Relative prevalence of upper respiratory tract obstructive disorders in two breeds of harness racehorses (185 cases: 1998-2006).

REASONS FOR PERFORMING STUDY: Two genetically and phenotypically distinct horse breeds are used for harness racing in Scandinavia: the Standardbred (SB) and Coldblooded Trotter. These racehorses have identical environmental, management and racing conditions. Therefore, this study was undertaken to identify and compare the relative prevalence of upper respiratory tract (URT) obstructive disorders in these 2 breeds. OBJECTIVES: To determine whether these 2 phenotypically different breeds of harness racehorses have different predispositions for URT disorders. METHODS: Retrospective study of 88 Norwegian Coldblooded Trotters (NCT) and 97 SBs referred to this hospital for URT evaluation between 1998 and 2006. Case records of all horses diagnosed with an URT disorder during resting endoscopy, and all horses undergoing high-speed treadmill videoendoscopy (HSTV) with one or more periods of induced poll flexion were evaluated. The relative prevalence of URT disorders between the 2 breeds was analysed using a Fisher's exact test. RESULTS: There was a significant (P<0.05) breed predisposition regarding 6 URT disorders. Bilateral dynamic laryngeal collapse associated with poll flexion and flaccid epiglottis was significantly more frequent in the NCT. Alar fold collapse and nasopharyngeal collapse were significantly more frequent in SBs. Epiglottic entrapment and nasal flutter were only diagnosed in the SBs. Dynamic disorders were more common than resting disorders in both breeds. CONCLUSION: URT obstructive disorders (dynamic laryngeal collapse associated with poll flexion, flaccid epiglottis, pharyngeal collapse, alar fold collapse, nasal flutter and epiglottic entrapment) are breed related, indicating an anatomic or functional cause. Periods of induced poll flexion during HSTV was essential to declare harness racehorses free of URT disorders. POTENTIAL RELEVANCE: Further anatomic or physiological studies comparing these breeds could potentially provide insight into the pathogenesis of certain URT obstructive disorders. Induced poll flexion should be included in routine HSTV examinations of all harness racehorses.

Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair.

BACKGROUND: The optimal treatment for recurrent inguinal hernia is of concern due to the high frequency of recurrence. METHODS: This randomized multicenter study compared the short- and long-term results for recurrent inguinal hernia repair by either the laparoscopic transabdominal preperitoneal patch (TAPP) procedure or the Lichtenstein technique. RESULTS: A total of 147 patients underwent surgery (73 TAPP and 74 Lichtenstein). The operating time was 65 min (range, 23-165 min) for the TAPP group and 64 min (range, 25-135 min) for the Lichtenstein group. Patients who underwent TAPP reported significantly less postoperative pain and shorter sick leave (8 vs 16 days). The recurrence rate 5 years after surgery was 19% for the TAPP group and 18% for the Lichtenstein group. CONCLUSION: The short-term advantage for patients who undergo the laparoscopic technique is less postoperative pain and shorter sick leave. In the long term, no differences were observed in the chronic pain or recurrence rate.

Incisional hernia repair in Sweden 2002.

Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.

Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia.

BACKGROUND: The Shouldice technique is the 'gold standard' of open non-mesh hernia repair. The aim of this study was to compare 5-year recurrence rates after Shouldice and laparoscopic transabdominal preperitoneal patch (TAPP) repair for primary inguinal hernia. METHOD: Men with a primary unilateral inguinal hernia were randomized to either Shouldice or TAPP operation. An independent observer scored the surgeons' performance. Follow-up comprised clinical examination after 1 year, a questionnaire after 2 and 3 years, and a clinical examination after 5 years. RESULTS: Between February 1993 and March 1996, 1183 patients were included. Nine hundred and twenty patients were followed for 5 years, 454 in the TAPP group and 466 in the Shouldice group. Recurrences were evenly distributed between groups throughout the follow-up period. The cumulative recurrence rate after 5 years was 6.6 per cent in the TAPP group and 6.7 per cent in the Shouldice group. Postoperative pain was a risk factor for recurrence after Shouldice operation but not after TAPP repair. There was a correlation between a low surgeon's performance score and recurrence. CONCLUSION: The 5-year recurrence rate is acceptable, with no difference between TAPP and Shouldice repair. Poor operative performance resulted in a higher recurrence rate. The TAPP operation represents an excellent alternative for primary inguinal hernia repair.

Secondary aortoenteric fistulae--changes from 1973 to 1993.

AIM: To investigate a series of patients with secondary aortoenteric fistulas and compare it with a previous series (1985-93 vs. 1973-84). DESIGN: Retrospective study of medical records. SETTING: Sixteen vascular surgical centers in Sweden. PATIENTS: Twenty-seven patients were identified making an overall incidence of 0.5% of all aortoiliac operations. Among aneurysm patients the incidence was significantly lower than in the previous series. One patient record could not be identified. Fourteen primary operations were for aortic aneurysm, 12 for occlusive disease and one was an aortorenal vein bypass. RESULTS: Symptoms of the fistula occurred after a median interval of 90 months which is significantly later than the previous series (32 months; p<0.05). The commonest presentation was bleeding followed by septis. The median diagnostic delay was 10.5 days, which was significantly shorter than in the previous series. Most fistulas involved the duodenum (88%). One patient died before surgery. The postoperative mortality was 28%, significantly lower than in the previous series (58%) (p<0.05). At the end of follow up (median 43 months) significantly more patients were alive than in the previous series (42% vs 18%) (p<0.05). CONCLUSION: Over a 21 year period there seems to have been a decrease in the frequency of secondary aortoenteric fistulas after aneurysm surgery, a longer interval before they occur, a shorter diagnostic delay, and a better survival.

Preoperative assessment of the risk for cardiac death following thrombo-embolectomy for acute lower limb ischaemia.

Cardiac monitoring and the selective use of initial non-operative management is reported to reduce the high mortality rate in patients with acute lower limb ischaemia. Early estimation, prior to selection of initial therapy, of the risk for intraoperative or postoperative cardiac death following thrombo-embolectomy is therefore important. The aim of this prospective multi-centre study was to develop a simple and clinically useful index for assessment of the risk of post-operative cardiac death. Patients judged to need thrombo-embolectomy for acute lower limb ischaemia were evaluated on admission for routine clinical, cardiac and limb ischaemia parameters that could be related to cardiac function and these parameters compared to postoperative cardiac outcome. Sixteen per cent of the 117 patients died from intraoperative or postoperative cardiac complications. Analysis revealed five admission parameters that significantly and independently predicted a high risk for cardiac death: mean arterial blood pressure below 90 mmHg, clinical sign(s) of cardiac decompensation, ischaemia affecting the thigh, haemoglobin concentration exceeding 140 gl-1, and a history of a myocardial infarction in the previous 4 weeks. Definition of risk points for each risk factor allowed a simple classification of each patient into one of three significantly different cardiac risk classes with cardiac death rates of 6 +/- 3%, 27 +/- 8% and 75 +/- 16%, respectively. More than two thirds of the patients belonged to the low risk group. The described risk index provides a tool for preoperative assessment of the cardiac death risk associated with early thrombo-embolectomy in patients with acute lower limb ischaemia.

Peroperative arterial recanalization with Kensey dynamic angioplasty. Histopathologic studies.

The morphology of occluded superficial femoral artery segments and of particles in the effluent fluid after dynamic Kensey catheter angioplasty was analyzed in six patients treated with an intraoperative retrograde technique. The effluent was collected during the procedure and the arteries were extirpated for microscopy after the recanalization attempt. In three patients with easy recanalization, histologic study showed highly cellular, proliferating connective tissue. In three patients with unsuccessful recanalization, mature, cell-poor connective healing tissue obliterated the lumen. The effluent contained particles measuring 14 to 320 microns, the largest of which had the potential to occlude small arteries. The results of this pilot study are to be regarded as preliminary.

Spigelian hernia.

The diagnosis of spigelian hernia presents greater difficulties than its treatment. The clinical presentation varies, depending on the contents of the hernial sac and the degree and type of herniation. The pain, which is the most common symptom, varies and there is no typical pain of spigelian hernia. Findings to facilitate diagnosis are palpable hernia and a palpable hernial orifice. Large, easily palpable spigelian hernias are not a diagnostic problem. It is small hernias and hernial orifices that are overlooked because they are masked by the subcutaneous fat and an intact external aponeurosis. In the absence of a palpable orifice or sac, persistent point tenderness in the spigelian aponeurosis with a tensed abdominal wall most strongly suggests the diagnosis. Spigelian hernia can be ruled out in patients without palpable tenderness. Ultrasonic scanning can be recommended for verification of the diagnosis in both palpable and nonpalpable spigelian hernia. The hernial orifice and sac can also be demonstrated by computed tomography, which gives more detailed information on the contents of the sac than does ultrasonic scanning. The treatment of spigelian hernia is surgical, and the risk of recurrence is small. A gridiron incision is excellent for operations for palpable hernias. If the hernia cannot be palpated preoperatively, preperitoneal dissection through a vertical incision is recommended. This gives good exposure, facilitates hernioplasty, and permits preperitoneal exploration and treatment of other abdominal wall hernias. The incision is also suitable for exploratory laparotomy, which should be performed on patients with abnormal ultrasonographic or computed tomographic findings in whom no palpable hernia can be detected preoperatively.

Non-palpable inguinal hernia in the female.

A total of 142 inguinal hernioplasties in 130 female patients with nonpalpable inguinal hernias were performed over a period of 8 years. The mean age in this series was 32 years. (Range 10-76 years). One hundred thirty six cases were followed 3-51 months postoperatively. One hundred seventeen of these (86%) were considered to have good results. Nonpalpable inguinal hernia in the female is clinically recognizable on the basis of intermittency, character and localization of the pain and typical findings at the clinical examination. About three quarters of these patients report in addition to dull inguinal pain, intermittent neuralgic pain and in almost two thirds of the patients a pin-prick hyperalgesia of the skin corresponding to the ilio-inguinal nerve can be demonstrated. It is also typical that all patients experience a distinct tenderness upon palpation over the deep inguinal ring during Valsalva's maneuvre. It is important to keep this condition in mind, especially since the patients respond well to surgical treatment.

Spigelian hernia.

This article reviews the literature on Spigelian hernia and discusses the anatomy, definitions, etiology, clinical diagnosis, and treatment. Ultrasonic scanning and computed tomography have been successful in improving diagnosis. In cases of palpable Spigelian hernia, a gridiron incision is recommended; in non-palpable hernia, a vertical incision and preperitoneal dissection offers several advantages.

Percutaneous transluminal angioplasty (PTA) for lower extremity arterial insufficiency.

Short term results of treatment with percutaneous transluminal angioplasty (PTA) for lower extremity arterial insufficiency are presented. During a two year period 54 PTA were attempted and 43 were successful. 42 patients were either free of symptoms or had objectively reduced ischemic symptoms and remained so during the follow-up period (mean 10.5 months). Successfully repeated PTA were performed in three patients for the management of occlusions within an arterial segment earlier dilatated. Reasons for unsuccessful PTA were mainly difficulties in passing the stenosis/occlusion with the guide wire or that dilation could not be completed because of extensive calcification in the arterial wall. The only complication requiring treatment was a bleeding from a puncture site in the femoral artery. PTA treatment of lower extremity arterial insufficiency is for many patients a good alternative or complement to reconstructive vascular surgery and a method that should be used to a greater extent in vascular surgery centers.

Thigh neuralgia as a symptom of obturator hernia.

A material of 8 patients with obturator hernias is presented. In 7 of the patients a neuralgic pain in the thigh was the main symptom and a hyperesthesia in the cutaneous segment of the obturator nerve was also common. A recognition and an early operation of this condition is important, since the mortality is high when an intestinal obstruction has complicated the disease.

Peritoneography in spigelian hernias.

Twelve patients with a minor Spigelian hernia not involving the intestines have been examined by combined peritoneography and herniography. The particular pathology of this hernia does not lend itself to be detected by these procedures.

Ultrasound as a diagnostic aid in ventral abdominal hernia.

Preliminary results are presented of ultrasound investigations in 34 patients with suspected abdominal hernias. All patients were explored surgically on the basis of clinical indications, and the surgical findings were compared with the results of the ultrasound investigation. Small hernias in the anterior abdominal wall (fascia Spigelii and linea alba) can be demonstrated by ultrasound, but there are certain circumstances which can lead to false positive ultrasound results.