Analgesic effect of bupivacaine on extraperitoneal laparoscopic hernia repair

BACKGROUND: Occurrence of cryptococcal endophthalmitis is rare and commonly is associated with widespread disseminated diseases. The authors report here a well-documented case of endogenous cryptococcal endophthalmitis without the preceding meningeal infection. METHODS: A 45-year-old female with a history of long-term use of systemic corticosteroid and cytotoxic drugs for systemic lupus erythematosus suffered from progressive visual loss in her left eye over 1 month. Large exudative retinal detachment and severe vitreous infiltration were observed. RESULTS: Histopathologic study of the retinal biopsy specimen established the diagnosis of cryptococcal endophthalmitis. Subsequent positive histopathologic study of the aspiration vitreous smear and epiretinal membrane confirmed the recurrence and persistence of the disease over 4 months after the initial presentation. Systemic amphotericin B-fluconazole and two doses of intravitreous amphotericin B injection eliminated the infection successfully. CONCLUSION: The authors report here a well-documented case of cryptococcal endophthalmitis and present the serial clinical and histopathologic pictures. The importance of retinal biopsy in diagnosis and the combined form of antifungal treatment also are shown.     

Laparoscopic vs open inguinal hernia repair. A randomized, controlled trial

Linear birefringence, an optical property that results from a material's structure and composition, can be used to study dynamic changes in tissue structure. Single, 200 microseconds-long pulses from a Ho:YAG laser emitting 2.1 microns radiation were used to induce changes in the linear birefringence of rat tail tendon. Such changes were measured on a millisecond timescale. The measured rate coefficients describing the denaturation are not predicted by previous studies of collagen denaturation induced by slower, lower-temperature heating. Two types of laser-induced collagen denaturation can be differentiated: thermal denaturation, which appears rate-limited, and thermomechanical denaturation, which is observed at higher laser radiant exposures. Neither process is described by standard Arrhenius-type kinetic models.     

A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair

BACKGROUND: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open). METHODS: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences. RESULTS: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open. CONCLUSIONS: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced.     

Overview of randomized trials in laparoscopic inguinal hernia repair

Purified phenolic glycolipid (PGL-1) from Mycobacterium leprae was used to detect IgG antibodies against PGL-1 in leprosy patients in an enzyme-linked immunosorbent assay (ELISA). A total of 698 sera were screened; they came from patients suffering from leprosy, autoimmune disease, myeloma, tuberculosis and sexually transmitted diseases (STDs). Cases with miscellaneous diseases and persons undergoing AIDS screening were also included. Sera from lepromatous and tuberculoid leprosy patients gave positivity rates of 60.5% and 41.7%, respectively. In non-leprosy cases, the PGL-1 ELISA showed an overall positivity rate of 6.9%; this was greatest in patients with tuberculosis (43.8%) followed by autoimmune diseases (40.9%) and miscellaneous cases including liver diseases (37.9%). This study emphasizes that PGL-1 ELISA has a low predictive value for diagnosis of active infection by Mycobacterium leprae. Positive reactions in a significant percentage of patients with autoimmune disease are intriguing and need indepth study.     

Laparoscopic transperitoneal versus extraperitoneal inguinal hernia repair: a prospective clinical trial

Myoporum laetum was collected in the municipalities of Rio Grande and Capao do Leao in winter and in Santa Vitoria in summer, autumn, winter and spring, in the state of Rio Grande do Sul, Brazil, and in the Department of Rocha, Uruguay, in winter and spring. The fresh green plant was fed to 17 sheep. All sheep developed clinical signs, except 1 that consumed only 4 g/kg bw daily during 10 d. Five of the 9 sheep dosed with 40 g/kg died. Four sheep dosed with plants from Uruguay at 40 g/kg, 6 sheep dosed with 20 g/kg, and 1 sheep dosed with 2 daily doses of 8 g/kg survived. Clinical signs were anorexia, restlessness, ruminal stasis, jaundice and dry feces with mucus or blood. All surviving sheep had photodermatitis in the face, ears, eyes and lips. Histologic lesions were characterized by periportal liver necrosis. Serum levels of AST, GGT and bilirubin were increased. M laetum from Uruguay was less toxic, suggesting a variation in toxicity among plants from different regions.     

Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost

OBJECTIVE: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. DESIGN: A randomised controlled trial of 403 patients with inguinal hernias. SETTING: Two acute general hospitals in London between May 1995 and December 1996. SUBJECTS: 400 patients with a diagnosis of groin hernia, 200 in each group. Main outcome measures: Time until discharge, postoperative pain, and complications; patients' perceived health (SF-36), duration of convalescence, and patients' satisfaction with surgery; and health service costs. RESULTS: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (chi2 = 6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was 335 pounds (95% confidence interval 228 pounds to 441 pounds) more than the cost of open repair. CONCLUSION: This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.     

Day-case laparoscopic hernia repair

Some 114 patients (median age 52 years) underwent laparoscopic hernia repair as a day-case procedure. Twenty-one patients had bilateral and 11 recurrent hernias. Some 113 patients underwent transabdominal preperitoneal mesh repair but one required conversion to open operation. Mean operating time was 24 min for unilateral and 38 min for bilateral repair. In an operating session of 3.5 h, up to five patients (mean 4.4) underwent surgery and as many as seven hernias were repaired. More than 10 per cent of patients were found to have a previously undiagnosed hernia on the opposite side. A total of 111 patients were discharged home on the day of surgery. Major complications included one omental bleed and one small bowel obstruction. Seroma was the commonest minor complication and occurred in 7 per cent of patients. More than 35 per cent of patients needed no postoperative analgesia. To date there has been one recurrence (follow-up range 2-18 months).     

Complications of laparoscopic paraesophageal hernia repair

The complications of laparoscopic paraesophageal hernia repair at two institutions were reviewed to determine the rate and type of complications. A total of 76 patients underwent laparoscopic paraesophageal hernia repair between December 1992 and April 1996. Seventy-one of them had fundoplication (6 required a Collis-Nissen procedure). Five patients underwent hernia reduction and gastropexy only. There was one conversion to laparotomy. Traumatic visceral injury occurred in eight patients (11%) (gastric lacerations in 3, esophageal lacerations in 2, and bougie dilator perforations in 3). All lacerations were repaired intraoperatively except for one that was not recognized until postoperative day 2. Vagus nerve injuries occurred in at least three patients. Three delayed perforations occurred in the postoperative period (4%) (2 gastric and 1 esophageal). Two patients had pulmonary complications, two had gastroparesis, and one had fever of unknown origin. Seven patients required reoperation for gastroparesis (n = 2), dysphagia after mesh hiatal closure of the hiatus (n = 1), or recurrent herniation (n = 4). There were two deaths (3%): one from septic complications and one from myocardial infarction. Paraesophageal hernia repair took significantly longer (3.7 hours) than standard fundoplication (2.5 hours) in a concurrent series (P <0.05). Laparoscopic paraesophageal hernia repair is feasible but challenging. The overall complication rate, although significant, is lower than that for nonsurgically managed paraesophageal hernia.     

Controlled trial of preperitoneal local anaesthetic for reducing pain following laparoscopic hernia repair

BACKGROUND: A prospective randomized trial was performed to determine whether local anaesthetic solutions injected into the preperitoneal space may provide additional pain relief following transabdominal preperitoneal laparoscopic hernia repair. METHODS: One hundred patients undergoing transabdominal preperitoneal laparoscopic hernia repair were allocated randomly to receive (1) bupivacaine 1.5 mg/kg, (2) bupivacaine 1.5 mg/kg with 1 in 200000 adrenaline, (3) bupivacaine 3 mg/kg or (4) saline instilled into the preperitoneal space at the end of the operation. An independent clinical assessor determined the level of pain using a visual analogue pain score and noted the parenteral and oral analgesia requirements at 4, 8, 12 and 24 h after operation. Results: At each of the time intervals, there was no significant difference between the groups for pain scores (at 24 h, P = 0.71) or the number of doses of either morphine (at 24 h, P = 0.73) or oral analgesia (at 24 h, P = 0.89). There was also no significant difference in the time to return to normal activity or work between the groups. CONCLUSION: This study suggests that instilling local anaesthetic into the preperitoneal space has no significant effect on postoperative pain relief requirement following laparoscopic hernia repair. Other methods of reducing postoperative pain should be sought that may facilitate day-case laparoscopic hernia surgery.     

Prospective randomized trial comparing Shouldice and Bassini-Kirschner operation technique in primary inguinal hernia repair

The authors conducted a prospective randomized trial to compare the Shouldice and the Bassini-Kirschner technique between April, 1994 and December, 1995. During this period 129 adult patients, mean age 54 (17-87) years underwent operation on primary inguinal hernias in their department. 63 Shouldice and 66 Bassini-Kirschner operations were performed by 17 surgeons. The duration of surgery, the technique of anesthesia, the perioperative complications, the duration of postoperative care, then one year after the operation the recurrence rate and the patient's subjective complains were investigated. 85 patients of 129 were examined one year after the operation in spite of that all the patients were invited for control. Both operations gave almost the same results in the perioperative period and nearly identical recurrence rate (4.44% in Shouldice and 5.0% in Bassini-Kirschner group). The patient's subjective complains were also very similar one year after the operation. The authors could not find significant difference in the results of the two types of surgery although they were well experienced with the Bassini-Kirschner operation and just starting to practice the Shouldice procedure. These facts suggest that having more experience with the Shouldice operation makes available the extreme low recurrence rate published by several authors.     

Nerve injury during laparoscopic inguinal hernia repair

This report presents a case of injury to the lateral cutaneous nerve of the thigh during laparoscopic inguinal hernia repair. Both this nerve and the femoral branch of the genitofemoral nerve are at risk during laparoscopic inguinal hernia repair. Pertinent anatomy is reviewed and suggestions made to prevent this injury. This case does not appear to be an isolated event, and hopefully this report will bring attention to this potential complication.     

Tension pneumothorax precluding laparoscopic repair of diaphragmatic hernia

BACKGROUND: Central Europe and the Czech Republic are specific in the prevalence of obesity which has increased by 10-40% during the last 10 years. METHODS: In the Czech republic there is 30 years of experience of a comprehensive approach to obesity treatment which includes: dietary treatment; exercise; behavioral modification; drug treatment; and bariatric surgery. Each of these approaches has its place in complex obesity management. Since 1983 bariatric surgery has been established in the Czech Republic for the treatment of morbid obesity. Vertical banded gastroplasty (VBG), gastric banding, laparoscopic nonadjustable and adjustable gastric bandings have been used over the years. Since 1993 laparoscopic gastric banding has been the only method used in our department. RESULTS: The comprehensive approach for obesity treatment in the Czech Republic has resulted in the development of obesity management and research centers, regional obesity units, obesity out-patients clinics and weight reduction clubs. The surgical treatment is a well-established part of this system and the long-term results of surgical treatment are acceptable both in terms of weight loss and complication rate. There has been no statistical difference in weight loss results following VBG and laparoscopic gastric banding, but there is a significant decrease in morbidity, and shorter hospital stay associated with laparoscopic gastric banding. CONCLUSIONS: The surgical approach in obesity treatment has an important place in the comprehensive care of obese patients. Laparoscopic gastric banding in the hands of an experienced surgeon is a method with low morbidity, short hospital stay and long-term weight loss results which are fully comparable with the results of other surgical approaches.     

A randomized controlled trial of guided imagery in bulimia nervosa

BACKGROUND: The objective of this study was to test a guided imagery therapy designed to enhance self-comforting in bulimia nervosa. METHODS: A randomized controlled trial compared 6 weeks of individual guided imagery therapy with a control group. Fifty participants who met DSM-III-R criteria for bulimia nervosa completed the study. Measures of eating disorder symptoms, psychological functioning and the experience of guided imagery therapy were administered. RESULTS: The guided imagery treatment had substantial effects on the reduction of bingeing and purging episodes; the imagery group had a mean reduction of binges of 74% and of vomiting of 73%. The imagery treatment also demonstrated improvement on measures of attitudes concerning eating, dieting and body weight in comparison to the control group. In addition, the guided imagery demonstrated improvement on psychological measures of aloneness and the ability for self-comforting. CONCLUSIONS: Evidence from this study suggests that guided imagery was an effective treatment for bulimia nervosa, at least in the short-term.     

New possibility in inguino-femoral hernia repair: laparoscopic herniaplasty

The development of minimally invasive surgery brought up the challenge: to repair the frequent inguino-femoral hernias laparoscopically. The authors performed 65 laparoscopic hernioplasties in one year: "transabdominal preperitoneal" technique was used in 61 cases und "intraperitoneal onlay mesh" in 4 cases. Fifty-three patients were operated on, 12 of them had bilateral hernias. Recurrent hernia was the indication in 22 patients (34%). The average operating time was 102 and 144 minutes in the unilateral and the bilateral cases, respectively. There was no wound infection, or general complication. Spontaneously dissolving seroma/hematoma of the spermatic cord was noticed and detected by ultrasound in 5 patients (7.7%). The neuralgia caused by the irritation of the nerves of the region in 4 patients (6.1%) disappeared without sequels after treatment with vitamins B. The 2 early recurrences (3.2%), considered to be caused by technical inexperience, these patients were treated successfully with the "intraperitoneal onlay mesh" technique. In the authors' opinion there are definite advantages of laparoscopic hernioplasty, namely the minimal postoperative pain, early mobilization, shorter hospital stay and early restoration of full physical activity (in 1-2 weeks) as well as the known disadvantages of this technique (narcosis, longer operative time, intraperitoneal procedure, higher costs).     

New trends: preperitoneal laparoscopic inguinal hernia repair

This paper focuses on the meaning and process of collaboration, particularly in the area of research and clinical practice. Much has been written about the existing gaps between research and the practice of nursing; however, action research is one mechanism that allows these elements to be drawn together. Research developed through collaborative participation has the potential to harness the energy, enthusiasm and talents of nurses at different levels and practice into a cohesive group motivated to achieve professional development and quality practice goals. Action research that is built on the philosophy of a quality within the process and significance of the group can lead to effective practice in nursing. Power can be found in partnership.     

Re: A randomized controlled trial of Intravenous clodronate

Pancoast's syndrome arises from neoplasms in 95% of cases but infection is a rare cause. We describe a patient with Pancoast's tumor secondary to tuberculosis. Pain caused by plexopathy and lack of diagnosis by noninvasive means led to the need for open biopsy.     

Comparison of laparoscopic versus open repair of paraesophageal hernia

Of seven cDNA-expressed human cytochrome P450 (P450) enzymes (P450s 1A2, 2B6, 2C9, 2C19, 2D6, 2E1, and 3A4) examined, P450 1A2 was the most active in catalyzing 2- and 4-hydroxylations of estradiol and estrone. P450 3A4 and P450 2C9 also catalyzed these reactions although to lesser extents than P450 1A2. P450 1A2 also efficiently oxidized estradiol at the 16alpha-position but was less active in estrone 16alpha-hydroxylation; the latter reaction and also estradiol 16alpha-hydroxylation were catalyzed by P450 3A4 at significant levels. Anti-P450 1A2 antibodies inhibited 2- and 4-hydroxylations of these two estrogens catalyzed by liver microsomes of some of the human samples examined. Estradiol 16alpha-hydroxylation was inhibited by both anti-P450 1A2 and anti-P450 3A4, while estrone 16alpha-hydroxylation was significantly suppressed by anti-P450 3A4 in human liver microsomes. Fluvoxamine efficiently inhibited the estrogen hydroxylations in human liver samples that contained high levels of P450 1A2, while ketoconazole affected these activities in human samples in which P450 3A4 levels were high. alpha-Naphthoflavone either stimulated or had no effect on estradiol hydroxylation catalyzed by liver microsomes; the intensity of this effect depended on the human samples and their P450s. Interestingly, in the presence of anti-P450 3A4 antibodies, alpha-naphthoflavone was found to be able to inhibit estradiol and estrone 2-hydroxylations catalyzed by human liver microsomes. The results suggest that both P450s 1A2 and 3A4 have major roles in oxidations of estradiol and estrone in human liver and that the contents of these two P450 forms in liver microsomes determine which P450 enzymes are most important in hepatic estrogen hydroxylation by individual humans. P450 3A4 may be expected to play a more important role for some of the estrogen hydroxylation reactions than P450 1A2. Knowledge of roles of individual P450s in these estrogen hydroxylations has relevance to current controversies in hormonal carcinogenesis [Service, R. F. (1998) Science 279, 1631-1633].     

A randomized controlled trial of early physiotherapy for high-risk infants

The potential therapeutic applications of encapsulated cells are enormous. In the US alone, it has been estimated that nearly half-a-trillion dollars are spent each year to care for patients who suffer tissue loss or dysfunction. Over 6 million patients suffer from neurodegenerative disorders such as Alzheimer's disease and Parkinson's disease, over 14 million patients suffer from diabetes, and millions more from liver failure, hemophilia, and other diseases caused by the loss of specific vital cellular functions. It appears likely that by the end of the decade clinical trials of encapsulated cells to treat many of these diseases will become a reality. The Food and Drug Administration has already authorized studies to evaluate the safety and biological activity of several types of systems. A number of issues will have to be addressed, including the sourcing of raw materials, the design and building of manufacturing facilities, the scale-up and optimization process, storage and distribution of the product, and quality control.