Five-year prospective follow-up of 430 laparoscopic totally extraperitoneal inguinal hernia repairs in 275 patients.

INTRODUCTION: Favourable short-term results, with respect to less postoperative pain and earlier return to physical activity, have been demonstrated with laparoscopic totally extraperitoneal (TEP) hernia repair compared with open mesh repair. However, there is limited data regarding long-term results. PATIENTS AND METHODS: The study cohort consisted of 275 consecutive patients undergoing TEP repair between 1996 and 2002. Patient demographics, details of surgery, postoperative complications, recurrence and chronic pain were collected from patient records and from a prospective database. All patients were seen at 6 weeks and then annually for 5 years following surgery. RESULTS: A total of 430 repairs were performed in the 275 patients (median age, 56 years; range, 20-94 years; men, 97.5%). Bilateral repair was performed in 168 patients (61.1%) and recurrent hernia repair in 79 patients (28.7%). Two patients were converted to an open procedure. Five-year follow-up was achieved in 72% of patients. Eleven patients (4%) died during the follow-up period due to unrelated causes. Hernia recurrence rate at 5 years was 1.1% per patient (three repairs). Recurrences were noted at 7 months, 2 years and 4 years following surgery. Chronic groin pain was reported by 21 patients (7.6%), seven of whom required referral to the pain team. CONCLUSIONS: TEP hernia repair is associated with a recurrence rate of 1% at 5 years in this series. Chronic groin symptoms are also acceptably few. This recurrence rate following TEP repair compares extremely favourably with open mesh repair, particularly as it includes a high proportion of recurrent repairs. As well as the proven early benefits, TEP repair can be considered a safe and durable procedure with excellent long-term results.

Duodenal obstruction by gallstone in the absence of cholecystoenteric fistula, an unusual complication of total gastrectomy: report of a case.

We present a case of gallstone obstruction of the duodenum in a post total gastrectomy patient without a cholecystoenteric fistula. The patient presented with epigastric pain. On abdominal computed tomography and percutaneous transhepatic choangiography imaging, the patient was found to have duodenal obstruction. At operation, the cause of obstruction was found to be a large gallstone in the third part of the duodenum, but there was no associated cholecystoenteric fistula. This report is the first to describe duodenal obstruction by a gallstone formed within the duodenum, in a patient post total gastrectomy with Roux-en-Y reconstruction, and highlights what can be a difficult diagnosis in such patients.

Review of the management of recurrent inguinal hernia.

BACKGROUND: There is little available evidence on the optimal management of recurrent inguinal hernia, particularly if the original procedure involved the use of mesh. This study was a review of recurrent hernia repair in a district hospital, involving both laparoscopic and open procedures. METHODS: The case notes of all patients who had a repair of a recurrent hernia between 1991 and 2000, inclusive, were examined; 171 procedures were included. Where known, the original repair was a nylon darn in 31%, mesh repair in 18%, and laparoscopic repair in 8%. RESULTS: The recurrent hernia was repaired using a Lichtenstein open mesh technique in 63% and by the totally extraperitoneal (TEP) method in 22%. Complication rates were highest after emergency surgery (all had open surgery), where 71% had complications and one patient died. For elective repairs, complication rates were similar after open (13%) and TEP (8%) repairs. The duration of hospital stay was also similar (1.2 vs 1.3 days, respectively), and a single recurrence was seen in each group. Patients with recurrence after primary mesh repair were also managed by both techniques with similar results. Open re-operation for mesh failure was technically straightforward. CONCLUSIONS: Most recurrent hernias are still repaired by open techniques. There was no convincing evidence of different outcomes for open and TEP repairs in this review. Even when the original hernia repair involved the use of mesh, further open repair by an experienced surgeon is justified.

Prospective evaluation of magnetic resonance cholangiography to detect common bile duct stones before laparoscopic cholecystectomy.

BACKGROUND: With the advent of laparoscopic cholecystectomy, endoscopic retrograde cholangiography (ERC) is frequently employed before operation to detect common bile duct stones. However, this is an invasive technique with recognized complications. This study evaluated the accuracy of magnetic resonance cholangiography (MRC) to detect choledocholithiasis in selected patients before laparoscopic cholecystectomy. METHODS: Patients scheduled for elective laparoscopic cholecystectomy, with risk factors for common bile duct stones, underwent MRC followed by ERC or peroperative cholangiography. RESULTS: Over a 2-year period 40 patients were studied. MRC had a sensitivity of 88 per cent, specificity of 93 per cent, positive predictive value of 78 per cent and negative predictive value of 97 per cent for the detection of common bile duct stones. CONCLUSION: MRC is a simple non-invasive method for preoperative screening for common bile duct stones in at-risk patients. In this study it would have reduced the need for ERC by three-quarters.

A comparative audit of prevalent, incident and interval cancers in the Avon breast screening programme.

The 4th year of the Avon breast screening programme comprises two distinct groups: those called for screening for the first time (prevalent group) and those who were initially screened 3 years earlier (incident group). The cancer detection rate, stage of disease and rate of interval cancers in these patients have been compared. For the prevalent groups of year 1 and year 4 there was no statistically significant difference in the cancer detection rate, proportion of small tumours or node positivity. For the prevalent and incident groups of year 4, there was no statistically significant difference in the cancer detection rate or proportion of small tumours. There were significantly fewer node-positive tumours in the incident group (5/45 vs 8/23; P < 0.05). Fifty-six interval cancers presented in the 3-year period between years 1 and 4 of screening; 28 (50%) after 24 months. The screening programme may result in tumours being detected at an earlier stage, but this may be offset by the high rate of interval cancers. This suggests that the time between screens may need to be reduced to 2 years.

Rate and classification of interval cancers in the breast screening programme.

There has been concern about the number of interval cancers which have been detected within the National Breast Screening Programme. A series of 134 women presenting with interval cancers was studied by prospective audit and the rate and radiological classification of the tumours determined. The cancers were classified as true (67), false-negative (22), unclassifiable (28), occult (12), and minimal sign (5). The interval cancer rate did not achieve the new National Guidelines in either the first 2 years or the 3rd interval year. The false-negative cancers presented mainly in the 1st interval year, whereas the true cancers were predominantly confined to the 2nd and 3rd years. These data suggest that alterations to the screening programme may be beneficial. It may be, however, that the programme is still on the learning curve and this should be taken into account when interpreting these data.

Plasminogen activators in oesophageal carcinoma.

The expression of components of the plasminogen activator system was investigated in patients with oesophageal carcinoma. Tumour and normal mucosa were obtained from resected oesophageal carcinomas and antigens were measured by enzyme-linked immunosorbent assay. Median levels of urokinase plasminogen activator (uPA) and the uPA receptor were higher in carcinoma than in matched normal mucosa (squamous cell carcinoma: uPA 4.05 versus 0.66 ng antigen per mg protein, uPA receptor 1.95 versus 0.50 ng/mg, n = 10, P < 0.05; adenocarcinoma: uPA 2.16 versus 0.61 ng/mg, uPA receptor 2.01 versus 0.49 ng/mg, n = 8, P < 0.05). Tissue plasminogen activator (tPA) level was lower than control values in squamous cell carcinoma but not in adenocarcinoma (1.97 versus 4.70 ng/mg, P < 0.05). There was no difference in plasminogen activator inhibitor (PAI) 1 level between carcinoma and normal mucosa. The PAI-2 level was lower than that in normals in adenocarcinoma only (6.0 versus 64.77 ng/mg, P < 0.05). These data support the hypothesis that membrane-bound uPA has a role in the breakdown of extracellular matrix in invasive oesophageal carcinoma.

Four-year evaluation of a direct-access fibreoptic sigmoidoscopy service.

Over a 4-year period, a direct-access fibreoptic sigmoidoscopy service was evaluated prospectively. In all, 756 patients were referred (median age 58 years, range 18-91 years). The principal indications were rectal bleeding (45%) or change of bowel habit (28%); both features were present in 13%. Abnormalities were present in 68% of examinations. Major disease was identified in 22% (carcinoma 7.0%, adenoma 6.3%, inflammatory bowel disease 8.3%) and minor disease in 53% (haemorrhoids 36.8%, severe diverticular disease 10.9%, non-adenomatous polyp 3.4%, perianal disease 1.4%). In patients under 40 years of age, major disease was rare (one carcinoma, three adenomas). Of the patients, 21% underwent barium enema for incomplete examination or suspected additional disease. No additional major disease was identified, but one carcinoma found in a patient with stricture. These data show that a direct-access fibreoptic sigmoidoscopy service produces a high diagnostic yield and may be of value to both patients and general practitioners in expediting a clinical colorectal service.

Human intraperitoneal fibrinolytic response to elective surgery.

Intra-abdominal adhesions develop in over 90 per cent of patients undergoing laparotomy. Peritoneal fibrinolysis is believed to be important in the pathophysiology of adhesion formation. This study investigated the fibrinolytic response of postoperative peritoneal fluid in 12 patients undergoing elective laparotomy. There was a significant reduction in the plasminogen activating activity to undetectable levels at 24 h, which was sustained at 48 h (P < 0.05). While there was an early reduction in the concentration of tissue plasminogen activator (median 40.0, 28.2, 16.3 and 31.9 ng/ml at 2, 6, 24 and 48 h respectively; P < 0.05), the abolition of functional fibrinolytic activity appeared to be secondary to a marked increase in the concentration of plasminogen activator inhibitor (PAI) 1 (median 86, 196, 800 and 730 ng/ml at 2, 6, 24 and 48 h respectively; P < 0.05) and PAI-2 (median less than 6, 12, 155 and 245 ng/ml at 2, 6, 24 and 48 h respectively; P < 0.05). This reduction in the plasminogen activating activity of peritoneal fluid may favour the formation of permanent fibrous adhesions following surgery.

Experimental adhesion prophylaxis with recombinant tissue plasminogen activator.

The deposition of fibrin in the peritoneal cavity leads to fibrous adhesion formation. Recombinant tissue plasminogen activator (rtPA), delivered locally, was investigated as a method of preventing adhesion formation. Six standardised areas of peritoneal ischaemia were formed in each of 36 male Wistar rats randomised to three intraperitoneal treatments: (A) no treatment control; (B) carboxymethylcellulose gel; (C) rtPA-carboxymethylcellulose gel combination. At 1 week all animals underwent relaparotomy and the number of ischaemic sites with an adhesion counted by an independent observer. rtPA-treated animals formed fewer adhesions compared with gel alone or controls (median number of adhesions 1.5 versus 2.5 versus 5, P < 0.001, ANOVA). Intraperitoneal rtPA in a slow-release formulation is able to reduce adhesion formation significantly in an animal model and may prove to have clinical benefit.

Effect of experimental peritonitis and ischaemia on peritoneal fibrinolytic activity.

OBJECTIVE: Measurement of the fibrinolytic response of the peritoneum to experimental peritonitis and ischaemia. DESIGN: Controlled study SETTING: Academic surgical unit, UK MATERIAL: Male Wistar rats INTERVENTIONS: Peritoneal injuries were caused in four groups of male Wistar rats (n = 35 in each group): (1) control group ("open and close" laparotomy); (2) bacterial peritonitis (mixed faecal flora); (3) chemical peritonitis (10 mg/ml tetracycline) and; (4) ischaemic peritoneum (ligated peritoneal buttons). Peritoneal biopsy specimens were taken from five animals in each group at seven time intervals and plasminogen activating activity (PAA) measured by fibrin plate assay. RESULTS: Compared with the control group the three peritoneal injuries produced a uniform reduction in PAA during the first 6 and 12 hours: at 6 hours the median PAA was 0.029 IU/cm2 for bacterial peritonitis, 0.021 IU/cm2 for chemical peritonitis, and 0.05 IU/cm2 for ischaemic peritoneum compared with 0.112 IU/cm2 for the control group; p < 0.001, ANOVA. At 12 hours the median PAA was 0.024 IU/cm2 for bacterial peritonitis, < or = 0.014 IU/cm2 for chemical peritonitis, and 0.05 IU/cm2 for ischaemic peritoneum compared with 0.112 IU/cm2 for the control group; p < 0.001, ANOVA. There then followed a rebound peak in all groups, maximal at 4-7 days, before a return to baseline values at two weeks. CONCLUSION: Peritoneal fibrinolysis was appreciably inhibited after three different standardised peritoneal injuries. The data support the hypothesis that there is a single pathophysiological mechanism of adhesion formation.

Tumour necrosis factor-mediated release of plasminogen activator inhibitor 1 by human peritoneal mesothelial cells.

Human mesothelial cells synthesize plasminogen activator inhibitor (PAI) 1 in inflamed peritoneal tissue. The role of tumour necrosis factor (TNF) in the mediation of this response was studied. Postoperative peritoneal drain fluid contained both TNF and PAI-1. Peak levels of TNF at 4 h (median 271 pg/ml) preceded a rise in PAI-1 concentration, which peaked at 18 h (median 943.1 ng/ml). Thus TNF may mediate increased PAI-1 release in inflamed peritoneum. TNF significantly increased the mean(s.e.m.) release of PAI-1 by human peritoneal mesothelial cells in vitro at 4 h (control 1.84(0.17) ng/micrograms versus TNF 2.37(0.17) ng/micrograms, P < 0.05), 6 h (2.53(0.09) versus 3.88(0.46) ng/micrograms, P < 0.05), 18 h (0.50(0.02) versus 1.04(0.11) ng/micrograms, P < 0.05) and 24 h (0.87(0.05) versus 1.35(0.11) ng/micrograms, P < 0.05). TNF may be an important mediator of PAI-1 production by human mesothelial cells during peritoneal inflammation.

Fibrinolytic activity of ascites caused by alcoholic cirrhosis and peritoneal malignancy.

Coagulopathy is a well recognised complication of peritoneovenous shunting for ascites. The relative contributions of primary fibrinolysis and disseminated intravascular coagulation remain controversial. Plasminogen activating activity was significantly lower in malignant ascites (n = 10, median < 0.02 (range < 0.02-1.26) IU/ml) than in alcoholic ascites (n = 10, 1.07 (0.30-1.49) IU/ml) (p < 0.05). Fibrinolytic activity was determined by a balance between tissue plasminogen activator and plasminogen activator inhibitor-1. There was no significant difference between the two groups in the concentration of tissue plasminogen activator (34 (12-64) ng/ml in malignant ascites v 29 (12-43) ng/ml in alcoholic ascites), but the concentration of plasminogen activator inhibitor-1 was significantly higher in malignant ascites (736 (213-1651) ng/ml) than in alcohol ascites (29 (12-43) ng/ml) (p < 0.05). Malignant ascites contained significantly higher concentrations of urokinase (0.7 (< 0.1-1.3) ng/ml v 0.2 (< 0.1-0.6) ng/ml in alcoholic ascites) and plasminogen activator inhibitor-2 (33 (< 6-140) ng/ml v 9 (< 6-28) ng/ml alcoholic ascites). The plasminogen activating activity of alcohol ascites may lead to primary fibrinolysis after peritoneovenous shunting. The considerably lower activity found in malignant ascites may explain why coagulopathy after shunting is less pronounced in this group of patients.

General surgeons' attitudes to the treatment and prevention of abdominal adhesions.

A questionnaire survey of general surgeons was undertaken to estimate the incidence of abdominal adhesions as a clinical problem and to establish current attitudes to the treatment of adhesional bowel obstruction and the prevention of adhesion formation. Replies were received from 362 of 416 surgeons (response rate 87%). In all, 76% (95% confidence limits, 72%-80%) of surgeons operate upon at least two patients each year with adhesional small bowel obstruction and 31% (26-36) operate upon more than five patients. More than five patients are admitted each year with suspected adhesional bowel obstruction by 64% (59-69) of surgeons and 35% (30-40) of surgeons found adhesions to be a problem during a non-adhesion-related laparotomy in more than five patients each year. This represents an estimated annual incidence of between 12,000 and 14,000 adhesion-related clinical problems in the United Kingdom. A number of preventive measures, such as the wearing of starch-free gloves (78% of surgeons; 95% CL 74%-82%), peritoneal lavage (68%; 63-73) and placement of the omentum beneath the wound closure (90%; 87-93) are generally accepted, whereas routine wetting of swabs (39%; 34-44) and the role of non-essential adhesiolysis (49%; 44-54) are controversial. Routine small bowel plication (1%; 0-2) and intubation (2%; 0-5) are rarely used. This survey gives an indication of the large burden on patients and the health services caused by abdominal adhesions, and demonstrates surgeons' wide variety of approaches to both the treatment and prevention of adhesion formation.

Plasminogen activator inhibitor 2 reduces peritoneal fibrinolytic activity in inflammation.

Fibrinolysis in peritoneal tissue may play a role in the development of intra-abdominal adhesions. The plasminogen-activating capacity of human peritoneum results largely from the presence of tissue plasminogen activator (tPA). Inflammation reduces peritoneal plasminogen-activating activity and leads to the appearance of plasminogen activator inhibitor (PAI) type 1. The role of PAI-2 in the inhibition of peritoneal fibrinolysis during inflammation was investigated in this study. The plasminogen-activating activity of peritoneal biopsy homogenates (seven inflamed, seven normal), measured using a fibrin plate technique, was reduced in inflamed compared with normal tissue (median < 0.07 versus 13.9 units/cm2, P < 0.01); tPA antigen levels were not significantly different (median 1.02 versus 1.34 ng/ml). PAI-1 and PAI-2 antigens were not detected in normal human peritoneum but were present in inflamed peritoneum (median concentration 8.8 ng/ml for PAI-1, 26.7 ng/ml for PAI-2). These inhibitors may be important factors in adhesion formation by contributing to the abolition of peritoneal plasminogen-activating activity.

The selective use of fine catheter peritoneal cytology and laparoscopy reduces the unnecessary appendicectomy rate.

The effect of a management protocol incorporating the selective use of fine catheter peritoneal cytology (FCPC) and laparoscopy on the unnecessary appendicectomy rate was studied in adult patients (> or = 16 years) treated at one district general hospital over an 11-month period. Appendicectomy was performed on 62 adult patients managed according to this protocol, six (10%) of whom had a histologically normal appendix and no other acute condition requiring surgery. A further 57 patients underwent appendicectomy after standard clinical assessment and investigation without the use of FCPC or laparoscopy. Nineteen (33%) of these patients had a histologically normal appendix removed, with no other acute condition requiring surgical treatment. The selective use of FCPC and laparoscopy significantly reduced the unnecessary appendicectomy rate from 33% to 10% (chi 2 = 10.0, P < 0.005). The more widespread use of these techniques in patients with suspected appendicitis is therefore recommended.