Twelve-year outcomes of watchful waiting versus surgery of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years and older:a randomised controlled trial

Background: Inguinal hernia belongs to the most common surgical pathology worldwide. Approximately, one third is asymptomatic. The value of watchful waiting (WW) in patients with asymptomatic or mildly symptomatic inguinal hernia has been established in a few randomised controlled trials (RCTs). The aim of this study was to assess long-term outcomes of a RCT comparing WW and elective surgery.Methods: In the original study, men aged ≥50 years with an asymptomatic or mildly symptomatic inguinal hernia were randomly assigned to WW or elective repair. In the present study, the primary outcome was the 12-year crossover rate to surgery, secondary outcomes were time-to-crossover, patient regret, pain, quality of life and incarceration. Dutch Trial Registry: NTR629. Findings: Out of 496 originally analysed patients, 488 (98.4%) were evaluable for chart review (WW: n = 258, surgery: n = 230), and 200 (41.0%) for telephone contact (WW: n = 106, surgery: n = 94) between November 2021 and March 2022 with a median 12 years follow-up (IQR 9–14). After 12 years, the estimated cumulative crossover rate to surgery was 64.2%, which was higher in mildly symptomatic than in asymptomatic patients (71.7% versus 60.4%, HR 1.451, 95% CI: 1.064–1.979). Time-to-crossover was longer in asymptomatic patients (50% after 6.0 years versus 2.0 years, p = 0.019). Patient regret was higher in the WW group (37.7 versus 18.0%, p = 0.002), as well as pain/discomfort (p = 0.031). Quality of life did not differ (p = 0.737). In the WW group, incarceration occurred in 10/255 patients (3.9%). Interpretation: During 12-year follow-up, most WW patients crossed over to surgery, significantly earlier with mildly symptomatic hernia. Considering the relatively low incarceration rate, WW might still be an option in asymptomatic patients with a clear preference and being well-informed about pros and cons.</p

Twelve-year outcomes of watchful waiting versus surgery of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years and older:a randomised controlled trial

Background: Inguinal hernia belongs to the most common surgical pathology worldwide. Approximately, one third is asymptomatic. The value of watchful waiting (WW) in patients with asymptomatic or mildly symptomatic inguinal hernia has been established in a few randomised controlled trials (RCTs). The aim of this study was to assess long-term outcomes of a RCT comparing WW and elective surgery. Methods: In the original study, men aged ≥50 years with an asymptomatic or mildly symptomatic inguinal hernia were randomly assigned to WW or elective repair. In the present study, the primary outcome was the 12-year crossover rate to surgery, secondary outcomes were time-to-crossover, patient regret, pain, quality of life and incarceration. Dutch Trial Registry: NTR629. Findings: Out of 496 originally analysed patients, 488 (98.4%) were evaluable for chart review (WW: n = 258, surgery: n = 230), and 200 (41.0%) for telephone contact (WW: n = 106, surgery: n = 94) between November 2021 and March 2022 with a median 12 years follow-up (IQR 9–14). After 12 years, the estimated cumulative crossover rate to surgery was 64.2%, which was higher in mildly symptomatic than in asymptomatic patients (71.7% versus 60.4%, HR 1.451, 95% CI: 1.064–1.979). Time-to-crossover was longer in asymptomatic patients (50% after 6.0 years versus 2.0 years, p = 0.019). Patient regret was higher in the WW group (37.7 versus 18.0%, p = 0.002), as well as pain/discomfort (p = 0.031). Quality of life did not differ (p = 0.737). In the WW group, incarceration occurred in 10/255 patients (3.9%). Interpretation: During 12-year follow-up, most WW patients crossed over to surgery, significantly earlier with mildly symptomatic hernia. Considering the relatively low incarceration rate, WW might still be an option in asymptomatic patients with a clear preference and being well-informed about pros and cons. Funding: The initial trial was funded by the Netherlands Organisation for Health Research and Development (ZonMW). This long-term study did not receive funding.</p

Neo-adjuvant chemotherapy followed by surgery versus surgery alone in high-risk patients with resectable colorectal liver metastases: The CHARISMA randomized multicenter clinical trial

Background: Efforts to improve the outcome of liver surgery by combining curative resection with chemotherapy have failed to demonstrate de

Management of anterior cutaneous nerve entrapment syndrome in a cohort of 139 patients.

Item does not contain fulltextOBJECTIVE: Anterior cutaneous nerve entrapment syndrome (ACNES) is generally neglected as a source of chronic abdominal pain. The aim of this study was to evaluate the efficacy of a diagnostic workup protocol and treatment regimen in patients with suspected ACNES. METHODS: A cohort of all consecutive patients presenting with chronic abdominal pain suggestive of ACNES between 2003 and 2008 was evaluated retrospectively. Patients were offered a single diagnostic injection of 1% lidocaine into the trigger point followed by subsequent therapeutic injections including corticosteroids. If pain was refractory, an anterior neurectomy was performed. Pain scores were done using a visual analog scale for evaluation of the injection regimen and Verbal Rating Scale (1-5) for long-term efficacy. RESULTS: A total of 139 patients with suspected ACNES (77% women, mean age 47 +/- 17 years) were evaluated. Eighty-one percent (n = 94) demonstrated a visual analog scale reduction of at least 50% after the first injection. Some 33% (n = 44) remained permanently pain-free after injection therapy only. Sixty-nine patients underwent a neurectomy, which was successful in 49 (71%). Long-term efficacy revealed in 71% (very) satisfying visual rating scale (1-2) results, whereas an additional 9% reported attenuated levels of pain (visual rating scale 3). CONCLUSION: A regimen of consecutive local trigger point injections is effective in one-thirds of patients with ACNES. Surgical neurectomy is effective in about two-thirds of the injection regimen refractory patients. Eighty percent of the entire ACNES population reports total or substantial pain relief on the long term.1 december 201

Surgery for refractory anterior cutaneous nerve entrapment syndrome (ACNES) in children.

Item does not contain fulltextBACKGROUND: Chronic abdominal pain (CAP) in children may be caused by entrapment of cutaneous branches of intercostal nerves (anterior cutaneous nerve entrapment syndrome, or ACNES). Local injection of anesthetics may offer relief, but pain is persistent in some children. This study is the first to describe the results of a 'cutaneous neurectomy' in children with refractory ACNES. METHODS: Chronic abdominal pain children with suspected ACNES refractory to conservative treatment received a cutaneous neurectomy in a day care setting. They were interviewed postoperatively using an adapted quality of life questionnaire (testing quality of life in children). RESULTS: All subjects (n = 6; median age, 15 years; range, 9-16 years) were previously healthy school-aged children without prior illness or earlier surgery. Each presented with intense abdominal pain and a positive Carnett sign. Blood, urine tests, and abdominal ultrasound investigations were normal. Delay in seeing a physician was 16 weeks, and school absence was 25 days. Before surgery, quality of life (pain, daily activities, and sports) was greatly diminished. After the neurectomy, all children were free of pain and had resumed their normal daily routine (follow-up at 6 months). CONCLUSIONS: The role of the abdominal wall as the source of childhood CAP is underestimated. Some children with CAP have ACNES. Children with refractory ACNES should be offered a cutaneous neurectomy, as this simple technique is effective in the short and long term.1 april 201

Pulsed radiofrequency or anterior neurectomy for anterior cutaneous nerve entrapment syndrome (ACNES) (the PULSE trial): study protocol of a randomized controlled trial

Contains fulltext : 176914.pdf (publisher's version ) (Open Access)BACKGROUND: Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES). This somewhat illusive syndrome is thought to be caused by the entrapment of end branches of the intercostal nerves residing in the abdominal wall. If ACNES is suspected, a local injection of an anesthetic agent may offer relief. If pain is recurrent following multiple-injection therapy, an anterior neurectomy entailing removal of the entrapped nerve endings may be considered. After 1 year, a 70% success rate has been reported. Research on minimally invasive alternative treatments is scarce. Pulsed radiofrequency (PRF) treatment is a relatively new treatment for chronic pain syndromes. An electromagnetic field is applied around the nerve in the hope of leading to pain relief. This randomized controlled trial compares the effect of PRF treatment and neurectomy in patients with ACNES. METHODS: Adult ACNES patients having short-lived success following injections are randomized to PRF or neurectomy. At the 8-week follow-up visit, unsuccessful PRF patients are allowed to cross over to a neurectomy. Primary outcome is pain relief after either therapy. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and unanticipated adverse events. The study is terminated 6 months after receiving the final procedure. DISCUSSION: Since academic literature on minimally invasive techniques is lacking, well-designed trials are needed to optimize results of treatment for ACNES. This is the first large, randomized controlled, proof-of-concept trial comparing two therapy techniques in ACNES patients. The first patient was included in October 2015. The expected trial deadline is December 2017. If effective, PRF may be incorporated into the ACNES treatment algorithm, thus minimizing the number of patients requiring surgery. TRIAL REGISTRATION: Nederlands Trial Register (Dutch Trial Register), NTR5131 ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131 ). Registered on 15 April 2015

Chronic Localized Back Pain Due to Posterior Cutaneous Nerve Entrapment Syndrome (POCNES): A New Diagnosis

Item does not contain fulltextMost patients with chronic back pain suffer from degenerative thoracolumbovertebral disease. However, the following case illustrates that a localized peripheral nerve entrapment must be considered in the differential diagnosis of chronic back pain. We report the case of a 26-year-old woman with continuous excruciating pain in the lower back area. Previous treatment for nephroptosis was to no avail. On physical examination the pain was present in a 2 x 2 cm area overlying the twelfth rib some 4 cm lateral to the spinal process. Somatosensory testing using swab and alcohol gauze demonstrated the presence of skin hypo- and dysesthesia over the painful area. Local pressure on this painful spot elicited an extreme pain response that did not irradiate towards the periphery. These findings were highly suggestive of a posterior version of the anterior cutaneous nerve entrapment syndrome (ACNES), a condition leading to a severe localized neuropathic pain in anterior portions of the abdominal wall. She demonstrated a beneficial albeit temporary response after lidocaine infiltration as dictated by an established diagnostic and treatment protocol for ACNES. She subsequently underwent a local neurectomy of the involved superficial branch of the intercostal nerve. This limited operation had a favorable outcome resulting in a pain-free return to normal activities up to this very day (follow-up of 24 months).We propose to name this novel syndrome "posterior cutaneous nerve entrapment syndrome" (POCNES). Each patient with chronic localized back pain should undergo simple somatosensory testing to detect the presence of overlying skin hypo- and dysesthesia possibly reflecting an entrapped posterior cutaneous nerve.Key words: Chronic pain, back pain, posterior cutaneous nerve entrapment, peripheral nerve entrapment, surgical treatment for pain, anterior cutaneous nerve entrapment

Adrenal Tumors with Unexpected Outcome: A Review of the Literature

The finding of an adrenal mass should induce a diagnostic work-up aimed at assessing autonomous hormone production and differentiating between benign and (potentially) malignant lesions. The common differential diagnosis in adrenal incidentaloma consists of (non-) functioning adenoma, pheochromocytoma, myelolipoma, metastasis, and primary carcinoma. There remains a category of lesions that are hormonally inactive and display nonspecific imaging characteristics. We provide a succinct literature review regarding pathologies from this category. Imaging and histological characteristics are discussed, as well as clinical management. In conclusion, an adrenal mass may present a diagnostic challenge. After exclusion of most common diagnoses, it can be difficult to differentiate between possible pathologies based on preoperative diagnostic tests. Surgical resection of possibly harmful tumors is indicated, for example, lesions with malignant potential or risk of spontaneous hemorrhage. Resection of an obviously benign lesion is not necessary, unless problems due to tumor size are expected

Risk factors for conversion during laparoscopic cholecystectomy - experiences from a general teaching hospital.

Item does not contain fulltextBACKGROUND AND AIMS: Laparoscopic cholecystectomy (LC) is the gold standard for treating symptomatic cholelithiasis. Conversion, however, is sometimes necessary. The aim of this study was to determine predictive factors of conversion in patients undergoing LC for various indications in elective and acute settings in a general teaching hospital. MATERIAL AND METHODS: A retrospective analysis was performed on 972 consecutive patients who underwent a laparoscopic cholecystectomy in Maxima Medical Centre in Veldhoven, the Netherlands, from January 2000 till January 2006. Recorded data were sex, age, indication for LC, conversion to open cholecystectomy, reason for conversion, performing surgeon, co-morbidity, type of complication, length of hospital stay and 30-day mortality. RESULTS: Conversion to open cholecystectomy was performed in 121 patients (12%). The most frequent reasons for conversion were infiltration/fibrosis of Calot's triangle (30%) and adhesions (27%). In the multivariate analyses male gender (OR 1.67, 95% CI 1.07-2.59), age >65 years (OR 2.10, 95% CI 1.32-3.34), acute cholecystitis (OR 11.8, 95% CI 6.98-20.1), recent acute cholecystitis (OR 4.71, 95% CI 2.42-9.18) and recent obstructive jaundice (OR 20.6, 95% CI 4.52-94.1) were independent predictive factors for conversion. CONCLUSIONS: Male gender, age >65 years, (recent) acute cholecystitis and recent obstructive jaundice are independent predictive risk factors for conversion. By appreciating these risk factors for conversion, preoperative patient counselling can be improved