Background
Informed consent (IC) is a process requiring a competent doctor, adequate transfer of information, and consent of the patient. It is not just a signature on a piece of paper. Current ...consent processes in surgery are probably outdated and may require major changes to adjust them to modern day legislation. A literature search may provide an opportunity for enhancing the quality of the surgical IC (SIC) process.
Methods
Relevant English literature obtained from PubMed, Picarta, PsycINFO, and Google between 1993 and 2009 was reviewed.
Results
The body of literature with respect to SIC is slim and of moderate quality. The SIC process is an underestimated part of surgery and neither surgeons nor patients sufficiently realize its importance. Surgeons are not specifically trained and lack the competence to guide patients through a legally correct SIC process. Computerized programs can support the SIC process significantly but are rarely used for this purpose.
Conclusions
IC should be integrated into our surgical practice. Unfortunately, a big gap exists between the theoretical/legal best practice and the daily practice of IC. An optimally informed patient will have more realistic expectations regarding a surgical procedure and its associated risks. Well-informed patients will be more satisfied and file fewer legal claims. The use of interactive computer-based programs provides opportunities to improve the SIC process.
This study aimed to determine whether a fasciectomy for recurrent chronic exertional compartment syndrome of the anterior leg (ant-CECS) after a minimally invasive fasciotomy is safe and beneficial.
...Demographics and clinical course of patients undergoing a fasciectomy for ongoing exercise-related leg pain (ERLP) after an earlier minimally invasive fasciotomy for ant-CECS were prospectively obtained using questionnaires. Patient-reported severity and frequency of pain, tightness, weakness, cramping, and paresthesia in rest and during exercise were scored before and after surgery. A successful outcome was defined as a self-reported good or excellent result.
Between January 2013 and March 2019, 24 of the 958 patients evaluated for ERLP were included in the study (15 females; median age, 24 yr; range, 14-37 yr). Intracompartmental pressure values before the minimally invasive fasciotomy and before the fasciectomy were not different. Perioperative findings were fibrotic bands, pseudofascias, or complete fusions of fascial edges. Postoperative superficial wound infections requiring oral antibiotics occurred in four legs. After rehabilitation, the total symptom scores during exercise and resting conditions decreased threefold compared with preoperatively (exercise, 55 ± 5 to 17 ± 3, P < 0.001; rest, 30 ± 4 to 10 ± 2, P < 0.001). All cardinal symptoms decreased significantly, but the largest improvements were reported for pain and tightness. At follow-up (median, 12 months; range, 2-65 months), 79% of patients reported a successful outcome, whereas 75% had returned to physical activity.
An anterior fasciectomy with associated treatment of correlated pathologies can be safe and beneficial in patients with ongoing ERLP who previously underwent a minimally invasive fasciotomy for ant-CECS.
Objective Prevalence of peripheral arterial disease is equal in men and women. However, women seem to suffer more from the burden of disease. Current studies on gender-related outcomes following ...supervised exercise therapy (SET) for intermittent claudication (IC) yield conflicting results. Methods A follow-up analysis was performed on data from the 2010 Exercise Therapy in Peripheral Arterial Disease (EXITPAD) study, a multicenter randomized controlled trial including IC patients receiving SET or a walking advice. The SET program was supervised by physiotherapists and included interval-based treadmill walking approximating maximal pain combined with activities such as cycling and rowing. Patients usually started with three 30-minute sessions a week. Training frequency was adapted during the following year on the basis of individual needs. The primary outcome was gender differences regarding the change in absolute claudication distance (ACD) after SET. ACD was defined as the number of meters that a patient had covered just before he or she was forced to stop walking because of intolerable pain. Secondary outcomes were gender differences in change of functional walking distance, quality of life, and walking (dis)ability after SET. Walking distances were obtained by standardized treadmill testing according to the Gardner-Skinner protocol. Quality of life was measured by the 36-Item Short Form Health Survey, and walking (dis)ability was determined by the Walking Impairment Questionnaire (WIQ). Measurements were performed at baseline and after 3, 6, 9, and 12 months. Only patients who met the 12-month follow-up measure were included in the analysis. Results A total of 113 men and 56 women were available for analysis. At baseline, groups were similar in terms of clinical characteristics and ACD walking distances (men, 250 meters; women, 270 meters; P = .45). ACD improved for both sexes. However, ACD increase was significantly lower for women than for men during the first 3 months of SET (Δ 280 meters for men vs Δ 220 meters for women; P = .04). Moreover, absolute walking distance was significantly shorter for women compared with men after 1 year (565 meters vs 660 meters; P = .032). Women also reported less on several WIQ subdomains, although total WIQ score was similar (0.69 for men vs 0.61 for women; P = .592). No differences in quality of life after SET were observed. Conclusions Women with IC benefit less during the first 3 months of SET and have lower absolute walking distances after 12 months of follow-up compared with men. More research is needed to determine whether gender-based IC treatment strategies are required.
Purpose
Anterior cutaneous nerve entrapment (ACNES) is characterized by neuropathic pain in a predictable, circumscript abdominal area. The diagnostic delay is long, with half of ACNES-affected ...individuals reporting nausea, bloating, or loss of appetite mimicking visceral disease. The aim of this study was to describe these phenomena and to determine whether treatment could successfully reverse the visceral symptoms.
Methods
This prospective observational study was conducted between July 2017 and December 2020 at SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven. Adult patients who fulfilled published criteria for ACNES and reported at least one visceral symptom at intake were eligible for the study. A self-developed Visceral Complaints ACNES Score (VICAS) questionnaire that scores several visceral symptoms (minimum 1 point, maximum 9 points) was completed before and after therapy. The success of treatment was defined as at least 50% reduction in pain.
Results
Data from 100 selected patients (86 females) aged 39 ± 5 years were available for analysis. Frequently reported symptoms were abdominal bloating (78%), nausea (66%) and altered defecation (50%). Successful treatment significantly reduced the number of visceral symptoms, with a VICAS before of 3 (range 1–8) and after of 1 (range 0–6) (
p
< 0.001). A low baseline VICAS was associated with successful treatment outcome (OR 0.738, 95% CI 0.546–0.999).
Conclusion
Patients with ACNES may report a variety of visceral symptoms. Successful treatment substantially reduces these visceral symptoms in selected patients.
To clarify the role of a surgical neurectomy on pain in refractory patients after conservatively treated anterior cutaneous nerve entrapment syndrome (ACNES).
ACNES is hardly ever considered in the ...differential diagnosis of chronic abdominal pain. Treatment is usually conservative. However, symptoms are often recalcitrant.
Patients older than 18 years with a diagnosis of ACNES were randomized to undergo a neurectomy or a sham procedure via an open surgical procedure in day care. Both the patient and the principal investigator were blinded to the nature of surgery. Pain was recorded using a visual analog scale (1-100 mm) and a verbal rating scale (score 0-5; 0 = no pain, 5 = severe pain) before surgery and 6 weeks postoperatively. A reduction of at least 50% in the visual analog scale score and/or 2 points on the verbal rating scale was considered a "successful response."
Forty-four patients were randomized between August 2008 and December 2010 (39 women, median age = 42 years; both groups, n = 22). In the neurectomy group, 16 patients reported a successful pain response. In contrast, significant pain reduction was obtained in 4 patients in the sham group (P = 0.001). Complications associated with surgery were hematoma (n = 5, conservative treatment), infection (antibiotic and drainage, n = 1), and worsened pain (n = 1).
Neurectomy of the intercostal nerve endings at the level of the abdominal wall is an effective surgical procedure for pain reduction in ACNES patients who failed to respond to a conservative regimen.
Background
Some patients with persistent inguinodynia following a Lichtenstein hernia repair fail all non-surgical treatments. Characteristics of mesh-related pain are not well described whereas a ...meshectomy is controversial. Aims were to define mesh-related pain symptoms, to investigate long-term effects of a meshectomy and to provide recommendations on meshectomy.
Methods
Consecutive patients undergoing open meshectomy with/without selective neurectomy for chronic inguinodynia following Lichtenstein repair were analysed including a follow-up questionnaire. Outcome measures were complications, satisfaction (excellent, good, moderate, poor) and hernia recurrence rate. Recommendations for meshectomy are proposed based on a literature review.
Results
Seventy-four patients (67 males, median age 56 years) underwent mesh removal (exclusively mesh, 26%; combined with tailored neurectomy, 74%) between June 2006 and March 2015 in a single centre. Complications were intraoperatively recognized small bowel injury (
n
= 1) and testicular atrophy (
n
= 2). A 64% excellent/good long-term result was attained (median 18 months). Success rates of a meshectomy (63%) or combined with a neurectomy (64%) were similar. Five hernia recurrences occurred during follow-up (7%). A patient with a pure mesh-related groin pain characteristically reports a ‘foreign body feeling’. Pain intensifies during hip flexion (car driving) and is attenuated following hip extension or supine position. Palpation is painful along the inguinal ligament whereas neuropathic characteristics (hyperpathic skin, trigger points) are lacking.
Conclusions
Mesh removal either or not combined with tailored neurectomy is beneficial in two of three patients with characteristics of mesh-related inguinodynia following Lichtenstein hernia repair who are refractory to alternative pain treatments.
The Dutch College of General Practitioners' guideline on peripheral arterial disease (PAD) provides clear recommendations on the management of PAD. An ankle brachial index (ABI) measurement, ...prescription of antiplatelet drugs and statins, and supervised exercise therapy (SET) for intermittent claudication (IC) are advised. The aims of this study were to determine the adherence of general practitioners (GPs) to their own guideline on PAD and to evaluate the reliability of primary care ABI measurements.
This was a cross-sectional study. All patients suspected of having symptomatic PAD who were referred by GPs to a large hospital in 2015 were evaluated regarding three of the guideline criteria: (i) ABI measurement; (ii) prescription of secondary prevention; (iii) initiation of SET. ABI values obtained in primary care and the hospital's vascular laboratory were compared using correlation coefficients and regression analysis. An abnormal ABI was defined as a value <.9 (normal ABI ≥.9).
Of 308 potential patients with new onset PAD, 58% (n = 178) had undergone ABI measurement prior to referral. A modest correlation between ABI values obtained in primary care and the vascular laboratory was found (r = .63, p < .001). Furthermore, a moderate reliability was calculated (intraclass correlation coefficient 0.60, 95% confidence interval 0.49–0.69, p < .001). Of the new patients with an abnormal ABI, 59% used antiplatelet drugs and 55% used statins. A referral for SET was initiated by a GP in 10% of new PAD patients with IC symptoms.
Adherence by Dutch GPs to their own society's PAD guideline has room for improvement. The reliability of ABI measurements is suboptimal, whereas rates of prescription of secondary prevention and initiation of SET as primary treatment for IC need upgrading.
This study compares tender point infiltration (TPI) and a tailored neurectomy as the preferred treatment for chronic inguinodynia after inguinal herniorraphy.
Some 11% of patients develop chronic ...discomfort after open inguinal herniorraphy. Both TPI and neurectomy have been suggested as treatment options, but evidence is conflicting.
Patients with chronic neuropathic pain after primary Lichtenstein repair and >50% pain reduction after a diagnostic TPI were randomized for repeated TPI (combined Lidocaine/corticosteroids /hyaluronic acid injection) or for a neurectomy. Primary outcome was success (>50% pain reduction using Visual Analog Scale, VAS) after 6 months. Cross-over to neurectomy was offered if TPI was unsuccessful.
A total of 54 patients were randomized in a single center between January 2006 and October 2013. Baseline VAS was similar (TPI: 55, range 10-98 vs neurectomy: 53, range 18-82, P = 0.86). TPI was successful in 22% (n = 6), but a neurectomy was successful in 71% (n = 17, P = 0.001). After unsuccessful TPI, 19 patients crossed over to neurectomy and their median VAS score dropped from 60 to 14 (P = 0.001). No major complications after surgery were reported. Two-thirds of patients on worker's compensation returned to work.
A tailored neurectomy is 3 times more effective than tender point infiltration in chronic inguinodynia after anterior inguinal hernia mesh repair. A step up treatment stratagem starting with tender point infiltration followed by a tailored neurectomy is advised.
Background
Chronic abdominal pain in children is occasionally caused by anterior cutaneous nerve entrapment syndrome (ACNES). Diagnosing and treating this typical peripheral abdominal wall neuropathy ...is challenging. Management usually starts with minimally invasive tender point injections. Nevertheless, these injections can be burdensome and might even be refused by children or their parents. However, a surgical neurectomy is far more invasive. Treatment with a Lidocaine 5% medicated patch is successfully used in a variety of peripheral neuropathies.
Aims
This single center retrospective case series aimed to evaluate the effectiveness and tolerability of lidocaine patches in children with ACNES.
Methods
Children aged under 18 diagnosed with ACNES who were treated with a 10 day lidocaine patch treatment between December 2021 and December 2022 were studied. Patient record files were used to collect treatment outcomes including pain reduction based on NRS and complications.
Results
Twelve of sixteen children (mean age 13 years; F:M ratio 3:1) diagnosed with ACNES started the lidocaine patch treatment. Two patients achieved a pain free status and remained pain free during a 4 and 7 months follow‐up. A third child reported a lasting pain reduction, but discontinued treatment due to a temporary local skin rash. Five additional patients reported pain reduction only during application of the patch. The remaining four children experienced no pain relief. No adverse effects were reported.
Conclusion
Lidocaine patches provides pain relief in a substantial portion of children with ACNES.
BackgroundIt is unclear whether supervised exercise therapy (SET), home based exercise therapy (HBET), and endovascular revascularisation (ER) for intermittent claudication (IC) have a meaningful ...impact on physical activity, despite extensive research on their effect on walking performance. MethodsMultiple databases were searched systematically up to May 2018 for randomised controlled trials with objective measurements of physical activity in patients with IC. A Bayesian network meta-analysis was performed comparing the change in physical activity between baseline and follow up between treatments (SET, HBET, ER) and control (usual care). The standardised mean difference (SMD) with 95% credible interval (CI) was calculated as a summary statistic and converted into steps per day to aid interpretation. ResultsEight trials involving 656 patients with IC investigating the short-term effect of treatment on daily physical activity were included. Both SET (SMD 0.41, 95% CI 0.10–0.72: this corresponds to a difference of + 803 steps/day on a pedometer) and HBET (SMD 0.50, 95% CI 0.18–0.88: + 980 steps/day) displayed a benefit over control, based on evidence of moderate and low quality, respectively. The benefit of ER compared with control was SMD 0.36 (95% CI –0.22 to 0.99: + 705 steps/day), but only one trial supplied direct evidence, resulting in a low rating of the quality of evidence. Comparisons between treatments yielded no statistically significant differences. The results were robust to several sensitivity analyses. ConclusionSET improves daily physical activity levels in patients with IC over control. HBET may have a similar benefit, while invasive treatment failed to lead to a statistically significant improvement of physical activity compared with control. However, the underlying quality of evidence for comparisons with ER and HBET is low, impeding definite conclusions.
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