The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons
Minor injuries of the anterior process of the calcaneus occur frequently and most heal uneventful... more Minor injuries of the anterior process of the calcaneus occur frequently and most heal uneventfully. The present series reports on 6 patients with persistent complaints after anterior process avulsion fractures. The avulsed fragments of the anterior process at the calcaneocuboid joint were surgically excised in all, which resolved the complaints completely in 4 patients and reduced the complaints significantly in 2. If conservative measures fail and the complaints are refractory, debridement of the anterior process avulsion fractures at the calcaneocuboid joint could be a viable option.
To estimate the importance of center and provider effect and its implication on the estimation of... more To estimate the importance of center and provider effect and its implication on the estimation of treatment effect in surgical randomized controlled trials. Provider and center effect may play an important role in the estimated treatment effect of multicenter surgical randomized controlled trials (RCTs). However, such effects are rarely accounted for in surgical RCTs. Analysis of patient-level data from 3 large surgical randomized controlled trials. One trial in ophthalmology comparing retinal detachment rate after retinal reattachment in 225 patients operated on by 32 providers across 10 centers; one trial in orthopaedics comparing Harris Hip Score after total hip replacement in 496 patients operated on by 22 providers across 18 centers; one trial in general surgery comparing recurrence rate of hernia repair in 200 patients operated on by 88 providers across 11 centers. A provider effect and a center effect were searched for by comparing nonadjusted and adjusted models. An analysis of volume (ie, number of procedures performed during the course of the trial) effect and, when relevant, a treatment-by-volume interaction was also sought. A significant provider effect was found in ophthalmology (P < 0.0001); center effect was not significant. In orthopaedics, significant provider (P = 0.0037) and volume effect (P = 0.019) were found; a correlation was found between provider effect and volume (r = 0.5, P = 0.018); moreover, a treatment-by-volume interaction was found (P = 0.033); treatment effect became significant when adjusting for volume and provider. In general surgery, center effect was more prominent than provider effect, although none were found significant. Provider and center effects play a significant role in the estimation of treatment effect of large randomized controlled surgical trials. Not accounting for such effects may lead to biased estimates and misleading conclusions. These effects should be accounted for in the design and analysis of such trials.
Hernia : the journal of hernias and abdominal wall surgery, 2005
Adult umbilical hernia is a common surgical condition mainly encountered in the fifth and sixth d... more Adult umbilical hernia is a common surgical condition mainly encountered in the fifth and sixth decade of life. Despite the high frequency of the umbilical hernia repair procedure, disappointingly high recurrence rates, up to 54% for simple suture repair, are reported. Since both mesh and suture techniques are used in our clinic we set out to investigate the respective recurrence rates and associated complications, retrospectively. Patients who were treated between January 1998 and December 2002 were identified from our hospital database and invited to attend the outpatient department for an extra follow-up, history taking and physical examination. The use of prosthetic material, occurrence of surgical site infection, body mass and height as well as recurrence were recorded at the time of this survey. In total, 131 consecutive patients underwent operative repair of an umbilical hernia. Twenty-eight percent of the patients were female (n = 37). In 12 patients (11%) umbilical hernia r...
Common surgical knowledge is that inguinal hernia repair in premature infants should be postponed... more Common surgical knowledge is that inguinal hernia repair in premature infants should be postponed until they reach a certain weight or age. Optimal management, however, is still under debate. The objective of this study was to collect evidence for the optimal management of inguinal hernia repair in premature infants. In the period between 2010 and 2013, data for all premature infants with inguinal hernia who underwent hernia correction within 3 months after birth in the Erasmus MC-Sophia Children's Hospital, Rotterdam were analyzed. Primary outcomes measures were the incidences of incarceration and subsequent emergency surgery. In a multivariate analysis, Cox proportional hazards model served to identify independent risk factors for incarceration requiring an emergency procedure. A total of 142 premature infants were included in the analysis. Median follow-up was 28 months (range 15 to 39 months). Seventy-nine premature infants (55.6%) presented with a symptomatic inguinal hernia; emergency surgery was performed in 55.7%. Complications occurred in 27.3% of emergency operations vs 10.2% after elective repair; recurrences occurred in 13.6% vs 2.0%, respectively. Very low birth weight (≤1,500 g) was an independent risk factor for emergency surgery, with a hazard ratio of 2.7 in the Cox proportional hazards model. More than half of premature infants with an inguinal hernia have incarceration. Those with very low birth weight have a 3-fold greater risk of requiring an emergency procedure than heavier premature infants. Emergency repair results in higher recurrence rates and more complications. Elective hernia repair is recommended, particularly in very low birth weight premature infants.
It has been suggested that early development of the incisional hernia is caused by perioperative ... more It has been suggested that early development of the incisional hernia is caused by perioperative factors, such as surgical technique and wound infection. Late development may implicate other factors, such as connective tissue disorders. Our objective was to establish whether incisional hernia develops early after abdominal surgery (i.e., during the first postoperative month). Patients who underwent a midline laparotomy between 1995 and 2001 and had had a computed tomography (CT) scan of the abdomen during the first postoperative month were identified retrospectively. The distance between the two rectus abdominis muscles was measured on these CT scans, after which several parameters were calculated to predict incisional hernia development. Hernia development was established clinically through chart review or, if the chart review was inconclusive, by an outpatient clinic visit. The average and maximum distances between the left and right rectus abdominis muscles were significantly larger in patients with subsequent incisional hernia development than in those without an incisional hernia (P < 0.0001). Altogether, 92% (23/25) of incisional hernia patients had a maximum distance of more than 25 mm compared to only 18% (5/28) of patients without an incisional hernia (P < 0.0001). Incisional hernia occurrence can thus be predicted by measuring the distance between the rectus abdominis muscles on a postoperative CT scan. Although an incisional hernia develops within weeks of surgery, its clinical manifestation may take years. Our results indicate perioperative factors as the main cause of incisional hernias. Therefore, incisional hernia prevention should focus on perioperative factors.
The objective of this study was to determine the best treatment of incisional hernia, taking into... more The objective of this study was to determine the best treatment of incisional hernia, taking into account recurrence, complications, discomfort, cosmetic result, and patient satisfaction. Long-term results of incisional hernia repair are lacking. Retrospective studies and the midterm results of this study indicate that mesh repair is superior to suture repair. However, many surgeons are still performing suture repair. Between 1992 and 1998, a multicenter trial was performed, in which 181 eligible patients with a primary or first-time recurrent midline incisional hernia were randomly assigned to suture or mesh repair. In 2003, follow-up was updated. Median follow-up was 75 months for suture repair and 81 months for mesh repair patients. The 10-year cumulative rate of recurrence was 63% for suture repair and 32% for mesh repair (P < 0.001). Abdominal aneurysm (P = 0.01) and wound infection (P = 0.02) were identified as independent risk factors for recurrence. In patients with small incisional hernias, the recurrence rates were 67% after suture repair and 17% after mesh repair (P = 0.003). One hundred twenty-six patients completed long-term follow-up (median follow-up 98 months). In the mesh repair group, 17% suffered a complication, compared with 8% in the suture repair group (P = 0.17). Abdominal pain was more frequent in suture repair patients (P = 0.01), but there was no difference in scar pain, cosmetic result, and patient satisfaction. Mesh repair results in a lower recurrence rate and less abdominal pain and does not result in more complications than suture repair. Suture repair of incisional hernia should be abandoned.
To estimate the importance of center and provider effect and its implication on the estimation of... more To estimate the importance of center and provider effect and its implication on the estimation of treatment effect in surgical randomized controlled trials. Provider and center effect may play an important role in the estimated treatment effect of multicenter surgical randomized controlled trials (RCTs). However, such effects are rarely accounted for in surgical RCTs. Analysis of patient-level data from 3 large surgical randomized controlled trials. One trial in ophthalmology comparing retinal detachment rate after retinal reattachment in 225 patients operated on by 32 providers across 10 centers; one trial in orthopaedics comparing Harris Hip Score after total hip replacement in 496 patients operated on by 22 providers across 18 centers; one trial in general surgery comparing recurrence rate of hernia repair in 200 patients operated on by 88 providers across 11 centers. A provider effect and a center effect were searched for by comparing nonadjusted and adjusted models. An analysis of volume (ie, number of procedures performed during the course of the trial) effect and, when relevant, a treatment-by-volume interaction was also sought. A significant provider effect was found in ophthalmology (P < 0.0001); center effect was not significant. In orthopaedics, significant provider (P = 0.0037) and volume effect (P = 0.019) were found; a correlation was found between provider effect and volume (r = 0.5, P = 0.018); moreover, a treatment-by-volume interaction was found (P = 0.033); treatment effect became significant when adjusting for volume and provider. In general surgery, center effect was more prominent than provider effect, although none were found significant. Provider and center effects play a significant role in the estimation of treatment effect of large randomized controlled surgical trials. Not accounting for such effects may lead to biased estimates and misleading conclusions. These effects should be accounted for in the design and analysis of such trials.
The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons
Minor injuries of the anterior process of the calcaneus occur frequently and most heal uneventful... more Minor injuries of the anterior process of the calcaneus occur frequently and most heal uneventfully. The present series reports on 6 patients with persistent complaints after anterior process avulsion fractures. The avulsed fragments of the anterior process at the calcaneocuboid joint were surgically excised in all, which resolved the complaints completely in 4 patients and reduced the complaints significantly in 2. If conservative measures fail and the complaints are refractory, debridement of the anterior process avulsion fractures at the calcaneocuboid joint could be a viable option.
To estimate the importance of center and provider effect and its implication on the estimation of... more To estimate the importance of center and provider effect and its implication on the estimation of treatment effect in surgical randomized controlled trials. Provider and center effect may play an important role in the estimated treatment effect of multicenter surgical randomized controlled trials (RCTs). However, such effects are rarely accounted for in surgical RCTs. Analysis of patient-level data from 3 large surgical randomized controlled trials. One trial in ophthalmology comparing retinal detachment rate after retinal reattachment in 225 patients operated on by 32 providers across 10 centers; one trial in orthopaedics comparing Harris Hip Score after total hip replacement in 496 patients operated on by 22 providers across 18 centers; one trial in general surgery comparing recurrence rate of hernia repair in 200 patients operated on by 88 providers across 11 centers. A provider effect and a center effect were searched for by comparing nonadjusted and adjusted models. An analysis of volume (ie, number of procedures performed during the course of the trial) effect and, when relevant, a treatment-by-volume interaction was also sought. A significant provider effect was found in ophthalmology (P < 0.0001); center effect was not significant. In orthopaedics, significant provider (P = 0.0037) and volume effect (P = 0.019) were found; a correlation was found between provider effect and volume (r = 0.5, P = 0.018); moreover, a treatment-by-volume interaction was found (P = 0.033); treatment effect became significant when adjusting for volume and provider. In general surgery, center effect was more prominent than provider effect, although none were found significant. Provider and center effects play a significant role in the estimation of treatment effect of large randomized controlled surgical trials. Not accounting for such effects may lead to biased estimates and misleading conclusions. These effects should be accounted for in the design and analysis of such trials.
Hernia : the journal of hernias and abdominal wall surgery, 2005
Adult umbilical hernia is a common surgical condition mainly encountered in the fifth and sixth d... more Adult umbilical hernia is a common surgical condition mainly encountered in the fifth and sixth decade of life. Despite the high frequency of the umbilical hernia repair procedure, disappointingly high recurrence rates, up to 54% for simple suture repair, are reported. Since both mesh and suture techniques are used in our clinic we set out to investigate the respective recurrence rates and associated complications, retrospectively. Patients who were treated between January 1998 and December 2002 were identified from our hospital database and invited to attend the outpatient department for an extra follow-up, history taking and physical examination. The use of prosthetic material, occurrence of surgical site infection, body mass and height as well as recurrence were recorded at the time of this survey. In total, 131 consecutive patients underwent operative repair of an umbilical hernia. Twenty-eight percent of the patients were female (n = 37). In 12 patients (11%) umbilical hernia r...
Common surgical knowledge is that inguinal hernia repair in premature infants should be postponed... more Common surgical knowledge is that inguinal hernia repair in premature infants should be postponed until they reach a certain weight or age. Optimal management, however, is still under debate. The objective of this study was to collect evidence for the optimal management of inguinal hernia repair in premature infants. In the period between 2010 and 2013, data for all premature infants with inguinal hernia who underwent hernia correction within 3 months after birth in the Erasmus MC-Sophia Children's Hospital, Rotterdam were analyzed. Primary outcomes measures were the incidences of incarceration and subsequent emergency surgery. In a multivariate analysis, Cox proportional hazards model served to identify independent risk factors for incarceration requiring an emergency procedure. A total of 142 premature infants were included in the analysis. Median follow-up was 28 months (range 15 to 39 months). Seventy-nine premature infants (55.6%) presented with a symptomatic inguinal hernia; emergency surgery was performed in 55.7%. Complications occurred in 27.3% of emergency operations vs 10.2% after elective repair; recurrences occurred in 13.6% vs 2.0%, respectively. Very low birth weight (≤1,500 g) was an independent risk factor for emergency surgery, with a hazard ratio of 2.7 in the Cox proportional hazards model. More than half of premature infants with an inguinal hernia have incarceration. Those with very low birth weight have a 3-fold greater risk of requiring an emergency procedure than heavier premature infants. Emergency repair results in higher recurrence rates and more complications. Elective hernia repair is recommended, particularly in very low birth weight premature infants.
It has been suggested that early development of the incisional hernia is caused by perioperative ... more It has been suggested that early development of the incisional hernia is caused by perioperative factors, such as surgical technique and wound infection. Late development may implicate other factors, such as connective tissue disorders. Our objective was to establish whether incisional hernia develops early after abdominal surgery (i.e., during the first postoperative month). Patients who underwent a midline laparotomy between 1995 and 2001 and had had a computed tomography (CT) scan of the abdomen during the first postoperative month were identified retrospectively. The distance between the two rectus abdominis muscles was measured on these CT scans, after which several parameters were calculated to predict incisional hernia development. Hernia development was established clinically through chart review or, if the chart review was inconclusive, by an outpatient clinic visit. The average and maximum distances between the left and right rectus abdominis muscles were significantly larger in patients with subsequent incisional hernia development than in those without an incisional hernia (P < 0.0001). Altogether, 92% (23/25) of incisional hernia patients had a maximum distance of more than 25 mm compared to only 18% (5/28) of patients without an incisional hernia (P < 0.0001). Incisional hernia occurrence can thus be predicted by measuring the distance between the rectus abdominis muscles on a postoperative CT scan. Although an incisional hernia develops within weeks of surgery, its clinical manifestation may take years. Our results indicate perioperative factors as the main cause of incisional hernias. Therefore, incisional hernia prevention should focus on perioperative factors.
The objective of this study was to determine the best treatment of incisional hernia, taking into... more The objective of this study was to determine the best treatment of incisional hernia, taking into account recurrence, complications, discomfort, cosmetic result, and patient satisfaction. Long-term results of incisional hernia repair are lacking. Retrospective studies and the midterm results of this study indicate that mesh repair is superior to suture repair. However, many surgeons are still performing suture repair. Between 1992 and 1998, a multicenter trial was performed, in which 181 eligible patients with a primary or first-time recurrent midline incisional hernia were randomly assigned to suture or mesh repair. In 2003, follow-up was updated. Median follow-up was 75 months for suture repair and 81 months for mesh repair patients. The 10-year cumulative rate of recurrence was 63% for suture repair and 32% for mesh repair (P < 0.001). Abdominal aneurysm (P = 0.01) and wound infection (P = 0.02) were identified as independent risk factors for recurrence. In patients with small incisional hernias, the recurrence rates were 67% after suture repair and 17% after mesh repair (P = 0.003). One hundred twenty-six patients completed long-term follow-up (median follow-up 98 months). In the mesh repair group, 17% suffered a complication, compared with 8% in the suture repair group (P = 0.17). Abdominal pain was more frequent in suture repair patients (P = 0.01), but there was no difference in scar pain, cosmetic result, and patient satisfaction. Mesh repair results in a lower recurrence rate and less abdominal pain and does not result in more complications than suture repair. Suture repair of incisional hernia should be abandoned.
To estimate the importance of center and provider effect and its implication on the estimation of... more To estimate the importance of center and provider effect and its implication on the estimation of treatment effect in surgical randomized controlled trials. Provider and center effect may play an important role in the estimated treatment effect of multicenter surgical randomized controlled trials (RCTs). However, such effects are rarely accounted for in surgical RCTs. Analysis of patient-level data from 3 large surgical randomized controlled trials. One trial in ophthalmology comparing retinal detachment rate after retinal reattachment in 225 patients operated on by 32 providers across 10 centers; one trial in orthopaedics comparing Harris Hip Score after total hip replacement in 496 patients operated on by 22 providers across 18 centers; one trial in general surgery comparing recurrence rate of hernia repair in 200 patients operated on by 88 providers across 11 centers. A provider effect and a center effect were searched for by comparing nonadjusted and adjusted models. An analysis of volume (ie, number of procedures performed during the course of the trial) effect and, when relevant, a treatment-by-volume interaction was also sought. A significant provider effect was found in ophthalmology (P < 0.0001); center effect was not significant. In orthopaedics, significant provider (P = 0.0037) and volume effect (P = 0.019) were found; a correlation was found between provider effect and volume (r = 0.5, P = 0.018); moreover, a treatment-by-volume interaction was found (P = 0.033); treatment effect became significant when adjusting for volume and provider. In general surgery, center effect was more prominent than provider effect, although none were found significant. Provider and center effects play a significant role in the estimation of treatment effect of large randomized controlled surgical trials. Not accounting for such effects may lead to biased estimates and misleading conclusions. These effects should be accounted for in the design and analysis of such trials.
Uploads
Papers by Jens Halm