1) days p < 0.001; mean (SD) time to return to physical activities: 27 (12.6) compared with 17 (12.2) days p < 0.001). Mean follow up was 24 months. Recurrence rates were 21% (22/ 103) after Bassini and 6% (7/114) after laparoscopic repair (p=0.001). CONCLUSION: Laparoscopic hernia repair is a safe operation, which has obvious advantages over the Bassini repair in terms of pain, use of analgesic drugs, resumption of activities, and recurrence. A disadvantage of the laparoscopic repair is the longer operating time.
There are more than 20 randomized trials that compare laparoscopic with open hernia repair. Results of these show a longer operating time, less postoperative pain, a faster return to normal activity, and increased costs for laparoscopic over open hernia repair. Recurrence rates are lower for laparoscopic compared with open nonmesh repairs.
Explore the source record for details and available documents.
Laparoscopic cholecystectomy began to gain ground in the late eighties. The smaller incision led to less postoperative pain and faster recovery. By now, the method has become a matter of controversy: the laparoscopic operation took more time than the 'minilaparotomy'. This criticism can be refuted: laparoscopy gives faster recovery than the conventional large incision and a better view than the 'minilaparotomy'.
RATIONALE AND OBJECTIVES: The authors determine the feasibility of dynamic magnetic resonance (MR) imaging in the diagnosis of groin hernia. METHODS: Ten volunteers and 10 patients with clinically evident and surgically proven herniations were evaluated using T1-, and T2-weighted sequences and two dynamic sequences. The visibility of anatomic structures that are crucial for the assessment and the differentiation of inguinofemoral herniations was evaluated. RESULTS: The inguinal rings could be identified in all subjects. The inferior epigastric vessels could be identified in 85%. In 10 patients, 11 hernias were found at MR imaging, whereas at surgery and physical examination 13 herniations were diagnosed (84.6%). The two hernias that were missed initially could be identified retrospectively on MR imaging. One volunteer showed a small bilateral inguinal hernia on MR imaging that could be confirmed on physical examination. CONCLUSIONS: The anatomic structures that are crucial for the assessment and the differentiation of inguinofemoral herniations can be identified prospectively with MR imaging.
BACKGROUND: Shouldice repair for primary inguinal hernia is reported to have better results than classic Bassini-type repairs. The indirect inguinal hernia with a firm posterior wall is often assumed to be adequately treated by high ligation and ring narrowing. STUDY DESIGN: This double randomized controlled trial compared high ligation and ring narrowing with Bassini-Stetten repair for the indirect inguinal hernia with a firm posterior wall, and Shouldice with Bassini-Stetten repair for the inguinal hernia with a weakened posterior wall, direct or indirect. This report focuses on longterm (12-15 years) recurrence rates. RESULTS: From July 1980 to May 1983, 102 indirect primary inguinal hernias with a firm posterior wall (group I) and 263 primary inguinal hernias with a weakened posterior wall (group II) were included. By 1995, 89 patients with 100 hernia repairs had died, and for 30 repairs the patients could not be located. In 41 hernia repairs, a recurrence had been established previously. Of the remaining 194 hernia repairs, followup was updated by physical examination in 179 (92%) and by telephone interview in 15 (8%). A total of 83 recurrences were recorded, 42% of which were asymptomatic at the time of diagnosis. Seventy-three percent of the recurrences happened > 2 years after the operation. The life-table method showed the following longterm (12-15 years) recurrence rates: group I, Bassini-Stetten 33% versus ring narrowing 34%; group II, Bassini-Stetten 32% versus Shouldice 15% (p = 0.033). CONCLUSIONS: The Shouldice is the best type of hernia repair, although the 15% recurrence rate is high. Bassini-Stetten and high ligation with ring narrowing are inadequate repairs, regardless of the type of hernia.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
The diffusion of six surgical endoscopic procedures in the Netherlands was investigated. Questionnaires were sent to 138 laparoscopic surgeons. They were asked which of the following laparoscopic procedures they had adopted in their hospital: cholecystectomy, appendicectomy, Nissen fundoplication, inguinal hernia repair, large bowel resection and thoracoscopic procedures. Furthermore, they were asked to indicate the influence of 13 pre-defined factors: "budget', "competition', "conference', "extra benefit', "media', "nature of the technology', "patient demand', "planning/logistics', "reimbursement', "service industry', "support industry', "surgical technique' and "training/course' on the adoption of those procedures. The adoption rates for the procedures were: 100%, 69%, 19%, 43%, 19% and 52%, respectively. In general, factors were assessed more positively by adopters than by non-adopters. Significant differences were mainly found for "extra benefit', "nature of the technology', "surgical technique' and "conference'. The surgeon's perception of the additional benefits of an endoscopic technique and, to a lesser degree, of its technical aspects were the most important factors in deciding whether or not to adopt a procedure. In an ideal diffusion model, a description is given of when and how the 13 factors can influence the diffusion of an endoscopic procedure in the desired direction. In this model, the extra benefit of a new procedure must be proven before other factors are allowed to influence the diffusion.
BACKGROUND & AIMS: Ursodeoxycholic acid prevents gallstone formation in selected patients. The aim of this study was to examine whether decreased concentration and nucleation-promoting activity of various proteins contribute to this beneficial effect. METHODS: Gallbladder bile of 13 patients with cholesterol gallstones treated with ursodeoxycholic acid (10 mg/kg(-1)/day(-1)) and of 13 untreated patients were compared. RESULTS: Total protein concentration in gallbladder bile (2.8 +/- 0.6 vs. 6.7 +/- 1.3 mg/mL; P=0.008) and concanavalin A-binding fraction (0.16 +/- 0.03 vs. 0.42 +/- 0.07 mg/mL; P=0.003) were strongly decreased by ursodeoxycholic acid therapy. Significant decreases were also found for gallbladder bile alpha1-acid glycoprotein, haptoglobin, immunoglobulin (Ig) A, IgG, gamma-glutamyl transpeptidase, and aminopeptidase N but not for IgM, mucin, or beta-glucuronidase. Decreases were most pronounced for proteins of canalicular membrane origin. Gallbladder bile total protein correlated with cholesterol saturation index (r=0.54; P=0.0047) but not with bile salt hydrophobicity index. Crystallization-promoting activity of the concanavalin A-binding fraction (assessed by nephelometry and microscopic examination) was also significantly decreased by ursodeoxycholic acid. CONCLUSIONS: Ursodeoxycholic acid strongly decreases levels of various proteins and nucleation-promoting activity in bile.
BACKGROUND: For a significant number of patients with severe or refractory gastroesophageal reflux disease, maintenance treatment with omeprazole and reflux surgery (Nissen fundoplication) are alternative treatment options. In this study maintenance treatment with omeprazole is compared with open and laparoscopic Nissen fundoplication from a health-economic perspective. METHODS: Meta-analysis of published articles to assess effectiveness and simple decision-analytic techniques to combine costs and effects are used. Findings and assumptions are submitted to sensitivity analysis. RESULTS: It is estimated that it costs approximately 1880 Dutch guilders to initially heal a patient with severe or refractory esophagitis with 40 mg omeprazole daily. When medical maintenance therapy was compared with surgery, it appeared that medical maintenance therapy with omeprazole (20-40 mg daily) for a prolonged period of time (more than 4 years) is less cost effective than a Nissen procedure. It is estimated that a laparoscopic Nissen will shift this so-called break-even point towards 1.4 years, mainly due to a shorter hospital stay. CONCLUSIONS: Although caution is required in drawing conclusions, it appears that replacing treatment with (laparoscopic) Nissen fundoplications in these patients might lead to substantial savings.
The results of recurrent inguinal hernia repair in a prospective cohort study were evaluated. From May 1986 to December 1990 75 patients with 150 hernias (24 primary, 126 recurrent) were operated using a technique based on Stoppa's preperitoneal mesh repair (giant prosthetic reinforcement of the visceral sac; GPRVS). All patients were at high risk for recurrence: they all had bilateral hernias, mostly bilateral recurrent and often repeatedly recurrent. All patients had a physical examination 1 week, 6 weeks and 1 year after operation. Sixty patients (94 per cent of surviving patients) had a physical examination after a mean follow-up of 5.7 (range 4-9) years. There were no major complications. There was one deep infection that healed without removing the mesh. One of the 75 patients (1 per cent) had a recurrence 2 months after the operation, due to a technical failure. Because of the excellent results, the ease of the procedure and the low complication rate, GPRVS is the authors' operation of choice for any recurrent inguinal hernia.
OBJECTIVES: To compare the foreign body reaction of the monofilament polypropylene (Prolene) mesh, and the multifilament Surgipro mesh. Both types of mesh are widely used in laparoscopic inguinal hernia repair. DESIGN: Prospective experimental study. SETTING: University hospital, The Netherlands. MATERIAL: Six female Yorkshire & Dutch landway pigs. INTERVENTION: Laparoscopic transabdominal implantation of six Surgipro meshes and six Prolene meshes in 12 inguinal sites. MAIN OUTCOME MEASURES: At 3, 6, and 12 weeks after implantation the foreign body reaction was measured by counting multinucleated giant cells at the mesh-tissue interface. RESULTS: At all times the numbers of multinucleated giant cells at the mesh tissue interface were significantly larger with Surgipro than with Prolene (p < 0.001). CONCLUSIONS: There is significantly more foreign body reaction after implantation of Surgipro than Prolene mesh.
In order to strike the most favorable balance between health benefits and costs, three treatment modalities for symptomatic cholelithiasis were compared in a cost-effectiveness study: extracorporeal shock-wave lithotripsy (ESWL), conventional cholecystectomy (CC), and laparoscopic cholecystectomy (LC). Data were analyzed from 55 patients who were treated by ESWL, 45 patients who had CC, and 47 patients who had LC. The study was performed by analysis of patients charts and a written questionnaire. After ESWL 35% of the patients were free of stones, 23% had fragments < or = 5 mm, and 42% had fragments > 5 mm at 1-year follow-up. Persistent complaints were reported by 59% after ESWL, 11% after CC, and 14% after LC (P < 0.001). New complaints arose in 12% after ESWL, 11% after CC, and in 5% after LC (P = NS). Patient appreciation score was highest for LC and lowest for ESWL. Mean hospital stay was 2.4 days for ESWL, 10 days for CC, and 3.5 days for LC. Overall costs of treatment were: $5,066 for ESWL; $5,893 for CC; and $3,117 for LC. This study reveals that laparoscopic cholecystectomy is the most effective treatment of the large majority of patients with symptomatic cholelithiasis. ESWL should only be considered in the case of a solitary, relatively small, completely radiolucent stone.
Forty-nine bile duct injuries, representing 0.8 per cent of 6076 laparoscopic cholecystectomies performed in the Netherlands in 1990-1992, were reviewed. The aim of the study was to classify the injuries according to severity, to identify possible risk factors contributing to the aetiology of such injuries and to correlate these with the severity of the injury. On the basis of operative findings, bile duct injuries were classified from minor (classes I-IIIa) to extensive with loss of bile duct tissue (IIIb) or localization in the liver hilum (IV). Of 49 injuries, there were 11 in class I, six in class II, ten in class IIIa, 18 in class IIIb and four in class IV. In 16 patients the injury was detected during laparoscopic cholecystectomy and the procedure converted to laparotomy. The duct injury was minor (class I-IIIa) in 14 of these 16 patients. In 20 of the 33 patients in whom identification of the injury was delayed to a second or third operation, more severe types of injury (classes IIIb and IV) were observed. Delayed detection was associated with greater severity (P = 0.002). Of eight patients with histologically proven acute cholecystitis at cholecystectomy, seven suffered severe injury (class IIIb or IV). Surgical experience with laparoscopic cholecystectomy was an important factor in the incidence of bile duct injury.