Long-term follow-up of a randomized controlled trial of Lichtenstein's operation versus mesh plug repair for inguinal hernia.

OBJECTIVE: To compare long-term results of Lichtenstein's operation versus mesh plug repair for open inguinal hernia repair. BACKGROUND: The technique of best choice in open prosthetic inguinal hernia repair remains a subject of ongoing debate. METHODS: In this prospective, randomized controlled multicenter trial, patients with primary or recurrent inguinal hernias were randomized to undergo either Lichtenstein's operation or mesh plug repair. The primary endpoint was the long-term recurrence rate. Secondary endpoints included chronic pain, sensibility disorders, and reoperation rate. RESULTS: In total, 697 hernias in 594 patients were randomized (297 patients per group). At a median follow-up of 6.5 years, 528 (76%) operated hernias in 444 (75%) patients were clinically evaluated. The recurrence rate was similar in both groups [mesh plug: 21/268 hernias = 7.8%; Lichtenstein: 21/260 hernias = 8.1%; adjusted odds ratio (OR): 0.92; 95% confidence interval (CI): 0.51, 1.68; P = 0.795]. We did not find a significant difference for chronic pain (Visual Analog Scale score >3) (OR: 0.58; 95% CI: 0.31, 1.09; P = 0.088) and sensory testing (17% vs 20% of patients; OR: 0.53; 95% CI: 0.21, 1.37; P = 0.190) between the 2 groups. There were less reoperations in the mesh plug than in the Lichtenstein's operation group (OR: 0.43; 95% CI: 0.22, 0.85; P = 0.016). CONCLUSIONS: The long-term results of this trial indicate not enough evidence for differences in recurrence, chronic pain, and sensibility disorders between mesh plug repair and Lichtenstein's operation but a lower likelihood for reoperation for mesh plug repair. Estimates for all endpoints were statistically not significant or based on large CIs. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov Identifier: NCT01637818.

[Fecal incontinence]. / Stuhlinkontinenz.

Fecal incontinence is underestimated in its prevalence. Therapeutic approaches vary; in mild-to-moderate cases, dietary changes and biofeedback sessions accompanied by specific medications can achieve a salutary effect. In cases of severe fecal incontinence, a conservative approach is ineffective and surgical intervention is indicated. However, several technical innovations and devices enable surgeons to offer patients reliable solutions for this functional disorder. While dynamic graciloplasty uses native muscle contraction ability to function as a new sphincter, the artificial bowel sphincter achieves the same goal by an inflatable cuff. A novel approach, which is suitable for selected patients with muscular and neurological defects alike, is the sacral nerve stimulator. It is crucial to choose the right procedure as determined by the underlying pathology.

Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection : Benefit with epidural analgesia.

BACKGROUND: Thoracic epidural analgesia (TEA) provides superior analgesia with a lower incidence of postoperative ileus when compared with systemic opiate analgesia in open colorectal surgery. However, in laparoscopic colorectal surgery the role of TEA is not well defined. This prospective observational study investigates the influence of TEA in laparoscopic colorectal resections. METHODS: All patients undergoing colorectal resection between November 2004 and February 2007 were assessed for inclusion into a prospective randomized trial investigating the influence of bisacodyl on postoperative ileus. All patients treated by laparoscopic resection from this collective were eligible for the present study. Primary endpoints were use of analgesics and visual analogue scale (VAS) pain scores. Secondary endpoint concerned full gastrointestinal recovery, defined as the mean time to the occurrence of the following three events (GI-3): first flatus passed, first defecation, and first solid food tolerated. RESULTS: 75 patients underwent laparoscopic colorectal resection, 39 in the TEA group and 36 in the non-TEA group. Patients with TEA required significantly less analgesics (metamizol median 3.0 g [0-32 g] versus 13.8 g [0-28 g] (p < 0.001); opioids mean 12 mg [+/-2.8 mg standard error of mean, SEM] versus 103 mg [+/-18.2 mg SEM] (p < 0.001). VAS scores were significantly lower in the TEA group (overall mean 1.67 [+/- 0.2 SEM] versus 2.58 [+/-0.2 SEM]; p = 0.004). Mean time to gastrointestinal recovery (GI-3) was significantly shorter (2.96 [+/-0.2 SEM] days versus 3.81 [+/-0.3 SEM] days; p = 0.025). Analysis of the subgroup of patients with laparoscopically completed resections showed corresponding results. CONCLUSION: TEA provides a significant benefit in terms of less analgesic consumption, better postoperative pain relief, and faster recovery of gastrointestinal function in patients undergoing laparoscopic colorectal resection.

Nonoperative treatment of splenic rupture in malaria tropica: review of literature and case report.

In many parts of the world malaria still is a major medical problem. Heavy international and transcontinental traveling carries malaria to non-endemic areas. Practicing physicians must be aware of the common, but also the rare and severe complications of malaria. During malaria changes in splenic structure can result in asymptomatic enlargement or complications such as hematoma formation, rupture, hypersplenism, ectopic spleen, torsion, or cyst formation. An abnormal immunological response may result in massive splenic enlargement. Spontaneous rupture of the spleen is an important and life threatening complication of Plasmodium vivax infection, but is rarely seen in Plasmodium falciparum malaria. The ability to properly diagnose and manage these complications is important. Spleen-conserving procedures should be the standard whenever possible especially in patients with a high likelihood of future exposure to malaria.

Laparoscopically assisted hemicolectomy for Crohn's disease: are we still getting better?

The most common indications for laparoscopic surgery in Crohn's disease include ileocolic resection and right hemicolectomy. The aim of this study was to compare the results of right hemicolectomy in an early phase versus a later phase. Between August 1992 and October 1998 all patients who underwent laparoscopic surgery for ileocolic resection and right hemicolectomy were divided into chronological groups: Group I = August 1992 to January 1996 and Group II = February 1996 to October 1998. Statistical analysis was performed using the Mann-Whitney test, Student t test, or Fisher's exact test. We identified 41 patients; 16 patients [eight females and eight males with an average age of 37.1 (range 20-59) years] were in Group I and 25 [16 females and nine males with an average age of 41.9 (range 15-74) years] were in Group II [P = not significant (NS)]. Overall there were five (12%) intraoperative complications reported: two (12%) in Group I and three (12%) in Group II (P = NS). Mean operative time was 149 (range 90-260) minutes in Group I versus 158 (range 100-285) minutes in Group II (P = NS). Mean length of hospital stay was 7.4 (range 4-18) days in Group I and 6.6 (range 3-20) days in Group II (P = NS). Four patients (25%) in Group I and seven (28%) in Group II had their procedures converted to laparotomy (P = NS). In Group I four (25%) patients had surgery-related postoperative complications, one of which was wound related. One patient has an anastomotic leak whereas two had prolonged postoperative ileus. In Group II six (24%) patients had surgery-related complications, two of which were wound related, three were cases of prolonged postoperative ileus, and one was an anastomotic leak (P = NS between Groups I and II). Perhaps as a result of the relative technical ease of right-sided resections or the nature of the disease the expected decrease in morbidity and conversion rate over time could not be shown.

Early versus delayed cholecystectomy in patients with biliary acute pancreatitis.

BACKGROUND: In patients with biliary acute pancreatitis (AP), cholecystectomy is mandatory to prevent further biliary events, but timing of cholecystectomy remains a subject of ongoing debate. The objective of the present, retrospective study was to compare the outcomes of early (within 2 weeks after onset of disease) versus delayed cholecystectomy in patients with biliary AP. METHODS: Between January 2000 and December 2005, 112 patients underwent cholecystectomy because of biliary AP. Thirteen patients were excluded from analysis because of necrotizing pancreatitis on the initial computed tomography. Thirty-two were operated within 14 days (group A) and 67 after a longer time period (group B). The primary end point of the study was the rate of biliary complications before cholecystectomy. RESULTS: There were no differences regarding conversion rates to open surgery (6% vs 3%; P = .59), local (3% vs 4%; P = 1.00), or systemic complications (0% vs 3%; P = 1.00), and mean postoperative stay (4.7 vs 5.7 days; P = .40). Nevertheless, a greater rate of recurrent biliary pancreatitis was found in the group undergoing cholecystectomy later (0% vs 13%; P < .03). CONCLUSION: The timing of cholecystectomy seems to have no clinically relevant effect on local or systemic complications, but delaying cholecystectomy is associated with an increase of biliary complications in patients with non-necrotizing biliary AP.

Multislice CT in adult colocolic intussusception: case report and review of the literature.

Intussusception in adults is generally a rare diagnosis and generally different from intussusception in children in terms of clinical presentation, etiology, and incidence (Begos et al., Am J Surg, 173:88-94, 1997; Watson and Bisset, Clin Radiol, 49:723-726, 1994; Felix et al., Am J Surg, 131:723-726, 1976). One third of these affect the large bowel. Adult intussusception shows clinically uncharacteristic symptoms of bowel obstruction; thus, the diagnosis is often clinically missed. We report the case of a 39-year-old woman suffering from long-term abdominal pain. This case report discusses the clinical advantages of multislice computed tomography for the diagnosis of adult intussusception and shows a comprehensive overview of the literature.

Carbon dye staining of sentinel lymph nodes facilitates microstaging of colon cancer patients.

BACKGROUND: Carbon dye, when peritumourally injected, permanently marks the drainage site of sentinel lymph nodes (SLN). The objective of the current study was to evaluate whether the use of carbon dye facilitated the detection of small nodal tumour infiltrates in colon cancer patients. METHODS: In a prospective trial, 19 patients underwent open, oncological resections of localized colon cancer and SLN procedure according to a standardized protocol. Isosulfan blue 1% and sterile filtered carbon dye (mixed 1:1) were injected into the subserosa circumferentially around the tumour. Lymph nodes staining blue were marked as SLN. Serial sections of each SLN were stained with hematoxylin and eosin (H&E) and with the pancytokeratin marker AE1/AE3. The intranodal presence and site of carbon particles were noted and compared with the location of possible tumour infiltrates. RESULTS: Identification of at least one SLN was successful in 18 patients (identification rate 95%). Four patients (22%) were pN+, 11 (61%) were pN0(i-). Three patients (17%) were upstaged from pN0(i-) to pN0(i+) as isolated tumour cells were detected in their SLN: in two (11%) of the three patients, carbon dye and isolated tumour cells were found in the same nodal compartment, hence facilitating the recognition of isolated tumour cells by the pathologist. CONCLUSION: The use of carbon dye in the SLN procedure for colon cancer may facilitate the detection of small nodal tumour infiltrates.

Simplified placement and management of cutting setons in the treatment of transsphincteric anal fistula: technical note.

BACKGROUND: We report one safe and standardized technique of seton placement and management. CONCLUSIONS: A simplified way to manage cutting setons helps to minimize manipulation and may reduce pain. In most patients our technique can be used with no additional anesthesia and in an outpatient setting.

Identification of sentinel lymph nodes in colon cancer depends on the amount of dye injected relative to tumor size.

Recent studies have shown that the sentinel lymph node (SLN) procedure might improve staging in colon cancer. However, low SLN identification and high false negative rates have also been reported. In a two-institution study, the SLN procedure with isosulfan blue 1% was performed according to a standardized protocol in 31 patients with open resections for colon cancer. Data were collected prospectively. The database was analyzed retrospectively to determine factors contributing to a low identification rate. The SLN identification rate was 87% and the false negative rate was 50%. Successful SLN identification was significantly associated with application of higher volumes of dye relative to the tumor diameter ( p = 0.04) and more frequent tumor localization in the sigmoid colon ( p = 0.04) as compared to missing SLN identification. The tumor diameter was not significantly different in the two groups. Sentinel lymph node identification in colon cancer depends on the amount of dye injected relative to the tumor size. Application of only 1 ml of dye-the amount generally recommended in the literature-is not sufficient in large tumors.