Transinguinal preperitoneal repair with the Polysoft patch: prospective evaluation of recurrence and chronic pain.

OBJECTIVE: The Polysoft patch was conceived to facilitate performance of the transinguinal preperitoneal patch method and combine the advantages of patch placement in the preperitoneal space and the open inguinal approach. The aim of this prospective study was to evaluate the rate of recurrence and chronic pain at midterm follow-up. METHODS: In a cohort of 200 hernia repairs involved in a prospective evaluation, midterm results of 171 cases operated on from 1 July 2004 to 31 December 2005 were assessed. The anesthesia was spinal in 136 (79.5%) cases, local in 26 (15.2%), and general in nine (5.3%). A questionnaire was sent to patients on 30 November 2006 asking about recurrence, chronic groin pain, and satisfaction. RESULTS: With a median follow-up of 21.9 months (11.6-29.4), 167 (97.7%) patients were evaluated, two were dead, and two were lost to follow-up. There were two (1.2%) recurrences that were reoperated on; both consisted of an indirect sac that protruded between the branches of the split patch. Eleven (6.6%) patients alleged the feeling of a foreign body, and 12 (7.2%) reported pain that occurred occasionally or upon effort but did not prevent activity. In one case, the pain present before operation was unchanged, and in three cases, the pain could clearly be attributed to an origin other than the hernia repair. No case of pain that impaired activity was observed. With regard to results, 98.2% of patients were satisfied and 97.6% declared that they would adopt the same method in case they had to be operated on for another hernia. CONCLUSION: These results suggest that the technique provides a low rate of recurrence and a low percentage of chronic pain that did not impair activity.

The Polysoft patch: prospective evaluation of feasibility, postoperative pain and recovery.

INTRODUCTION: The Polysoft patch was conceived to associate the advantages of placement of the patch in the preperitoneal space (PPS) and easiness of the inguinal incision. The aim of this study was to evaluate prospectively the feasibility and postoperative outcome of this method. METHODS: Two hundred Polysoft repairs were performed in 191 consecutive patients with Nyhus types III and IV hernias. The anesthesia was spinal in 146 patients (76.4%), local in 36 (18.8%) and general in 9 (4.7%). The patch was placed in the PPS through the hernial orifice in the fascia in direct hernias and through the internal orifice in indirect ones. The technical points and postoperative course data were prospectively recorded and postoperative pain was assessed daily by visual analogue scale (VAS) in 25 patients. RESULTS: The method was achieved in all the cases. The type of the hernias was as follows: 59 direct, 129 indirect (including 28 pantaloon and 16 sliding), 3 inguino-femoral and 9 recurrent. The size of the patch used was medium in 152 cases (76%) and large in 48 (24%). The large patch was used more in pantaloon, sliding and inguino-femoral hernias. In direct hernias the patch was not split; in indirect hernias the patch was split (so the wings recreate a new internal orifice around the spermatic cord) in 79 cases (61.2%) and not split (with the cord parietalized) in 50 cases (38.8%). The length of operation, postoperative hospital stay, return to daily activity, to work and analgesics consumption were [median +/- SD (extremes)]: 35 min +/- 9.1 (20-60), 1 day +/- 0.4 (0-5), 3 days +/- 1.8 (0-8), 15 days +/- 9.7 (1-30) and 3 days +/- 2.3 (0-10), respectively. The median number of analgesics units was 8 +/- 5.9 (0-32). The values of pain assessed daily by VAS (on 100) varied from 20.4 +/- 19.7 (0-60) at day 0, 25.0 +/- 24.5 (0-80) at day 1 to 7.5 +/- 13.7 (0-50) at day 7; the mean value for the week was 16.7 +/- 16.7 (0-57). There were 14 (7%) benign postoperative complications. CONCLUSION: This study permitted the definition of some technical points and showed that the Polysoft patch can be used for all types of hernias with a weak posterior wall, including complex cases (big scrotal, pantaloon, sliding and recurrent), with a low risk of postoperative complications, a low level of postoperative pain and a short recovery time.

[Reducing the hospital stay after colorectal resection]. / Réduire la durée d'hospitalisation après résection colorectale.

INTRODUCTION: The postoperative hospital stay after colorectal resection is about 15 days in France, when some authors have published a postoperative stay of 2 to 5 days. The aim of this work was to obtain a postoperative hospital stay less than 7 days. PATIENTS AND METHODS: Sixty-one patients who underwent a colorectal resection performed by laparotomy were included in the study: 16 right hemicolectomies, 9 left hemicolectomies, 15 sigmoidectomies and 21 anterior resections were performed. The operation was performed through a midline incision extended over the umbilicus in 13 cases, limited below the umbilicus in 22 cases and elective in 26 cases (right transverse in 16 and left iliac fossa in 10 cases). The protocol comprised epidural analgesia or wound infusion with ropivacaine, restricted intravenous fluids, early oral feeding and active mobilisation. RESULTS: The median and mean times of discharge were 6 and 7.3 days respectively; 36 patients (59%) were discharged on postoperative days 3 to 6, 8 patients (13%) on days 7 and 17 (28%) after day 7. A nasogastric tube was necessary in 2 cases (3.3%). Ten (16%) postoperative complications and 3 (5%) readmissions occurred. There were no deaths. CONCLUSION: Although the postoperative stay cannot be reduced in all the cases, a median hospital stay inferior to which is currently observed can easily be obtained by applying some simple and inexpensive means. This is advantageous for the patient, whose recovery is faster, and contributes to reduce the cost, which is of crucial importance today.

Rectal duplication in an adult: unusual cause of a buttock mass. Report of a case.

PURPOSE: Duplications of the rectum are extremely rare embryologic events, with almost 70 cases reported in the world literature. We report on a 39-year-old female patient with a duplication of the rectum. METHODS: Physical examination showed a left buttock mass; rectal examination revealed the presence of a painless mass compressing the rectum posterolaterally, confirmed by computerized tomography. RESULTS: The patient was operated on with a abdominal then a sacrococcygeal approach. After a complete excision, the postoperative course was unremarkable. Histology revealed a rectal duplication lined with heterotopic cylindric ciliated epithelium. DISCUSSION: This case shows that the diagnosis of rectal duplication is difficult and can be confused with other types of anorectal pathology. The presence of heterotopic ciliated epithelium has rarely been described. Complete excision of the duplication should be possible in most cases using a transcoccygeal, transanal, or abdominoperineal approach, depending on anatomic considerations.

Influence of donor and recipient genotypes on CYP2D6 phenotype after liver transplantation: a study of mutations CYP2D6*3 and CYP2D6*4.

OBJECTIVE: After liver transplantation (LT), genotypic differences between the recipient and the transplanted liver, medications and post-LT complications may all affect drug metabolism. We have studied the effect of two CYP2D6 mutations in the donor and the recipient on post-LT CYP2D6 phenotype. METHOD: The CYP2D6 phenotype was assessed in 48 patients before and after LT with debrisoquine or dextromethorphan. CYP2D6*3 (CYP2D6A) and CYP2D6*4 (CYP2D6B) mutations were detected in the donor and the recipient using polymerase chain reaction. RESULTS: Before LT, 40 subjects were classified as extensive metabolisers (EM) and 8 as poor metabolisers (PM); after transplantation, 41 were EMs and 7 were PMs. Genotype and phenotype were in agreement in 100% of EMs and 40% of PMs. The low percentage of agreement in PMs could not be explained by severely altered liver function. The phenotype of 13 subjects was apparently changed by LT: 6 EMs became PMs and 7 PMs became EMs. All four subjects in whom genotype changed following LT had a corresponding change in phenotype: two EM subjects became PMs and two PM subjects became EMs. CONCLUSION: The low percentage of agreement in PMs may be partly explained by mutations other than CYP2D6*3 and CYP2D6*4. Nevertheless, our study shows that the CYP2D6 genotype of the donor controls the phenotype of the recipient of a liver transplantation.

Cystic rectal duplication: a rare cause of neonatal intestinal obstruction.

A case of cystic rectal duplication revealed on day 2 of life by a low intestinal occluding syndrome is reported. Radiologic imaging (ultrasonography, cystography, rectography) showed a large, retrorectal liquid formation in the pelvis and abdomen, with pelvic compression of the terminal alimentary canal and lower urinary tract. Magnetic resonance imaging demonstrated a liquid formation with clearly defined edges and no medullary involvement, thus ruling out the possibility of a previous meningeal hernia. Biological markers were within normal limits. On day 4, a 9 x 6-cm cystic rectal duplication was removed, followed by a temporary colostomy. Pathologic examination demonstrated typical rectal architecture with ciliated cells. Radiologic and clinical findings at 2-month follow-up were reassuring. This case report is exceptional for the following reasons: (1) As a rule, rectal duplications are relatively rare (70 cases reported in the literature); (2) The means of disclosing a neonatal rectal duplication is unusual (4 cases reported in the literature); (3) The volume of the malformation was considerable; and (4) Heterotopic ciliated epithelium was present.