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Key Clinical Message A symptomatic arcuate line hernia should be considered in patients with acute lower abdominal complaints. This rare internal herniation is caused by a sharp ending of the posterior aponeurotic sheath of the rectus muscle, rather than the more common gradual delineation, and can cause strangulation or incarceration of abdominal contents. A symptomatic arcuate line hernia should be considered in patients with acute lower abdominal complaints. This rare internal herniation is caused by a sharp ending of the posterior aponeurotic sheath of the rectus muscle, rather than the more common gradual delineation, and can cause strangulation or incarceration of abdominal contents.

Background Evidence is accumulating that, similar to other ventral hernias, umbilical and epigastric hernias must be mesh repaired. The difficulties involved in mesh placement and in mesh-related complications could be the reason many small abdominal hernias are still primary closed. In laparoscopic repair, a mesh is placed intraperitoneally, while the most common procedure is open surgery is pre-peritoneal mesh placement. A recently developed alternative method is the so-called patch repair, in this approach a mesh can be placed intraperitoneally through open surgery. In theory, such patches are particularly suitable for small hernias due to a reduction in the required dissection. This simple procedure is described in several studies. It is still unclear whether this new approach is associated with an equal risk of recurrence and complications compared with pre-peritoneal meshes. The material of the patch is in direct contact with intra-abdominal organs, it is unknown if this leads to more complications. On the other hand, the smaller dissection in the pre-peritoneal plane may lead to a reduction in wound complications. Methods/Design 346 patients suffering from an umbilical or epigastric hernia will be included in a multi-centre patient-blinded trial, comparing mesh repair with patch repair. Randomisation will take place for the two operation techniques. The two devices investigated are a flat pre-peritoneal mesh and a Proceed Ventral Patch®. Stratification will occur per centre. Post-operative evaluation will take place after 1, 3, 12 and 24 months. The number of complications requiring treatment is the primary endpoint. Secondary endpoints are Verbal Descriptor Scale (VDS) pain score and VDS cosmetic score, operation duration, recurrence and costs. An intention to treat analysis will be performed. Discussion This trial is one of the first in its kind, to compare different mesh devices in a randomized controlled setting. The results will help to evaluate mesh repair for epigastric an umbilical hernia, and find a surgical method that minimizes the complication rate. Trial registration Netherlands Trail Registration (NTR) www.trialregister.nl 2010 NTR2514 NL33995.060.10

Recently, excellent results are reported on laparoscopic lavage in patients with purulent perforated diverticulitis as an alternative for sigmoidectomy and ostomy.The objective of this study is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis). In this multicentre randomised trial all patients with perforated diverticulitis are included. Upon laparoscopy, patients with purulent peritonitis are treated with laparoscopic lavage and drainage, Hartmann's procedure or sigmoidectomy with primary anastomosis in a ratio of 2:1:1 (LOLA-arm). Patients with faecal peritonitis will be randomised 1:1 between Hartmann's procedure and resection with primary anastomosis (DIVA-arm). The primary combined endpoint of the LOLA-arm is major morbidity and mortality. A sample size of 132:66:66 patients will be able to detect a difference in the primary endpoint from 25% in resectional groups compared to 10% in the laparoscopic lavage group (two sided alpha = 5%, power = 90%). Endpoint of the DIVA-arm is stoma free survival one year after initial surgery. In this arm 212 patients are needed to significantly demonstrate a difference of 30% (log rank test two sided alpha = 5% and power = 90%) in favour of the patients with resection with primary anastomosis. Secondary endpoints for both arms are the number of days alive and outside the hospital, health related quality of life, health care utilisation and associated costs. The Ladies trial is a nationwide multicentre randomised trial on perforated diverticulitis that will provide evidence on the merits of laparoscopic lavage and drainage for purulent generalised peritonitis and on the optimal resectional strategy for both purulent and faecal generalised peritonitis. Nederlands Trial Register NTR2037.

Abstract Background: Annually 16,000 appendectomies are performed in the Netherlands, of which 15-20% are negative. In 2010, to reduce this unacceptable percentage of superfluous appendectomies, the Dutch Association for Surgery introduced the ‘Appendicitis Guideline'. This guideline recommends the use of imaging. In this observational prospective study the added value of imaging in everyday clinical practice is evaluated. Methods: All patients with suspected appendicitis were included at the emergency department of a Dutch teaching hospital during the period from September 2011 to May 2012 (n = 350; 237 adults and 113 children under 18 years). Adherence to the guideline was evaluated. Results: 75 Patients (21%) were not referred for imaging because of a low suspicion or alternative diagnosis. In 16 patients (5%) the guideline was not followed. Of the 259 patients (74%) who underwent ultrasonography, 105 (30%) also underwent computed tomography (CT). 127 appendectomies were performed, showing appendicitis in 112 patients (88%); 15 appendectomies (12%) were negative. In the latter group, 12 were performed after false positive imaging results, and 3 following inconclusive imaging results. Conclusion: When using imaging in the diagnosis of appendicitis, the percentage of negative appendectomies remains close to the percentage declared as unacceptable by the publishers of the guideline.

Introduction: Preoperative work-up in colorectal cancer is comprehensive and can be time consuming. In our institution, the preoperative track for colorectal patients was reorganized in order to reduce the therapeutic delay and the number of outpatient clinic visits. We assessed the impact upon the patient outcomes. Methods: All consecutive patients with colon cancer who entered the reorganized preoperative track between January 2008 and December 2009 (n = 87) were retrospectively compared with a consecutively diagnosed traditionally evaluated patient group diagnosed between January 2005 and December 2006 (n = 108). Time between diagnostic procedures and surgery as well as needed number of preoperative outpatient department visits were calculated. All rectal malignancies, patients who received preoperative chemotherapy and/or radiotherapy and patients who underwent emergency procedures were excluded from analysis. Results: Time between colonoscopy and surgery was reduced from [median (25–75%)] 44 (34–54) to 27 (21–34) days, p < 0.001. The number of outpatient department visits declined from 6 (5–7) to 3 (3–4), p < 0.001. Time between first diagnostic test and colonoscopy was reduced from 44 (11–68) to 9 days (0–30), p < 0.001. Time between first diagnostic test and operation was reduced from 85.5 (56–120.5) to 42 days (28–62), p < 0.001. Before the reorganizations, 7% of colonoscopies were ordered by GPs and went up afterwards to 60%. Conclusion: Reorganization of traditional logistic routes for patients diagnosed with colon cancer reduces therapeutic delay and improves care. Moreover, the surgeon, gastroenterologist and oncologist can focus on the oncologic patient and his/her family instead of having to perform administrative tasks.

Physical activity (PA) is associated with improved overall survival (OS) among colorectal cancer (CRC) patients, but research on PA changes after diagnosis remains limited. This study examines associations between OS and changes in PA from CRC diagnosis onward, across stage- and treatment-related subgroups. Data were analyzed from patients in two large CRC cohorts (PLCRC and COLON) enrolled between August 2010 and December 2022 (follow-up until February 1st, 2024). This included 3,395 stage I-IIA patients who underwent surgery only, 2,406 stage IIB/C-III patients who received (neo-)adjuvant therapy, and 669 metastatic CRC (mCRC) patients. PA was assessed via the validated SQUASH questionnaire at diagnosis (T0), and at 6, 12, and 24 months post-diagnosis (T6 to T24). Moderate-to-vigorous-intensity recreational activity was quantified by calculating Metabolic Equivalent of Task (MET) hours per week. Associations with OS were examined for change (active [tertile 2 and 3] vs inactive [tertile 1]) between timepoints using multivariable Cox proportional hazards models. Among surgery-only patients, change from inactivity to activity between T0 and T6 was significantly associated with OS (HR 0.58 [95% CI 0.35-0.96]). For (neo-)adjuvantly treated patients, significant associations were observed between T6 and T12 (0.53 [0.31-0.90]). Among mCRC patients, a significant association was observed between T6 and T12 (0.53 [0.29-0.99]). Changing from inactivity to activity is significantly associated with prolonged survival during the early months post-diagnosis for surgery-only CRC patients, and later for those undergoing (neo-)adjuvant therapy or with metastatic disease. Validation is warranted in interventional studies.

Regular physical activity (PA) is associated with improved overall survival (OS) in stage I–III colorectal cancer (CRC) patients. This association is less defined in patients with metastatic CRC (mCRC). We therefore conducted a study in mCRC patients participating in the Prospective Dutch Colorectal Cancer cohort. PA was assessed with the validated SQUASH questionnaire, filled-in within a maximum of 60 days after diagnosis of mCRC. PA was quantified by calculating Metabolic Equivalent Task (MET) hours per week. American College of Sports and Medicine (ACSM) PA guideline adherence, tertiles of moderate to vigorous PA (MVPA), and sport and leisure time MVPA (MVPA-SL) were assessed as well. Vital status was obtained from the municipal population registry. Cox proportional-hazards models were used to study the association between PA determinants and all-cause mortality adjusted for prognostic patient and treatment-related factors. In total, 293 mCRC patients (mean age 62.9 ± 10.6 years, 67% male) were included in the analysis. Compared to low levels, moderate and high levels of MET-hours were significantly associated with longer OS (fully adjusted hazard ratios: 0.491, (95% CI 0.299–0.807, p value = 0.005) and 0.485 (95% CI 0.303–0.778, p value = 0.003), respectively), as were high levels of MVPA (0.476 (95% CI 0.278–0.816, p value = 0.007)) and MVPA-SL (0.389 (95% CI 0.224–0.677, p value < 0.001)), and adherence to ACSM PA guidelines compared to non-adherence (0.629 (95% CI 0.412–0.961, p value = 0.032)). The present study provides evidence that higher PA levels at diagnosis of mCRC are associated with longer OS.

Background Recently, excellent results are reported on laparoscopic lavage in patients with purulent perforated diverticulitis as an alternative for sigmoidectomy and ostomy. The objective of this study is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis). Methods/Design In this multicentre randomised trial all patients with perforated diverticulitis are included. Upon laparoscopy, patients with purulent peritonitis are treated with laparoscopic lavage and drainage, Hartmann's procedure or sigmoidectomy with primary anastomosis in a ratio of 2:1:1 (LOLA-arm). Patients with faecal peritonitis will be randomised 1:1 between Hartmann's procedure and resection with primary anastomosis (DIVA-arm). The primary combined endpoint of the LOLA-arm is major morbidity and mortality. A sample size of 132:66:66 patients will be able to detect a difference in the primary endpoint from 25% in resectional groups compared to 10% in the laparoscopic lavage group (two sided alpha = 5%, power = 90%). Endpoint of the DIVA-arm is stoma free survival one year after initial surgery. In this arm 212 patients are needed to significantly demonstrate a difference of 30% (log rank test two sided alpha = 5% and power = 90%) in favour of the patients with resection with primary anastomosis. Secondary endpoints for both arms are the number of days alive and outside the hospital, health related quality of life, health care utilisation and associated costs. Discussion The Ladies trial is a nationwide multicentre randomised trial on perforated diverticulitis that will provide evidence on the merits of laparoscopic lavage and drainage for purulent generalised peritonitis and on the optimal resectional strategy for both purulent and faecal generalised peritonitis. Trial registration Nederlands Trial Register NTR2037

How sitting and physical activity can affect sleep in people living with and beyond colorectal cancer: Introduction: Poor sleep quality is common among people living with and beyond colorectal cancer. However, the effect of sitting, standing, and physical activity on sleep duration and quality has not been studied extensively. Therefore, this study investigated how sitting and physical activity affect sleep in people living with and beyond colorectal cancer over a period of 5 years after their treatment ended. Methods: 401 survivors of colorectal cancer were included within this study. These survivors were measured repeatedly over a period of 5 years. We used a device worn on the thigh to measure how much time people spent sitting, standing, and moving. Additionally, we measured how many hours people spent sleeping, how their sleep quality was, and whether people had trouble falling asleep using diaries and questionnaires. Results: After treatment, people who spent more time sitting, standing, and being physically active had a shorter sleep duration. In addition, people who spent more time standing had improved sleep quality and less trouble falling asleep. We also observed that people who spent time moving at a higher intensity experienced less trouble falling asleep. Conclusion: These results indicate that survivors who stand and move more experience less sleep problems and have less trouble falling asleep. Therefore, there may be a critical role for these behaviours in improving sleep in survivors of colorectal cancer. More research is needed to investigate the effects of substituting sitting by more time standing and being physically active.

Severe fecal incontinence is a problem that may substantially diminish a person's quality of life. 1 , 2 The prevalence of persistent fecal incontinence in the United States has been reported to be 2.3 percent. 3 Treatment methods such as a change of diet, the use of constipating agents or daily enemas, and training in biofeedback can often be effective. 4 If conservative treatment fails, several surgical treatments, including the creation of a colostomy, have been used with varying success. One surgical treatment is the construction of a neosphincter around the anal canal with the gracilis muscle. 5 The results of this procedure have been . . .