Recurrence and complications after laparoscopic versus open inguinal hernia repair: results of a prospective randomized multicenter trial.

BACKGROUND: The aim of this prospective randomized multicenter trial was to evaluate the recurrence rates and complications of open versus laparoscopic repairs of inguinal hernias. METHODS: Patients with primary unilateral inguinal hernias were randomized to Shouldice repair, Bassini operation, tension-free hernioplasty (Lichtenstein repair), laparoscopic transabdominal extraperitoneal hernioplasty (TEP), or laparoscopic transabdominal preperitoneal hernioplasty (TAPP). The primary outcome parameter was the rate of recurrence at 3 years. The secondary outcome was the rate of intraoperative, perioperative, and long-term complications. Follow-up comprised of clinical examination after 1, 2, and 3 years. RESULTS: Three hundred and sixty-five patients were randomly assigned to one of the five procedures. The intention-to-treat analysis showed that the cumulative 3-year recurrence rate was 3.4% in the Bassini group, 4.7% in the Shouldice group, 0% in the Lichtenstein group, 4.7% in the TAPP group, and 5.9% in the TEP group (p = 0.48). Comparing open (Bassini, Shouldice, Lichtenstein) versus laparoscopic (TAPP, TEP) techniques (p = 0.29) and comparing the use of mesh prostheses (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) (p = 0.74) showed no significance in the rate of recurrence. The rates of intraoperative (p = 0.15), perioperative (p = 0.09), and long-term complications (p = 0.13) were without significance between the five groups. Comparing mesh techniques (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) showed no significance in the rate of complications. The per-protocol analysis for the comparison of mesh (Lichtenstein, TAPP, TEP) versus suturing (Bassini, Shouldice) techniques revealed that recurrences (p = 0.74), intraoperative (p = 0.64), perioperative (p = 0.27), and long-term complications (p = 0.91) were evenly distributed. CONCLUSIONS: In this multicenter study, no significant difference in the recurrence rate and complications between laparoscopic and open methods of hernia repair was revealed.

A new biliodigestive anastomosis technique to prevent reflux and stasis.

BACKGROUND: The Roux-en-Y procedure for biliodigestive drainage is most widely accepted, but 10% to 15% of patients postoperatively suffer from a blind-loop syndrome or cholangitis due to motility disorders. A new biliodigestive technique is evaluated in a rat model to prevent these complications. METHODS: This experimental study in Wistar rats compares the Roux-en-Y technique with a new biliodigestive anastomosis creating a jejunal loop with luminal occlusion. Clinical parameters, small bowel motility, bacteriologic growth, and liver histopathology were evaluated in native and postoperative animals within a study period of 180 days. RESULTS: Both operative procedures were well tolerated. After 6 months intense fibrosis of the liver and high-grade purulent cholangitis were observed in animals in the Roux-en-Y group. In these animals enterobacter and enterococci overgrowth was found. Myoelectric small bowel recordings revealed significant impairment of slow-wave frequency, aboral velocity, and action potentials (percentage of phase III) in Roux-en-Y animals. CONCLUSIONS: Motility disorders after conventional Roux-en-Y biliodigestive anastomosis are pivotal for histomorphological damage and infectious findings and can be prevented by using the new technique to create a jejunal loop with luminal occlusion.

Beneficial effects of Batimastat (BB-94), a matrix metalloproteinase inhibitor, in rat experimental colitis.

BACKGROUND AND AIMS: Matrix metalloproteinases (MMPs) represent a group of enzymes that regulate cell-matrix composition playing a major role in the inflammatory response. In the present study we evaluated the ability of the MMP inhibitor Batimastat (BB-94) to modify the course of experimental colitis induced in the rat by trinitrobenzensulfonic acid (TNB). METHODS: Colitis was induced in 40 rats by intracolonic administration of TNB. Animals were divided into four groups of ten rats each: group 1 received only intracolonic TNB, group 2 received TNB+5 mg/kg intraperitoneal BB-94, group 3 TNB+10 mg/kg BB-94 and group 4 TNB+20 mg/kg BB-94. The MMP inhibitor was administered 30 min before induction of colitis and twice daily until death. Ten rats receiving only intracolonic 0.9% saline served as controls. Animals were killed after seven days; segments of colon were removed and used for histological score of inflammation and myeloperoxidase (MPO) activity. RESULTS: Rats receiving only intracolonic 0.9% saline showed no evidence of colitis. The inflammation score was 0.9, MPO activity 0.235 U/mg. Group 1 (TNB-treated rats) exhibited a high inflammation score (12.4) and MPO activity (0.715 U/mg). Conversely, BB-94-treated rats showed, compared to the TNB group, a significantly lower inflammation score and MPO activity in a dose-dependent fashion. Group 2: inflammatory score 10.1, MPO activity 0.474 (p < 0.05 vs. TNB); group 3: inflammatory score 8.3, MPO activity 0.287 (p < 0.01 vs. TNB); group 4: inflammatory score 5.0, MPO activity 0.256 (p < 0.01 vs. TNB). CONCLUSIONS: Treatment with BB-94 has dose-dependent beneficial effects on the inflammatory alterations in rat experimental colitis. Thus, the inhibition of MMPs may represent a novel therapeutic approach for treatment of intestinal inflammation.

Long-term outcome after switch from cyclosporine-based triple-drug immunosuppression to double therapy at three months.

Cyclosporin A (CyA) together with steroids and azathioprine (Aza) has been successfully used for prophylactic immunosuppression in numerous recipients of kidney allografts. The aim of this study was to evaluate the long-term effect of reducing this initial triple-drug therapy to double-drug therapy at 3 months. One hundred consecutive recipients of a cadaveric renal allograft with stable and good graft function were randomly allocated to continue with CyA and steroids (group 1) or CyA and Aza (group 2). Both groups were comparable with regard to all relevant patient characteristics. After a mean observation period of 55 (26-76) months no significant difference was observed in the incidence of acute rejection episodes after conversion (4 in group 1 and 5 in group 2), or in the incidence of graft loss (4 in group 1 and 5 in group 2); all graft rejection episodes were easily reversed with steroid pulses and patients switched back to triple-drug therapy. Patient survival was 94% in group 1 and 100% in group 2 at 55 months. In group 1, however, a higher number of viral infections and steroid-related side effects was noted. From these data it is concluded that initial triple-drug therapy can safety be reduced to a CyA-based double-drug combination after 3 months in renal allograft recipients with stable function. The combination with Aza is recommended because of its fewer side effects.

Twenty-three years of follow-up in patients with total colonic aganglionosis.

The main purpose of our study was to evaluate the outcome of patients with total colonic aganglionosis diagnosed and treated in our hospital. Seven of our twelve patients died within 6 month after birth due to infectious complications or underlying other diseases. 5 patients are alive after subtotal colectomy and ileo-rectal anastomosis, and were investigated for late complications, social integration, stool behavior, local status and laboratory parameters 12 and 23 years after surgery. All patients developed almost normally and were socially and professionally integrated. Although all had an accelerated passage of stools, no signs of malnutrition were found. One patient developed a recto-sacral fistulae and sacral osteomyelitis eight years after surgery and needed an ileostomy. After ileo-rectostomy all patients were continent with a grown rectal stump, had no strictures and a normal appearance of the mucosa.

Dopamine-1-receptor stimulation and mucosal tissue oxygenation in the porcine jejunum.

OBJECTIVE: To evaluate the effects of dopamine-1-receptor stimulation on intestinal mucosal tissue oxygenation. DESIGN: Prospective, experimental, controlled trial. SETTING: Animal research laboratory. SUBJECTS: Anesthetized domestic pigs (30 to 45 kg). INTERVENTIONS: A small segment of the jejunal mucosa and serosa was exposed by midline laparotomy and antimesenteric incision. Fenoldopam, a selective dopamine-1-receptor agonist, was infused in steps, exponentially increasing from 0.6 to 9.6 micrograms/kg/min via a central venous catheter (n = 8, fenoldopam group), whereas a second group (n = 6, saline group) was only given the solvent. MEASUREMENTS AND MAIN RESULTS: Systemic hemodynamics as well as systemic and jejunal acid base and blood gas variables were measured using an arterial catheter, a thermodilution pulmonary artery catheter, and a jejunal venous catheter. Jejunal mucosal and serosal tissue PO2 were measured by means of Clark-type surface oxygen electrodes. Oxygen saturation and relative concentration of mucosal microvascular hemoglobin were measured by means of tissue reflectance spectrophotometry. In the fenoldopam group, systemic oxygen delivery (12.5 +/- 0.8 mL/kg/min at baseline) increased by 56% (p < .001) above baseline values. Mean arterial pressure remained unchanged. Fenoldopam produced a 51% increase in mucosal PO2 (23.8 +/- 2.8 torr [3.2 +/- 0.4 kPa] at baseline; p < .001) and a 31% increase in mucosal hemoglobin oxygen saturation (55.4 +/- 8.3% at baseline; p < .001), but not change in serosal PO2 (58 +/- 4.8 torr [7.7 +/- 0.6 kPa] at baseline). CONCLUSIONS: Fenoldopam improves tissue oxygenation of the porcine jejunum in a dose-related manner. This effect is limited to the inner mucosal layer. Dopamine-1-receptor agonists should be evaluated in patients presenting with signs of intestinal mucosal ischemia.

The impact of jejunal transplant peristalsis on enteric flora.

The importance of phase III of the migrating myoelectric complex (MMC) for homeostasis of enteric flora is well documented. The goal of this study was to evaluate in an isogeneic rat model the effect of MMC changes on the self-purging capacity of the jejunal graft. The proximal 25% of the entire jejunoileum of Lewis rats was transplanted orthotopically. Electrodes were then fixed to the graft. Native bowel of five rats and five rats with analogue jejunal segmentation served as controls. Myoelectric recordings were carried out until day 21, when animals were killed for bacteriologic analysis of the segments analyzed myoelectrically and the of neighboring gut. MMCs were observed in all animals during all recordings. Phase III was irregular in transplants because of long-lasting periods of phase III absence alternating with phase III occurring more frequently. The variation coefficient of phase III periodicity calculated for grafts was 48.74, for native bowel 14.79, and for segmented jejunum 22.9. Enteric flora found in all specimens consisted of colonic-like microorganisms. Titers of microorganisms in grafts did not differ from control segments. These findings show that phase III periodicity is severely altered in jejunal grafts. Homeostasis of enteric flora, however, is not influenced by the transplant procedure.

Life-threatening gastrointestinal bleeding after liver transplantation due to hepatic artery pseudoaneurysm perforating into the common bile duct. A case report.

A 54-year-old male presented with acute rejection and life-threatening gastrointestinal bleeding 2 months following orthotopic liver transplantation. Since no bleeding was identified in the entire gastrointestinal (GI) tract, hematobilia was first suspected and an arteriocholedochal fistula angiographically confirmed. Two days after resection of a pseudoaneurysm of the hepatic artery (HA) with primary repair and closure of the bile duct fistula, hepatic artery thrombosis (HAT) occurred. Various attempts to revascularize the HA eventually failed. Two weeks later, a CT scan showed necrotic areas within the two left lateral segments. At relaparotomy, major parts of the bile duct were found to be necrotic, and the biliary anastomosis was therefore abandoned and necrotic tissue removed. HAT was otherwise well tolerated by the graft and, at a further relaparotomy some weeks later, a hepaticojejunostomy was performed. Two years after transplantation the patient is well with a normally functioning graft.

Dopamine and mucosal oxygenation in the porcine jejunum.

The effect of intravenously delivered dopamine on jejunal tissue oxygenation was studied in 12 pigs anesthetized with midazolam and sufentanil and mechanically ventilated. A small segment of the jejunal mucosa and serosa was exposed by midline laparotomy and antimesenteric incision. Mucosal and serosal tissue PO2, mucosal microvascular hemoglobin oxygen saturation, and mucosal hemoglobin concentration were measured by means of Clark-type oxygen electrodes and tissue reflectance spectrophotometry, respectively. In five animals electromyogenic potentials of the jejunal wall were recorded. Measurements were performed under baseline conditions and after intravenous infusion of 2, 4, 8, 16, 32, and again 2 micrograms.kg-1.min-1 of dopamine. The drug produced a dose-related increase in mucosal PO2 (from 26.5 Torr at baseline to 49 Torr at 32 micrograms of dopamine; P < 0.001) and mucosal hemoglobin oxygen saturation (from 55.1 to 70.1%; P < 0.03) but no change in serosal PO2 (from 70.6 to 65.5 Torr). In nine animals baseline mucosal PO2 and mucosal hemoglobin oxygen saturation showed rhythmic oscillations with a frequency of 2.5-5 cycles/min that could not be related to electromyogenic potentials. Dopamine decreased the oscillation amplitude of these two parameters (P < 0.001), and at doses > 16 micrograms.kg-1.min-1 they were no longer present. Dopamine therefore improves mucosal oxygenation of the porcine jejunum in a selective and dose-related manner. At higher doses the preexisting oscillatory pattern of mucosal oxygenation, which is most likely due to vasomotion, is impeded.