External cervical resorption: part 2 - management.

Effective management of external cervical resorption (ECR) depends on accurate assessment of the true nature and accessibility of ECR; this has been discussed in part 1 of this 2 part article. This aim of this article was firstly, to review the literature in relation to the management of ECR and secondly, based on the available evidence, describe different strategies for the management of ECR. In cases where ECR is supracrestal, superficial and with limited circumferential spread, a surgical repair without root canal treatment is the preferred approach. With more extensive ECR lesions, vital pulp therapy or root canal treatment may also be indicated. Internal repair is indicated where there is limited resorptive damage to the external aspect of the tooth and/or where an external (surgical) approach is not possible due to the inaccessible nature of subcrestal ECR. In these cases, root canal treatment will also need to be carried out. Intentional reimplantation is indicated in cases where a surgical or internal approach is not practical. An atraumatic extraction technique and short extraoral period followed by 2-week splinting are important prognostic factors. Periodic reviews may be indicated in cases where active management is not pragmatic. Finally, extraction of the affected tooth may be the only option in untreatable cases where there are aesthetic, functional and/or symptomatic issues.

Clinical application of foot strike run retraining for military service members with chronic knee pain.

INTRODUCTION: Military training is associated with a high incidence of knee pain. Conversion from a rearfoot to non-rearfoot strike during running is effective at reducing knee pain in research environments. The purpose of this report was to demonstrate run retraining as a clinical intervention for service members with knee pain. METHODS: Sixteen service members with running-related chronic knee pain underwent run retraining that converted foot strike from a rearfoot to a non-rearfoot strike using real-time visual feedback. The Lower Extremity Functional Scale (LEFS) and Numerical Pain Rating Scale (NPRS) for knee pain during running were assessed pretraining, at the final training session and at a 1-month follow-up. During running, foot inclination angle and vertical ground reaction force (VGRF) average loading rate were measured pretraining and at 1 month of follow-up. RESULTS: Service members underwent 7.4±1.0 training sessions over the course of 15.8±4.6 days. LEFS improved by 8±6 points immediately after retraining, with an overall improvement of 10±6 points from pretraining to 1-month follow-up (p<0.01). NPRS improved by 2.0±0.4 points immediately after retraining, with an overall improvement of 2.0±0.4 points from pretraining to 1-month follow-up (p<0.01). Conversion to a non-rearfoot strike pattern was apparent at follow-up for all but two patients. VGRF average loading rate decreased by 56%±17% (p<0.01) from pretraining to 1-month follow-up. CONCLUSIONS: Knee pain and function improved as a result of non-rearfoot strike run retraining, which supports the clinical use of this evidence-based intervention.

Prevention of mother to child transmission of HIV infection in Pacific countries.

INTRODUCTION: A generalized epidemic of HIV infection has been evolving in Papua New Guinea over the last decade, whereas in other Pacific Island countries and territories (PICT) HIV transmission has generally been less widespread. Programmes to detect HIV infection in pregnant women and to prevent mother to child transmission (MTCT) during either delivery or breast-feeding can decrease the incidence of infection in infants. The limited health infrastructure present in some PICT may delay the implementation of effective programmes to decrease MTCT of HIV. METHODS: We used a standardized questionnaire to survey health-care providers in 22 PICT for information on the epidemiology of HIV infection and strategies used during 2004 to prevent MTCT of HIV infection in their country. We supplemented these survey responses with data obtained from regional organizations supporting national responses to HIV. RESULTS: We obtained responses from 21 PICT. The reported prevalence of known HIV infection was >150 per 100 000 persons in Papua New Guinea, approximately 100 per 100 000 persons in French Polynesia, Guam, New Caledonia and Tuvalu and <50 per 100 000 persons in the remaining 14 PICT. Other than in Papua New Guinea, where an estimated 500 pregnant women had HIV infection diagnosed in 2004, reported HIV infection among pregnant women was rare. Ten PICT reported that an HIV antibody test was offered as a routine component of antenatal care and 11 reported that antiretroviral medications were available for the prevention of MTCT of HIV infection. CONCLUSION: The prevalence of HIV infection differs greatly between PICT with a varying risk of MTCT of HIV infection. Successful prevention of MTCT of HIV infection throughout the PICT will require improved uptake of antenatal HIV antibody testing and better access to antiretroviral medications.

Monitoring Chinese hamster ovary cell culture by the analysis of glucose and lactate metabolism.

Monitoring cell growth is crucial to the success of an animal cell culture process that can be accomplished by a variety of direct or indirect methodologies. Glucose is a major carbon and energy source for cultured mammalian cells in most cases, but glycolytic metabolism often results in the accumulation of lactate. Glucose and lactate levels are therefore routinely measured to determine metabolic activities of a culture. Typically, neither glucose consumption rate nor lactate accumulation rate has a direct correlation with cell density due to the changes in culture environment and cell physiology. We discovered that although the metabolic rate of glucose or lactate varies depending on the stages of a culture, the cumulative consumption of glucose and lactate combined (Q(GL)) exhibits a linear relationship relative to the integral of viable cells (IVC), with the slope indicating the specific consumption rate of glucose and lactate combined (q(GL)). Additional studies also showed that the q(GL) remains relatively constant under different culture conditions. The insensitivity of the q(GL) to process variations allows a potentially easy and accurate determination of viable cell density by the measurement of glucose and lactate. In addition, the more predictable nature of a linear relationship will aid the design of better forward control strategies to improve cell culture processes.

Reward shifts and motor responses following microinjections of opiate-specific agonists into either the core or shell of the nucleus accumbens.

Differences in pharmacology, anatomical connections, and receptor densities between the "core" and "shell" of the nucleus accumbens suggest that behavioral activity normally modulated by the accumbens, such as reward and motor functions, may be differentially regulated across the mediolateral axis. This study investigated the effects of opiate receptor-specific agonists on reward and motor functions in either the accumbens core or shell, using the intracranial self-stimulation (ICSS) rate-frequency curve-shift method. Microinjections of the mu opiate receptor-specific agonist, DAMGO (vehicle, 0.03 nmol, and 0.3 nmol), or the delta opiate receptor-specific agonist DPDPE (vehicle, 0.3 nmol, 3.0 nmol), were administered bilaterally in a random dose order with a minimum of 3 days between injections. Rats were tested over three consecutive 20-min rate-frequency curves immediately following a microinjection to investigate the time course of drug effects. Both opiate agonists decreased the ICSS frequency necessary to maintain half-maximal response rates when injected into the medial and ventral shell region of the accumbens. However, DAMGO microinjections into the lateral accumbens core or the control site of the caudate increased the frequency necessary to elicit half-maximal response rates, while DPDPE microinjections into these regions had no effect. Evaluation of motor effects show that administration of DAMGO resulted in a suppression of activity in all locations. In contrast, DPDPE microinjections resulted in little or no effect on lever pressing activity at any location.

Obturator hernia: current diagnosis and treatment.

BACKGROUND: Obturator hernia is a rare pelvic hernia for which both diagnosis and therapy are difficult. Because symptoms are nonspecific and specific physical findings are often obscure, diagnosis of obturator hernia is often delayed until laparotomy for bowel obstruction. Strangulation is frequent, and mortality remains high (25%). Primary closure of the hernia defect is difficult because adjacent tissues are not easily mobilized. Although a variety of techniques have been described, surgical repair has not been standardized. METHODS: We report a case of bilateral obturator hernia with incarceration in association with bilateral femoral hernia in which these problems were satisfactorily addressed. RESULTS: The hernias were diagnosed by computed tomography (CT) scan and repaired with synthetic mesh placed in the preperioneal space. This technique is well suited to unilateral and bilateral combinations of obturator, inguinal, and femoral hernias. CT scan in the work-up of severe gastrointestinal symptoms with weight loss may lead to a diagnosis of occult hernia, thereby allowing elective repair and, hopefully, a reduction in mortality risk. CONCLUSIONS: We recommend CT scan for suspected obturator hernia and preperitoneal mesh repair of noninfected cases.

Urinary adenosine excretion in patients receiving amphotericin B.

BACKGROUND: Intravenous amphotericin B (AMB) administration in animals causes renal vasoconstriction, ischemia, and oliguria that may result in irreversible renal injury; the mechanism of AMB nephrotoxicity may be similar in human beings. Adenosine is excreted in urine by the ischemic kidney. We hypothesized that adenosine excretion and oliguria would be a marker for patients who later would manifest AMB-associated renal insufficiency and that pre-AMB saline administration (which ameliorates AMB nephrotoxicity) would negate the change in adenosine excretion and urine output. METHODS: Twenty hospitalized patients being treated at the direction of their attending physician and who were receiving AMB (15 to 75 mg intravenously) had urine collected for 1 hour before and for 2 hours during AMB infusion. Eleven patients received normal saline solution (500 ml intravenously) before the AMB infusion; the other nine formed the comparator group. An aliquot of each urine collection was precipitated with perchloric acid to remove protein and cellular elements and centrifuged, and the supernatant was assayed for adenosine by using high-pressure liquid chromatography. RESULTS: Infusion of AMB was associated with a decrease in mean urine output both in patients who received saline solution (245 before versus 149 ml/hr during AMB infusion, p = 0.04) and in patients in comparator group (139 versus 89 ml/hr, p = 0.027). The mean urinary adenosine excretion was unchanged in the saline-loaded group (0.1354 before versus 0.1255 mmol/hr during drug infusion, p = 0.25) and was decreased in the comparator group (0.2276 versus 0.1127 mmol/hr, p = 0.01). Development of renal insufficiency did not correlate with the change in urine output or adenosine excretion. CONCLUSIONS: AMB infusion in human beings results in decreased urine output and decreased adenosine excretion. The latter effect is prevented by a pre-AMB saline load. The changes in urine output and adenosine excretion are not predictive of the development of renal insufficiency.

Hypothesis: compartmentalization of cytokines in intraabdominal infection.

BACKGROUND: Although the proximal role of systemic cytokines in the infectious-inflammatory cascades is well recognized, the magnitude and meaning of its intraperitoneal levels in peritonitis have received little attention. We hypothesized that in peritonitis a significant and clinically relevant cytokine-mediated inflammatory response is compartmentalized in the peritoneal cavity. METHODS: MEDLINE was used to search the literature for all articles dealing with experimental, primary, and secondary bacterial peritonitis and cytokines. RESULTS: Bacterial peritonitis is associated with an immense intraperitoneally compartmentalized cytokine response, with plasma levels of cytokines representing only the tip of the iceberg. Although certain amount of cytokines may be beneficial to the peritoneal defense mechanisms, higher levels correlate with adverse outcome. Thus it is plausible to look at acute peritonitis as initially a combined infective (microorganism) and inflammatory (cytokines) process. The clinical significance of the distinction between peritoneal inflammation and infection and the relevance of our findings to the stratification and treatment of peritonitis are discussed. CONCLUSIONS: Current surgical and antibiotic therapy for peritonitis is able to clear the peritoneal cavity of infective concentration of bacteria, but many patients continue to die of an uncontrolled activation of the inflammatory cascade. We suggest that one potential venue for therapeutic progress is the modulation of the compartmentalized peritoneal inflammatory response.

Prospective trial of proximal gastric vagotomy.

Forty men who were to have elective operation for nonobstructive duodenal or pyloric channel ulcer were randomized prospectively to undergo either proximal gastric vagotomy without drainage (PGV, n = 18) or selective vagotomy, antrectomy, and gastroduodenostomy (SVA, n = 22). Gastric acid analyses were accomplished before and 3 and 12 months after operation. Clinical interviews were conducted yearly. Thirty-nine patients were evaluable at 2 years, 25 at 4 years, and 15 at 5 years. No operative deaths occurred. Recovery was more rapid and the incidence of serious operative morbidity was lower after PGV than after SVA. Reduction of basal and stimulated gastric secretion was greater after SVA than PGV. Significant long-term sequelae other than recurrent ulcer were less frequent after PGV compared to SVA. Recurrent ulcer may occur more often after PGV; 3-month gastric secretory studies may be helpful in anticipating recurrence. Patients who undergo PGV have a particularly increased risk of developing pyloric channel ulcer disease, and low secretory values indicating an adequate vagotomy do not assure future protection from pyloric channel ulcer recurrence. Long-term sequelae after SVA, particularly dumping, do not have dependable reoperative options, whereas antrectomy should be a reliable reoperative solution to ulcer recurrence after PGV. PGV, performed correctly with a 5 to 7 cm vagal-esophageal separation, is preferable to vagotomy and resection for elective treatment of nonobstructing duodenal ulcer disease.

Treatment of intra-abdominal infections is appropriate with single-agent or combination antibiotic therapy.

In a prospective, randomized, single-blind trial, we studied 112 adults with intra-abdominal infections and compared antibiotic therapy with cefoxitin plus placebo to therapy with tobramycin plus clindamycin. Seventy-five percent of patients receiving tobramycin-clindamycin and 71% of those receiving cefoxitin-placebo had either shock, bacteremia, malnutrition, alcoholism, rapidly or ultimately fatal underlying disease, infection originating from the distal small bowel or colon, or had had failed therapy before treatment ("high-risk" group). One third of the patients in both groups grew bacteria in the initial culture resistant to the antibiotic regimen used. Ten patients receiving cefoxitin-placebo (17%) and 11 receiving tobramycin-clindamycin (21%) had recurrence of infection or died of infection (clinical failures). Nineteen failures occurred in high-risk patients (p less than 0.05) and 17 were in patients that had antibiotic-resistant bacteria in the initial culture (p less than 0.01). Adverse effects were rare and remitted after antibiotics were stopped. Our results suggest that both cefoxitin and tobramycin-clindamycin are appropriate antibiotic regimens to treat intra-abdominal infections. Clinical failure is more common in high-risk patients and when antibiotic-resistant organisms are isolated from initial cultures.

The risk of infection after colon injury.

We reviewed 137 patients with colon injury and applied multiple regression analysis to determine the influence of various parameters on colon-related infection. The complications of intra-abdominal abscess, wound infection, and peristomal abscess occurred in 25% of patients. The mortality rate was 3.6%, and four of five late deaths were caused by infection. Multiple regression analysis identified the amount of blood transfused, patient age, number of associated injuries, and injury to the spleen as significantly associated with infection (p less than 0.05). In the absence of these risk factors, the likelihood of infection is low, suggesting that primary repair or resection and anastomosis are safe methods of management for colon injury. When these factors are present, the risk of infection is high, and colostomy is the preferred method of management.

Effects of adrenergic agents on colonic motility.

Sympathetic hyperactivity has been implicated as an etiologic factor in postoperative ileus. The effects of methoxamine (alpha-agonist) and isoproterenol (beta-agonist) on colon contractions and blood flow were studied in nine monkeys. Phentolamine (alpha-antagonist) and propranolol (beta-antagonist) were used to block the effects of the appropriate agonist. Methoxamine caused a dose-related inhibition of colon contractions and a decrease in inferior mesenteric artery (IMA) blood flow. Isoproterenol caused a dose-related inhibition of colon contractions and an increase in IMA blood flow. The contractile and blood flow effects of methoxamine were blocked by phentolamine and those of isoproterenol by propranolol. Mechanical reduction of IMA blood flow by an amount equivalent to that observed with the highest dose of methoxamine caused no change in contractions in the segment of colon supplied by the IMA. Both alpha- and beta-agonists inhibit colon contractions and have the expected effects on IMA blood flow. The contractile and blood flow responses of the agonists can be blocked by appropriate antagonists. The blood flow changes are not responsible for the contractile changes. These results indicate that sympathetic hyperactivity may play a role in postoperative ileus.

Proximal gastric vagotomy versus selective vagotomy with antrectomy: results of a prospective, randomized clinical trial after four to twelve years.

This prospective, randomized study of selective vagotomy with antrectomy (SVA) versus proximal gastric vagotomy (PGV) for patients with duodenal ulcer compares the incidence of recurrent duodenal ulcer and postoperative morbidity during a 4- to 12-year follow-up period. In 46 patients with SVA there were no recurrent ulcers, but 26% of these individuals had serious digestive problems that were not amenable to medical treatment. The 40 patients with PGV had eight recurrent ulcers (20%), but five of these were found in the first 15 patients (33%) compared with three in the 25 patients (12%) who had operations after the need for extensive periesophageal denervation was discovered in the mid-1970s. Most recurrent ulcers were amenable to medical treatment, but 5% of the patients who had PGV had postoperative dysphagia that required periodic bougienage. The data are consistent with several interpretations, depending on the bias of the individual. However, based upon the fact that recurrent ulcers could be managed nonoperatively after PGV versus the lack of effective treatments for postgastrectomy complaints after SVA, it is reasonable to consider wider use of PGV. There are reasons to believe that the variable ulcer recurrence rates after PGV can be explained by subtle differences in operative technique, including those based upon use of the Congo red test for completeness of vagotomy. Unlike SVA, PGV remains an operative procedure in evolution that requires further clinical investigation. At this time either operation can be applied if both the surgeon and the patient have a clear understanding of the possible effects.

Inguinal hernia repair before and after prostatic resection.

From 1976 through 1981, 864 men had inguinal hernia repairs and 328 had prostatic resections at our Veterans Administration Hospital. Forty-four patients had symptomatic prostatic obstruction that required either transurethral or open prostatic resection within 12 months of hernia repair. Twenty-seven patients had prostatectomy prior to hernia repair, 16 had hernia repair before prostatic resection, and one had simultaneous procedures. There were no urinary tract infections (UTIs) after hernia repair in patients who had had prostatectomy first, while five patients who had hernia repair before prostatectomy developed UTI after hernia repair (P less than 0.01). The incidence of UTI after hernia repair correlated with the need for and duration of bladder catheterization as a result of prostatic obstruction. Complications after prostatectomy were similar regardless of the order of operation. There were no episodes of incarceration or strangulation in patients awaiting hernia repair after prostatectomy. These results suggest that, when an inguinal hernia and symptomatic prostatic obstruction occur together, the performance of prostectomy before hernia repair lowers the risk of morbidity by decreasing the incidence of UTI after hernia repair. This approach does not expose the patient to any additional risk related to the inguinal hernia.

Factors influencing the risk of early and late serious infection in adults after splenectomy for trauma.

We reviewed the clinical course of 245 adults who underwent splenectomy for trauma to assess the risk of both early and late serious infection. Twenty-one patients (9%) had an early serious infection (sepsis) during hospitalization for splenectomy. The mortality rate was 62% in patients with early sepsis, and encapsulated bacteria were isolated from the blood of 43% of patients with sepsis. Only one of 58 patients with isolated splenic injury had sepsis (2%), and the risk of early sepsis increased when three or more concomitant injuries were present (p less than 0.05). Stepwise multiple regression analysis revealed that patients with injuries to the pancreas, colon, or central nervous system or with extremity fractures had an increased risk of sepsis (p less than 0.05). The risk of sepsis was not influenced by age, the type of injury, delay in operation, use of drains, or other individual injuries. Sufficient information was available to assess the risk of late serious infection for 140 surviving patients (63%). Follow-up ranged from 2 to 277 months. Three late infections occurred at 2, 8, and 15 years after splenectomy; two were due to Streptococcus pneumoniae. None of these patients died. There were no identifiable factors influencing the risk of late infection. These results suggest that the risk of early serious infection in adults after splenectomy for trauma is low when isolated splenic injury is present but that this risk is increased by both the degree of injury and the presence of certain associated injuries. Encapsulated bacteria are frequent pathogens in both early and late infections. The mortality rate related to an early septic episode is high, but the risk of late serious infection is low and is not related to identifiable factors that decrease host defenses.

Surgical sepsis: constancy of antibiotic susceptibility of causative organisms.

BACKGROUND: It is well documented that antibiotic therapy exerts selective pressure on bacteria. Conversion of bacteria from susceptible to resistant to antibiotics has been observed often during antimicrobial therapy. It has been postulated that human intestinal reservoirs facilitate communication of transposons that can transfer resistance determinants among various bacterial species. METHODS: This study examined the susceptibilities of organisms isolated from infected abdomens to a number of antibiotic agents during a 12-year time interval. Analysis included 1102 isolates recovered from 255 specimens, representing the following genera: Bacteroides, Clostridium, Gemella, Fusobacterium, Peptostreptococcus, Porphyromonas, Prevotella, Enterococcus, Staphylococcus, Streptococcus, Pseudomonas, and Enterobacteriaceae. Strains were tested against beta-lactam agents, beta-lactams in combination with beta-lactamase inhibitors, first, second, and third generation cephalosporins, aminoglycosides, clindamycin, metronidazole, chloramphenicol, and imipenem. RESULTS: The results indicated that during a time period of more than a decade essentially no change occurred in the antibiotic susceptible fraction of all species tested. CONCLUSIONS: Abdominal sepsis is caused by leakage of endogenous intestinal flora. This study suggests that the intestinal flora is not permanently affected by short-term antibiotic therapy and that older antibiotics are appropriate first-line therapeutic agents for community-acquired infections caused by normal intestinal flora.

Effects of halothane, enflurane, and nitrous oxide on colon motility.

Previous work from this laboratory has demonstrated that the colon, particularly the left colon, is the major site of persistent postoperative ileus after both minimal and more extensive abdominal operations. Inhalation anesthetics have been implicated in the past as a possible cause of altered postoperative bowel function, but direct evidence of such a role in postoperative ileus is lacking. In this investigation, the effects of three inhalation anesthetic agents, halothane, enflurane, and nitrous oxide, on contractile function of the right and left colon were investigated in monkeys. Enflurane and halothane administration caused cessation of contractions in both the left and right colon; suppression of motor activity continued throughout the period of anesthetic administration. Recovery of normal contractile function occurred relatively promptly after cessation of anesthesia with these drugs. Return of normal contractions was more prompt in the right than in the left colon. Administration of nitrous oxide was not associated with significant suppression of contractile function of either the the right or left colon. None of the three agents studied appear to have any role in typical postoperative ileus.

Postoperative ileus: a colonic problem?

Postoperative electromechanical activity of the gastric antrum, small bowel, right colon, and sigmoid colon was recorded in stumptail monkeys in response to retroperitoneal dissection and transient clamping of the renal pedicle. Bipolar silver electrodes and extraluminal bonded strain gauge transducers were used to record slow-wave and spike discharges and contractions of intestinal smooth muscle. After operation myoelectric activity was decreased transiently in the antrum and for only a few hours in the small bowel. Right colon contractile activity was decreased significantly for 24 hours and that of the sigmoid colon for 72 hours. Postoperative inhibition of bowel motility appears to be most profound and persistent in the colon.

Relationship of duration of postoperative ileus to extent and site of operative dissection.

Postoperative ileus has been thought to be related to intraoperative manipulation of the intestines and to the duration of operative procedures. In order to study the effect of these variables on the postoperative myoelectrical activity of the intestine, six stumptailed monkeys had strain-gauge force transducers and bipolar electrodes placed on gastric antrum, mid-small bowel, right colon, and sigmoid colon. The animals were then subjected to three operations in random order varying in extent and site of dissection: (1) midline incisions, mobilization of right colon and kidney, clamping of renal pedicle, and extensive blunt dissection of right retroperitoneum; (2) the same operation but done on the left side; and (3) midline incision and gentle digital manipulation of the intestines. The first two procedures involved much more intestinal handling and dissection and took five to six times longer than the minimal laparotomy procedure. Postoperative inhibition of bowel motility was most profound and persistent in the colon. The duration and pattern of postoperative ileus in these experiments were independent of the extent, site, and duration of the operative procedure.

A comparison of prosthetic materials used to repair abdominal wall defects.

A large abdominal wall hernia, not amenable to primary closure, may require insertion of a prosthesis. The ideal prosthesis maintains strength, is incorporated by surrounding tissues, and does not stimulate adhesions. These qualities vary among available synthetic prostheses. We tested tensile strength, bursting strength, and adhesion formation in response to six materials used in repair of abdominal wall hernias. Adult Sprague-Dawley rats (196) were randomly divided into a control group and six experimental groups. A 4 by 4 cm full-thickness resection of abdominal wall was closed with patches of polypropylene mesh (Marlex), polyglactin 910 mesh (Vicryl), expanded polytetrafluoroethylene (Gore-tex), Dacron-reinforced silicone rubber (Silastic), preserved human dura (PHD), or polypropylene mesh overlying gelatin film (Marlex and Gelfilm, respectively). In controls the 4 cm longitudinal full-thickness incisions were closed primarily. Seven rats randomly selected from each group were sacrificed after 1, 2, 4, and 8 weeks; bursting and tensile strength (tensiometer) and adhesion formation were assessed. There were no differences in bursting strength among the experimental groups at each testing period. Although bursting strength increased linearly with time it was significantly weaker than in controls at 1 and 8 weeks (P less than 0.05). Tensiometric data were inconclusive due to wide variability within the experimental groups. Adhesion formation was moderate to maximal at all evaluation periods for Marlex and Gore-tex. Early adhesion formation was minimal to moderate for both PHD and Vicryl, but later increased with PHD and decreased with Vicryl as this prosthesis was absorbed. No adhesions formed with Marlex and Gelfilm until the gelatin dissolved (1 week), after which the adhesion response was similar to that with Marlex alone. No adhesions formed after Silastic implantation, but graft extrusion and evisceration were common (75%). Controls had no adhesions at all evaluation periods. Wound strength was similar for all prosthetic materials. Absorbable prosthetic Vicryl provided the best long-term protection against adhesions.