Infection of laparoscopically inserted inguinal hernia repair mesh following subsequent emergency open surgery: a report of two cases.

We present two cases of laparoscopically inserted mesh for inguinal hernia repair that became infected following emergency open bowel surgery. We believe that there is an increased risk of infection due to the larger size of mesh used in the laparoscopic repair but also due to the patient not volunteering the information because of the minimally invasive nature of the procedure.

Thoracoscopic excision of mediastinal parathyroid adenomas: a report of two cases.

Two patients with primary hyperparathyroidism caused by solitary ectopic mediastinal parathyroid adenomas have been successfully treated by thoracoscopic excision. The patients were not suitable for open thoracic surgery. Both had right-sided adenomas confirmed by sestamibi and computerised tomography - one adjacent to the oesophagus at the level of D3, the other anterolateral to the ascending aorta. Both procedures were performed through one 12-mm camera port and two 5-mm operating ports, and were uncomplicated, with 30-45 minutes skin-to-skin operating time. Both patients were well enough to be discharged the next day, and both rapidly became normocalcaemic. At follow-up, neither had developed any complications. In selected cases, where an ectopic adenoma lies immediately deep to the mediastinal pleura, thoracoscopic excision offers considerable advantage over open thoracic surgery.

Thoracic aortic aneurysm presenting with dysphagia: a fatal delay in diagnosis.

Extrinsic oesophageal compression leading to dysphagia is a recognised but uncommon sole presentation of thoracic aortic aneurysms. This has been referred to as Dysphagia Aortica, and is a late presentation of large thoracic aneurysms, or a symptom of impending aorto-oesophageal fistula. We present the case of a 67 year old woman who presented repeatedly with dysphagia and weight loss over a 3 month period to specialists in three different disciplines. Eventually, a type II thoraco-abdominal aortic aneurysm causing extrinsic compression of the oesophagus was discovered. When dealing with patients who present with dysphagia, if no other cause is discovered, a thoracic aortic aneurysm should form part of the differential diagnosis, as this is potentially curable, and delays in diagnosis and treatment predispose to rupture and death.

Torted and ruptured wandering spleen presenting as a surgical emergency in pregnancy.

Wandering spleen (WS) is characterised by incomplete fixation of the spleen to its supporting linorenal and gastrosplenic ligaments. It can predispose to life-threatening complications due to torsion of its vascular pedicle, splenic infarction, portal hypertension, and haemorrhage. A 27-year-old, 36-week prima gravida underwent emergency caesarean section for tachycardia and hypotension. A healthy baby girl was delivered. However, she remained shocked despite aggressive fluid therapy and intraoperatively it was noted that there was significant intraperitoneal bleeding and the on-call surgical team was summoned. Midline laparotomy revealed a lacerated, infarcted, hypermobile spleen found with free intraperitoneal bleeding. The unsalvageable spleen was resected and the patient went on to make an excellent recovery. The aetiology of WS is contentious. With an increased frequency among multiparous females of reproductive age, some suggest the hormonal effects of pregnancy as contributing factors. Clinical presentations range from an asymptomatic abdominal mass to acute abdominal pain with hypovolaemic shock. WS poses a serious threat to life due to thrombosis, bleeding, or infarction. Ultrasound scan and CT scan are equally effective in the diagnosis. Patients with asymptomatic WS should be treated with elective splenopexy, however, in the acute presentation, splenectomy is the procedure of choice.

Randomized clinical trial of three-layer paste and four-layer bandages for venous leg ulcers.

BACKGROUND: Both four-layer and three-layer paste bandages are widely used in the treatment of venous leg ulcers. The aim of this study was to compare the efficacy of these two bandaging regimens. METHODS: The study was a prospective, randomized, open comparison of a consecutive cohort of 133 patients with venous ulcers. Participants were stratified by ulcer size into one of three groups and were randomized within each group to receive either three-layer paste or four-layer bandages. All patients were followed for 1 year. The time taken to complete ulcer healing was the primary endpoint. The time taken to apply the bandages, comfort, tolerability and cost were also assessed. Analysis was performed on the basis of intention to treat. RESULTS: Ulcers healed completely in 51 (80 per cent) of 64 patients treated with three-layer paste bandages compared with 45 (65 per cent) of 69 patients treated with the four-layer regimen (P = 0.031). This difference developed only after 20 weeks of treatment. The median times to complete healing were 12 weeks for three-layer and 16 weeks for four-layer treatment (P = 0.040). Results of venous function tests, including half-refilling times, were similar in the two groups. CONCLUSION: Three-layer paste bandages were significantly more effective at healing venous ulcers than the four-layer regimen in this study.

Randomized clinical trial comparing the efficacy of two bandaging regimens in the treatment of venous leg ulcers.

BACKGROUND: Many venous ulcers are healed by the application of external compression. It has been suggested that bandages capable of producing greater compression enhance healing. The aim of this study was to compare the time to total healing of venous ulcers in two groups of patients treated with different compression regimens in a randomized prospective trial. METHODS: A total of 112 patients was studied and all were treated with a zinc-impregnated paste bandage applied directly to the ulcer. Fifty-seven patients had the paste covered by Tensopress and 55 by Elastocrepe bandages. Both groups had a tubular bandage applied over the top to retain the bandage in place. All ulcers were stratified and randomized within one of three size groups. The 'venous' aetiology of the ulcer was confirmed on completion by calf pump function tests. RESULTS: By 26 weeks, 58 per cent of the patients treated with Tensopress and 62 per cent of those treated with Elastocrepe bandages were healed. The median healing times were 9 and 9.5 weeks respectively. Similar numbers of patients were excluded or withdrawn from both groups. Large ulcers healed significantly more slowly than small ulcers. CONCLUSION: There was no significant improvement in venous ulcer healing using higher compression elastic bandages.

Value of isotope lymphography in the diagnosis of lymphoedema of the leg.

BACKGROUND: Isotope lymphography has largely replaced contrast lymphography in the diagnosis of lymphoedema. Its accuracy has only been assessed in small studies and it is not known if it can identify patients with a proximal lymphatic obstruction who may be suitable for lymphatic bypass surgery. METHODS: Three hundred and ninety-five patients suspected to have lymphoedema were investigated by isotope lymphography between 1985 and 1995. Contrast lymphography was also carried out in 29 of these patients because the isotope results were thought to be misleading, or because lymphatic bypass surgery was being considered. RESULTS: In the 29 patients who had both investigations isotope lymphography detected 20 of 24 abnormal lymphatic systems. Four legs with obstructed groin lymphatics were reported as normal. Two legs with normal contrast lymphograms were erroneously diagnosed as having lymphoedema in the isotope study. Detectable groin nodes on the scintigrams were indicative of either normal lymphatics or proximal lymphatic obstruction. An increase in isotope uptake over 30-60 min of less than 50 per cent, or a total absence of isotope within groin nodes, was a sensitive indicator that patients were unsuitable for lymphatic bypass surgery. CONCLUSION: Isotope lymphography is a moderately sensitive test for lymphoedema, which will mistakenly classify some normal legs as lymphoedematous. It will usually correctly identify patients who are suitable for lymphatic bypass surgery.

Restenting malignant oesophageal strictures.

BACKGROUND: Self-expanding metal stents are used to palliate malignant strictures of the oesophagus. This study was designed to identify the characteristics of patients requiring restenting of malignant oesophageal strictures. METHODS: Fifty-three stents were inserted in 42 patients. Thirty-two patients did not require further stenting (once-stented group). Ten patients received second stents for recurrent oesophageal obstruction (restented group), with one patient requiring restenting a second time. Comparisons were drawn between the once-stented and restented groups with regard to survival, patient, tumour and procedural characteristics. RESULTS: There were no significant differences with regard to tumour grade, tumour type, involvement of the cardia, procedural difficulties or the need for postprocedural oesophageal dilatation between the two groups. Survival from initial stenting was significantly greater in the restented group (median 24 (range 4-43) weeks) than in the once-stented group (median 9.5 (range 1-84) weeks) (P < 0.05). The mean length of stents used in the once-stented group was significantly greater than that of the initial stents used in the restented group (12 versus 10 cm, P = 0.032). CONCLUSION: Inserting a covered stent through a previously inserted uncovered stent is an uncomplicated and well tolerated technique which maintains palliation from obstructing oesophageal carcinoma. The need for restenting cannot be predicted on the basis of tumour characteristics alone.

Retrograde flow in the deep veins of subjects with normal venous function.

BACKGROUND: Duplex ultrasonography has become the optimal non-invasive method of assessing the deep venous system of the leg. The stimuli used to promote reverse flow, subject positioning, and the veins scanned have varied between studies. Reverse flow of less than 0.5 s is accepted as 'normal', however, all published studies have demonstrated 'normal' subjects with deep vein reverse flow exceeding this time. The aim of this study was to establish the duration of reverse flow in all deep vein segments, and to determine the optimal method of eliciting reverse flow in individuals with proven normal deep vein function. METHODS: Duplex scanning was used to detect the presence and duration of reverse flow in the superficial femoral, popliteal and posterior tibial veins of 61 legs with normal venous function. The veins were scanned with each subject inclined at 10 degrees, 45 degrees and standing erect. The abrupt release of distal tourniquet compression and the Valsalva manoeuvre were used as stimuli for reverse flow. RESULTS: There was significantly less reverse flow in distal veins than in proximal veins when the subject was scanned at 10 degrees and 45 degrees. Median (range) reverse flow in the femoral vein at 10 degrees was 0.21 (0-1.18) s, posterior tibial vein 0.08 (0-0.67) s, (P < 0.0001); in the femoral vein at 45 degrees was 0.14 (0.04-2.14) s, posterior tibial vein 0.07 (0-0.56) s, (P < 0.0001). The duration of reverse flow was significantly less in the superficial femoral and popliteal veins when the subjects were erect than when inclined at 10 degrees and 45 degrees. Median (range) reverse flow in the femoral vein at 10 degrees was 0.21 (0-1.18), and when standing 0.1 (0-1.36) (P < 0.0001); below-knee popliteal vein at 10 degrees was 0.15 (0.04-1.95) s, and when standing 0.10 (0-1.03) (P = 0.0004). Reverse flow of more than 0.5 s was never elicited in the posterior tibial veins if the subject stood, nor did it occur in the popliteal vein during a Valsalva manoeuvre. CONCLUSION: The optimal sites to assess deep vein reverse flow are the posterior tibial vein following removal of distal compression with the patient standing, and the popliteal vein during a Valsalva manoeuvre, as retrograde flow more than 0.5 s does not occur in subjects with normal venous function.

Twelve years experience of vena cava filtration.

Fourteen patients have required vena caval interruption in a period of 12 years at St Thomas' Hospital. Half of these patients had an underlying malignancy. None of these patients have had clinical or lung scan evidence of recurrent emboli. There were no deaths related to filter insertion and no patient died of a pulmonary embolism. Vena caval interruption is a procedure that is rarely necessary but may be valuable in carefully selected patients.

Role of transoesophageal echocardiography in determining the source of peripheral arterial embolism.

Thirty patients with peripheral arterial embolism underwent conventional transthoracic echocardiography. Transoesophageal echocardiography was also performed in ten of the same patients. The detection rate of cardiac abnormalities considered responsible for embolism was five of 20 in patients who received only transthoracic echocardiography and eight of ten in those who underwent transoesophageal echocardiography. One abnormality was detected by transthoracic echocardiography in the ten patients who received both tests, while eight cardiac or aortic abnormalities were discovered by transoesophageal echocardiography (P < 0.05). Transoesophageal echocardiography is significantly better than conventional transthoracic echocardiography at detecting cardiac sources of peripheral arterial embolism.

Growth factors, tissue and urokinase-type plasminogen activators in venous ulcers.

Bioimmunoassays for tissue and urokinase-type plasminogen activators (t-pA and u-pA), and enzyme-linked immunosorbent assays (ELISA) for t-pA were performed on biopsies from the edge and base of 15 venous ulcers. TGF-beta 1, bFGF and PDGF were assessed by ELISA in the edge and base of 19 further venous ulcers and 7 biopsies of normal skin. The presence of all three growth factors and u-pA was confirmed immunohistochemically. T-pA was detected using the ELISA and the bioimmunoassay, but was quantified in 3/15 ulcer bases and 4/15 ulcer edges using the bioimmunoassay only. U-pA was measured in all ulcer samples except one. TGF-beta 1 was measured in 13/19 ulcer bases and 9/19 edges, while free TGF-beta 1 was measured in only 2/19 bases and 4/19 edges. Venous ulcer bases contain significantly greater quantities of u-pA, TGF-beta 1, and bFGF than ulcer edges. TGF-beta 1 was never detected in normal skin. There is significantly less bFGF in normal skin than in venous ulcer bases, but not edges (p = 0.013, p = 0.31 respectively, Mann Whitney U-test). There was a good correlation between ulcer edge TGF-beta 1 and time to healing in ten ulcers that healed within six months from the date of biopsy (r = -0.56, p = 0.065, Spearman Rank Correlation). There was a significantly greater amount of ulcer edge bFGF in the ulcers that healed within six months than those that remained unhealed (p = 0.036, Mann-Whitney U-test).(ABSTRACT TRUNCATED AT 250 WORDS)