Sustained remission of systemic lupus erythematosus related calciphylaxis.

Calciphylaxis continues to present a clinical challenge for patient management. As in this case, it can be associated with connective tissue disease (CTD) such as systemic lupus erythematosus (SLE). Unlike previous reported cases, long-term remission has been attained. This provides some insight into methods of therapy as well as potential pathogenic models for this disease.

Day-case inguinal hernia repair in the elderly: a surgical priority.

PURPOSE: To compare patients over 70 years old with those under 50 years old undergoing inguinal hernia repair. PATIENTS AND METHODS: Fifty patients aged >70 years (group A) and 50 patients age <50 years (group B) underwent local anaesthetic mesh repair. The mean age for group A was 77.2 years (range 70-85) and for group B it was 40.2 years (range 17-49). There were 46 patients with comorbidities in group A and seven in group B. There were 30 patients with cardiac comorbidities in group A and two in group B. RESULTS: There were no major complications, infections, haematomas or unplanned admissions in either group. Patients >70 years of age had less post-operative discomfort and recovered more quickly than patients aged <50 years. The number of days of analgesic use and time to return to normal activities was longer in the younger group, 6.0 versus 3.4 and 21 versus 13, respectively. There was no significant difference between the groups in patients having discomfort at 3 months post-operatively. More patients were satisfied in the older group, though the difference was not statistically significant. CONCLUSION: Elective inguinal hernia repair under local anaesthetic in the elderly has a good outcome, even if there are significant comorbidities. Ambulatory surgery is feasible in this age group and age alone or co-existing disease should not be a barrier to elective day-case inguinal hernia repair.

Groin hernias in women.

A consecutive series of 255 women with primary groin hernias repaired electively over a five-year period, was reviewed. There were 271 hernias; the majority, 182 (67%) were indirect inguinal hernias, 35 (14%) were direct, and 54 (20%) were femoral. There were no major post-op complications and no recurrences. Most patients presented with a swelling but in 13 cases there was pre-operative discomfort only. Groin pain in women should arouse suspicion of an occult hernia. Lichtenstein repair for inguinal hernia is easier than in men, and as effective.

Simultaneous repair of bilateral groin hernias using local anaesthesia: a review of 199 cases with a five-year follow-up.

BACKGROUND: There has been controversy concerning the simultaneous repair of bilateral groin hernias and the method of anaesthesia. METHODS: A consecutive series of 199 bilateral inguinal hernias was repaired by the Lichtenstein non-tension mesh technique over a two-year period (1997-98). In 96% of them local anaesthesia was used. These were reviewed after five years. RESULTS: There were no increased recurrence or infection rates, with both between 0.5-1%. Pulmonary and urinary complications did not occur. The cost of this technique is substantially less than sequential or laparoscopic operations. DISCUSSION: The reasons advanced for sequential repair of bilateral hernias have been the lower risks of infection and recurrence. Neither of these fears is evident from this study. Furthermore, the use of local anaesthesia permits the operation to be done in a day care clinic. CONCLUSIONS: Simultaneous bilateral repair of inguinal hernias using local anaesthesia is as effective as sequential repair, at lower cost and with less total time off work.

Tension-free mesh repair of umbilical hernia as a day case using local anaesthesia.

BACKGROUND: Umbilical hernias are a common surgical problem with a high recurrence rate using conventional suture techniques. This prospective study examined the feasibility of tension-free mesh repair as a day case using local anaesthetic (LA) for all primary umbilical hernias. METHOD: Fifty-four patients (eight women) were operated on; 49 using LA. Through a periumbilical skin incision the margins of the sac were freed from the edges of the defect, and a space was made in the extraperitoneal plane. In defects <3 cm in diameter, a cone of polypropylene (pp) mesh was inserted and attached with nonabsorbable sutures. In defects >3 cm, a flat piece of pp mesh was inserted into the extraperitoneal space as a sublay. No attempt was made to close the fascial defect. RESULTS: Postoperative pain was graded as mild ( n=37) and moderate ( n=17). No patient had severe postoperative pain. Seven superficial wound infections responded to oral antibiotics. In no case it was necessary to remove the mesh. There were no other complications. Patients were recalled between 2 and 6 years postopertively-mean follow-up 43 months (28- 67). There were no recurrences. CONCLUSION: Umbilical hernia repair can be carried out safely and securely under LA with a tension-free mesh technique (cone or a sublay patch) with a low morbidity, negligible recurrence rate, and a high degree of patient satisfaction. It should be the procedure of choice for all such hernias.

Prospective study of open preperitoneal mesh repair for recurrent inguinal hernia.

BACKGROUND: Recurrent inguinal hernia presents a significant clinical problem with high re-recurrence and complication rates, particularly when an anterior approach is used. This study evaluated the open preperitoneal approach for repair of recurrent inguinal hernia. METHODS: This was a prospective cohort study of 101 consecutive patients with 114 recurrent inguinal hernias. All were operated on using an open preperitoneal technique and prosthetic mesh by the method of Stoppa or Wantz. Follow-up was at 2-6 weeks, 15 and between 42 and 54 months. RESULTS: There were no major complications. There was one infection and one case of retention of urine. There were no testicular complications. There were five recurrences, all within 6 months of operation, four of which were among the first 20 cases. Modifications to the original technique were made, and one recurrence occurred in the remaining 81 patients (1 per cent) or 106 hernias (1 per cent). CONCLUSION: Preperitoneal mesh repair gives results far superior to those of the commonly used anterior approach. It is safer and easier to learn than laparoscopic repair and is the procedure of choice for complex multirecurrent inguinal hernia.

Colchicine-induced bone marrow suppression: treatment with granulocyte colony-stimulating factor.

Bone marrow aplasia is a frequent complication of colchicine poisoning. This typically occurs on day 3 to 5 postexposure, and the blood cell counts remain depressed for a week or more. Unfortunately, because patients suffering from colchicine toxicity develop multiple organ complications and sepsis, the morbidity and mortality associated with bone marrow depression is high. In this article, we present three cases of colchicine toxicity in which granulocyte colony-stimulating factor (G-CSF) was used to treat bone marrow depression. In all three cases, there was a dramatic increase in the white cell count and, to a lesser extent, the platelet count. In view of the critical nature of the bone marrow depression and multi-organ toxicity induced by colchicine, we believe that consideration of the use of G-CSF to shorten the duration of neutropenia is warranted.

Three thousand one hundred seventy-five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia.

BACKGROUND: Controversy exists over the relative advantages of open mesh repair compared with open stitching methods and the laparoscopic approach. STUDY DESIGN: Two thousand nine hundred six (2,906) consecutive unselected adult patients underwent 3,175 primary inguinal hernia repairs using polypropylene mesh, under local anesthesia on an ambulatory basis. The age range was 15-92 years. The study specifically investigated the postoperative course with regard to pain, complications, and time of return to work. RESULTS: There were no postoperative deaths and no cases of urinary retention. Two percent of patients developed a hematoma. The incidence of deep infection was 0.3%. No case of testicular atrophy occurred. Postoperatively 19% of patients used no analgesia at all; 60% used oral analgesics for up to 7 days. There was a gradual decrease in time of return to work over four successive 1-year periods. Manual workers returned to work in 15 days (median) in the first year, reducing to 9 days in the fourth year. The overall median time of return to work across the whole group was 9 days. There were eight recurrences with an 18-month to 5-year followup. CONCLUSIONS: Open mesh repair under local anesthesia is an effective day case technique, particularly in the elderly and medically unfit. The economic benefits are enhanced by low morbidity, early return to normal activities and low recurrence rates.

The Lichtenstein repair.

The description of the Lichtenstein tension-free mesh repair 12 years ago opened a new era in groin hernia repair. Without the risk for severe morbidity, it can be readily carried out on patients previously considered unsuitable for hernia repair. Fears of complications related to mesh implantation have proved to be without foundation. As a local anesthetic outpatient procedure without the need for complex and expensive instrumentation, combined with the ability of patients to return to work in a short time, overall costs can be kept to a minimum without in any way compromising the safety or the long-term success of the procedure.