A modified Chevrel technique for ventral hernia repair: long-term results of a single centre cohort.

PURPOSE: To evaluate the short- and long-term results after a modified Chevrel technique for midline incisional hernia repair, regarding surgical technique, hospital stay, wound complications, recurrence rate, and postoperative quality of life. These results will be compared to the literature derived reference values regarding the original and modified Chevrel techniques. METHODS: In this large retrospective, single surgeon, single centre cohort all modified Chevrel hernia repairs between 2000 and 2012 were identified. Results were obtained by reviewing patients' medical charts. Postoperative quality of life was measured using the Carolina Comfort Scale. A multi-database literature search was conducted to compare the results of our series to the literature based reference values. RESULTS: One hundred and fifty-five patients (84 male, 71 female) were included. Eighty patients (52%) had a large incisional hernia (width ≥ 10 cm) according the definition of the European Hernia Society. Fourteen patients (9%) underwent a concomitant procedure. Median length-of-stay was 5 days. Within 30 days postoperative 36 patients (23.2%) had 39 postoperative complications of which 30 were mild (CDC I-II), and nine severe (CDC III-IV). Thirty-one surgical site occurrences were observed in thirty patients (19.4%) of which the majority were seroma (16 patients 10.3%). There was no hernia-related mortality during follow-up. Recurrence rate was 1.8% after a median follow-up of 52 months (12-128 months). Postoperative quality of life was rated excellent. CONCLUSIONS: The modified Chevrel technique for midline ventral hernias results in a moderate complication rate, low recurrence rate and high rated postoperative quality of life.

Randomized clinical trial comparing self-gripping mesh with a standard polypropylene mesh for open inguinal hernia repair.

BACKGROUND: The introduction of mesh for open inguinal hernia repair has reduced the rate of recurrence, allowing research to focus on prevention of postoperative pain. In an effort to reduce chronic pain, a semiresorbable, lighter and self-gripping mesh was developed. METHODS: A double-blind randomized clinical trial was conducted comparing the self-gripping mesh with a standard polypropylene mesh repair. Patients over 18 years of age undergoing open primary hernia repair were included. Pain was measured on a six-point verbal rating scale (VRS) and a 150-mm visual analogue scale (VAS). Postoperative pain reduction from baseline pain (ΔVAS), complications and return to work/hobbies were studied. Data were collected at baseline, 3 weeks, 3 months and 1 year after surgery (primary outcome). RESULTS: A total of 363 patients were analysed. Median age was 59 (range 19-88) years. Baseline VRS and VAS scores were similar for the two groups. There was no difference in VRS scores at 1-year follow-up. Duration of surgery was significantly shorter with the self-gripping mesh (mean 40 min versus 49 min for standard mesh repair; P < 0·001). At 3 weeks, ΔVAS in patients receiving the self-gripping mesh was significantly larger (-10·6 versus -5·0 respectively; P = 0·049) and less subjective discomfort was reported (P = 0·016). Complication rates, return to work and recurrence rates were similar, although there were more recurrences in the self-gripping mesh group (5·5 versus 2·2 per cent; P = 0·103). CONCLUSION: A self-gripping mesh for hernia repair may result in less pain in the early postoperative phase but chronic postherniorraphy pain is not affected. Recurrence rates may be a potential disadvantage. REGISTRATION NUMBER: NTR1212 (http://www.trialregister.nl).

A consecutive series of 235 epigastric hernias.

BACKGROUND: Epigastric herniation is a common, though not always symptomatic condition. It is likely, that in accordance to the tension-free principles for other hernias, epigastric hernia repair should be mesh based. METHODS: Patients from two large hospitals were investigated retrospectively if they were operated on an epigastric hernia for the past 6 years. Follow-up was completed with a postal questionnaire. RESULTS: A total of 235 patients (50 % male) were operated. Sixty-eight patients were operated with mesh and 167 patients with suture repair. Forty-six patients were loss-to follow-up (19.6 %). In the mesh operated patients the recurrence rate was 10.9 % (n = 6) compared to 14.9 % (n = 20) in the suture repair group. Cox-regression analysis showed an increased risk for recurrence in the suture repair group (odds ratio 1.43; 95 % CI 0.56-3.57; p = 0.44). Operation time for mesh repair (47 min) was significantly longer compared to suture repair (29 min) (p < 0.0001). Thirty-seven patients had previous or other anterior wall hernias. A total of 51 patients smoked and 14 patients had diabetes mellitus. Fourteen patients used steroids and 22 patients suffered from a chronic lung disease. Subgroup analysis showed a significant difference for pain in patients in which re-operation for a recurrence occurred (p = 0.004). CONCLUSIONS: This is one of the largest reported series on solely epigastric hernias. A recurrence occurred more often after sutured repair compared to mesh repair. No differences in chronic pain was seen between mesh and suture repaired patients. Male:female ratio of 1:1, which is different from the 3:1 ratio found in previous older smaller studies, could be more reliable.

Effective surgical treatment of the carotid sinus sindrome.

Elderly patients frequently suffer from dizziness and syncope; however, an underlying disease may not always be identified. Three patients aged 69, 71 and 56, respectively, experienced spells of dizziness and syncope. Massage of the carotid sinus demonstrated the presence of a carotid sinus syndrome (CSS), an abnormal baroreflex response of the carotid sinus that leads to asystole and extreme hypotension. Conventional treatment is generally by insertion of a pacemaker. These patients, however, were referred to the vascular surgery department of our hospital for removal of adventitial layers of proximal portions of the internal carotid artery. Recovery was uneventful; all three are now free of symptoms. CSS should be considered in the differential diagnosis of dizziness and syncope. Surgical denervation of the carotid artery is a valid treatment option, especially in the vasodepressive or mixed type of CSS.

Repair of giant midline abdominal wall hernias: "components separation technique" versus prosthetic repair : interim analysis of a randomized controlled trial.

BACKGROUND: Reconstruction of giant midline abdominal wall hernias is difficult, and no data are available to decide which technique should be used. It was the aim of this study to compare the "components separation technique" (CST) versus prosthetic repair with e-PTFE patch (PR). METHOD: Patients with giant midline abdominal wall hernias were randomized for CST or PR. Patients underwent operation following standard procedures. Postoperative morbidity was scored on a standard form, and patients were followed for 36 months after operation for recurrent hernia. RESULTS: Between November 1999 and June 2001, 39 patients were randomized for the study, 19 for CST and 18 for PR. Two patients were excluded perioperatively because of gross contamination of the operative field. No differences were found between the groups at baseline with respect to demographic details, co-morbidity, and size of the defect. There was no in-hospital mortality. Wound complications were found in 10 of 19 patients after CST and 13 of 18 patients after PR. Seroma was found more frequently after PR. In 7 of 18 patients after PR, the prosthesis had to be removed as a consequence of early or late infection. Reherniation occurred in 10 patients after CST and in 4 patients after PR. CONCLUSIONS: Repair of abdominal wall hernias with the component separation technique compares favorably with prosthetic repair. Although the reherniation rate after CST is relatively high, the consequences of wound healing disturbances in the presence of e-PTFE patch are far-reaching, often resulting in loss of the prosthesis.

Abberant sex habits leading to acute limb ischemia and hematuria.

We report a case of a 42 year-old man suffering from an acute limb ischemia. Upon urokinase treatment he developed gross hematuria. Finally, CT scanning revealed a self-inserted foreign body not only causing thrombosis of the external iliac artery, but also forming an arteriovesical fistula. This case emphasises the importance of detailed history taking and thorough further investigation in recurrent macroscopic hematuria in a patient. Massive bleeding from the bladder should alert the doctor for a rare, but life-threatening arteriovesical fistula.

[Cannabis use and untreated HIV-infection: unknown risk factors for premature peripheral artery disease]. / Cannabisgebruik en onbehandelde HIV-infectie: weinig bekende risicofactoren voor vroegtijdig perifeer arterieel vaatlijden.

A 32-year-old woman presented with a painful leg and a gangrenous big toe. Her medical history included HIV-infection that had remained untreated for 8 years. In addition, she had smoked about 10 cannabis-cigarettes daily during the previous 15 years. Physical examination and angiography confirmed the presence of severe peripheral artery disease in the left lower leg. She received a femorodistal bypass graft but the gangrene was progressive, ultimately necessitating a lower leg amputation. Histopathological examination revealed intimal fibrosis and thrombosis with recanalisation in combination with fragmentation of the internal elastic membrane. Peripheral artery disease is often associated with lower extremity ischaemia, mostly affecting elderly patients and almost always caused by atherosclerosis. When ischaemic symptoms manifest themselves in young individuals (<40 years), rare causes of obliterative arterial disease, such as inflammation or post-traumatic vascular injury, must be excluded. Use of cannabis and untreated HIV infection are both relatively unknown risk factors for the onset of premature non-atherosclerotic arterial disease. Stopping the smoking of cannabis appears to have a favourable effect on the ischaemic symptoms. Whether treatment of HIV-infection can affect the course of premature peripheral vascular disease is unknown. When deciding whether or not to give antiviral therapy, care providers should also consider the increased cardiovascular mortality rates associated with these treatment regimens. In the case described, the HIV-infection was considered the most likely cause of the peripheral artery disease, based on all the histopathological findings.

Randomized study comparing cardiac response in endovascular and open abdominal aortic aneurysm repair.

BACKGROUND: The aim was to compare the cardiac response and the incidence of adverse cardiac events during and after endovascular (EVAR) and open (OR) repair of abdominal aortic aneurysms (AAAs). METHODS: Seventy-six patients with an AAA suitable for EVAR, and in a general condition allowing open surgery were randomized to EVAR (57 patients) or OR (19 patients). The analysis was on an intention-to-treat basis. Haemodynamic variables were assessed intraoperatively before, during and after aortic occlusion. During the procedure myocardial ischaemia was identified with use of electrocardiography (ECG) and transoesophageal echocardiography (TEE). After operation, cardiac complications were diagnosed by clinical observation, 12-lead ECG at 1 h, 1 day and 7 days, echocardiography at 1 month and measurement of cardiac enzymes. RESULTS: After aortic occlusion, a greater decrease in systemic vascular resistance compared with baseline was observed with OR than with EVAR (- 396 and - 70 dyne s/cm5 respectively; P = 0.03). The stroke work index, as a direct measure of myocardial performance, demonstrated a decrease during OR and an increase during EVAR during aortic occlusion (- 6.6 and + 1.7 g m/m2 respectively; P = 0.03) as well as after aortic occlusion (- 7.6 and + 3.4 g m/m2 respectively; P < 0.01), compared with baseline. The incidence of postoperative clinical cardiac complications was comparable in the two study groups; however, myocardial ischaemia, as observed by ECG and TEE, was observed more frequently in the OR group (ten of 19 versus 15 of 57 patients; P = 0.05). CONCLUSION: Haemodynamic changes were less severe and there was a lower incidence of myocardial ischaemia during EVAR than during OR. Studies are needed to demonstrate whether this may reduce the operative mortality rate.

Abdominal pain as a first symptom of iliac vein thrombosis.

Two patients are described with abdominal pain as a first symptom of primary iliac vein thrombosis. This phenomenon can be regarded to be analogous to the calf tenderness when thrombosis arises from the venous sinusoids in the calf muscles which is the usual localisation. When one is aware of this clinical entity, thrombotic occlusion will be recognized as the cause of the complaints, instead of being regarded to be a complication of another, yet unknown disease.