'Treatment of the sportsman's groin': British Hernia Society's 2014 position statement based on the Manchester Consensus Conference.

INTRODUCTION: The aim was to produce a multidisciplinary consensus to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of Sportsman's groin (SG). METHODS: Experts in the diagnosis and management of SG were invited to participate in a consensus conference held by the British Hernia Society in Manchester, U.K. on 11-12 October 2012. Experts included a physiotherapist, a musculoskeletal radiologist and surgeons with a proven track record of expertise in this field. Presentations detailing scientific as well as outcome data from their own experiences were given. Records were made of the presentations with specific areas debated openly. RESULTS: The term 'inguinal disruption' (ID) was agreed as the preferred nomenclature with the term 'Sportsman's hernia' or 'groin' rejected, as no true hernia exists. There was an overwhelming agreement of opinion that there was abnormal tension in the groin, particularly around the inguinal ligament attachment. Other common findings included the possibility of external oblique disruption with consequent small tears noted as well as some oedema of the tissues. A multidisciplinary approach with tailored physiotherapy as the initial treatment was recommended with any surgery involving releasing the tension in the inguinal canal by various techniques and reinforcing it with a mesh or suture repair. A national registry should be developed for all athletes undergoing surgery. CONCLUSIONS: ID is a common condition where no true hernia exists. It should be managed through a multidisciplinary approach to ensure consistent standards and outcomes are achieved.

Absence of bacterial resistance to povidone iodine.

Povidone iodine is now being increasingly used in hospitals as an antiseptic. The possible habituation of bacteria to iodine was studied by serial passage of two strains of Pseudomonas aeruginosa, two strains of Escherichia coli, two strains of Klebsiella aerogenes, and one strain of Serratia marcescens in subinhibitory concentrations. After 20 passages, no significant change was observed in the minimal inhibitory concentration, minimal bactericidal concentration, and killing times between parent strains and 20th subcultures under standardized conditions.

Histopathology of benign non-palpable breast lesions identified by mammography.

Over four years the histological features of benign breast diseases, diagnosed after biopsy of non-palpable mammographic abnormalities, were reviewed and correlated with the mammographic appearances. The histological features were compared with those from all other benign biopsy specimens taken during the same period. The incidence of sclerosing adenosis and microcalcifications was considerably higher in the group of non-palpable mammographic lesions; fibrous disease of the breast and radial scar (infiltrating epitheliosis) were also more common. There was no difference in the incidence of epithelial hyperplasia between the two groups. Correlation with the mammographic appearances showed that microcalcification was most often associated with blunt duct adenosis and that stromal distortion or masses were most often caused by fibrous disease.

Variations in steroid receptor status with disease stage in breast cancer.

Oestrogen and progesterone receptor (ER and PgR) distribution in three clinical subgroups of 421 breast carcinomas was analysed. The groups comprised (1) early breast cancer (T1-2a, N0M0; n = 64); (2) untreated advanced fungating cancer (n = 27) and (3) advanced cancer relapsing after endocrine therapy (n = 29). Receptor distribution in each of the subgroups was compared to that of the total population. The advanced fungating group contained no ER--ve/PgR--ve tumours and the distribution was also significantly different from the total population (P less than 0.001 by Chi-squared test). The proportion of tumours in the total population that contained greater than 40 fmol/mg ER was 187/421 (44.4%). There was no significant difference between the early breast cancer group and the total population (P greater than 0.9). However, the proportion of tumours containing ER greater than 40 fmol/mg in the advanced fungating cancer group (16/27, 59.3%) was significantly higher than in the total population (P less than 0.01). This difference may be partially explained by the older age at presentation in this group. In the relapsed after endocrine therapy group only four of 29 (13.8%) contained ER greater than 40 fmol/mg which was significantly different from the total (P less than 0.001). There was a higher proportion of early breast cancers containing PgR greater than 40 fmol/mg than in the total population (P less than 0.001). There was no significant difference between PgR distribution in the advanced fungating and relapsed groups compared to the total population. The data suggest that patients presenting with advanced fungating cancer are more likely to respond to endocrine therapy than the population as a whole, and that in breast cancer that has relapsed following endocrine therapy receptor levels decrease with progression of the disease.

Prophylactic intraperitoneal povidone-iodine in alimentary tract surgery.

In controlled experiments intraperitoneal povidone-iodine significantly reduced the mortality of mice (p less than 0.01) and rats (p less than 0.01) with induced peritonitis. Povidone-iodine irrigation of the rat colon before and after anastomosis did not interfere with healing or inhibit peritoneal adhesion formation. However, a newly formulated povidone-iodine solution containing increased PVP significantly reduced adhesion formation in a controlled study in rats.

Tamoxifen in breast conservation therapy.

Breast conservation surgery for early breast cancer requires post-operative radiotherapy to give local control rates equivalent to mastectomy. Three hundred and thirty-five women presenting with symptomatic breast lumps and receiving radiotherapy and adjuvant systemic therapy at St. Bartholomew's, have actuarial 8-year local relapse-free rates of 90% for T1 and 83% for T2,3 presenting cases. Amongst 49 elderly and/or medically frail patients treated with a similar surgical policy but post-operative tamoxifen only (for standard risk features), the local relapse-free rates were 96% for T1 and 43% for T2,3. Most relapses occurred in the first 2 years in both groups. We conclude that, in the absence of high risk features (defined), breast conservation surgery and tamoxifen only is a safe option for T1 disease in the elderly, but that the risk of local relapse is considerably higher when this policy is employed for patients presenting with larger tumors.

A reappraisal of the use of antiseptics in surgical practice.

The use of antiseptics was reappraised because of the increasing problem of antibiotic-resistant bacteria. A formaldehyde (noxythiolin) and a halogen (povidone-iodine) were investigated, these being the most appropriate antiseptic groups. Povidone-iodine solution significantly reduced the mortality of mice (P less than 0.01) and rats (P less than 0.01) with peritonitis. Noxythiolin (1% and 0.5%) did not. Antiseptic irrigation of the rat colon before and after anastomosis resulted in significantly fewer 'poor' anastomoses (P less than 0.05) without inhibiting healing. Noxythiolin 2.5% and 1% significantly reduced peritoneal adhesion formation in rats, but a newly formulated povidone-iodine solution with increased polyvinylpyrrolidone content was superior to noxythiolin 1% and 0.5%. Povidone-iodine neither inhibited rat abdominal wound healing nor induced bacterial resistance. In 3 subsequent controlled clinical trials a dry-powder povidone-iodine formulation halved wound infection after grid-iron appendicectomy (P less than 0.025), reduced infection in elective 'clean' surgery, and significantly reduced infection after a wide variety of 'potentially contaminated' abdominal procedures (P less than 0.01). A return to the principles of Lister is advocated.

An antibiotic policy for surgical patients.

This paper offers guidance on antibiotic usage in surgical patients. A policy is outlined rather than the comprehensive coverage of every surgical situation. The principles of antibiotic prescribing are given. The antibiotics available and their routes of administration are reviewed. Indications for the prophylactic and therapeutic use of antibiotics are discussed. Factors causing the failure of antibiotic therapy are considered in brief.

A study of the effect of povidone-iodine on polymorphonuclear leucocyte chemotaxis.

Studies were made of the effect of povidone-iodine on polymorphonuclear leucocyte chemotaxis. Polymorphonuclear leucocytes were incubated with various concentrations of povidone-iodine and allowed to migrate across a membrane towards a chemotactic agent. Chemotactic movement was found to decrease as the concentration of povidone-iodine rose, 75 micrograms/ml completely inhibiting all movement. A concentration of 10 micrograms/ml of povidone-iodine was found actively to repel the white cells. In vivo studies in mice showed a reduction in polymorphonuclear leucocytes at wound surfaces in the presence of povidone-iodine dry powder spray.

Prevention of intraperitoneal adhesions: a comparison of noxythiolin and a new povidone-iodine/PVP solution.

Peritoneal adhesions were induced in 250 female Wistar rats by the excision and closure of a right lower quadrant parietal peritoneal defect. After closure of the defect each rat was randomly allocated to one of five treatment groups: A, control with no instillate; B, control with Ringer solution; C, noxythiolin 0.5 per cent solution; D, noxythiolin 1 per cent solution; E povidone-iodine/PVP solution. Two millilitres of the appropriate solution were injected into the peritoneal cavity just before closure of a standard 4-cm midline incision. Assessment of adhesion formation was made at 1 week in ignorance of the treatment group. Noxythiolin 1 per cent was more effective than Ringer solution and noxythiolin 0.5 per cent in reducing the mean number of adhesions (P less than 0.05) but was inferior to povidone-iodine/PVP (P less than 0.05). Povidone-iodine/PVP solution significantly reduced the number of adhesions compared with the four other groups. In addition, it significantly reduced the mean length of attachment of each adhesion compared with the two control groups (P less than 0.001).

Prophylactic interparietal povidone-iodine in abdominal surgery.

This study sought to determine in a district general hospital (a) the frequency and nature of bacterial contamination at operation, (b) the incidence of consequent infection and (c) the prophylactic effect, if any, of interparietal povidone-iodine against postoperative wound infection. Bacterial contamination was shown in 49 per cent of all the abdominal surgical wounds at the end of operation. From 61 per cent of the subsequently infected wounds, organisms identified as contaminants at operation were again found. Interparietal instillation of povidone-iodine resulted in a statistically significant reduction in wound infection (P less than 0.01) in treated patients compared with untreated, randomized, matched controls. It was of significant value in cases of intestinal resection and peritonitis, in obese patients and in those with paramedian incisions. Laboratory studies indicate that povidone-iodine does not induce bacterial resistance. This chemical antibacterial agent may thus provide a preferable alternative to antibiotics in preventing such infections.

Local management of surgical sepsis.

The most important aspect of the prevention of infection in traumatic wounds is early and thorough débridement. In elective surgery there is no substitute for meticulous technique. The successful treatment of established infection depends on early diagnosis and accurate localization of the sepsis, followed by incision and adequate drainage or, in the case of an infected viscus, excision.

Surgical drainage.

The principle factor governing the efficacy of a drain is the tissue reaction to the constituent material. This was appreciated during the early development of drainage. Modern materials have been available for more than 20 years but have escaped sound clinical evaluation. In abdominal surgery there is virtually no evidence to support routine intraperitoneal drainage especially with latex rubber unless it is intended to create a fibrous tract as with T-tube drainage of the biliary tree. When drainage is used either static symphonage (Fig. 7), low pressure suction or sump suction with a bacterial air inlet filter should be employed. Silicone rubber (Silastic) tubes are the preferred material. In the parietes closed suction drainage is safe and has achieved a sound reputation for improving healing where serosanguinous oozing is expected. High pressure suction is probably the most effective system. Because of the risk of infection, open drainage systems should, in general, be avoided, especially where a prosthesis is present. Finally, if in doubt, all surgeons should recall the words of Halsteads in 1898 "No drainage at all is better than the ignorant employment of it" rather than the advice of Lawson Tait.

Noxytiolin and peritoneal adhesion formation.

Clinical and experimental studies have suggested that intraperitoneal noxytiolin prevents adhesion formation. A reliable experimental animal model was therefore established and the effect of noxytiolin on adhesion formation was evaluated in a controlled trial using 80 rats. All 40 rats given Ringer solution developed adhesions, whereas in 7 out of 40 given noxytiolin no adhesions were found (P less than 0-02). Noxytiolin reduced both the total and the mean number of adhesions formed (P less than 0-2) and their mean length of attachment (P less than 0-05). The anti-adhesive effect of noxytiolin may be due to its anticoagulant, cytotoxic or antibacterial properties.

A study of the effect of povidone-iodine on wound healing.

The effect of dry powder povidone-iodine (Disadine D.P.) on wound healing was assessed experimentally and clinically. It did not interfere with wound healing macroscopically, histologically or mechanically in Wistar rats. One hundred and one patients undergoing 'clean' elective surgery were included in the controlled clinical study and povidone-iodine did not affect wound healing in any way. In the control group 4% of patients developed infection compared with none of those sprayed with povidone-iodine. No adverse reaction to povidone-iodine was seen in either study. This antiseptic offers a safe alternative to antibiotics for use at operation whenever there is risk of wound infection from operative bacterial contamination.

Aminoglutethimide as second-line hormonal therapy in advanced breast cancer: response and toxicity.

Seventy-nine postmenopausal patients received aminoglutethimide (AG; 750 mg daily) and hydrocortisone therapy for metastatic or locally recurrent breast cancer following the failure of other hormonal therapy. Fourteen of 64 patients, tolerating the drug and assessable for response, achieved a complete or partial response. Disease stabilisation occurred in a further 2 patients giving a response rate of 25% in these patients. Median duration of response was 10 months. Response rates to AG were not significantly different whether or not there had been a response to previous hormonal therapy but a trend to higher response rates in ER rich tumours was observed. Those with a longer interval from first relapse to the start of AG appeared more likely to respond. Side-effects were noted in 35 patients overall (44%) and in 70% of those over the age of 65 years. Treatment was discontinued because of toxicity in 10 patients and there was one death due to agranulocytosis. AG is active in postmenopausal breast cancer following failure of first-line hormonal therapy, toxicity limiting its use earlier in the disease.