Short- and long-term results of operative iliac artery release in endurance athletes.

OBJECTIVE: Endurance athletes can develop intermittent claudication due to sports-related flow limitations of the iliac artery (FLIA) caused by arterial kinking. In the present study, we investigated the short- and long-term efficacy of an operative release for iliac artery kinking. METHODS: Between 1996 and 2015, all patients with a diagnosis of FLIA due to iliac artery kinking without substantial arterial stenosis (<15%) or an excessive arterial length (vessel length to straight ratio, <1.25) who had undergone surgery were included. The short-term follow-up protocol consisted of cycling tests, the ankle brachial index with a flexed hip, and Doppler echography examinations to determine the peak systolic velocity before and 6 to 18 months after surgery. Additionally, the short- and long-term efficacy were evaluated using questionnaires. RESULTS: A total of 142 endurance athletes (155 legs; 88.4% male; median age, 26 years; interquartile range [IQR], 22-31 years) were available for analysis. In the short term, the symptoms had decreased in 83.9% of the patients, with an overall 80.3% satisfaction rate. Power during a maximal cycling test had improved from 420 W (IQR, 378-465 W) to 437 W (IQR, 392-485 W; P < .001). The symptom-free workload had increased from 300 W (IQR, 240-340 W) to 400 W (IQR, 330-448 W; P < .001). The postexercise ankle brachial index with a flexed hip had increased from 0.53 (IQR, 0.40-0.61) to 0.57 (IQR, 0.47-0.64; P = .002), and the peak systolic velocity with a flexed hip had decreased from 1.88 m/s (IQR, 1.45-2.50 m/s) to 1.52 m/s (IQR, 1.19-2.07 m/s; P < .001). Postoperative imaging studies revealed some degree kinking in 33.9%, mostly asymptomatic. The long-term results were evaluated after a median of 15.2 years (IQR, 10.9-19.5 years). The athletes had cycled an additional 125.500 km (IQR, 72.00-227.500 km), which was approximately equal to the 131.000 km (IQR, 98.250-220.000 km) cycled before the diagnosis of FLIA. On the long term, 63.9% of the athletes reported persistent reduction of complaints, with an overall 59.1% satisfaction rate. Eight patients had required reintervention, six because of treatment failure and two because of newly developed FLIA. CONCLUSIONS: Operative iliac artery release for sports-related functional kinking in the absence of stenosis or an excessive vessel length was effective for most athletes in the short and long term.

The GroinPain Trial: A Randomized Controlled Trial of Injection Therapy Versus Neurectomy for Postherniorraphy Inguinal Neuralgia.

OBJECTIVE: This study compares tender point infiltration (TPI) and a tailored neurectomy as the preferred treatment for chronic inguinodynia after inguinal herniorraphy. BACKGROUND: Some 11% of patients develop chronic discomfort after open inguinal herniorraphy. Both TPI and neurectomy have been suggested as treatment options, but evidence is conflicting. METHODS: Patients with chronic neuropathic pain after primary Lichtenstein repair and >50% pain reduction after a diagnostic TPI were randomized for repeated TPI (combined Lidocaine/corticosteroids /hyaluronic acid injection) or for a neurectomy. Primary outcome was success (>50% pain reduction using Visual Analog Scale, VAS) after 6 months. Cross-over to neurectomy was offered if TPI was unsuccessful. RESULTS: A total of 54 patients were randomized in a single center between January 2006 and October 2013. Baseline VAS was similar (TPI: 55, range 10-98 vs neurectomy: 53, range 18-82, P = 0.86). TPI was successful in 22% (n = 6), but a neurectomy was successful in 71% (n = 17, P = 0.001). After unsuccessful TPI, 19 patients crossed over to neurectomy and their median VAS score dropped from 60 to 14 (P = 0.001). No major complications after surgery were reported. Two-thirds of patients on worker's compensation returned to work. CONCLUSION: A tailored neurectomy is 3 times more effective than tender point infiltration in chronic inguinodynia after anterior inguinal hernia mesh repair. A step up treatment stratagem starting with tender point infiltration followed by a tailored neurectomy is advised.

Groin Pain Characteristics and Recurrence Rates: Three-year Results of a Randomized Controlled Trial Comparing Self-gripping Progrip Mesh and Sutured Polypropylene Mesh for Open Inguinal Hernia Repair.

OBJECTIVE: The aim of this study was to investigate long-term groin pain and inguinal hernia recurrence rates of 2 types of mesh and to describe the evolution of postoperative groin sensory disturbances. SUMMARY OF BACKGROUND DATA: Some patients with an inguinal hernia develop chronic pain following open mesh insertion. Previous trials comparing a semi-resorbable, self-gripping Progrip mesh with a standard sutured polypropylene mesh found conflicting results regarding recurrence rates and residual groin pain. METHODS: Patients aged >18 years scheduled for open primary hernia repair were randomized to a self-gripping mesh (Progrip) or a polypropylene mesh (standard). Removal of the inguinal nerves was left to the discretion of the surgeon. Pain was measured using Visual Analogue Scale (VAS) over a 3-year period. Pain characteristics and hernia recurrences were determined using physical examination. RESULTS: Data of 274 patients were complete (75% three-year follow-up rate). Pain steadily decreased over time in both groups in a similar fashion (moderate pain 3.7% in each group). Hyperesthesia was experienced by 2.2% and 3.7% and hypoesthesia in 12% and 19% in Progrip and standard group, respectively. One of seven Progrip patients reported a foreign body feeling versus 1 of 5 standard patients (P = 0.06). Altered skin sensations were not related to a neurectomy. Hernia recurrence rate was 11.5% in the Progrip and 5% in the standard group (P = 0.05). CONCLUSIONS: Three years after insertion of a self-gripping Progrip mesh or a sutured polypropylene mesh for an open primary inguinal hernia repair, groin pain is minimal, although altered groin skin sensations and foreign body feeling are quite common. A Progrip hernia repair is associated with a high recurrence rate.

Mesh Removal and Selective Neurectomy for Persistent Groin Pain Following Lichtenstein Repair.

BACKGROUND: Some patients with persistent inguinodynia following a Lichtenstein hernia repair fail all non-surgical treatments. Characteristics of mesh-related pain are not well described whereas a meshectomy is controversial. Aims were to define mesh-related pain symptoms, to investigate long-term effects of a meshectomy and to provide recommendations on meshectomy. METHODS: Consecutive patients undergoing open meshectomy with/without selective neurectomy for chronic inguinodynia following Lichtenstein repair were analysed including a follow-up questionnaire. Outcome measures were complications, satisfaction (excellent, good, moderate, poor) and hernia recurrence rate. Recommendations for meshectomy are proposed based on a literature review. RESULTS: Seventy-four patients (67 males, median age 56 years) underwent mesh removal (exclusively mesh, 26%; combined with tailored neurectomy, 74%) between June 2006 and March 2015 in a single centre. Complications were intraoperatively recognized small bowel injury (n = 1) and testicular atrophy (n = 2). A 64% excellent/good long-term result was attained (median 18 months). Success rates of a meshectomy (63%) or combined with a neurectomy (64%) were similar. Five hernia recurrences occurred during follow-up (7%). A patient with a pure mesh-related groin pain characteristically reports a 'foreign body feeling'. Pain intensifies during hip flexion (car driving) and is attenuated following hip extension or supine position. Palpation is painful along the inguinal ligament whereas neuropathic characteristics (hyperpathic skin, trigger points) are lacking. CONCLUSIONS: Mesh removal either or not combined with tailored neurectomy is beneficial in two of three patients with characteristics of mesh-related inguinodynia following Lichtenstein hernia repair who are refractory to alternative pain treatments.

A ruptured abdominal aortic aneurysm that requires preoperative cardiopulmonary resuscitation is not necessarily lethal.

OBJECTIVE: A ruptured abdominal aortic aneurysm (RAAA) is associated with a high mortality rate. If cardiopulmonary resuscitation (CPR) is required before surgical repair, mortality rates are said to approach 100%. The aim of this multicenter, retrospective study was to study outcome in RAAA patients who required CPR before a surgical (endovascular or open) repair (CPR group). RAAA patients who did not need CPR served as controls (non-CPR group). METHODS: Over a 5-year time period, demographic and clinical characteristics and specifics of preoperative CPR if necessary were studied in all patients who were treated for a RAAA in three large, nonacademic hospitals. RESULTS: A total of 199 consecutive RAAA patients were available for analysis; 176 patients were surgically treated. Thirteen of these 176 patients (7.4%) needed CPR, and 163 (92.6%) did not. A 38.5% (5 of 13) survival rate was observed in the CPR group. Thirty-day mortality was almost three times greater in the CPR group compared with the non-CPR group (61.5% vs 22.7%; P = .005). Both CPR patients who received endovascular aortic repair survived. In contrast, survival in 11 CPR patients who underwent open RAAA repair was 27% (3 of 11; P = .128). A trend for higher Hardman index was found in patients who received CPR compared with patients who did not receive CPR (P = .052). The 30-day mortality in patients with a 0, 1, 2, or 3 Hardman index was 16.1%, 31.0%, 37.9%, and 33.3%, respectively (P = .093). CONCLUSIONS: An RAAA that requires preoperative CPR is not necessarily a lethal combination. Patient selection must be tailored before surgery is denied.

Ruptured iliac artery aneurysm presenting as acute right heart failure and cardiac arrest.

Aortocaval fistula due to aneurysmal degradation can result in obscure clinical signs but with life-threatening sequelae. Our patient presented with multiple cardiac arrests because of sudden right heart decompensation after a ruptured iliac aneurysm into the adjacent iliac vein. He fully recovered after emergency open surgical repair. High awareness with subtle clinical signs is of great importance.

Surgical management of inguinal neuralgia after a low transverse Pfannenstiel incision.

OBJECTIVE: The authors assessed the long-term pain relief after local nerve blocks or neurectomy in patients suffering from chronic pain because of Pfannenstiel-induced nerve entrapment. SUMMARY BACKGROUND DATA: The low transverse Pfannenstiel incision has been associated with chronic lower abdominal pain because of nerve entrapment (2%-4%). Treatment options include peripheral nerve blocks or a neurectomy of neighboring nerves. Knowledge on adequate (surgical) management is scarce. METHODS: Patients treated for iliohypogastric and/or ilioinguinal neuralgia after a Pfannenstiel incision received a questionnaire assessing current pain intensity (by 5-point verbal rating scale), complications, and overall satisfaction. RESULTS: Twenty-seven women with Pfannenstiel-related neuralgia were identified between 2000 and 2007. A single diagnostic nerve block provided long-term pain relief in 5 patients. Satisfaction in women undergoing neurectomy (n = 22) was good to excellent in 73%, moderate in 14%, and poor in 13% (median follow-up, 2 years). Complications were rare. Successful treatment improved intercourse-related pain in most patients. Comorbidities (endometriosis, lumbosacral radicular syndrome) and earlier pain treatment were identified as risk factors for surgical failure. CONCLUSIONS: Peripheral nerve blocking provides long-term pain reduction in some individuals. An iliohypogastric or ilioinguinal nerve neurectomy is a safe and effective procedure in most remaining patients.