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P de Ruiter

Publications and source records attributed to P de Ruiter.

At least 19 recordsLinked to original sources
PubMed2003

Implications of removing a normal appendix.

BACKGROUND: The diagnosis of acute appendicitis remains difficult and therefore 15-30% of the removed appendices appear to be normal. The aim of this study was to investigate morbidity, mortality and costs of removing a normal appendix in patients with suspected appendicitis. PATIENTS AND METHODS: Retrospective study of patients who underwent a negative appendectomy for suspected appendicitis in the period 1991-1999 with a median follow-up of 4.4 years. Patients who underwent an elective appendectomy or appendectomy for other reasons were excluded. RESULTS: In 285 patients (70% women, 30% men) a normal appendix was removed. In 192 (67%) patients a muscle-splitting incision was performed, in 6 (2%) a median laparotomy, and in 51 (18%) the normal appendix was removed by laparoscopy. In 36 patients (13%) a diagnostic laparoscopy was converted to a muscle-splitting incision. Complications occurred in 16 (6%) patients, in 5 (2%) a re-operation was needed. The mean hospital stay was 4.4 (SE 2.8) days, in case of complications 7.4 (SE 4.2) days. The mean extra hospital costs of a negative appendectomy were EUR 2712. CONCLUSION: The removal of a normal appendix has considerable complications and costs. In an attempt to prevent these costs, extra diagnostic tools should be considered. Expensive diagnostic tools such as diagnostic laparoscopy should be used selectively in order not to further increase costs.

Adolescent↗
PubMed2001

A normal appendix found during diagnostic laparoscopy should not be removed.

BACKGROUND: Diagnostic laparoscopy has been introduced as a new diagnostic tool for suspected appendicitis. While the normal appendix used to be removed routinely, laparoscopy allows us to leave a normal looking appendix in place. This latter strategy is, however, not generally accepted. The long-term results of not removing a normal looking appendix were evaluated. METHODS: This was a prospective evaluation of 109 diagnostic laparoscopies for suspected appendicitis in which a normal looking appendix was left in place. After a median follow-up of 4.4 years a telephone questionnaire was performed. RESULTS: There were no false-negative laparoscopies. In 65 patients (60 per cent) another diagnosis was obtained (group 1). In 44 patients (40 per cent) no diagnosis was obtained (group 2). After a median interval of 8 months, 15 patients presented to the emergency department for symptoms possibly involving the appendix, during the median follow-up of 4.4 years. This resulted in readmission of nine patients, of whom eight were reoperated. In only one patient (1 per cent) was a histologically proven appendicitis found and the appendix removed. Some 105 patients were eligible for follow-up. Of the 100 patients interviewed (95 per cent), nine patients (9 per cent) (six in group 1 and three in group 2) still had recurrent pain in the right lower abdominal quadrant. There were no differences between patients with or without another diagnosis obtained during preceding laparoscopy. CONCLUSION: It is safe to leave a normal looking appendix in place when a diagnostic laparoscopy for suspected appendicitis is performed, even if another diagnosis cannot be found at laparoscopy.

Adult↗
PubMed2001

Phenotypic variation in a family with partial androgen insensitivity syndrome explained by differences in 5alpha dihydrotestosterone availability.

Mutations in the androgen receptor (AR) gene result in a wide range of phenotypes of the androgen insensitivity syndrome (AIS). Inter- and intrafamilial differences in the phenotypic expression of identical AR mutations are known, suggesting modifying factors in establishing the phenotype. Two 46,XY siblings with partial AIS sharing the same AR gene mutation, R846H, but showing very different phenotypes are studied. Their parents are first cousins. One sibling with grade 5 AIS was raised as a girl; the other sibling with grade 3 AIS was raised as a boy. In both siblings serum levels of hormones were measured; a sex hormone-binding globulin (SHBG) suppression test was completed; and mutation analysis of the AR gene, Scatchard, and SDS-PAGE analysis of the AR protein was performed. Furthermore, 5alpha-reductase 2 expression and activity in genital skin fibroblasts were investigated, and the 5alpha-reductase 2 gene was sequenced. The decrease in SHBG serum levels in a SHBG suppression test did not suggest differences in androgen sensitivity as the cause of the phenotypic variation. Also, androgen binding characteristics of the AR, AR expression levels, and the phosphorylation pattern of the AR on hormone binding were identical in both siblings. However, 5alpha-reductase 2 activity was normal in genital skin fibroblasts from the phenotypic male patient but undetectable in genital skin fibroblasts from the phenotypic female patient. The lack of 5alpha-reductase 2 activity was due to absent or reduced expression of 5alpha-reductase 2 in genital skin fibroblasts from the phenotypic female patient. Exon and flanking intron sequences of the 5alpha-reductase 2 gene showed no mutations in either sibling. Additional intragenic polymorphic marker analysis gave no evidence for different inherited alleles for the 5alpha-reductase 2 gene in the two siblings. Therefore, the absent or reduced expression of 5alpha-reductase 2 is likely to be additional to the AIS. Distinct phenotypic variation in this family was caused by 5alpha-reductase 2 deficiency, additional to AIS. This 5alpha-reductase deficiency is due to absence of expression of the 5alpha-reductase iso-enzyme 2 as shown by molecular studies. The distinct phenotypic variation in AIS here is explained by differences in the availability of 5alpha-dihydrotestosterone during embryonic sex differentiation.

3-Oxo-5-alpha-Steroid 4-Dehydrogenase↗
PubMed2000

Selective use of diagnostic laparoscopy in patients with suspected appendicitis.

BACKGROUND: Diagnostic laparoscopy has been introduced as a new diagnostic tool for patients with acute appendicitis. We performed diagnostic laparoscopy when the clinical diagnosis of appendicitis was in doubt. The aims of this study were to evaluate this strategy and to analyze the efficacy of diagnostic laparoscopy in patients with suspected appendicitis. PATIENTS AND METHODS: All patients referred to our hospital with suspected appendicitis during the period 1994-1997 were evaluated prospectively. The clinical diagnosis was determined by the surgeon or resident on call based on the patient's history, physical examination, and leukocyte count. The patients were divided into three groups: group 1: appendicitis not likely. These patients were observed for 24 h or discharged. When they showed signs of appendicitis in 24 h, they were transferred to either group 2 or 3; group 2: doubt concerning diagnosis. These patients underwent diagnostic laparoscopy, and appendectomy was performed if indicated; group 3: In these patients the diagnosis appendicitis was felt to be certain. They were treated by primary appendectomy by an open procedure. In this study, 1,050 patients, 531 women (51%), 389 men (37%), and 130 children (12%) <11 yrs, were evaluated. RESULTS: Altogether, 377 diagnostic laparoscopies were performed, leaving 109 healthy-looking appendices in place. This reduced the negative appendectomy rate from 25% to 14% in all surgically managed patients. The negative appendectomy rate for the women in group 2 was reduced from 49% to 14%, and for the men from 22% to 11%, so it also seemed worthwhile to perform diagnostic laparoscopy in men. Because the appendix sana was left in place in only three children, the benefit from laparoscopy is relatively small for children. In 48% of these patients a second diagnosis was obtained, most of them gynecologic in nature. There were no false-negative laparoscopies and no complications resulting from the laparoscopic procedure. CONCLUSIONS: Diagnostic laparoscopy is a safe procedure that reduced the appendix sana rate without increasing the total number of operations. It is a useful method for obtaining other, mostly gynecologic, diagnoses. To further reduce the appendix sana rate, better criteria for laparoscopic assessment of the appendix are needed.

Acute Disease↗
PubMed1998

[Good short-term and mid-term results after laparoscopic Nissen fundoplication for gastroesophageal reflux].

OBJECTIVE: Analysis of per- and postoperative complications and functional results in the short and medium-long term following Nissen laparoscopic fundoplication for reflux oesophagitis. DESIGN: Prospective, descriptive. SETTING: Academic Hospital of the Free University in Amsterdam and Medical Centre Alkmaar, the Netherlands. METHOD: Between January 1992 and June 1997 in both hospitals, 50 patients with reflux oesophagitis were operated on laparoscopically and investigated pre- and postoperatively according to a protocol involving scoring of symptoms, endoscopy and pH-measurement; in some of the patients, manometry, gastric emptying studies and an insulin provocation test were also performed. RESULTS: There was no surgical mortality. Peroperative complications were seen in five patients. Conversion to laparotomic fundoplication was necessary in five patients. Five patients had mild postoperative complications. The mean hospital stay after operation was 5.5 days. Three to six months after discharge 90% of the patients reported the functional results to be good or perfect (n = 100). After a mean follow-up of 48 months this was 97% (n = 30); recurrence was seen in two patients (7%). Three patients had to be re-operated for severe dysphagia. CONCLUSION: Laparoscopic fundoplication performed by an experienced surgeon is a good technique offering definite advantages to the patient. The short and medium-long term results are good.

Adult↗
PubMed1998

Indications for laparoscopic colorectal surgery. Results from the Medical Centre Alkmaar, The Netherlands.

BACKGROUND: Between November 1991 and May 1995, a series of laparoscopic colectomies were performed in our hospital. METHODS: Our main aim was to define more specifically the indications for laparoscopic colectomy. RESULTS: A total of 69 patients underwent laparoscopic surgery for benign polypoid colorectal disease (n = 10), inflammatory bowel disease (n = 24), and colorectal malignancy (n = 35). Of the latter group, four patients underwent a palliative procedure. The conversion rate of the whole group was 29%. The main reason to convert was infiltrative growth in inflammatory disease or cancer. Respectively, seven (10%) and 12 (17%) patients sustained complications in the perioperative and early postoperative phase. Two patients died perioperatively (3%). The mean hospital stay was 12 days. On follow-up, 11 patients had developed a stenotic anastomosis, which was successfully dilated in all cases. After 3 years, the survival rate according to Kaplan-Meier is 86%, 66%, 68%, and 0% for Dukes' A, B, C, and D color carcinoma, respectively. In one patient with a Dukes B carcinoma, port site metastases were found. CONCLUSIONS: Justifiable indications for laparoscopic colorectal surgery include (a) a benign polyp 20-50 cm from the anal ring; (b) mobile, inflammatory large bowel disease; (c) palliation in case of malignant disease, preferably of the left hemicolon. It remains to be proven that laparoscopic colectomy is superior and not just equivalent to open colectomy. This is especially true for resections of colorectal carcinoma with curative intent. Therefore a cost/benefit analysis should be performed in a prospective, randomized setting.

Adult↗
PubMed1997

Decision analysis in the management of duodenal adenomatosis in familial adenomatous polyposis.

BACKGROUND: Patients with familial adenomatous polyposis are not only at high risk of developing adenomas in the colorectum but a substantial number of patients also develop polyps in the duodenum. Because treatment of duodenal polyps is extremely difficult and it is unknown how many patients ultimately develop duodenal cancer, the value of surveillance of the upper digestive tract is uncertain. AIMS: (1) To assess the cumulative risk of duodenal cancer in a large series of polyposis patients. (2) To develop a decision model to establish whether surveillance would lead to increased life expectancy. METHODS: Risk analysis was performed in 155 Dutch polyposis families including 601 polyposis patients, and 142 Danish families including 376 patients. Observation time was from birth until date of last contact, death, diagnosis of duodenal cancer, or closing date of the study. RESULTS: Seven Dutch and five Danish patients developed duodenal cancer. The lifetime risk of developing this cancer by the age of 70 was 4% (95% confidence interval 1-7%) in the Dutch series and 3% (95% confidence interval 0-6%) in the Danish series. Decision analysis showed that surveillance led to an increase in life expectancy by seven months. CONCLUSIONS: Surveillance of the upper digestive tract led to a moderate gain in life expectancy. Future studies should evaluate whether this increase in life expectancy outweighs the morbidity of endoscopic examination and proximal pancreaticoduodenectomy.

Adenomatous Polyposis Coli↗
PubMed1996

Molecular genetic tests as a guide to surgical management of familial adenomatous polyposis.

BACKGROUND: In familial adenomatous polyposis the only curative treatment is colectomy, and the choice of operation lies between restorative proctocolectomy (RPC) and colectomy with ileorectal anastomosis (IRA). The RPC procedure carries a higher morbidity but, unlike IRA, removes the risk of subsequent rectal cancer. Since the course of familial adenomatous polyposis is influenced by the site of mutation in the polyposis gene, DNA analysis might be helpful in treatment decisions. METHODS: We evaluated the incidence of rectal cancer in polyposis patients who had undergone IRA, and examined whether the requirement for subsequent rectal excision because of cancer or uncontrollable polyps was related to the site of mutation. FINDINGS: Between 1956 and mid-1995, 225 patients registered at the Netherlands Polyposis Registry had undergone IRA. In 87 of them, a pathogenetic mutation was detected. 72 patients had a mutation located before codon 1250 and 15 patients after this codon. The cumulative risk of rectal cancer 20 years after surgery was 12%, and at that time 42% had undergone rectal excision. The risk of secondary surgery was higher in patients with mutations in the region after codon 1250 than in patients with mutations before this codon (relative risk 2.7, p < 0.05). INTERPRETATION: On this evidence, IRA should be the primary treatment for polyposis in patients with mutations before codon 1250, and RPC in those with mutations after this codon.

Adenomatous Polyposis Coli↗
PubMed1996

Stratification for elective laparoscopic cholecystectomy.

BACKGROUND: In a former retrospective study in our clinic, an improvement in patient care was observed after the introduction of laparoscopic cholecystectomy. The aim of this study was to verify whether this improvement could be maintained or even be further improved. METHODS: Retrospective evaluation of all patients who underwent an elective cholecystectomy due to symptomatic cholelithiasis. We compared the results of 1992, the year of the introduction of laparoscopic cholecystectomy with 1993, the year that laparoscopic cholecystectomy became standard procedure. Also we compared specialized with general surgeons. RESULTS: In comparison with 1992 more elective cholecystectomies were performed in 1993 (162 vs 211). In 1993 there were more primary laparoscopic procedures (86 vs 93%) but due to an increase in conversion rate in 1993 (2.5 vs 10%) the overall number of open procedures remained comparable (17 vs 16%). In 1993 there was an increase in cholecystectomies by general surgeons (56 vs 72%). The general surgeons almost doubled their conversion rate in 1993 (6 vs 13%) while that of the specialized surgeons remained comparable (0 vs 2%). Morbidity and mortality remained comparable between 1992 and 1993 and between specialized and general surgeons. CONCLUSIONS: The quality of patient care has not significantly been altered. An improvement could be made if more laparoscopic operations were performed by specialized surgeons, but this would negatively interfere with the working methods of a general hospital. Therefore we suggest stratification: Certain patients, as high-risk patients, preferably should be operated on by specialized surgeons, while routine operations could be performed by general surgeons.

Cholecystectomy, Laparoscopic↗
PubMed1995

[Results of the introduction of laparoscopic cholecystectomy on morbidity and mortality of gallbladder surgery in a large regional hospital].

OBJECTIVE: To analyse the impact of the introduction of laparoscopic cholecystectomy on overall morbidity and mortality of gall bladder surgery. DESIGN: Retrospective study. SETTING: Medisch Centrum Alkmaar, Alkmaar. METHODS: All cholecystectomies performed in our final 'prelaparoscopic' year 1990 were compared with all cholecystectomies performed in 1992, the year in which laparoscopic cholecystectomy has become a standard procedure, thus eliminating selection bias. The analysis included morbidity and mortality related to all procedures. RESULTS: In 1990, 173 open cholecystectomies were performed, in 1992 40, and 146 laparoscopic ones; the conversion rate was 4%. The number of patients undergoing investigation for common bile duct stones did not change, but there was a shift from intraoperative cholangiography to preoperative ERCP. In 1992 more endoscopic sphincterotomies were performed (13.5%, versus 5.4% in 1990; p = 0.02). One patient died from complications due to diagnostic ERCP. There was no difference in mortality rate of all procedures taken together, between the two years (3/186 in 1992 (1.6%); 2/173 in 1990 (1.2%)). The morbidity rate of all procedures in 1992 was slightly less than in 1990 (chi 2 = 1.91; p = 0.2). There were no common bile duct injuries caused by laparoscopy. In 1992, the mean operation time was longer than in 1990 (82 versus 46 min; p < 0.001) and the median postoperative hospital stay was significantly shorter than in 1990 (2 versus 6 days; p < 0.001). CONCLUSION: Introduction of laparoscopic cholecystectomy was responsible for shorter hospital stays and longer operation times. When common bile duct stones were predicted, endoscopic sphincterotomy was performed more frequently. These changes did not negatively influence morbidity and mortality rates for gall bladder surgery in general.

Adolescent↗
PubMed1992

Successful local repair of paracolostomy hernia with a newly developed prosthetic device.

The basic cause of paracolostomy hernia is enlargement of the trephine opening in the abdominal wall, due to tangential forces working on the circumference of the opening. Our attempts of hernia repair with polypropylene mesh were not successful, as the diameter of the hole in the mesh tended to enlarge with time. For this reason we developed a new device, which secures the desired diameter of the opening. The prosthesis consists of a polypropylene ring with an internal diameter of 20, 25 or 30 mm, mounted in the centre of a polypropylene mesh. In 14 patients with a parastomal hernia, complicating an end colostomy, this prosthesis has been used. In one patient the implant had to be removed owing to infection. In the remaining 13 patients no recurrence or other complications have been noted after a median follow-up of 18 months (range 5-35 months). We conclude that the presented prosthetic device seems to be a useful adjunct for the local repair of a paracolostomy hernia.

Adult↗