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Gooszen AW, Tollenaar RAEM, Geelkerken RH, Smeets HJ, Bemelman WA, Van Schaardenburgh P, Gooszen HG. Authors' reply. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2002.20095.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- A W Gooszen
- Department of Surgery, Utrecht University Hospital, Utrecht, The Netherlands
| | - R A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - R H Geelkerken
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - H J Smeets
- Department of Surgery, Bronovo Hospital, The Hague, The Netherlands
| | - W A Bemelman
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - H G Gooszen
- Department of Surgery, Utrecht University Hospital, Utrecht, The Netherlands
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Gooszen AW, Tollenaar RAEM, Geelkerken RH, Smeets HJ, Bemelman WA, Schaardenburgh PV, Gooszen HG. Correspondence: 5. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2002.t01-1-20095.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gooszen AW, Tollenaar RA, Geelkerken RH, Smeets HJ, Bemelman WA, Van Schaardenburgh P, Gooszen HG. Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease. Br J Surg 2001; 88:693-7. [PMID: 11350443 DOI: 10.1046/j.1365-2168.2001.01748.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND A primary anastomosis after resection of the sigmoid colon for suspected acute complicated diverticular disease has the advantage of saving the patient a secondary operation for restoring bowel continuity. Fear of anastomotic leakage often deters surgeons from making a primary anastomosis. METHODS A series of 45 patients who underwent primary anastomosis was studied prospectively to evaluate the feasibility of a primary anastomosis following acute sigmoid resection. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Mannheim Peritonitis Index (MPI) and Hughes' peritonitis classification were used to classify patients and to detect factors predictive of postoperative outcome. Death, anastomotic leakage and septic complications were main outcome measures. RESULTS Neither anastomotic leakage (four of 45 patients) nor death (three of 45) was related to a higher MPI, APACHE II or Hughes' score. More postoperative septic complications were seen in patients with a MPI over 16. Death, anastomotic leakage, reintervention and wound infection were observed more frequently in patients who presented with colonic obstruction than in those with abscess or perforation. CONCLUSION Primary anastomosis is safe and effective in non-obstructed cases of complicated diverticular disease. Colonic obstruction seems to be a risk factor for the development of postoperative complications.
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Affiliation(s)
- A W Gooszen
- Departments of Surgery, Utrecht University Hospital, Utrecht, The Netherlands
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Gooszen AW, Gooszen HG, Veerman W, Van Dongen VM, Hermans J, Klien Kranenbarg E, Tollenaar RA. Operative treatment of acute complications of diverticular disease: primary or secondary anastomosis after sigmoid resection. Eur J Surg 2001; 167:35-9. [PMID: 11213818 DOI: 10.1080/110241501750069792] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess the comparative effects of two surgical regimens on the outcome of acute complicated diverticular disease. DESIGN Retrospective study. SETTING Teaching hospital, The Netherlands. SUBJECTS 60 patients who presented with acute complicated diverticular disease. INTERVENTIONS 28 patient were treated by sigmoid resection and a Hartmann operation, and 32 by resection with primary anastomosis and defunctioning stoma. MAIN OUTCOME MEASURES Morbidity and mortality. RESULTS The severity of peritonitis and the amount of faecal contamination were similar in the 2 groups. 12 patients died (7 in the Hartmann group and 5 in the primary anastomosis group). There were 3 radiological leaks with no clinical implications in the primary anastomosis group. 6 patients in the Hartmann group and 5 in the primary anastomosis group required reoperations for intra-abdominal abscess or infection. 7 and 3 patients, respectively, developed dysfunction of their stomas, and 9/21 and 3/27, respectively, required a permanent stoma (p = 0.02, 95% confidence interval of difference 0.07 to 0.56). 3 patients in the Hartmann group developed anastomotic leaks after closure of their stomas, 1 of whom required reoperation but died. No patient developed an anastomotic leak after closure of the stoma in the primary anastomosis group. CONCLUSION Both regimens are accepted treatments for patients with acute complicated diverticular disease, but because of the higher morbidity after the Hartmann procedure we prefer primary anastomosis with covering stoma.
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Affiliation(s)
- A W Gooszen
- Department of Surgery, University Medical Centre Utrecht, The Netherlands
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Bosscha K, Nieuwenhuijs VB, Gooszen AW, van Duijvenbode-Beumer H, Visser MR, Verweij WR, Akkermans LM. A standardised and reproducible model of intraabdominal infection and abscess formation in rats. Eur J Surg 2000; 166:963-7. [PMID: 11152259 DOI: 10.1080/110241500447146] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To develop a standardised and reproducible model of intra-abdominal infection and abscess formation in rats. DESIGN Experimental study. SETTING University hospital, The Netherlands. SUBJECTS 36 adult male Wistar rats. INTERVENTIONS In 32 rats, peritonitis was produced using two different concentrations of Escherichia coli (E. coli) and Bacteroides fragilis (B. fragilis) incorporated in fibrin clots (E. coii 1 x 10(5) colony forming units (CFU)/ml or 1 x 10(8) CFU/ml, B. fragilis: 1 x 10(8) CFU/ml). Four rats with fibrin clots without bacteria served as uninfected controls. MAIN OUTCOME MEASUREMENTS Macroscopy and bacterial counts in peritoneal fluid, blood, and fibrin clots after 24 hours, 4 days, 7 days, and 4 weeks. RESULTS Macroscopically, there were signs of intra-abdominal infection and abscesses. With the higher starting concentration of E. coli, macroscopic signs were more pronounced and in nearly all rats bacterial counts in peritoneal fluid and fibrin clots showed persistently high numbers of E. coli and B. fragilis for at least 7 days (E. coli = 2 x 10(3) to 1 x 10(6) CFU/ml and 5 x 10(7) to 9 x 10(8) CFU/clot; B. fragilis = 1 x 10(3) to 1 x 10(6) CFU/ml and 5 x 10(7) to 6 x 10(8) CFU/clot). CONCLUSION This standardised and reproducible model of intra-abdominal infection and abscess formation seems well suited for further use and development in experiments on the pathophysiology of intra-abdominal infection and abscesses.
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Affiliation(s)
- K Bosscha
- Department of Surgery, University Hospital Utrecht, The Netherlands
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Abstract
PURPOSE The hypothesis is that the impact of a temporary stoma on a patient's daily life is determined by complications and related stoma care problems. METHOD A prospective clinical trial was performed, studying complications and social well-being of 37 patients with loop ileostomy and 39 patients with a loop colostomy (randomly assigned comparison). Patients were categorized according to degree of social restriction. The association between the degree of social restriction and the presence of stoma care problems and complications was assessed. Follow-up was scheduled every three months until the stoma was closed (94 percent). RESULTS There is no relation between stoma type (ileostomy or colostomy) and degree of social restriction (chi-squared test, P = 0.42). The more stoma care problems or complications seen, the higher the degree of social restriction: significantly more stoma care problems were seen in the completely isolated group of patients when compared with the patients who were less socially restricted (Spearman correlation coefficient 1 = 0.35, P = 0.003). Especially stoma leakage, peristomal skin irritation, dietary prescriptions, retraction, and prolapse of the stoma have significant impact on the patient's daily life. CONCLUSION Stoma surgery has a great influence on a patient's daily life. There is a clear relation between the number of stoma care problems and the degree of social restriction. Follow-up of stoma patients under close surveillance of stoma care nurse to minimize stoma care problems and a careful surgical technique are advocated for good stoma care.
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Affiliation(s)
- A W Gooszen
- Department of Surgery, University Hospital Utrecht, The Netherlands
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Gooszen AW, Geelkerken RH, Hermans J, Lagaay MB, Gooszen HG. Temporary decompression after colorectal surgery: randomized comparison of loop ileostomy and loop colostomy. Br J Surg 1998; 85:76-9. [PMID: 9462389 DOI: 10.1046/j.1365-2168.1998.00526.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Loop ileostomy or loop transverse colostomy for temporary decompression of a left colonic anastomosis represents an important issue in abdominal surgery. METHODS A randomized study, comparing loop ileostomy (n = 37; group 1) or loop transverse colostomy (n = 39; group 2), was conducted. Patients were followed from construction to closure of the stoma. RESULTS Age, weight, sex and indication for surgery were similar in both groups. After stoma construction complications were reported in nine of 37 patients in group 1 and in one of 39 in group 2 (P < 0.01), leading to postoperative death in five of 37 in group 1 and one of 39 in group 2. In the period between stoma construction and closure significant differences were observed only in prolapse rate (one of 32 group 1, 16 of 38 group 2; P < 0.01), need for temporary adaptation of clothing (eight of 32 group 1, 22 of 38 group 2; P < 0.01) and dietary guidelines (23 of 32 group 1, four of 38 group 2; P < 0.01). One patient died in group 1 and four in group 2; the deaths were not stoma related. After stoma closure eight of 29 patients in group 1 had complications and there were two deaths compared with three of 32 and no deaths in group 2. CONCLUSION Both types of stoma carry a high complication rate with a considerable associated mortality rate. The interval between stoma construction and closure has substantial impact on social and economic status. Based on all three phases studied, routine use of transverse colostomy is advised if decompression of the left colon is indicated.
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Affiliation(s)
- A W Gooszen
- Department of Surgery, University Hospital of Utrecht, The Netherlands
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Timmermans DR, Gooszen AW, Geelkerken RH, Tollenaar RA, Gooszen HG. Analysis of the variety in surgeons' decision strategies for the management of left colonic emergencies. Med Care 1997; 35:701-13. [PMID: 9219497 DOI: 10.1097/00005650-199707000-00004] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The aim of this study is to analyze surgeons' decision strategies about the optimal treatment for acute sigmoid resection for different patients. In particular, the authors wished to determine the predominant accepted treatment choice among surgeons, to determine the importance of patient characteristics for surgeons' evaluations of the appropriateness of treatments, and to identify the variety in decision strategies. METHODS A survey was carried out among all surgical members of the Netherlands Society of Gastro Intestinal Surgery, who evaluated 16 patient cases. Approximately 70% of the members completed the survey. RESULTS Overall, the predominant accepted strategy is resection, delayed anastomosis, and colostomy (Hartmann procedure). Consensus in terms of preferred treatment, however, was low. The most important factors influencing surgeons' evaluations of the appropriateness of treatments were the age of a patient, the degree of peritonitis, and the degree of fecal contamination. Further analysis showed that the variety in surgeons' decision strategies could not be explained by differences in experience, but was shown to be related to the evaluation of the appropriateness of treatment for 60-year-old patients and patients with a local peritonitis. Except for these factors, surgeons did not differ fundamentally in the evaluation of the factors that make a treatment more appropriate. Surgeons agreed about the optimal treatment for older patients in poor condition, although there is no epidemiologic literature to support this consensus position. CONCLUSIONS This study showed that lack of consensus in surgeons' choice of treatment could be explained partly by disagreement of the appropriateness of treatments for some, rather than all, patients.
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Affiliation(s)
- D R Timmermans
- Medical Decision Making Unit, Leiden University, The Netherlands
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van den Bosch HC, Tjon a Tham RT, Gooszen AW, Fauquenot-Nollen JM, Lamers CB. Celiac disease: small-bowel enteroclysis findings in adult patients treated with a gluten-free diet. Radiology 1996; 201:803-8. [PMID: 8939235 DOI: 10.1148/radiology.201.3.8939235] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE To correlate the radiologic, histopathologic, and clinical findings in patients with celiac disease after treatment with a glutenfree diet. MATERIALS AND METHODS Pretreatment and follow-up enteroclysis radiographs from 15 adult patients with known celiac disease were reviewed. Diagnosis of celiac disease was made at adult age. Changes in small-bowel morphology were determined by comparing enteroclysis findings before and after treatment with a gluten-free diet and were correlated with histopathologic and clinical findings. RESULTS Eight of 15 patients (group I) showed increased small-bowel abnormalities. All patients had increased symptoms, and all but one, whose condition had deteriorated, showed stable disease at biopsy. Group II patients (five of 15) showed improvement at follow-up enteroclysis. Biopsy findings showed improvement in small-bowel morphology in four patients and no change in one. Clinically, four patients showed improvement, and one had stable disease. Group III patients (two of 15) showed no change from initial to follow-up enteroclysis. Both showed partial atrophy, which was consistent with biopsy findings. In all patients, clinical symptoms correlated better with enteroclysis results (r = .48; P < .005) than they did with follow-up biopsy results (r = .18). True celiac disease-related malignancies and coexisting tumors occurred in 10 of 15 patients. CONCLUSION Enteroclysis appears to be more reliable than does biopsy in evaluation of response to a gluten-free diet in adults with celiac disease.
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Affiliation(s)
- H C van den Bosch
- Department of Diagnostic Radiology, Catharina Ziekenhuis, Eindhoven, The Netherlands
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Gooszen AW, Tjon A Tham RT, Veselic M, Bolk JH, Lamers CB. Inflammatory fibroid polyp simulating malignant tumor of the colon in a patient with multiple hamartoma syndrome (Cowden's disease). AJR Am J Roentgenol 1995; 165:1012-3. [PMID: 7676955 DOI: 10.2214/ajr.165.4.7676955] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Gooszen AW, Geelkerken RH, Tollenaar RA, Timmermans DR, Kievit J, Gooszen HG. [Surgical strategy in acute or elective sigmoid resection in The Netherlands; survey based on a marketing model]. Ned Tijdschr Geneeskd 1994; 138:2005-10. [PMID: 7935958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To gain insight into the operative strategies used by Dutch surgeons for complicated diverticulitis and sigmoid carcinoma, and into the influence of patient risk factors and surgeon's experience on the preferred operative strategy. DESIGN Descriptive. METHOD A questionnaire was sent to all 148 members of the Dutch Society of Gastrointestinal Surgery, concerning 32 fictitious patients with sigmoid pathology. It was based on conjoint-analysis, a model used in marketing research. This model analyses qualities that make a product preferable to another product of the same product group. The operative choices were: resection with Hartmann's procedure, resection with primary anastomosis after on-table lavage, or with primary anastomosis only, or no primary resection but diverting stoma only, or some personal technique. The survey focused on experience of the surgeons with the operative procedures, and on treatment choices in four fictitious cases frequently encountered in general surgery. RESULTS There was little agreement concerning the preferred surgical option for treatment of complicated diverticular disease or sigmoid carcinoma. With the exception of one fictitious young, electively operated 'ideal' patient (resection with primary anastomosis) there is hardly any consensus among the surgeons with respect to preferred treatment. CONCLUSIONS Reasons to depart from the conceptually optimal treatment (resection and anastomosis) in complicated cases (from the point of view of the surgeon or the patient), and absence of agreement on responsible other treatment could be differences in appraisal of the importance of several risk factors, or differences in acquired decision making strategies. The literature offers no answer to the question which techniques should be preferred under various circumstances.
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Affiliation(s)
- A W Gooszen
- Academisch Ziekenhuis, afd. Heelkunde, Leiden
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