Randomised study of Lichtenstein compared with Shouldice inguinal hernia repair by surgeons in training.

OBJECTIVE: To compare the outcome following Lichtenstein open mesh technique or Shouldice repair for inguinal hernia operated on by surgeons in training. DESIGN: Prospective, randomised, trial. SETTING: District hospital, Sweden. SUBJECTS: 200 men with primary inguinal hernias. INTERVENTIONS: Lichtenstein mesh repair or Shouldice repair. MAIN OUTCOME MEASURES: Duration of operation, postoperative pain assessed by visual analogue scale (VAS), complications within 30 days, duration of sick leave, and recurrence within one year. RESULTS: 178 patients were available for evaluation (n = 89 in each group). There were no significant differences in duration of operation, pain score, or incidence of postoperative complications. Patients in the mesh group took significantly less sick leave (mean 18.2 days) than those in the Shouldice group (23.8 days, p<0.05). The number of recurrences differed significantly between the groups with 9 in the Shouldice group and none in the mesh group (p<0.01). CONCLUSION: For surgeons in training the Lichtenstein open mesh technique is a better method of inguinal hernia repair than the Shouldice technique. The outcome is better for the patients and it is more cost-effective.

Fibrinolysis in the upper gastrointestinal tract.

There is a higher level of fibrinolytic activity in gastric venous blood than in arterial blood entering the stomach and peripheral venous blood. The higher activity is probably attributable to blood vessels in the wall of the stomach, which have been shown by histochemical methods to contain fibrinolysis activators. The mucosal cells of the stomach and duodenum also contain fibrinolysis activators. The gastric juice of healthy individuals and peptic ulcer patients show little or no activity, whereas that of patients with erosive haemorrhagic gastroduodenitis shows pronounced fibrinolytic activity. In patients with a history of haemorrhagic episodes there is a considerably higher degree of fibrinolytic activity than in those without a history of bleeding. These findings indicate that there may be a connection between local fibrinolysis and bleeding from the upper gastrointestinal tract.

Tranexamic acid in acute upper gastrointestinal bleeding.

The effect of the antifibrinolytic substance, tranexamic acid, has been studied in 5 double-blind, randomized, placebo-controlled trials in patients with acute upper gastrointestinal bleeding. The results of these trials have varied with regard to blood transfusion requirements and the frequency of operations. All of the studies have shown lower mortality in patients treated with tranexamic acid. Thus tranexamic acid would seem to be indicated in acute upper gastrointestinal bleeding.

Cisobitan in treatment of prostatic cancer. A prospective controlled multicentre study.

Cisobitan, an organosilicon compound with estrogenic and antigonadotropic properties has been evaluated clinically in comparison with an estrogen preparation. In a multicenter study a total of 140 patients with well and moderately well differentiated prostatic cancer were randomly allocated to treatment with Cisobitan or Estradurin/Etivex, 70 to each group. Of 34 patients with poorly differentiated prostatic cancer 18 were given Cisobitan--and 16 were given Estracyt-treatment. Among the patients with well and moderately well differentiated prostatic cancer there were, disregarding mortality, no major differences in subjective, objective or laboratory response to the two kinds of treatment. The pattern of side effects was similar, but oedema requiring diuretics occurred more often in the estrogen treated group. There was a significant difference in mortality at 12 months between the groups, two in the Cisobitan group and ten in the estrogen treated group. Cancer was the cause of death in two patients in the estrogen treated group. All other patients succumbed in cardiovascular diseases. At 24 months the difference in mortality rate was less pronounced: Another ten patients had died in the Cisobitan treated group and seven among the estrogen treated patients. Cancer was responsible for the deaths in seven of the Cisobitan patients compared to four of the estrogen treated patients. Within three years one more patient in both groups had died. Of the 34 patients with poorly differentiated cancer, twelve were alive at the 24 months' follow up, six in the Cisobitan group and six in the Estracyt group.

Influence of major surgery on plasminogen activator activity in superficial hand veins.

In 108 patients the plasminogen activator (PA) activity in superficial hand veins was measured with a fibrin slide technique before and after a major surgical operation. In the early postoperative period the PA activity was significantly decreased and the PA activity did not return to its preoperative value until the 14th postoperative day. The postoperative decrease was more than 0.5 arbitrary unit in 90 patients, resulting in an abnormally low value in 44. Overweight or an operation time of 180 min or more was found to increase the proportion of patients with a postoperative decrease in the PA activity. No sure relationship was demonstrable in the postoperative PA activity between patients with venous thrombosis and those without.

Intravenous pyelography versus radioisotope renography combined with plain roentgenography of the urinary tract in the follow-up of patients with ureteral calculi.

Isotope renography combined with plain roentgenography of the urinary tract was compared with intravenous pyelography in the follow-up of 50 patients with pyelographically confirmed, radiopaque ureteral stone. The combined method was as informative as intravenous pyelography regarding the site of the obstruction, and gave better information on the function of the renal parenchyma and the passage of urine. Since in the combined method the level of radiation to which the patient is exposed is much lower than in intravenous pyelography, and since no allergic reaction to the combined method has been reported, it would seem useful in the follow-up of patients with roentgenographically visualized ureteral stone.

Effect of ethyloestrenol on fibrinolysis in the vessel wall.

Forty-nine patients with decreased fibrinolytic activity in the vessel walls or a decreased release mechanism, or both, were treated with ethyloestrenol for three to 17 months. Forty-five of the patients had had recurrent, phlebographically verified, deep venous thrombosis (DVT) and four had arterial thrombosis. Ethyloestrenol 8 mg/day was given to 31 patients and 4 mg/day was given to 12. The remaining six patients had been treated with a combination of phenformin and ethloestrenol. The phenformin was withdrawn but they were kept on ethyloestrenol 8 mg/day. Another 15 patients with a normal fibrinolytic system--four with recurrent DVT and 11 with severe arteriosclerosis--were given ethyloestrenol 8 mg/day. The spontaneous fibrinolytic activity, local fibrinolytic activity during standardised venous occlusion of the arms, and fibrinolytic activity of the vessel walls increased significantly after treatment with ethyloestrenol 8 mg/day for three months. No further increase occurred after three months, and ethyloestrenol 4 mg/day had no effect. No values rose significantly in the patients with a normal fibrinolytic system. One patient suffered a recurrence within three months of treatment, before the fibrinolytic system became normal. In one patient the fibrinolytic defect reappeared after 10 months in spite of continued treatment. Two of the three women of fertile age developed irregular cycles and intermenstrual bleeding, which disappeared when the treatment was withdrawn. No other side effects were observed.

Phenformin and ethyloestrenol in recurrent venous thrombosis.

Altogether 75 patients, 60 of whom had recurrent idiopathic deep venous thrombosis, 10 recurrent superficial thrombophlebitis and 5 retinal venous thrombosis, were given a combination of 100 mg phenformin and 8 mg ethyloestrenol a day for periods varying between 3 and 48 months (mean 16.2). Initially, all the patients had an abnormally low plasminogen activator content in the walls of superficial veins and/or a decreased capacity to release plasminogen activator from the vein walls on venous occlusion of the arms. The combination elicited a significant increase in the spontaneous fibrinolytic activity and in the local fibrinolytic activity during standardized venous occlusion of the arms (assayed on fibrin plates) after treatment for 3 months (p less than 0.001). These activities then remained normal throughout the observation period. In 65 of the 75 patients studied, the plasminogen activator level in the vein wall (histochemically assayed by the method of Pandolfi) was abnormally low intitially. The level had increased significantly after treatment for 3 months (p less than 0.001). After treatment for 12 months all the patients except 2 were normal. The patients in this material had had 2-20 episodes of venous thrombosis, the most recent 5 years before the institution of treatment, in spite of dicoumarol treatment. During treatment 9 thrombotic episodes occurred; in 5 of these patients the fibrinolytic activity of the vessel wall was not normal at the time of the recurrence. Except in 1 patient, who developed lactic acidosis, the side-effects were not severe.

Thrombosis and oral contraceptives: possible predisposition.

The coagulation factors and components of the fibrinolytic system were examined in 31 women with a previous history of phlebographically-verified thrombosis during the use of oral contraceptives of the combined type. Special attention was given to the histochemically-determined fibrinolytic activator content of the wall of biopsy specimens of superficial veins. None of the patients was taking contraceptives at the time of the investigation. Pathological changes, particularly in the fibrinolytic defence system, were found in most of the patients. They may be regarded as predisposed to thrombosis, and one might wonder whether these patients would sooner or later have had their thrombosis even if they had not used contraceptives. The concentration of antithrombin III was normal, indicating that this test is of no value for detecting patients predisposed to thrombosis, who should preferably not take oral contraceptives.