C.J.H.M. van Laarhoven

Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm.

Objective: Boerhaave’s syndrome is a spontaneous rupture of the oesophagus with a lack of diagnostic and treatment consistency in the literature. Therefore, we reviewed all published literature in order to design a treatment algorithm based on the literature. Study Design: A systematic literature review written in the English language since 1975. Results: We reviewed all known literature. Treatment of the Boerhaave syndrome was divided into three categories: conservative, endoscopic and surgical approach. The survival rate of all treatments was 75, 100 and 81%, respectively. Conclusion: Boerhaave’s syndrome should be treated endoscopically when diagnosed within 48 h and when there are no signs of sepsis. However, when a patient is diagnosed within 48 h and has a septic profile, thoracotomy with hemifundoplication and pleural/mediastinal drainage should be performed; and in case of intra-abdominal leakage, a laparotomy for local repair should be performed. When a patient is diagnosed after 48 h, conservative treatment should be followed and only when a patient gets a septic profile is surgical treatment indicated.

Sexual function and continence after ileo pouch anal anastomosis: a comparison between a meta-analysis and a questionnaire survey

Background and aimsIleo pouch anal anastomosis (IPAA) is the standard restorative procedure for patients with ulcerative colitis and familial adenomatous polyposis, but its pros and cons have not been explored in depth. This study analyzed the long-term complications such as incontinence and sexual dysfunction after IPAA.Patients and methodsNetherlands Society for Crohn’s disease and Ulcerative Colitis) A questionnaire on complications, sexual dysfunction, and continence was sent to all 137 members of the Netherlands Society for Crohn’s disease and Ulcerative Colitis who had IPAA; the questionnaire was returned by 111. Results of the questionnaire were compared with those of a meta-analysis on pooled incidences of complications after IPAA, as previously performed and reported.ResultsPelvic sepsis was reported by 15.3% of respondents. The reported incidence of sexual dysfunction (19.8%), passive incontinence (23.4%), and soiling (39.3%) was significantly higher than that in the meta-analysis. Nevertheless, 90% of the population was satisfied with the results of the IPAA.ConclusionThis study underlines that the operation itself, freeing patients of their disease, provides the major satisfaction and improvement of quality of life, even when patients have pouch-related complications such as sexual dysfunction and some degree of fecal incontinence.

Robustness assessments are needed to reduce bias in meta-analyses that include zero-event randomized trials.

OBJECTIVES:Meta-analysis of randomized trials with binary data can use a variety of statistical methods. Zero-event trials may create analytic problems. We explored how different methods may impact inferences from meta-analyses containing zero-event trials.METHODS:Five levels of statistical methods are identified for meta-analysis with zero-event trials, leading to numerous data analyses. We used the binary outcomes from our Cochrane review of randomized trials of laparoscopic vs. small-incision cholecystectomy for patients with symptomatic cholecystolithiasis to illustrate the influence of statistical method on inference.RESULTS:In seven meta-analyses of seven outcomes from 15 trials, there were zero-event trials in 0 to 71.4% of the trials. We found inconsistency in significance in one of seven outcomes (14%; 95% confidence limit 0.4%–57.9%). There was also considerable variability in the confidence limits, the intervention-effect estimates, and heterogeneity for all outcomes.CONCLUSIONS:The statistical method may influence the inference drawn from a meta-analysis that includes zero-event trials. Robustness assessments are needed to reduce bias in meta-analyses that include zero-event trials.

POSTOPERATIVE TREATMENT OF INTERNALLY FIXED ANKLE FRACTURES: A PROSPECTIVE RANDOMISED STUDY

In a prospective, randomised trial of 81 patients with fractures of the ankle of AO types A, B and C we compared two regimes of postoperative management after internal fixation. The patients were mobilised either non-weight-bearing with crutches or weight-bearing in a below-knee walking plaster. We found a temporary benefit in subjective evaluation only (65 v 50 points, Mann-Whitney test, cft, p=0.02) for those with a below-knee walking plaster. There were no significant differences between the groups in the loaded dorsal range of movement (25 degrees v 23 degrees, Mann-Whitney test, cft, p = 0.16) or in the overall clinical result. Both treatments were considered to be satisfactory and their choice depends on the ability to mobilise non-weight-bearing, wound healing, the type of work and personal preference.

Quality of life, health-related quality of life and health status in patients having restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a systematic review

Aim  There are numerous studies on quality of life (QoL), health‐related quality of life (HRQoL), and health status (HS) in patients undergoing surgery for ulcerative colitis. A systematic review of published literature was conducted to establish the quality of these studies and to determine QoL, HRQoL, and HS in patients after ileal pouch‐anal anastomosis for ulcerative colitis.

Randomized clinical trial of chronic pain after the transinguinal preperitoneal technique compared with Lichtenstein's method for inguinal hernia repair

Preliminary experience has suggested that preperitoneal mesh positioning causes less chronic pain than Lichtensteins technique for inguinal hernia repair. Therefore, a randomized clinical trial was conducted with the aim of evaluating the incidence of postoperative chronic pain after transinguinal preperitoneal (TIPP) mesh repair versus Lichtensteins technique.

EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones

Gallstones or cholelithiasis are a major public health problem in Europe and other developed countries and affect up to 20% of the population. Gallstone disease is the most common gastrointestinal disorder for which patients are admitted to hospitals in European countries [1]. The interdisciplinary care for patients with gallstone disease has advanced considerably during recent decades thanks to a growing insight into the pathophysiological mechanisms and remarkable technical developments in endoscopic and surgical procedures. In contrast, primary prevention for this common disease is still in its infancy. The EASL Clinical Practice Guidelines (CPG) on the prevention, diagnosis and therapy of gallstones aim to provide current recommendations on the following issues:

The totally extraperitoneal method versus Lichtenstein's technique for inguinal hernia repair: a systematic review with meta-analyses and trial sequential analyses of randomized clinical trials.

Background Lichtensteins technique is considered the reference technique for inguinal hernia repair. Recent trials suggest that the totally extraperitoneal (TEP) technique may lead to reduced proportions of chronic pain. A systematic review evaluating the benefits and harms of the TEP compared with Lichtensteins technique is needed. Methodology/Principal Findings The review was performed according to the ‘Cochrane Handbook for Systematic Reviews’. Searches were conducted until January 2012. Patients with primary uni- or bilateral inguinal hernias were included. Only trials randomising patients to TEP and Lichtenstein were included. Bias evaluation and trial sequential analysis (TSA) were performed. The error matrix was constructed to minimise the risk of systematic and random errors. Thirteen trials randomized 5404 patients. There was no significant effect of the TEP compared with the Lichtenstein on the number of patients with chronic pain in a random-effects model risk ratio (RR 0.80; 95% confidence interval (CI) 0.61 to 1.04; p = 0.09). There was also no significant effect on number of patients with recurrences in a random-effects model (RR 1.41; 95% CI 0.72 to 2.78; p = 0.32) and the TEP technique may or may not be associated with less severe adverse events (random-effects model RR 0.91; 95% CI 0.73 to 1.12; p = 0.37). TSA showed that the required information size was far from being reached for patient important outcomes. Conclusions/Significance TEP versus Lichtenstein for inguinal hernia repair has been evaluated by 13 trials with high risk of bias. The review with meta-analyses, TSA and error matrix approach shows no conclusive evidence of a difference between TEP and Lichtenstein on the primary outcomes chronic pain, recurrences, and severe adverse events.

Quality of life and health status before and after ileal pouch-anal anastomosis for ulcerative colitis.

Ileal pouch–anal anastomosis (IPAA) is considered the surgical treatment of choice for patients with ulcerative colitis. Quality of life (QoL) and health status are the most important patient‐related outcomes. Studies investigating QoL are often cross‐sectional and focus on health status. This longitudinal study evaluated QoL and health status after IPAA for ulcerative colitis and compared these with reference data from a healthy population.

Deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery: a systematic review and meta-analysis

Neuromuscular block (NMB) is frequently used in abdominal surgery to improve surgical conditions by relaxation of the abdominal wall and prevention of sudden muscle contractions. The evidence supporting routine use of deep NMB is still under debate. We aimed to provide evidence for the superiority of routine use of deep NMB during laparoscopic surgery. We performed a systematic review and meta-analysis of studies comparing the influence of deep vs moderate NMB during laparoscopic procedures on surgical space conditions and clinical outcomes. Trials were identified from Medline, Embase, and Central databases from inception to December 2016. We included randomized trials, crossover studies, and cohort studies. Our search yielded 12 studies on the effect of deep NMB on the surgical space conditions. Deep NMB during laparoscopic surgeries improves the surgical space conditions when compared with moderate NMB, with a mean difference of 0.65 (95% confidence interval (CI): 0.47-0.83) on a scale of 1-5, and it facilitates the use of low-pressure pneumoperitoneum. Furthermore, deep NMB reduces postoperative pain scores in the postanaesthesia care unit, with a mean difference of - 0.52 (95% CI: -0.71 to - 0.32). Deep NMB improves surgical space conditions during laparoscopic surgery and reduces postoperative pain scores in the postanaesthesia care unit. Whether this leads to fewer intraoperative complications, an improved quality of recovery, or both after laparoscopic surgery should be pursued in future studies. The review methodology was specified in advance and registered at Prospero on July 27, 2016, registration number CRD42016042144.