Johan Lange

An international consensus algorithm for management of chronic postoperative inguinal pain

PurposeTension-free mesh repair of inguinal hernia has led to uniformly low recurrence rates. Morbidity associated with this operation is mainly related to chronic pain. No consensus guidelines exist for the management of this condition. The goal of this study is to design an expert-based algorithm for diagnostic and therapeutic management of chronic inguinal postoperative pain (CPIP).MethodsA group of surgeons considered experts on inguinal hernia surgery was solicited to develop the algorithm. Consensus regarding each step of an algorithm proposed by the authors was sought by means of the Delphi method leading to a revised expert-based algorithm.ResultsWith the input of 28 international experts, an algorithm for a stepwise approach for management of CPIP was created. 26 participants accepted the final algorithm as a consensus model. One participant could not agree with the final concept. One expert did not respond during the final phase.ConclusionThere is a need for guidelines with regard to management of CPIP. This algorithm can serve as a guide with regard to the diagnosis, management, and treatment of these patients and improve clinical outcomes. If an expectative phase of a few months has passed without any amelioration of CPIP, a multidisciplinary approach is indicated and a pain management team should be consulted. Pharmacologic, behavioral, and interventional modalities including nerve blocks are essential. If conservative measures fail and surgery is considered, triple neurectomy, correction for recurrence with or without neurectomy, and meshoma removal if indicated should be performed. Surgeons less experienced with remedial operations for CPIP should not hesitate to refer their patients to dedicated hernia surgeons.

Multimodal treatment of perianal fistulas in Crohn’s disease: seton versus anti-TNF versus advancement plasty (PISA): study protocol for a randomized controlled trial

BackgroundCurrently there is no guideline for the treatment of patients with Crohn’s disease and high perianal fistulas. Most patients receive anti-TNF medication, but no long-term results of this expensive medication have been described, nor has its efficiency been compared to surgical strategies. With this study, we hope to provide treatment consensus for daily clinical practice with reduction in costs.Methods/DesignThis is a multicentre, randomized controlled trial. Patients with Crohn’s disease who are over 18 years of age, with newly diagnosed or recurrent active high perianal fistulas, with one internal opening and no anti-TNF usage in the past three months will be considered. Patients with proctitis, recto-vaginal fistulas or anal stenosis will be excluded. Prior to randomisation, an MRI and ileocolonoscopy are required. All treatment will start with seton placement and a course of antibiotics. Patients will then be randomised to: (1) chronic seton drainage (with oral 6-mercaptopurine (6MP)) for one year, (2) anti-TNF medication (with 6MP) for one year (seton removal after six weeks) or (3) advancement plasty after eight weeks of seton drainage (under four months anti-TNF and 6MP for one year). The primary outcome parameter is the number of patients needing fistula-related re-intervention(s). Secondary outcomes are the number of patients with closed fistulas (based on an evaluated MRI score) after 18 months, disease activity, quality of life and costs.DiscussionThe PISA trial is a multicentre, randomised controlled trial of patients with Crohn’s disease and high perianal fistulas. With the comparison of three generally accepted treatment strategies, we will be able to comment on the efficiency of the various treatment strategies, with respect to several long-term outcome parameters.Trial registrationNederlands Trial Register identifier: NTR4137 (registered on 23 August 2013).

Algorithmic Approach to the Workup and Management of Chronic Postoperative Inguinal Pain

Tension-free mesh repair of inguinal hernia has led to uniformly low recurrence rates. Morbidity associated with this operation is mainly related to chronic pain. No consensus guidelines exist for the management of this condition. A group of surgeons considered experts on inguinal hernia surgery was solicited to develop the algorithm. This algorithm can serve as a guide with regard to the diagnosis, management, and treatment of these patients and improve clinical outcomes. If an expectative phase of a few months has passed without any amelioration of chronic postoperative inguinal pain (CPIP), a multidisciplinary approach is indicated and a pain management team should be consulted. Pharmacologic, behavioral, and interventional modalities including nerve blocks are essential. If conservative measures fail and surgery is considered, triple neurectomy, correction for recurrence with or without neurectomy, and meshoma removal if indicated should be performed. Surgeons less experienced with remedial operations for CPIP should not hesitate to refer their patients to dedicated hernia surgeons.

The Multidisciplinary Management of Acute Complicated Diverticulitis

Background: Acute complicated diverticulitis (ACD) is an important and increasing issue in Western countries that leads to a significant impact and burden for patients, but also for the society due to its effects on hospital costs. In recent years, essential progression has been made regarding the research and implementation of novel or improved treatment strategies for the various disease entities of ACD. Much debated topics in the multidisciplinary approach of patients with ACD, such as the choice for nonoperative treatment options, the role of percutaneous drainage for diverticular abscesses, the role of laparoscopic lavage for perforated diverticulitis with purulent peritonitis, and the role of sigmoidectomy with primary anastomosis for patients with perforated diverticulitis, require clinicians to attentively follow and participate in these discussions. Summary: The aim of this review article is to provide clinicians with a structured overview of the recent literature on the multidisciplinary management of complicated diverticulitis by a panel of experts on the topic. By performing an extensive literature search in the online medical databases MEDLINE (Ovid) and Embase, insights into nonoperative treatment, percutaneous drainage, minimally invasive and open surgical treatment of ACD are provided. Furthermore, a comprehensive algorithm for the treatment of ACD has been developed. Key Messages: Accurate patient evaluation and selection based on patient and disease characteristics is of paramount importance to determine the appropriate treatment strategy for patients with complicated diverticulitis. The presence of an experienced surgeon with advanced skills in laparoscopic emergency colorectal surgery is crucial for the treatment of patients with perforated diverticulitis in order to properly evaluate, select and treat patients suitable for nonoperative or operative treatment with an open or laparoscopic approach.