Marc R. Scheltinga

Chronic sequelae of common elective groin hernia repair

BackgroundThe aim of this study was to assess long-term chronic pain, numbness and functional impairment after open and laparoscopic groin hernia repair in a teaching hospital.MethodsWe performed a cross-sectional study in which all adult patients with a groin hernia repair between January 2000 and August 2005 received a questionnaire by post. It contained questions concerning frequency and intensity of pain, presence of bulge, numbness, and functional impairment.ResultsOne thousand seven hundred and sixty-six questionnaires were returned (81.6%) and after a median follow-up period of nearly 3xa0years 40.2% of patients reported some degree of pain. Thirty-three patients (1.9%) experienced severe pain. Almost one-fourth reported numbness which correlated significantly with pain (Pxa0<xa00.001). Other variables, identified as risk factors for the development of pain were age (Pxa0<xa00.001) and recurrent hernia repair (Pxa0=xa00.003). One-fifth of the patients felt functionally impaired in their work or leisure activities.ConclusionChronic pain and functional impairment are very common long-term complications after groin herniorrhapy in Dutch teaching hospitals.

Evaluating postherniorrhaphy groin pain: Visual Analogue or Verbal Rating Scale?

IntroductionSeveral tools for pain measurement including a Visual Analogue Scale (VAS) and a Verbal Rating Scale (VRS) are currently used in patients with chronic pain. The aim of the present study was to determine which of these two pain tests performs optimally in patients following groin hernia repair.Patients and methodsA questionnaire identified pain level in a cohort of patients that had previously undergone corrective groin hernia surgery. Current pain intensity was graded on a four-point VRS scale (no pain, mild, moderate or severe pain) and on a 100-mm VAS scale (0xa0=xa0no pain, 100xa0=xa0unbearable). “Scale failure” (one or both tests not completed correctly) was determined, and cut-off points for the VAS test were calculated by creating the optimum kappa coefficient between both tools.ResultsThe response rate was 78.2% (706/903). Scale failure was present in VAS tests more than VRS (VAS: 12.5%, 88/706 vs. VRS: 2.8%, 20/706; Pxa0<xa00.001). Advanced age was a risk factor for scale failure (Pxa0<xa00.001). The four categories of VRS corresponded to mean VAS scores of 1, 20, 42, and 78xa0mm, respectively. VAS categories associated with the highest kappa coefficient (kxa0=xa00.78) were as follows: 0–8xa0=xa0no pain, 9–32xa0=xa0mild, 33–71xa0=xa0moderate, >71xa0=xa0severe pain. VAS scores grouped per VRS category showed considerable overlap. Age and sex did not significantly influence cut-off points.ConclusionsBecause of lower scale failure rates and overlapping VAS scores per VRS category, the VRS should be favored over the VAS in future postherniorrhaphy pain assessment. If VAS is preferred, the presented cut-off points should be utilized.

Time of onset in haemodialysis access-induced distal ischaemia (HAIDI) is related to the access type

BACKGROUNDnA small portion of haemodialysis patients develop hand ischaemia (HAIDI, haemodialysis access-induced distal ischaemia) in the presence of an arteriovenous access (AVA). It is unknown if the time of onset of ischaemia is related to the type of AVA. This review aims to investigate if a relationship is present between the type of AVA and the time of onset and intensity of HAIDI.nnnMETHODSnStandard databases and reference lists of the pertinent literature were systematically searched. HAIDI was classified as acute (<24 h after routine access construction), subacute (within 1 month) or chronic (>1 month). Location, type and follow-up of AVA were tabulated.nnnRESULTSnTwenty-one studies reporting on surgically or percutaneously corrected HAIDI patients (n = 464) fulfilled the inclusion criteria. Acute HAIDI strongly (88%) correlated with non-autogenous AVA. In contrast, chronic HAIDI was predominantly (91%) observed following autogenous AVA based on the cubital segment of the brachial artery. A simple clinical classification for chronic HAIDI guiding treatment strategies is proposed.nnnCONCLUSIONSnHand ischaemia occurring early after routine access surgery is usually related to grafts and not to autogenous access construction. If patients have several risk factors for acute hand ischaemia (diabetes), nephrologists and vascular surgeons may choose an autogenous AVA. A disadvantage of an autogenous access is its association with chronic hand ischaemia, particularly if constructed with a brachial artery.

Banding of hemodialysis access to treat hand ischemia or cardiac overload.

A hemodialysis access may lead to cardiac overload (CO) or hand ischemia [hemodialysis access induced distal ischemia (HAIDI). Surgical banding restricts access flow and promotes distal perfusion. Aim of the study was to investigate short‐ and long‐term clinical success of banding in these patient groups. After evaluation using a standard protocol, banding procedures (nu2003=u200319) were performed in patients (nu2003=u200317) with a hemodialysis access flow ≥2u2003l/minute or with refractory HAIDI. Various parameters including access flow, digital brachial index (DBI), and symptomatology of hand ischemia using a standard scoring system were determined before and after the operation. Surgical banding in CO patients (nu2003=u20039) lowered access flows by 2u2003l (Flowpreop 3.2u2003±u20030.3u2003l/minute vs. Flowpostop 1.2u2003±u20030.1u2003l/minute, pu2003<u20030.001). Banding in HAIDI patients (nu2003=u200310) increased DBI from 0.52u2003±u20030.08 to 0.65u2003±u20030.08 (pu2003=u20030.05), whereas ischemic symptomatology was attenuated (153u2003±u200333 to 42u2003±u200315, pu2003<u20030.02). All patients successfully continued dialysis, and immediate access occlusions (<3u2003months) were not observed. Access flows remained at acceptable levels after a mean follow‐up of 30u2003months in surviving patients (nu2003=u200311, flow: 1.0u2003±u20030.1 l/min). Two patients were reoperated for recurrent CO (one and 28u2003months postoperatively). Surgical banding monitored by measurement of flow and finger pressures is an effective short‐ and long‐term treatment modality for hemodialysis access related CO or distal ischemia.

Anatomy of the carotid sinus nerve and surgical implications in carotid sinus syndrome

BACKGROUNDnThe carotid sinus syndrome (CSS) is characterized by syncope and hypotension due to a hypersensitive carotid sinus located in the carotid bifurcation. Some patients ultimately require surgical sinus denervation, possibly by transection of its afferent nerve (carotid sinus nerve [CSN]). The aim of this study was to investigate the anatomy of the CSN and its branches.nnnMETHODSnTwelve human carotid bifurcations were microdissected. Acetylcholinesterase (ACHE) staining was used to identify location, side branches, and connections of the CSN.nnnRESULTSnA distinct CSN originating from the glossopharyngeal (IX) nerve was identified in all specimens. A duplicate CSN was incidentally present (2/12). Mean CSN length measured from the hypoglossal (XII) nerve to the carotid sinus was 29 +/- 4 mm (range, 15-50 mm). The CSN was frequently located on anterior portions of the internal carotid artery, either laterally (5/12) or medially (6/12). Separate connections to pharyngeal branches of the vagus (X) nerve (6/12), vagus nerve itself (3/12), sympathetic trunk (2/12), as well as the superior cervical ganglion (2/12) were commonly observed. The CSN always ended in a network of small separate branches innervating both carotid sinus and carotid body.nnnCONCLUSIONnAnatomical position of the CSN and its side branches and communications is diverse. From a microanatomical standpoint, CSN transection as a single treatment option for patients with CSS is suboptimal. Surgical denervation at the carotid sinus level is probably more effective in CSS.nnnCLINICAL RELEVANCEnSome patients suffering from CSS ultimately require surgical carotid sinus denervation, possibly by transection of its afferent nerve (CSN). This study was performed to investigate the anatomy of the CSN using a nerve-specific ACHE staining technique. Microdissection demonstrated a great variability of the CSN and its branches. Simple high transection of the CSN may lead to an incomplete sinus denervation in patients with CSS. Surgical denervation at the level of the carotid sinus itself may be more effective in CSS.

Surgical banding for refractory hemodialysis access-induced distal ischemia (HAIDI).

Hemodialysis patients may develop distal ischemia in an extremity harboring a functioning arteriovenous access (AVA). Surgery is indicated if conservative treatment including catheter-based therapies fails. The role of surgical banding for refractory hemodialysis access-induced distal ischemia (HAIDI) is systematically reviewed (n=39 articles). If banding is executed without an intraoperative monitoring tool (“blind”), or guided by finger pressures only, clinical success and access patency rates are low (<50%). In contrast, banding is clinically successful when access flow is monitored during the operative procedure, with excellent long-term patency of banded AVAs (97%, 17 ± 3 months). Banding is the method of choice in HAIDI patients with a normal or high access flow (>1.2 l/min) provided that flow and distal perfusion are closely monitored intraoperatively.

Compartment Pressure Curves Predict Surgical Outcome in Chronic Deep Posterior Compartment Syndrome

Background: Results of surgery for chronic exertional compartment syndrome (CECS) of the lower leg deep posterior compartment are inferior compared with other types of CECS. Factors predicting success after surgery are unknown. Purpose: To study the prognostic value of preoperative compartmental pressure curves in patients receiving surgery for deep posterior compartment CECS. Study Design: Case series; Level of evidence, 4. Methods: Intracompartmental pressures (ICPs) of patients with deep posterior lower leg CECS were obtained at 4 time points (ie, before, immediately after, and 1 and 5 minutes after a standard exercise challenge test). Area under the 4-point pressure curve was calculated. Patients received a questionnaire investigating residual symptoms after surgery. Results: A complete data set was available for 52 patients (men, n = 23; age, 33 ± 14 years). They rated their 3-month postoperative clinical outcome as excellent (14%), good (38%), fair (35%), or poor (13%). Outcome at 3 months was related to the area under the preoperative 4-point pressure curve (excellent, 127 ± 28; good, 113 ± 25; fair, 100 ± 22; and poor, 88 ± 15; P = .005; odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01-1.08). At the long-term follow-up (39 ± 24 months), all 5 cardinal symptoms (pain, tight feeling, cramps, weakness, and diminished sensibility) were greatly attenuated (P < .001) in the successfully operated group. Long-term success was 48%. Delay in diagnosis was related to poor outcome (P = .04). Correlations between pressures/area under the 4-point pressure curve and long-term outcome were not significant, however. Conclusion: Preoperative measured intracompartmental pressures obtained in rest and after a standard exercise test may predict success of surgery for deep posterior compartment CECS of the lower limb. Further standardizing of preoperative pressure protocols may confirm that compartmental pressure analysis has diagnostic as well as predictive properties.

Multidisciplinary treatment for peripheral arterial occlusive disease and the role of eHealth and mHealth

Increasingly unaffordable health care costs are forcing care providers to develop economically viable and efficient health care plans. Currently, only a minority of all newly diagnosed peripheral arterial occlusive disease (PAOD) patients receive efficient and structured conservative treatment for their disease. The aim of this article is to introduce an innovative effective treatment model termed ClaudicatioNet. This concept was launched in The Netherlands as a means to combat treatment shortcomings and stimulate cohesion and collaboration between stakeholders. The overall goal of ClaudicatioNet is to stimulate quality and transparency of PAOD treatment by optimizing multidisciplinary health care chains on a national level. Improved quality is based on stimulating both a theoretical and practical knowledge base, while eHealth and mHealth technologies are used to create clear insights of provided care to enhance quality control management, in addition these technologies can be used to increase patient empowerment, thereby increasing efficacy of PAOD treatment. This online community consists of a web portal with public and personal information supplemented with a mobile application. By connecting to these tools, a social community is created where patients can meet and keep in touch with fellow patients, while useful information for supervising health care professionals is provided. The ClaudicatioNet concept will likely create more efficient and cost-effective PAOD treatment by improving the quality of supervised training programs, extending possibilities and stimulating patient empowerment by using eHealth and mHealth solutions. A free market principle is introduced by introducing transparency to provided care by using objective and subjective outcome parameters. Cost-effectiveness can be achieved using supervised training programs, which may substitute for or postpone expensive invasive vascular interventions.

Long-term Results of Surgical Decompression of Chronic Exertional Compartment Syndrome of the Forearm in Motocross Racers

Background: Chronic exertional compartment syndrome (CECS) is occasionally observed in the forearm flexor muscles of motocross racers. Long-term results of fasciectomy and fasciotomy for this syndrome are scarce. Purpose: To study the long-term effects of 2 surgical techniques for forearm flexor CECS. Study Design: Case series; Level of evidence, 4. Methods: A database of patients with forearm CECS who underwent surgery was analyzed. Long-term pain reduction (visual analog scale [VAS], 0-100) and efficacy were evaluated using a questionnaire. Results: Data of 24 motocross racers were available for analysis. Intracompartmental pressures during rest, during provocation, and after 1 and 5 minutes of provocation were 15 ± 4, 78 ± 24, 29 ± 10, and 25 ± 7 mm Hg, respectively. Painful sensations in the forearm were reduced from 53 to 7 (median VAS; P < .001). Both fasciectomy (n = 14) and fasciotomy (n = 10) were equally effective. More than 95% (23/24) of the patients were satisfied with the postoperative result after 5 ± 2 years’ follow-up. Conclusion: Surgical fasciotomy and fasciectomy of the forearm flexor compartment are equally successful in motocross racers suffering from forearm CECS.

Is surgery effective for deep posterior compartment syndrome of the leg? A systematic review

Background Results of surgery for lower leg deep posterior chronic exertional compartment syndrome (dp-CECS) are inferior compared to other types of CECS. Factors influencing suboptimal surgical results are unknown. The purpose of this systematic review was to provide a critical analysis of the existing literature on the surgical management of dp-CECS aimed at identifying parameters determining surgical results. Methods A literature search was performed using Pubmed, EMBASE, MEDLINE and CINAHL (EBSCO). Studies including surgical results for dp-CECS were systematically reviewed. Results 7 studies of level III evidence reporting on a total of 131 patients met inclusion criteria (>5 patients, reporting intracompartmental pressures (ICP), clearly stating postoperative outcome). Only four studies strictly adhered to predefined ICP criteria. Cutoff ICP levels varied widely among the 7 studies. Surgical procedures ranged from a superficial crural fasciotomy to multiple fasciotomies of various deep posterior compartments. No single surgical procedure proved superior. Prolonged high ICP levels following provocation were associated with postoperative success. Success rates after fasciotomy were modest ranging from 30% to 65%. Risk factors for failure of surgery were not identified. Conclusions The quality of studies reporting on surgery for dp-CECS is poor. Prospective, controlled or randomised studies are lacking. Diagnostic criteria and surgical techniques are diverse. As functional results of current management regimes are disappointing, future studies of dp-CECS should focus on optimising diagnostic criteria and standardisation of treatment modalities.