Worldwide hernia repair: variations in the treatment of primary unilateral inguinal hernias in adults in the United Kingdom and in low- and middle-income countries.

INTRODUCTION: In this invited commentary, we aim to quantify and explain the variation between, and also within, developed healthcare systems (using the UK as an example) and low- to middle-income countries (LMICs). Rather than including complex cases, we have looked only at 'uncomplicated' primary unilateral inguinal hernias, an area where limited variation may be identified. METHODS: Data were obtained from Hospital Episode Statistics and structured surveys in the United Kingdom and in low- and middle-income countries. CONCLUSION: There is widespread variation in the repair of 'uncomplicated' primary inguinal hernias worldwide and within developed healthcare systems.

A prospective cohort study comparing the African and European hernia.

INTRODUCTION: The prevalence of inguinal hernia in Ghana, western Africa, is as high as 7.7% of the population. The elective operation rate is significantly lower because many of the hernias are repaired as emergencies. This discrepancy results in a pool of longstanding large hernias. PATIENTS AND METHODS: This prospective cohort study compared consecutive patients having day case local anaesthetic inguinal hernia repairs under the Plymouth Hernia Service, UK, and in Ghana, Africa. Assessment was made of hernia size and subscapular skin-fold thickness. In the Ghanaian group, data were collected on patient age, type of inguinal hernia, duration of the hernia, and disability caused. RESULTS: A total of 241 patients were included in the study (UK: n = 106, Ghana: n = 135). The mean age of the UK group was 62 years (range 28-91 years) and of the Ghanaian group 34 years (range 2 months-80 years). One hundred and twelve (82.9%) of the Ghanaian hernias were indirect. Ninety (67%) of the Ghanaian hernias extended into the scrotum compared with 7 (6.0%) in the UK group. The Ghanaian hernias were significantly larger (P = 0.01) and the patients significantly thinner (P = 0.02). In the Ghanaian group, 22 (16%) of the patients were unable to work due to their hernia, and in a further 87 (64%) patients, the hernia limited daily activity. One hundred and fifteen (85%) of the Ghanaian hernias were present for more than 1 year, and of those, 50 (37%) had been present for more than 5 years. CONCLUSION: In Ghana (a developing country), the hernia is larger than the UK hernia. The majority of Ghanaian hernias are indirect and occur in a young population. This places an economic burden on the country. Appropriate management is needed to reduce the pool of these hernias.

Operation hernia: humanitarian hernia repairs in Ghana.

Ghana has a high incidence of inguinal hernias and the healthcare system is unable to deliver an adequate repair rate. This results in morbidity and mortality and has a knock-on effect on the local economy. A project has been set up to try and reduce the burden of these hernias by establishing Africa's first Hernia Centre. This is supported by structured visits by European surgeons to the centre. In October 2006, a team of four surgeons, two specialist registrars, one hernia nurse specialist, and three nurses was assembled in order to open the Hernia Centre, which will provide a base for the delivery of hernia services in the West of Ghana. A 2-year teaching programme has been formulated, tailored to the needs of local surgeons and nurses, with the aim of developing an integrated team that will initially deliver up to 50 hernia repairs each month. It is planned that the centre will be supported by structured periodic visits from surgeons and nurses based in Plymouth, the European Hernia Society, and any other volunteers wishing to support the link.

A pragmatic approach to cutaneous nerve division during open inguinal hernia repair.

AIMS: Chronic pain following inguinal hernia repair may be related to the handling of cutaneous nerves. This study aims to investigate the frequency of cutaneous nerve division in routine practice and the effect that nerve division has on long-term pain outcomes. METHODS: The outcomes of 172 patients who underwent open inguinal hernia repair over a two-year period during the course of a clinical trial were recorded prospectively for 1 year. Pain scores for patients in whom one of the nerves was divided were compared with those of patients in whom all three were preserved. RESULT: All nerves were preserved in 95 cases (55.2%). The ilioinguinal, genital and iliohypogastric nerves were divided in 33 (19.2%), 12 (7.0%) and 14 (8.1%) cases, respectively. There was no significant difference in pain scores between any of the nerve division groups compared to the group in which all three were preserved. There were three (1.7%) cases of significant chronic pain, two in which no nerves were divided. CONCLUSION: The division of cutaneous nerves during inguinal hernia repair has no significant effect on postoperative pain. However, there are very few adverse outcomes, and so, a pragmatic approach of dividing nerves when they would otherwise be damaged may be appropriate.

The European hernia society groin hernia classification: simple and easy to remember.

After reviewing the available classifications for groin hernias, the European Hernia Society (EHS) proposes an easy and simple classification based on the Aachen classification. The EHS will promote the general and systematic use of this classification for intraoperative description of the type of hernia and to increase the comparison of results in the literature.

Operation Hernia to Ghana.

Inguinal hernia repair and Caesarian section are the two most commonly occurring operations in Africa. Trained surgeons are few, distances between hospitals are large and strangulated hernia is the most common cause of intestinal obstruction. Numerous deaths and cases of permanent disability occur because patients with inguinal hernias requiring elective or urgent surgery are not properly cared for, or they do not actually reach hospital. Operation Hernia was a humanitarian mission between the European Hernia Society and the Plymouth-Takoradi (Ghana) Link conceived specifically to treat and teach groin hernia surgery in the Western region of Ghana.

Effects of alpha-difluoromethylornithine on the growth of experimental Wilms' tumor and renal adenocarcinoma.

Because polyamines are essential for cellular growth and differentiation, and because human renal carcinomas have spermidine levels that are higher than those in normal renal tissue, effects of 2-difluoromethylornithine (DFMO) on the growth of experimental renal tumors were investigated. DFMO is a specific enzyme-activated irreversible inhibitor of ornithine decarboxylase, the rate-limiting enzyme controlling polyamine biosynthesis. DFMO (2%) in drinking water was administered to BALB/c mice with intrarenal transplants of a renal adenocarcinoma cell suspension and to Wistar/Furth rats with s.c. transplants of a Wilms' tumor. At 28 days, renal carcinomas in DFMO-fed mice weighed 72% less than those in control animals (p less than 0.001). Wilms' tumor weight was not affected by DFMO feeding. DFMO caused 72 to 75% inactivation of ornithine decarboxylase activity and reduced putrescine levels in renal carcinoma and Wilms' tumor, reduced spermidine levels in Wilms' tumor, and apparently raised spermine levels in the latter as a consequence. DNA content was not affected by DFMO feeding. The mean number of lung metastases in DFMO-fed, renal carcinoma-bearing mice was 0.1 and in controls was 1.4 (p less than 0.001). DFMO feeding increased survival of mice bearing renal carcinomas by 3.0 +/- 0.8 (S.E.) days (p less than 0.05), i.e., from 30.5 +/- 0.8 days to 33.5 +/- 1.2 days. DFMO did not affect the growth of Wilms' tumor; however, in renal adenocarcinoma, it reduced growth, prevented lung metastases, and increased survival.

Effects of alpha-difluoromethylornithine and 5-fluorouracil on the proliferation of a human colon adenocarcinoma cell line.

Because alpha-difluoromethylornithine (DFMO) reduces the incidence of experimental colon cancers, inhibits the growth of human lung cancer cells and human leukemia cells in culture, and in combination with methylglyoxal (bis)guanylhydrazone induces remission in children with leukemia, its effectiveness against a human colon adenocarcinoma cell line (Colo 205) was tested alone and in combination with 5-fluorouracil (5-FU). Both DFMO (2 X 10(-4) M) and 5-FU (10(-6) M) inhibited Colo 205 cell proliferation. Above 5 X 10(-4) M DFMO (p less than 0.001) and at 10(-4) M 5-FU (p less than 0.001), Colo 205 growth was completely inhibited. Although DFMO did not sensitize Colo 205 cells to a noninhibitory concentration of 5-FU, the effectiveness of inhibitory concentrations of 5-FU and DFMO in reducing Colo 205 cell growth was additive. DFMO (2 X 10(-4) M) caused 89 to 93% inhibition of ornithine decarboxylase activity (p less than 0.001) and reduced levels of putrescine (93%; p less than 0.01) and spermidine (57%; p less than 0.02). Growth rate and the intracellular putrescine and spermidine contents were restored by 10(-6) M putrescine. DFMO could be an effective chemotherapeutic agent against human colonic cancer because of its effects at such unusually low concentrations in vitro.

Inhibition of ornithine decarboxylase with 2-difluoromethylornithine: reduced incidence of dimethylhydrazine-induced colon tumors in mice.

2-Difluoromethylornithine (DFMO) was administered to 1,2-dimethylhydrazine (DMH)-treated mice to reduce colonic polyamine levels and mucosal hyperplasia. Mice received 1% DFMO in drinking water throughout the experiment and were given injections of DMH (20 mg/kg) weekly for 28 weeks. DFMO inactivated 93% of colonic ornithine decarboxylase activity. Although DMH treatment did not induce colonic ornithine decarboxylase activity by Week 28, the putrescine content was increased 31% in DMH-treated mice (p less than 0.01). Concurrent treatment with DFMO depressed putrescine content (42 to 63%) and spermidine content (27 to 38%), but it increased spermine content (18 to 22%). At Week 28 of treatment with DMH alone, RNA content was increased 8.6% (p less than 0.01), DNA content 10% (p less than 0.01), DNA specific activity 24% (p less than 0.01), and crypt depth 20% (p less than 0.01), but not in mice receiving DMH and DFMO. At 28 weeks, 13 of 17 mice (76%) treated with DMH alone had histologically confirmed colon cancers; of mice treated with DMH and DFMO, two of 18 (11%) had colonic tumors. Throughout the experiment, 50 colon cancers developed in 16 DMH-treated mice (mean, 3.12 tumors/mouse); three mice treated with DMH and DFMO developed three colon cancers total (p less than 0.001). Reduction of colonic polyamine levels after DFMO treatment prevents proliferative changes induced by DMH and reduces the incidence of tumors.

Is there a role for hernia subspecialists? Or is this a step too far?

Specialization influences the way that we deliver surgical care and has a direct impact on surgeons, healthcare systems and patients. Abdominal wall hernia repairs are among the most commonly performed surgical procedures worldwide, and over 20 million prosthetic meshes are inserted annually. Worldwide outcomes from groin hernia repair, as reflected by 5-year recurrence rates, range from 1 to 4 %. However, the results for incisional hernia repair are at least ten times worse, with worldwide recurrence rates of about 25 % and upwards. This editorial aims to debate the argument for and against hernia subspecialists and provide a framework for implementing specialist hernia services.

Potentiation of 1,2-dimethylhydrazine-induced anal carcinoma by epidermal growth factor in mice.

Because epidermal growth factor (EGF) can modify cell proliferation in the gastrointestinal tract, effects of EGF were studied on the development of colonic, rectal, and anal neoplasms in male mice treated with 1,2-dimethylhydrazine (DMH) (20 mg/kg/wk for 20 weeks). DMH treatment caused a 13% increase in colonic RNA content, a 16% increase in DNA content, and 28% greater crypt depth. EGF (5 micrograms on alternate days during weeks 20 to 22) administered to DMH-treated mice produced no additional changes in colonic mucosa. At 30 weeks colorectal tumors were present in 13 of 20 mice treated with DMH (mean number of tumors per mouse 2.3 +/- 0.5) and 18 of 24 mice (mean 2.6 +/- 0.7) treated with DMH and EGF. Anal tumors were present in two of 20 DMH-treated mice (mean 0.1 +/- 0.07) but in eight of 24 DMH-EGF-treated mice (mean 0.33 +/- 0.1) (X2 = 4.84; p less than 0.05 for prevalence). Although EGF in this dose has no effect on the frequency of colorectal adenocarcinomas, the frequency of anal squamous cell carcinomas is increased more than three fold.

Inhibition of ileal and colonic ornithine decarboxylase activity by alpha-difluoromethylornithine in rats: transient atrophic changes and loss of postresectional adaptive growth.

To determine the role of putrescine synthesis in adaptive hyperplasia of the ileum and colon, DL-alpha-difluoromethylornithine (DFMO), an enzyme-activated, irreversible inhibitor of ornithine decarboxylase (ODC), the enzyme controlling putrescine biosynthesis, was fed to rats after excision of the proximal half of the small bowel. A rise in ODC activity (280% in the proximal ileum, 62% in the proximal colon) and a rise in putrescine content (220% in the proximal ileum, 250% in the proximal colon) normally accompanied characteristic cytochemical adaptive increases in the ileum and colon at day 6. Inclusion of 1% DFMO (2.1 gm/kg/day) in drinking water for 12 hours before operation and for 14 days thereafter decreased ODC activity by 85% to 96%, reduced levels of putrescine and spermidine and measurements of the adaptive response by 50% in the ileum, and abolished the adaptive response in the colon. During the first 10 days of DFMO feeding, villous atrophy and other hypoplastic changes occurred in control rats, but by 14 days of DFMO feeding atrophy and hypoplasia were no longer present. Although DFMO inhibits adaptive hyperplasia occurring in the ileum and colon of rats after resection of the proximal half of the small bowel, spontaneous recovery of villous atrophy occurs during further DFMO feeding and may protect the host during chemotherapy.

Lichtenstein patch or Perfix plug-and-patch in inguinal hernia: a prospective double-blind randomized controlled trial of short-term outcome.

BACKGROUND: Open mesh used in anterior inguinal hernia repair can be configured as a flat patch (Lichtenstein operation) or as a cone-shaped preformed plug and supplementary patch (plug-and-patch operation; Perfix Plug; Davol Inc, Cranston, RI). METHODS: One hundred forty-one patients were randomly allocated and blinded to receive either a Lichtenstein patch or a Perfix plug-and-patch. Information before the operation and on postoperative days 3 and 14 was recorded by an independent blinded observer to include operating time, postoperative pain, analgesic medication, return to activity and work, and quality of life assessment. RESULTS: Operating time (32 vs 37.6 minutes) was significantly shorter in the plug-and-patch group (P = .01). During days 1 through 8, patients who had undergone the plug-and-patch operation experienced less pain, and their physical functioning on day 3 was significantly better (P = .013). Days of analgesic medication (4.0 vs 4.6 days), return to normal activity (2.8 vs 3.6 days), return to work (17.0 vs 20.8 days), and total days of work missed (14.3 vs 16.1 days) were similar in both groups (P = NS for all comparisons). CONCLUSIONS: Compared with patients who received the Lichtenstein patch for ambulatory inguinal hernia repair, patients who underwent the Perfix plug-and-patch operation experienced less postoperative pain in the first 8 days after the operation but consumed similar postoperative analgesic medication. The rate of return to normal activity and work is similar in both groups, which indicates no superiority for the plug-and-patch operation in overall rehabilitation and societal costs. Overall hospital costs are greater for the plug-and-patch operation ($120 [US]) compared with the Lichtenstein patch ($20 [US]), with a negligible (5.6 minutes) saving of operating room time for the plug-and-patch operation.

Acute pancreatitis: an overview of emerging pharmacotherapy.

Biotechnology has enabled greater understanding of the cellular and molecular biology of acute pancreatitis and has offered the possibility of a new generation of biodrugs to treat this disease. The proteases inhibitor gabexate mesilate has proven to be effective for endoscopic retrograde cholangiopancreatography-induced pancreatitis but, given the low incidence of this condition, its cost-effectiveness has to be evaluated. Randomised controlled trials have shown no benefit for somatostatin or its analogue octreotide although some practitioners continue to use it to prevent organ damage and complicated disease. Antioxidant therapy has been thoroughly investigated in animal models but the results of large scale clinical trials are awaited. The use of kinin inhibitors is in its infancy and has not yet reached the clinic. Considerable interest has been engendered in nitric oxide (NO), firstly for its beneficial use in acute lung injury resulting from the multi-organ failure of acute pancreatitis and secondly, the possible benefits of NOS inhibition to prevent pancreatitic necrosis. Tumour necrosis factor antagonism and interleukin- 1 blockade are 2 therapies awaiting clinical trials because there is overwhelming evidence of their benefit in animal models. Interleukin-10, an anticytokine, may have similar benefits and has been shown to be beneficial in animal models when given as pretreatment. The only biodrug that has progressed to phase III clinical trials is the platelet-activating factor antagonist lexipafant. Successful phase II studies have been followed up by a phase III study indicating benefits in reduction of organ failure and pseudocyst formation and reduction in mortality when treatment is given within 48 hours of onset of the disease. Finally, prophylactic therapy with selected antibacterials in patients with predicted severe disease can reduce local complications and possibly mortality.

Lung injury in the microembolic model of acute pancreatitis and amelioration by lexipafant (BB-882), a platelet-activating factor antagonist.

Acute pancreatitis is associated with the development of pulmonary dysfunction in a number of patients. The aim of this study was to determine whether acute lung injury was a feature of the microembolic model of pancreatitis in rats and to assess the therapeutic effect of lexipafant (BB-882), a potent platelet-activating factor antagonist, on the lung injury. Acute pancreatitis was induced by microembolisation of the pancreas with 20-microns polystyrene microspheres. After 12 h tissue capillary permeability was assessed by an Evans blue dye (EBD) extravasation technique and compared with that in control animals. A further group of animals received an intraperitoneal injection of BB-882 (5 mg/kg) 30 min after the induction of pancreatitis. There was a significantly increased tissue content of EBD in the pancreas and lungs of the group of animals with acute pancreatitis (p < 0.05). BB-882 ameliorated the pulmonary changes when administered after the induction of pancreatitis, as demonstrated by a significant reduction in the EBD content of the lungs (p < 0.01). Increased pulmonary vascular permeability is an early feature of the microembolic model of acute pancreatitis and these changes appear to be modified by the administration of BB-882, providing further evidence for the potential role of platelet-activating factor antagonists in the treatment of acute pancreatitis and its complications.

Investigation of the interleukin 1 gene cluster and its association with acute pancreatitis.

The interleukin 1 (IL-1) gene cluster has been implicated in acute pancreatitis. Penta-allelic and bi-allelic polymorphisms exist in the IL-1RN and IL-1B genes, respectively. The aim of the study was to investigate these polymorphisms in acute pancreatitis. Genotype and allele frequencies were determined in patients (n = 116) and healthy controls (n = 170) using the polymerase chain reaction. PCR products from the IL-1B study were further digested with Taq I restriction endonuclease. Patients were categorised according to aetiology, severity, and organ-failure scores. Allele 1 of the IL-1RN polymorphism was significantly increased in patients compared with controls (72.0 vs. 63.0%; p = 0.029, Pc = 0.029), in severe cases compared with controls (81.9 vs. 63.0%; p = 0.002, Pc = 0.004), in idiopathics compared with controls (82.4 vs. 63.0%; p = 0.002, Pc = 0.006), and in severe cases compared with mild cases (81.9 vs. 67.5%; p = 0.023, Pc = 0.046). Allele 2 was significantly decreased in severe cases compared with controls (18.1 vs. 33.0%; p = 0.013, Pc = 0.026), in idiopathics compared with controls (17.6 vs. 33%; p = 0.013, Pc = 0.039), and in severe cases compared with mild cases (18.1 vs. 32.5%; p = 0.023, Pc = 0.046). No significant differences were found for the Taq I allele or genotype frequencies between controls and patients/subgroups of patients. IL-1RN appears to determine severity of acute pancreatitis and susceptibility to idiopathic acute pancreatitis. No association was found between IL-1B and the disease.

Chemoprevention and chemotherapy by inhibition of ornithine decarboxylase activity and polyamine synthesis: colonic, pancreatic, mammary, and renal carcinomas.

Specific, irreversible, inhibition of ODC activity with DFMO and resultant low levels of intracellular polyamines markedly suppress the induction of experimental colonic and mammary cancers and hold promise for augmenting the multidrug chemotherapy of established colonic, pancreatic, renal and mammary cancers without increasing systemic toxicity.

Audit of patient outcomes after herniorrhaphy.

The efficacy of a surgical procedure is a measure of outcome when performed by specialists. The monotonous excellence of countless cohort studies bears witness to the efficacy of numerous techniques of herniorrhaphy. Effectiveness, however, is of far greater relevance to health care commissioners than efficacy. Audit is an instrument of effectiveness and can be further developed to study cost-effectiveness where outcomes do not differ greatly.

Embryology, anatomy, and surgical applications of the preperitoneal space.

The preperitoneal space is presented from an embryologic, anatomic, and surgical standpoint in detail. Because this space is one of the most used areas for the repair of groin hernias, knowledge of its embryology and anatomy is essential.