Open tension-free Cooper ligament repair for femoral hernia.

Many techniques have been described for the repair of femoral hernia. The technique applying the principles of the tension-free method of McVay's Cooper ligament repair by covering all potential hernia sites in the myopectineal orifice with a mesh has also been described, but no report has yet been published with large number of cases and long follow-up period. We used this technique in 28 patients (19 females and 9 males) with femoral hernia. The average operating time was 40 min (range 25-75) and average follow-up period was 40 months (range 6-75). No postoperative infection or seroma was recorded. There was no recurrence at the time of writing. This technique seems to be a good alternative for the repair of femoral hernia and also for concurrent femoral hernia with inguinal hernia.

Carboxymethylcellulose coated on visceral face of polypropylene mesh prevents adhesion without impairing wound healing in incisional hernia model in rats.

Adhesions between viscera and mesh may result in intestinal obstruction and fistulae formation. Fewer adhesions with sodium carboxymethylcellulose (SCMC)-coated polypropylene mesh (PM) has been reported, but impaired wound healing was the major concern. We investigated the adhesion-prevention effect of SCMC in different concentrations, as coating only on visceral face of PM and its effects on wound healing. A full-thickness abdominal wall defect was created in 28 rats, which were then divided into three groups. In Group I (control), the defect was repaired with PM only; in Group II and Group III, the defects were repaired with 1% and 1.6% SCMC-coated-PM, respectively. All animals were sacrificed at day 30, and histological evaluation and adhesion scoring were done. Animals in the group in which 1.6% SCMC-coated PM was used developed significantly fewer adhesions compared with other animals (P=0.04). Histological evaluation using a semiquantitative scoring system showed no difference between the groups in fibrosis and inflammation scores (P=0.9 and P=0.3, respectively), and thickness of fibrosis on mesh was also similar (P=0.5). SCMC in 1.6% concentration as coating only on the visceral face of PM reduced the incidence and severity of adhesions without impairing wound healing.

Comparison of local and general anesthesia in tension-free (Lichtenstein) hernioplasty: a prospective randomized trial.

To compare pulmonary effects, postoperative pain and fatigue, morbidity, patient satisfaction, and cost of different anesthetic techniques for inguinal hernia repair, 50 patients were randomized to local and general anesthesia groups (LA and GA). All patients received the same premedications and the same postoperative analgesic regimen. The standardized postoperative analgesic, intramuscular pyroxicam 20 mg, was given to all patients in the recovery room and an additional 20 mg on the same day was given as requested by each patient. Pulmonary function studies and arterial blood gas analysis were performed 1 h prior to the operation and at the postoperative 8th and 24th hours. All patients underwent Lichtenstein's tension-free hernioplasty. Postoperative pain and fatigue were registered 8 h and 24 h after the operation. A questionnaire was filled out by the patients, and they were asked to give grades for the general comfort of the anesthesia and the surgical procedure (1 = worst, 10 = best). Postoperative pulmonary function tests were significantly poorer in the GA group both on 8th- and 24th-hour measurements (P < 0.05). Patients who underwent LA had significantly lower PCO2 and higher PO2 at the postoperative 8th hour (P<0.05). Mean postoperative pain and fatigue scores revealed a significant difference in favor of local anesthesia at only the 8th hour (P<0.05). There were two complications, one in each group (a hematoma in LA and a urinary retention in GA). Patient satisfaction grades were not different in the two groups. We conclude that LA in inguinal hernia repair does not adversely affect pulmonary functions, patients feel less pain, and patient satisfaction is comparable to that with GA.

Imprint cytology in the endoscopic diagnosis of gastrointestinal malignancies.

BACKGROUND/AIMS: To compare imprint cytology with histopathology regarding diagnostic accuracies and quickness in the diagnosis of gastrointestinal malignancies. METHODOLOGY: Multiple endoscopic biopsies were taken from 146 patients having various lesions without a prior histopathological diagnosis. Imprint smears were prepared, using all biopsied tissues, on 3-5 slides. Tissues were fixed in 10% formalin. Time from the materials were received at the pathology laboratory to when the results were available was recorded. Cytopathologists and histopathologists, blinded to each other's diagnosis, examined the imprint smears and tissues. RESULTS: Average time to get imprint cytology results was shorter than that of histopathology (55 minutes vs. 8 days). Fifty-eight patients had a final diagnosis of malignancy. Histopathology and imprint were positive in 56 and 54, respectively. Eighty-eight patients had benign histopathology, all of these had negative imprint results. False-negative and false-positive rates for imprint were 6.8%, 0% and for histopathology were 3.4%, 0%, respectively. CONCLUSIONS: Imprint cytology is an easy, reliable method that can be used as an adjunctive measure with histopathology. It gives the earliest information about the nature of the lesion with a minimum misdiagnosis risk. Imprint cytology lets the surgeon plan a therapeutic strategy approximately 1 week earlier.

The influence of omentectomy on the inflammatory phase of anastomotic healing.

BACKGROUND/AIMS: Proper wound healing of the alimentary tract is essential for the prevention of the significant mortality and morbidity associated with complications. The effects of omentectomy on the inflammatory phase of anastomotic healing in rats were examined. METHODOLOGY: Sixty male Wistar-Albino rats that weighed about 200-220 g were used in this study. Animals were divided into three groups as colon anastomosis, colon anastomosis + partial omentectomy and colon anastomosis + total omentectomy. On the third postoperative day, all animals were sacrificed under anesthesia. Bursting pressure of anastomosis amounts and types of cells in the anastomosis, and nitric oxide, malondialdehyde, superoxide dismutase levels in the anastomosis and serum was examined. RESULTS: Bursting pressure values were 102.60 +/- 13.41 mm Hg, 105 +/- 10.80 mm Hg and 102.50 +/- 11.12 mm Hg in the colon anastomosis, colon anastomosis + partial omentectomy and colon anastomosis + total omentectomy groups, respectively (P > 0.05). A significant increase in macrophage count was found in the colon anastomosis + total omentectomy group when compared with the colon anastomosis group (P = 0.02). According to the comparisons with percentages, there was a significant difference in lymphocyte counts between colon anastomosis and colon anastomosis + total omentectomy groups (P = 0.04). The blood level of superoxide dismutase was higher in the colon anastomosis + total omentectomy group than the other two groups, and in the colon anastomosis + partial omentectomy group than the colon anastomoses group (P = 0.0001). There was a significant increase in the blood level of nitric oxide when comparing the colon anastomosis + total omentectomy group with colon anastomosis group (P = 0.02). The tissue level of malondialdehyde was higher in the colon anastomosis + total omentectomy group than the other two groups (P < 0.0001). CONCLUSIONS: Omentectomy may influence the outcome of the inflammatory phase of wound healing in rats. But systemic compensatory regulation of body can tolerate these detrimental effects and wound healing continues in its regular manner.

Lack of evidence that obesity is a cause of pilonidal sinus disease.

OBJECTIVE: To find out whether pilonidal sinus is more common among obese people. DESIGN: Retrospective study from hospital records. SETTING: Two university hospitals, Turkey. SUBJECTS: 419 patients who were operated on for pilonidal sinus disease; and 213 age and sex matched patients with benign diseases other than pilonidal sinus disease and who were not morbidly obese acted as controls. MAIN OUTCOME MEASURES: Comparison of body mass index (BMI) in the two groups. RESULTS: Patients with BMI of 25-30 were classified as overweight (61/419, 15% compared with 28/213, 13%), and those with BMI of 30 or more as obese (7/419 compared with 4/213, 2% in each group). Mean (SD) BMI of patients with pilonidal sinus disease was 26.0 (3.9) compared with 25.6 (3.9) in the control group (p = 0.4). CONCLUSION: Obesity alone is not an important factor in the aetiology of pilonidal sinus disease.

Post-traumatic combined transdiaphragmatic intercostal and lumbar hernia.

Traumatic rupture of the diaphragm following blunt trauma is rare. Lumbar hernia in association with blunt trauma is even rarer. To our knowledge, the combination of these two entities has not previously been reported. We describe such a case and review the literature.

An experimental study evaluating the effect of Mitomycin C on the prevention of postoperative intraabdominal adhesions.

BACKGROUND: Fibroblast proliferation is one of the well-known mechanisms for postoperative intraabdominal adhesion formation. Inhibition of fibroblast proliferation is an attractive field of investigation in the prevention of adhesions. Mitomycin C (MMC) is a cytotoxic agent that alkylates and crosslinks DNA and also inhibits fibroblast proliferation up to a few weeks. We aimed to determine the effect of MMC on the prevention of adhesions. MATERIALS AND METHODS: Generation of adhesions in rats by brushing a 1-cm(2) area of the cecum and the peritoneum on the right side of the abdominal wall was followed by intraperitoneal administration of saline, 1 mg/kg MMC, and 0.5 mg/kg MMC in saline. After 45 days, formation of adhesions was graded. RESULTS: The average adhesion scores of the control, and MMC (1 mg/kg), MMC (0.5 mg/kg) groups were 3.2 +/- 0.7, 0.8 +/- 0.6, and 0.7 +/- 0.8, respectively. Adhesion scores of the two MMC-treated groups were significantly lower than that of the control group (P < 0.001). There was no difference between the two MMC groups (P > 0.05). No side effect of MMC was observed. CONCLUSION: MMC was found to be very effective in the prevention of postoperative intraabdominal adhesions.

The role of obesity on the recurrence of pilonidal sinus disease in patients, who were treated by excision and Limberg flap transposition.

Recurrence of pilonidal sinus disease after surgical intervention is not a very rare problem although sophisticated reconstruction procedures have been developed. Recurrence is thought to be related to the anatomical status of the patients, i.e., depth of the intergluteal groove. Obese patients have deeper intergluteal grooves. The aim of this study was to use body mass index (BMI) as an objective indicator of obesity to determine whether there is a relationship between BMI and recurrence of pilonidal sinus disease. BMI was calculated preoperatively in 114 patients with pilonidal sinus disease who were treated by excision and Limberg flap transposition between 1996-1999 in general surgery departments of two university hospital clinics. Fifteen patients were referred to our clinics after surgical intervention carried out at other institutions. Their average BMI was calculated by using their hospital records. The mean follow-up period was 24 months (range 10-36). Six of the 114 patients (5%) had recurrence. The mean BMI of patients with and without recurrence was 29.35 and 27.415, respectively (P<0.05). The mean BMI of 15 patients referred to us because of recurrent disease was 29.41; however, that of patients with primary pilonidal sinus disease was 27.212 (P<0.05). Their BMI before their first operation was 29.30. This was also significantly higher than patients with primary disease (P<0.05). We conclude that obese patients with high BMI have a higher risk of recurrence of pilonidal sinus disease after surgical intervention.

Traumatic rupture of the diaphragm.

Diaphragmatic rupture following trauma is often an associated and missed injury. The diagnosis is difficult, so is usually made intraoperatively. Twenty-one patients with traumatic rupture of the diaphragm (TRD) who presented between 1995 and 1998 were retrospectively analysed: 12 had penetrating injuries and nine had blunt injuries. Right-sided defects exceeded left (12 vs 9). Only seven patients had signs and symptoms directly referrable to rupture of the diaphragm. All patients were operated on through a midline laparotomy. Diaphragmatic hernia was seen in six patients (28.5%); 20 (95%) patients had concomitant injuries. The liver was the most commonly injured organ (10 patients). The aim of this study was to report our experiences with TRD and review the literature. We conclude that correct preoperative diagnosis of TRD needs a high index of suspicion. It can be diagnosed intraoperatively by explorative laparotomy. Most ruptures can be repaired by the abdominal approach.

Imprint cytology in the diagnosis of Helicobacter pylori. Does imprinting damage the biopsy specimen?

OBJECTIVE: To investigate the efficacy of imprint cytology in the diagnosis of Helicobacter pylori infection and whether it damages the biopsy specimen for subsequent histologic examination. STUDY DESIGN: Two antral biopsies were taken from 76 patients with dyspeptic symptoms undergoing upper gastrointestinal endoscopy. Imprint cytology was made from the first specimen. This specimen was fixed in 10% formalin and sent for histopathologic examination. The second specimen was directly fixed in 10% formalin for routine histopathologic examination without being used for an imprint. The imprint smears were examined by cytopathologists. The biopsy specimens were examined by pathologists who did not know which specimens were used for the imprints. RESULTS: H pylori was seen in smears from 55 (72%) patients and in both biopsy specimens from the same patients. The pathologists could not recognize the biopsy specimens from which the imprints were made. Concordance between imprint cytology and histopathology was 100%. CONCLUSION: Imprint cytology is a suitable test for H pylori diagnosis, and imprints do not adversely affect the quality of the biopsy specimen.

Experimental study on the role of mast cells in peritoneal adhesion formation.

OBJECTIVE: To investigate the potential role of mast cell stabilisation in the prevention of post-operative adhesions. DESIGN: Laboratory animal experiment. SETTING: University hospital, Turkey. SUBJECTS: Ninety Wistar albino rats. INTERVENTION: Under anaesthesia, a lower midline laparotomy was performed, the caecum exposed and grasped until haemorrhage occurred. The rats were divided into three groups. Group 1, 2 and 3 were intra-peritoneally administered 1 ml of saline, disodium cromoglycate 5 mg/kg in 1 ml of saline and 10 mg/kg in 1 ml of saline, respectively thirty minutes prior to laparotomy and immediately subsequent to abdominal closure. They were later sacrificed, laparotomy repeated and the presence and extent of intraabdominal adhesions evaluated. RESULTS: Adhesion scores were best in the high disodium cromoglycate dose group of rats (p < 0.05) and the number of degranulated mast cells was significantly low in this group (p < 0.05). CONCLUSION: Disodium cromoglycate may be an effective agent for attenuating adhesion formation when administered in suitable doses.

Apical hypertrophic cardiomyopathy presenting as acute subendocardial myocardial infarction.

Two patients with apical hypertrophic cardiomyopathy presented with angina at rest and giant inverted T waves in precordial leads on the electrocardiogram. At cardiac catheterisation one patient had mild coronary artery disease, the other had normal coronary arteries. In both, there was a systolic pressure gradient between the apex and main left ventricular cavity exceeding 100 mmHg. The presence of rest angina with the electrocardiographic findings lead to a mistaken, initial diagnosis of acute subendocardial myocardial infarction.

Assessment of coronary stent by intravascular ultrasound.

The use of intravascular ultrasound to assess the adequacy of the deployment of an intracoronary stent is described. Although angiographically a good result was suggested, intravascular ultrasound showed this to be misleading.

Metabolic, hematological, and cardiac effects of long-term isradipine treatment in mild-to-moderate essential hypertension.

Twenty-four patients with mild-to-moderate hypertension (19 women, 5 men; mean age of 49 +/- 9.1 years) completed a 2-week washout phase followed by 1 week of single-blind placebo. Patients were then given isradipine at 2.5 mg twice daily, which was increased to up to 7.5 mg twice daily according to the blood pressure response, over a 12-month period. Thirteen patients completed the trial. The supine and sitting blood pressure decreased to normal levels within 6 weeks of starting active treatment. Heart rate remained unchanged. Plasma cholesterol and triglycerides did not change significantly. Plasma high-density lipoprotein (HDL) cholesterol increased significantly (p less than 0.05) and a decrease (NS) was observed in low-density lipoprotein (LDL) cholesterol and in the LDL/HDL cholesterol ratio. Very-low-density lipoprotein (VLDL) cholesterol did not change, nor did other biochemical laboratory tests, or electrocardiographic and echocardiographic parameters. The most notable side effects were headache (n = 1), flushing (n = 1), palpitations (n = 3), and pretibial edema (n = 1). In conclusion, our results indicate that isradipine is safe and effective in the long-term treatment of mild-to-moderate hypertension. It also appears to have beneficial effects on lipid metabolism.