Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery.

BACKGROUND: Incisional herniation is a common complication of abdominal aortic aneurysm (AAA) repair. This study investigated whether prophylactic mesh placement could reduce the rate of postoperative incisional hernia after open repair of AAA. METHODS: This randomized clinical trial was undertaken in three hospitals. Patients undergoing elective open AAA repair were randomized to routine abdominal mass closure after AAA repair or to prophylactic placement of polypropylene mesh in the preperitoneal plane. RESULTS: Eighty-five patients with a mean age of 73 (range 59-89) years were recruited, 77 (91 per cent) of whom were men. There were five perioperative deaths (6 per cent), two in the control group and three in the mesh group (P = 0.663), none related to the mesh. Sixteen patients in the control group and five in the mesh group developed a postoperative incisional hernia (hazard ratio 4.10, 95 per cent confidence interval 1.72 to 9.82; P = 0.002). Hernias developed between 170 and 585 days after surgery in the control group, and between 336 and 1122 days in the mesh group. Four patients in the control group and one in the mesh group underwent incisional hernia repair (P = 0.375). No mesh became infected, but one was subsequently removed owing to seroma formation during laparotomy for small bowel obstruction. CONCLUSION: Mesh placement significantly reduced the rate of postoperative incisional hernia after open AAA repair without increasing the rate of complications.

The association between referral source and stage of disease in patients with colorectal cancer.

OBJECTIVE: The colorectal fast track (FT) referral system was set up to ensure patients with suspected cases of colorectal cancer (CRC) received prompt access to specialized services. The aim of this study was to ascertain the association between referral source and the time it took to be seen by a colorectal surgeon to establish whether referral source had any association with the stage of disease at presentation in patients with CRC. METHOD: Consecutive patients with newly diagnosed CRC presenting between October 2002 and September 2004 were identified retrospectively. Mode of presentation, symptoms, treatment and histopathology data were analysed. RESULTS: Data for 193 patients were analysed. Ninety seven patients (50%) presented via the FT system, 43 (22.5%) from nonfast track outpatient sources (NFT) and 53 (27.5%) as emergencies. NFT patients took significantly longer to be seen by a colorectal specialist than FT patients (median 69 vs 31 days; P < 0.001) and to initiation of treatment (median 57.5 vs 42.5 days; P = 0.001). Overall 152 patients (79%) presented with symptoms that met the FT criteria. A significantly lower number of NFT (P = 0.001) and emergency patients (P < 0.001) presented with FT symptoms compared with patients referred through the FT system. There was no significant difference between referral groups in patients undergoing surgery with potentially curative intent or stage of disease. CONCLUSION: Nonfast track referral leads to a significant delay in being seen by a specialist and in initiation of treatment but no association with more advanced stage of disease or a reduction in potentially curative surgery was found.