The repair of large ventral hernias in patients with severe cardio-respiratory disease: Volume transposition technique.

Massive hernias of the abdominal wall present a major challenge to the general surgeon. In some extreme cases of patients with severe cardio-respiratory disease, the repair of such hernias may be impracticable. In these cases, we believe the volume transposition technique is appropriate. In this approach, the hernia volume is calculated and the wall repaired with mesh to accommodate the estimated volume of the hernia sac, thus avoiding any increase in intra-abdominal pressure. We believe this technique is simple, reproducible and useful in cases that are inoperable due to cardio-respiratory problems that make any loss of lung volume unacceptable.

Do we really know the symptoms of inguinal hernia?

PURPOSE: Although there is a high incidence of inguinal hernia in developed countries, few studies have been conducted to describe the symptoms, and these few only address the local symptoms, not those presenting at other levels. The aim of the present study is to conduct a detailed review of the symptoms, both inguinal and otherwise, of patients with inguinal hernia. METHODS: A case-control study was designed to compare the symptoms presented by 231 patients diagnosed with inguinal hernia with those of a second group of 231 randomly-selected subjects. In the hernia group, the symptoms were also evaluated according to the location of the hernia (right, left, bilateral). RESULTS: Significant differences (more symptomatology in patients with hernia) were found for the following items: groin pain, genital pain, urinary symptoms, abdominal pain, increased peristalsis and tenesmus. On the contrary, the control patients presented greater symptomatology with respect to back pain and diaphragm pain. CONCLUSIONS: Patients with inguinal hernia present a wide variety of symptoms, and these are not restricted to the inguinal area. It is important to be aware of this fact to convey accurate information to the patient, especially with regard to postoperative expectations.

Platelet-rich fibrin sealant as a treatment for complex perianal fistulas: a multicentre study.

INTRODUCTION: The incidence of perianal fistulas is high, and this condition has a profoundly negative impact on patients' quality of life. The problem is greater when the fistula tract is high because treatment is necessarily complex (limited surgery may lead to recurrence, while aggressive surgery is associated with higher rates of faecal incontinence). To achieve a balance between these two options, we suggest that complex fistulas should be treated by sealing the tract with platelet-rich fibrin. Our objective is to evaluate the medium- to long-term results obtained from the treatment of complex perianal fistulas by sealing with platelet-rich fibrin. MATERIAL AND METHODS: Prospective longitudinal multicentre study involves three colorectal surgeons working at three hospitals. The study period was October 2010 to June 2013, during which a total of 60 patients were treated for complex fistulas. In all cases, the intervention consisted of curetting the fistula tract, sealing it with platelet-rich fibrin and closing the internal orifice. We evaluated the clinical outcomes (clinical examination and pelvic magnetic resonance (MRI)) and the quality of life results, both general (SF-36) and gastrointestinal (GIQLI questionnaire) in periodic reviews during consultation. RESULT: The median follow-up period was 24 months (11-43 months), during which in 40 patients (66.66 %) the fistulas remained closed, with a zero rate of faecal incontinence. The results of the quality of life questionnaires are comparable (indeed, they are better in some items for the cured patients) to those of the reference population. CONCLUSION: In our opinion, this procedure is safe and its results are promising in terms of clinical outcome and medium- to long-term quality of life.

Resorbable synthetic mesh supported with omentum flap in the treatment of giant hiatal hernia.

Covering a large hiatal hernia with a mesh has become a basic procedure in the last few years. However, mesh implants are associated with high complication rates (esophageal erosion, perforation, fistula, etc.). We propose using a synthetic resorbable mesh supported with an omental flap as a possible solution to this problem. A 54-year-old female patient with a large hiatal defect (9 cm) was laparoscopically implanted with a synthetic resorbable mesh supported with an omental flap. The surgical procedure was successful and the patient was discharged on postoperative day 2. On a follow-up examination 6 months after surgery, she remained free of relapse or complication signs. Supporting an implanted resorbable mesh with an omental flap may be a solution to the problems posed by large esophageal hiatus defects. However, more studies based on larger patient samples and longer follow-up periods are necessary.

Psychological modulation in patients surgically intervened for gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) has been related with certain psychological dimensions. The influence of mood, emotional intelligence, and perceived quality of life on clinical symptoms and outcome of antireflux surgery was evaluated in GERD patients with and without hiatal hernia. The study included 61 patients who were diagnosed with GERD between 2003 and 2008: 16 of them without hiatal hernia (group A) and 45 of them with hiatal hernia (group B). All of these patients had undergone laparoscopic antireflux surgery. Patients were clinically examined and evaluated with the following instruments: Short Form (SF)-36 Health Survey, Gastrointestinal Quality of Life Index, Hospital Anxiety and Depression (HAD) Scale, and Trait Meta-Mood Scale (TMMS)-24. Proportions were compared by using the chi-squared test; averages were compared by using the Student's t-test (with Bonferroni's correction). In general, our patients intervened for GERD showed results lower than normal or close to the lower limit of normal in the administered tests. Patients in the group without hernia were younger (P < 0.001) and with lower American Society of Anaesthesiologists risk. They showed higher scores in the SF-36 dimensions: Physical Functioning, Physical Role and Emotional Role, and lower scores in the Social Role (P < 0.001). They showed lower scores in the Emotional dimension of Gastrointestinal Quality of Life Index (P = 0.0068) and worse results in the Hospital Anxiety and Depression subscales of Anxiety (P < 0.001) and Depression (not significant). Men in the group without hernia showed higher scores than men in the group with hernia in the TMMS subscales corresponding to Emotional Clarity and Emotional Repair (P < 0.001). Women in the group with hernia showed higher scores than women in the group without hernia regarding Emotional Clarity (P = 0.0012). GERD patients showed poor results in all the tests, and patients without hiatal hernia compared with patients with hernia showed higher levels of anxiety, which interfered with their social life. Moreover, they showed lower tolerance to stress and higher frustration, fear, and worry. On the basis of such unfavorable phychoemotional results observed with GERD patients (especially those without hernia) in the different tests, we propose that improving our knowledge of the psychological profile of GERD patients - particularly those without hiatal hernia - could help in designing individualized medical and psychological therapies and increase success rates.

Thoracic disk herniation, a not infrequent cause of chronic abdominal pain.

This study assesses the proportion of patients presenting with nonvisceral chronic abdominal pain who have thoracic disk herniation as a possible cause. We designed a descriptive transversal study of patients attending our offices between February 2009 and October 2010, with a complaint of chronic abdominal pain of suspected abdominal wall source (positive Carnett sign). Nuclear magnetic resonance (NMR) of the spinal column was performed on all patients. When the NMR showed thoracic disk herniation the patients were treated according to their etiology. We also evaluated the symptoms in patients with thoracic disk herniation and their response to the applied treatment. Twenty-seven patients with chronic abdominal pain were evaluated. The NMR results in 18 of these 27 patients (66.66%) showed evidence of disk herniation. We report on the results of these 18 patients, emphasizing that the symptoms are florid and varied. Many patients had been previously diagnosed with irritable bowel syndrome. Thoracic disk herniation may account for chronic abdominal pain in many patients who remain undiagnosed or are diagnosed with irritable bowel syndrome. Thus, this possibility needs to be taken into account to achieve a correct diagnosis and a suitable mode of treatment.

Laparoscopic cholecystectomy in patients over 70 years of age: review of 176 cases.

INTRODUCTION: We assessed the results of laparoscopic cholecystectomy in 176 patients over the age of 70 years. PATIENTS AND METHODS: The study included all patients older than 70 years of age who underwent laparoscopic surgery cholelithiasis during the previous ten years. Variables studied included age, sex, type of operation (programmed/emergency), comorbidity, anesthetic risk, intraoperative cholangiography, conversion to open surgery, number of trocars, reoperation, residual choledocholithiasis, postoperative hospital stay, morbidity and mortality. RESULTS: The study included 176 patients (23.29% men and 76.71% women). The mean age was 74.86 years. The mean hospital stay was 1.27 days, with 16.98% morbidity and 0.56% mortality. CONCLUSIONS: Laparoscopic cholecystectomy is a safe procedure in older patients. It results in faster recovery, a shorter postoperative stay and lower rates of morbidity and mortality than open bile duct surgery.

Study of factors related to quality of life in patients with locally advanced rectal cancer.

OBJECTIVES: Given the increasing concern about the physical, psychological, and social welfare of patients surgically treated for rectal cancer, we designed a study of the factors influencing quality of life in these patients. EXPERIMENTAL DESIGN: We prospectively analyzed factors related to quality of life in a cohort of patients using the Nottingham Health Profile and the EORTC questionnaire (QLQ-CR 38). PATIENTS: A total of 116 patients with locally advanced rectal cancer surgically treated in our hospital from 1994 to 1999. RESULTS: Quality of life scores for the various factors studied showed that quality of life was worse in women, in patients with tumors in the middle third of the rectum, and in patients undergoing low anterior resection. CONCLUSIONS: Factors influencing quality of life in patients surgically treated for locally advanced rectal cancer included sex, tumor site, and surgical technique. Since only this latter factor is modifiable, we suggest that the surgical technique be individualized in persons with mid-lower and lower-third tumors of the rectum, bearing in mind that quality of life in amputated patients is, in many respects, better than that of patients with preserved sphincters.

Molecular characterization of the B-2 DNA puff gene of Rhynchosciara americana.

We have sequenced a 2.5-kb DNA fragment of the B-2 DNA puff from the sciarid Rhynchosciara americana and have defined its transcription unit. This puff is active during the formation of the communal cocoon, which is important for successful metamorphosis of this species and coincides with the final cycle of polytenization in its salivary glands. The B-2 polypeptide, together with the products of two other previously characterized DNA puffs, seems to be engaged in an interaction that results in a gradual modification and hardening of the cocoon structure. The B-2 messenger is temporally regulated in apparent coordination with the other puff products. The predicted polypeptide has characteristics similar to polypeptides from previously sequenced DNA puff genes, in particular those from the R. americana C-8 gene and the Bradysia hygida C-4 gene. The cloned sequence of the B-2 puff is differentially amplified in the three gland regions examined, achieving its highest amplification level of approximately fourfold (two extra cycles) in the anterior segment of the gland. The C-3 DNA puff sequence was also found to be differentially amplified in the different gland regions. Implications of the widespread presence of DNA amplification as a form of gene regulation in the Sciaridae are discussed.

Analysis of the amplification and transcription of the C3-22 gene of Rhynchosciara americana (Diptera: Sciaridae) in transgenic lines of Drosophila melanogaster.

Drosophila melanogaster was transformed with an 18 kb fragment of the C3 DNA puff of Rhynchosciara americana, including the C3-22 gene and the origins of replication that direct amplification. Different tissues and developmental stages of five independent transgenic lines were analyzed by quantitative Southern blot hybridization. No indication was found that the transformed fragment was amplified, strongly suggesting that factors involved in DNA puff amplification have not been conserved in Drosophila. Transcription of the C3-22 gene in the transgenic lines was found to be at a low and constitutive level throughout development. These results indicate that, unlike other DNA puff genes, the factors that regulate the C3-22 gene are not conserved in Drosophila.