Preperitoneal prosthetic inguinal herniorrhaphy without a relaxing incision

A consecutive series of 276 men had 317 inguinal hernias repaired by the preperitoneal approach. Of these, 162 (59 per cent) had 194 (61 per cent) "complete" repairs using Marlex prostheses. Fifty-five of 152 indirect hernias (36 per cent) were patched similarly. Seventeen of twenty-two mixed bilateral defects (77 per cent) had a prosthetic patch. Thrity-three of forty-eight repairs (68 per cent) for recurrent hernia in forty-five men also employed Marlex. Two patients died postoperatively. Four of 194 repairs using Marlex failed. These preliminary results indicate that the advantages of preperitoneal exposure can be complemented by an initially satisfactory technic of repair using a prosthesis instead of the classic relaxing incision, which is difficult to use with this posterior approach.     

Laparoscopic inguinal herniorrhaphy: the new gold standard of hernia repair?

The surgical treatment of the common inguinal hernia has been one of the most analyzed and debated topics in medicine. Recently, with the success of laparoscopic cholecystectomy, interest in minimally invasive surgical techniques has led to it's application for inguinal hernia repair. Current laparoscopic herniorrhaphies are based on the principles of conventional open preperitoneal repairs and are classified into two types: 1) transabdominal preperitoneal repair (TAPP) and 2) totally extraperitoneal repair (TEP). Common advantages to both techniques include a decrease in postoperative pain, earlier return to normal activity, and improved cosmesis. Both laparoscopic techniques have the disadvantage of requiring general or regional anesthesia and increased procedural costs. Lastly, there is a concern that laparoscopic hernia repair has not been around long enough to know the risk of late recurrences. Laparoscopic herniorrhaphy, however, is a viable alternative to standard open inguinal hernia repair.     

Local anaesthesia in inguinal herniorrhaphy: our experience in Ile-Ife, Nigeria

Over 75 pc of 138 patients prospectively studied tolerated field block local anaesthesia for inguinal herniorrhaphy. This tolerance was, however, lower in the younger age groups. There were few complications and patients were discharged within 24 to 72 hours.     

Mesh configurations in laparoscopic extraperitoneal herniorrhaphy. A comparison of techniques

BACKGROUND: Laparoscopic total extraperitoneal (TEP) hernia repair utilizes slit mesh that is placed around the spermatic cord to secure the prosthesis and prevent recurrence. Because of concern that encircling of the cord might increase pain and morbidity, we compared patients with mesh repairs using encircled and nonencircled techniques. METHODS: The 191 male patients who underwent bilateral TEP repairs were divided into three groups. In 100 consecutive patients (group A), the slit mesh was closed around both spermatic cords; in 56 patients (group B), the slit mesh was tucked under the spermatic cords but not closed; in 35 consecutive patients (group C), the slit was closed around one cord and tucked under the other, in a randomized fashion. RESULTS: The groups had similar operative times (A: 83 +/- 25 min; B: 79 +/- 21; C; 77 +/- 24), use of pain medication (A: 2.7 +/- 2.5 days; B: 2.4 +/- 1.9; C: 3.1 +/- 2.4), and recovery before return to work (A: 7.9 +/- 7.0 days; B: 8.2 +/- 6.1; C: 6.7 +/- 4.8). The incidence of indirect hernias was similar in all groups. Complication rate was 20% in A, 20% in B, and 14% in C (p = NS). Chronic pain was more frequent in A (A: 6, B: 0, p = 0. 06). In group C, fluid collections were more common on the closed side (closed: 3, tucked: 0; p = 0.08). There were no recurrences in any group. CONCLUSIONS: Closing the slit around the spermatic cord in laparoscopic inguinal hernia repair is not essential for prevention of early recurrence. Fluid collections tended to be more frequent when the mesh was closed around the cord, and chronic pain was more frequent in the group with closed mesh bilaterally.     

The medtronic intact porcine valve: ten-year clinical review

OBJECTIVE: Our objective was to assess the long-term mortality and morbidity associated with the Medtronic Intact valve (Medtronic, Inc, Minneapolis, Minn). METHOD: Between 1983 and 1996, 447 patients (280 men and 167 women) received 466 Intact valves: 280 aortic, 156 mitral, and 30 tricuspid. The mean age was 57 years (median 63 years), with 45% younger than 60 years. The mean New York Heart Association class was 3.1. The follow-up was 98% complete and extended for 39 months (1-154 months) and 1324 patient-years. There were 32 valves at risk at 10 years after implantation. Doppler echocardiography was performed whenever possible in patients followed up for longer than 4 years (mean 8 years) after implantation. RESULTS: Ten-year overall actuarial survival was 30% +/- 6% (14% +/- 7% for New York Heart Association classes IV-V and 39% +/- 8% for classes I-III). At 10 years freedom from infective endocarditis was 92% +/- 3%, freedom from thromboembolism was 80% +/- 5%, and freedom from nonstructural valve deterioration was 95% +/- 2%. Ten-year freedom from explantation was 64% +/- 6%, freedom from valve-related events was 51% +/- 6%, and freedom from valve-related death was 88% +/- 3%. There were 26 examples of structural valve deterioration, mainly caused by leaflet calcification (in 17 cases) and by buttress detachment (in 6 cases). In the aortic position at 10 years freedom from structural valve deterioration was 81% +/- 9%, but with only 1 event in patients older than 40 years (freedom 92% +/- 8%) and 100% freedom in patients older than 60 years. There was also 100% freedom from structural valve deterioration in the tricuspid position. In the mitral position freedom was 65% +/- 8%, with no significant difference between age groups. CONCLUSION: The Intact valve provides superior results in the aortic position in patients older than 40 years and in the tricuspid position at all ages.     

Anti-tuberculous initial drug resistance of Mycobacterium tuberculosis in Kenya: a ten-year review

Our experience at the Respiratory Diseases Research Unit (RDRU), over the last 10 years (1981-1990) on the initial drug resistance pattern, focusing on three drugs viz: isoniazid (H), streptomycin (S) and rifampicin (R) is presented. Records on all isolates of M. tuberculosis from one specimen of every newly diagnosed patient recruited countrywide between 1981-1990 were reviewed. We analyzed records of 6,514 isolates and found that total resistance to the three drugs had increased from 8.9% to 14.4%. Resistance to H alone increased from 6.8% to 10.2% while that of S alone from 0.8% to 1.8%. Resistance to R was between 0.1% and 0.3%. Generally, the increase in the resistance trend to both H and S was statistically significant (p = < 0.05 and 0.03, respectively). Although in our analysis we did not address the possible impact of HIV infection, we hope that these findings form a basis for evaluation of this and other possible factors on the emergence of anti-TB drug resistance in future studies.     

Emergence of drug-resistant tuberculosis in Jerusalem: ten-year retrospective review

Drug-resistant tuberculosis (TB) has emerged as a worldwide problem. The annual incidence of TB has increased in Israel in the last decade, mainly due to successive waves of immigration. Few data are available on drug-resistant TB in Israel A 10-year retrospective review was conducted on all patients who had been infected with culture-proven Mycobacterium tuberculosis and had been admitted to our hospital. Forty-seven patients had culture-positive TB; 27 (57%) were male, 20 (43%) were female; mean age (+/- SD) was 56 +/- 23 years. Twenty patients (43%) had pulmonary TB. Three patients (6.4%) had single-drug resistance; 4 patients (8.5%) had multi-drug resistance. Six of the seven patients (86%) with drug-resistant TB had been diagnosed after 1990. Six of the 20 patients (30%) with pulmonary TB had drug-resistant organisms. Six of the 7 patients (86%) with drug-resistant TB had pulmonary infection, as compared to 15/40 (37%) of the patients with drug-susceptible TB (p < 0.001). Six of the 7 patients (86%) with drug-resistant TB had a history of TB. Fifteen percent (14.9%) of all new cases diagnosed with TB in our hospital in the last 10 years had drug-resistant M. tuberculosis. Thirty percent of patients with pulmonary TB had drug-resistant organisms. Drug-resistant TB has evidently emerged in Israel and poses a serious clinical and social threat. A strong case for directly-observed treatment in Israel should be made, especially since the incidence of TB here is still small.     

Postoperative apnea in former preterm infants after inguinal herniorrhaphy. A combined analysis

BACKGROUND: Controversy exists as to the risk for postoperative apnea in former preterm infants. The conclusions of published studies are limited by the small number of patients. METHODS: The original data from eight prospective studies were subject to a combined analysis. Only patients having inguinal herniorrhaphy under general anesthesia were included; patients receiving caffeine, regional anesthesia, or undergoing other surgical procedures were excluded. A uniform definition for apnea was used for all patients. Eleven risk factors were examined: gestational age, postconceptual age, birth weight, history of respiratory distress syndrome, bronchopulmonary dysplasia, neonatal apnea, necrotizing enterocolitis, ongoing apnea, anemia, and use of opioids or nondepolarizing muscle relaxants. RESULTS: Two hundred fifty-five of 384 patients from eight studies at four institutions fulfilled study criteria. There was significant variation in apnea rates and the location of apnea (recovery room and postrecovery room) between institutions (P < 0.001). There was considerable variation in the duration and type of monitoring, definitions of apnea, and availability of historical information. The incidence of detected apnea was greater when continuous recording devices were used compared to standard impedance pneumography with alarms or nursing observations. Despite these limitations, it was determined that: (1) apnea was strongly and inversely related to both gestational age (P = 0.0005) and postconceptual age (P < 0.0001); (2) an associated risk factor was continuing apnea at home; (3) small-for-gestational-age infants seemed to be somewhat protected from apnea compared to appropriate- and large-for-gestational-age infants; (4) anemia was a significant risk factor, particularly for patients > 43 weeks' postconceptual age; (5) a relationship to apnea with history of necrotizing enterocolitis, neonatal apnea, respiratory distress syndrome, bronchopulmonary dysplasia, or operative use of opioids and/or muscle relaxants could not be demonstrated. CONCLUSIONS: The analysis suggests that, if it is assumed that the statistical models used are equally valid over the full range of ages considered and that the average rate of apnea reported across the studies analyzed is accurate and representative of actual rates in all institutions, the probability of apnea in nonanemic infants free of recovery-room apnea is not less than 5%, with 95% statistical confidence until postconceptual age was 48 weeks with gestational age 35 weeks. This risk is not less than 1%, with 95% statistical confidence, for that same subset of infants, until postconceptual age was 56 weeks with gestational age 32 weeks or postconceptual age was 54 weeks and gestational age 35 weeks. Older infants with apnea in the recovery room or anemia also should be admitted and monitored. The data do not allow prediction with confidence up to what age this precaution should continue to be taken for infants with anemia. The data were insufficient to allow recommendations regarding how long infants should be observed in recovery. There is additional uncertainty in the results due to the dramatically different rates of detected apnea in different institutions, which appear to be related to the use of different monitoring devices. Given the limitations of this combined analysis, each physician and institution must decide what is an acceptable risk for postoperative apnea.     

Normal tension glaucoma: a ten-year follow-up

The authors describe the results obtained in 10 years of observation of a group of 41 eyes affected by normal tension glaucoma. An evolution of perimetric defects was found in 29.26% of the eyes examined.     

Pancreatic trauma: a ten-year multi-institutional experience

Our objective was to determine the incidence, management, and outcome of traumatic pancreatic injury. A retrospective review was performed of all patients with pancreatic injury admitted to two Level I trauma hospitals over a 10-year period. Comparisons were made with Chi square or Fisher's exact tests. Of 16,188 trauma admissions, 72 patients (0.4%) had pancreatic injury. The mean age was 30 years, and 30 patients (69%) were male. Mechanism of injury was gunshot in 32 (45%), blunt in 27 (37%), and stab wound in 13 (18%). The pancreas was involved in 1.1 per cent of patients with penetrating injuries compared to 0.2 per cent with blunt injuries (P < 0.01). There were 18 grade I (25%), 32 grade II (45%), 16 grade III (22%), and 5 grade IV (7%) injuries. Initial diagnosis was made intraoperatively in 63 patients and by computed tomography in 8. The mean injury grade was significantly lower on computed tomography compared to surgical exploration (0.4 vs 2.0; P < 0.05). Operative procedures included distal pancreatectomy in 23 (32%), exploration only in 22 (31%), external drainage in 13 (18%), pancreatorrhaphy in 4, internal drainage in 2, and proximal resection in 2. Mortality was 16.6 per cent and was not related to the mechanism or grade of injury. Mean Injury Severity Score and transfusion requirements were significantly greater in patients who died (P < 0.05). Morbidity occurred in 30 patients (42%), including pancreatic fistula (11%), pancreatitis (7%), and pancreatic pseudocyst (3%). Six patients (8%) developed intra-abdominal abscesses, and all had associated liver or intestinal injuries. In patients with grade I and II injuries, morbidity was higher with external drainage compared to exploration without drainage. Pancreatic injury is infrequent and is more often associated with penetrating trauma. Diagnosis is most commonly made by exploration and cannot be excluded by computed tomography. Drainage of low-grade injuries may not be necessary. Morbidity and mortality in patients with pancreatic trauma is significant and is primarily due to associated injuries.     

Active infective endocarditis in infants and childhood: ten-year review of surgical therapy

OBJECTIVE: The aim of this study was to determine whether or not continuous combined HRT used with GnRH-a for the treatment of endometriosis can prevent hypoestrogenic side effects associated with GnRH-a. METHODS: Forty premenopausal women with laparoscopically proven endometriosis entered the study. The patients were randomized into two groups. Group I (n = 19) received 3.75 mg i.m. leuprolide acetate (LA) every 4 weeks for 24 weeks. Group II (n = 21) received 3.7 mg LA combined with 1.25 mg oral conjugated equine estrogen (CEE) and 5 mg oral medroxyprogesterone acetate (MA). RESULTS: Total revised AFS score as well as total pelvic pain scores decreased significantly (P < .001) in both groups. However, a statistically significant difference of hot flushes and sweating was reported by women receiving LA + HRT as compared to those treated with LA alone (P < .001). Furthermore, the bone loss at the lumbar spine was 4.2% in group I compared to 0.9% in group II at the end of the study. CONCLUSIONS: This study suggests that 1.25 mg CEE + 5 mg MA is effective in preventing hypoestrogenic side effects caused by GnRH-a, while the treatment of endometriosis is not impaired.     

Repair of interrupted aortic arch: a ten-year experience

Eighty-two consecutive patients with interrupted aortic arch were referred to our institution between 1985 and 1995. Three died before any attempt at operation and 79 underwent surgical repair. Median age at operation was 9 days (range 1 day to 6 years) and median weight was 3.0 kg (range 1.8 to 20 kg). All but one were in severe congestive heart failure and 31.5% had oliguria or anuria. Preoperative pH varied between 6.8 and 7.4 (median 7.3). Sixty-nine received prostaglandin E1 infusion and 54 received mechanical ventilation. Aggressive preoperative ressucitation was necessary in 43 cases. Preoperative transfontanellar echography (performed routinely) since 1987 revealed intracerebral bleeding in six patients. Type A interrupted aortic arch was present in 37 cases, 41 patients had type B, and one had type C. Interrupted aortic arch was associated with single ventricular septal defect in 35 cases, 24 patients had associated complex heart defects, and 30 had significant subaortic stenosis (six had both subaortic stenosis and complex association). Aortopulmonary window was found in four patients, truncus arteriosus was found in eight, and transposition of the great arteries was found in five, double-outlet right ventricle was found in one, single ventricle was found in three, multiple ventricular septal defects were found in two and superior-inferior ventricles were found in one. Sixty-four patients underwent single-stage repair and 15 underwent multistage repair. Aortic arch repair consisted of direct anastomosis in 59 cases, patch augmentation in eight, and conduit interposition in 12. Ten patients underwent associated pulmonary artery banding and 19 underwent concomitant repair of complex associated lesions. The subaortic stenosis was addressed by four surgical techniques: myotomy or myectomy in five patients; creation of a double-outlet left ventricle, aortopulmonary anastomosis, and conduit insertion between the right ventricle and pulmonary artery bifurcation in four; no direct attempt to relieve the subaortic stenosis in six; and left-sided ventricular septal defect patch in 15. Mean duration of deep hypothermic circulatory arrest, crossclamp time, and cardiopulmonary bypass time were 38.8 +/- 15.6 min, 60.5 +/- 24.7 min, and 143 +/- 40.1 min, respectively. Postoperative mortality rate was 18.9% (70% confidence limits 14% to 24.6%), and overall mortality rate was 31% (70% confidence limits 20.9% to 42.2%). The results have improved with time, with an overall operative mortality rate of 12% since 1990. Univariate statistical analysis revealed that early survival was influenced by preoperative renal function, detection of cerebral bleeding by transfontanellar echography, the number of cardioplegic injections, and the date of operation. Multivariate analysis revealed that preoperative renal function and the number of cardioplegic injections were independent risk factors for early mortality. Echocardiographic measurements of the left heart-aorta complex with preoperative Z values as low as-4 demonstrated rapid growth after repair. In the presence of subaortic stenosis, better survival was obtained with a left-sided patch for ventricular septal defect closure (p < 0.05). Twenty-three patients underwent 26 reoperations for recoarctations (seven), left bronchial compression (two), second-stage repair (eight), right ventricle-pulmonary artery conduit replacement (three), and miscellaneous (four). One of the survivors was reoperated on for subaortic membrane. Survival at 5 years for the entire series was 70%. For isolated forms, it was 73.5% (90% for 1990 to 1995), for complex forms it was 70%, and in the presence of subaortic stenosis it was 60%. In conclusion, interrupted aortic arch remains a surgical challenge with continually improving results. Early diagnosis with preoperative resuscitation and adequate myocardial protection seem extremely important for further improvements. Associated subaortic stenosis or complex lesions     

Volvulus of the sigmoid colon: a ten-year study

A ten-year study of volvulus of the sigmoid colon is presented. Although the results of treatment of volvulus of the sigmoid colon are generally improving, the challenge for further improvement remains.     

The Oxford medial unicompartmental arthroplasty: a ten-year survival study

Retrieval studies have shown that the use of fully congruent meniscal bearings reduces wear in knee replacements. We report the outcome of 143 knees with anteromedial osteoarthritis and normal anterior cruciate ligaments treated by unicompartmental arthroplasty using fully congruous mobile polyethylene bearings. At review, 34 knees were in patients who had died and 109 were in those who were still living. The mean elapsed time since operation was 7.6 years (maximum 13.8). We established the status of all but one knee. There had been five revision operations giving a cumulative prosthetic survival rate at ten years (33 knees at risk) of 98% (95% CI 93% to 100%). Considering the knee lost to follow-up as a failure, the 'worst-case' survival rate was 97%. No failures were due to polyethylene wear or aseptic loosening of the tibial component. One bearing which dislocated at four years was reduced by closed manipulation. The ten-year survival rate is the best of those reported for unicompartmental arthroplasty and not significantly different from the best rates for total knee replacement.     

Primary duodenal adenocarcinoma: a ten-year experience with 79 patients

The comet assay is frequently used to measure DNA damage in individual cells. In order to better understand the mechanisms behind the technique, we have studied the behaviour of DNA under different electrophoresis conditions in mammalian cells exposed to gamma radiation. The comet tails obtained after neutral electrophoresis seem to consist of DNA loops which are attached to structures in the nucleus, since the DNA cannot move in the second direction after two-dimensional electrophoresis. When the DNA is labelled by a short pulse, microautoradiography reveals that all label appear in the head of the comets when neutral electrophoresis is applied. After chase incubation, the label moves out into the tails. This gives further support to the view that the DNA loops are fixed to some structure in the nucleus where also the DNA synthesis takes place. Under alkaline electrophoresis conditions, however, the entire comet tails move in the new electrophoresis direction. Thus, it appears that the alkaline comet tails consist of free DNA fragments. Further, the effects of alkaline concentration and sodium chloride during unwinding and electrophoresis are discussed. Throughout the study, a protocol for drying and fixation of the comets has been used.     

Laparoscopic inguinal hernioplasty: a community hospital''s experience

We investigated the expression of glucose transporter (GLUT) protein isoforms in two human retinoblastoma cell lines, Y79 and WERI-Rb1, by Western blotting analysis with anti-GLUT1, 2, 3, and 4 antibodies. GLUT1 and GLUT4 proteins were detected in Y79, whereas GLUT1 and GLUT3 proteins were found in WERI-Rb1. GLUT2 protein was not detected in Y79 or WERI-Rb1. Our findings are of interest because (1) the expression of GLUT protein isoforms in the two retinoblastoma cell lines was different, and (2) GLUT4 protein, the insulin-sensitive GLUT isoform, was detected in Y79. This suggests that these cell lines have different mechanisms of glucose transport.