Open ventral hernia repair with a composite ventral patch - final results of a multicenter prospective study.

BACKGROUND: This study assessed clinical outcomes, including safety and recurrence, from the two-year follow-up of patients who underwent open ventral primary hernia repair with the use of the Parietex™ Composite Ventral Patch (PCO-VP). METHODS: A prospective single-arm, multicenter study of 126 patients undergoing open ventral hernia repair for umbilical and epigastric hernias with the PCO-VP was performed. RESULTS: One hundred twenty-six subjects (110 with umbilical hernia and 16 with epigastric hernia) with a mean hernia diameter of 1.8 cm (0.4-4.0) were treated with PCO-VP. One hundred subjects completed the two-year study. Cumulative hernia recurrence was 3.0% (3/101; 95%CI: 0.0-6.3%) within 24 months. Median Numeric Rating Scale pain scores improved from 2 [0-10] at baseline to 0 [0-3] at 1 month (P < 0.001) and remained low at 24 months 0 [0-6] (P < 0.001). 99% (102/103) of the patients were satisfied with their repair at 24 months postoperative. CONCLUSIONS: The use of PCO-VP to repair primary umbilical and epigastric defects yielded a low recurrence rate, low postoperative and chronic pain, and high satisfaction ratings, confirming that PCO-VP is effective for small ventral hernia repair in the two-year term after implantation. TRIAL REGISTRATION: The study was registered publically at clinicaltrials.gov ( NCT01848184 registered May 7, 2013).

Identification and management of the ilio-inguinal and ilio-hypogastric nerves in open inguinal hernia repair: benefits of self-gripping mesh.

PURPOSE: A large randomized, multicenter European study recently reported a reduction in early pain after open inguinal surgery when self-gripping mesh was used compared with sutured Lichtenstein repair. This secondary exploratory study is focused on the influence of nerve identification and handling on post-operative pain. METHODS: Post-operative VAS pain data and Surgical Pain Scores (SPS) from 507 patients included in this study were analyzed according to whether inguinal nerves were preserved or resected during surgery to investigate whether identification and peri-operative nerve handling impact post-operative pain. RESULTS: Preservation of the ilio-hypogastric nerve during Lichtenstein mesh repair with suture fixation was associated with significantly more post-operative pain compared with resection at each follow-up (p ≤ 0.003). This difference was not significant with self-gripping mesh repair. The decrease from baseline in post-operative VAS and SPS scores were significantly greater after self-gripping mesh repair compared to Lichtenstein repair at 1 year, but only when the ilio-hypogastric nerve was preserved (VAS scores, p = 0.009; SPS scores, p = 0.015). No such difference was observed with the ilio-inguinal nerve. When self-gripping mesh was used, preservation of the ilio-hypogastric nerve was associated with significantly greater decreases in post-operative pain (change in VAS score from baseline) compared with Lichtenstein repair at each follow-up (p ≤ 0.018). CONCLUSIONS: The ilio-hypogastric nerve is in danger of being traumatized during Lichtenstein mesh repair with suture fixation. The use of self-gripping mesh was shown to reduce the level of post-operative pain when the ilio-hypogastric nerve was preserved. Resection of the ilio-hypogastric nerve during Lichtenstein repair eliminates this difference.

Metabolic adaptations of skeletal muscle to voluntary wheel running exercise in hypertensive heart failure rats.

The Spontaneously Hypertensive Heart Failure (SHHF) rat mimics the human progression of hypertension from hypertrophy to heart failure. However, it is unknown whether SHHF animals can exercise at sufficient levels to observe beneficial biochemical adaptations in skeletal muscle. Thirty-seven female SHHF and Wistar-Furth (WF) rats were randomized to sedentary (SHHFsed and WFsed) and exercise groups (SHHFex and WFex). The exercise groups had access to running wheels from 6-22 months of age. Hindlimb muscles were obtained for metabolic measures that included mitochondrial enzyme function and expression, and glycogen utilization. The SHHFex rats ran a greater distance and duration as compared to the WFex rats (P<0.05), but the WFex rats ran at a faster speed (P<0.05). Skeletal muscle citrate synthase and beta-hydroxyacyl-CoA dehydrogenase enzyme activity was not altered in the SHHFex group, but was increased (P<0.05) in the WFex animals. Citrate synthase protein and gene expression were unchanged in SHHFex animals, but were increased in WFex rats (P<0.05). In the WFex animals muscle glycogen was significantly depleted after exercise (P<0.05), but not in the SHHFex group. We conclude that despite robust amounts of aerobic activity, voluntary wheel running exercise was not sufficiently intense to improve the oxidative capacity of skeletal muscle in adult SHHF animals, indicating an inability to compensate for declining heart function by improving peripheral oxidative adaptations in the skeletal muscle.

Age attenuates leucine oxidation after eccentric exercise.

Aging may alter protein metabolism during periods of metabolic and physiologic challenge. The purpose of this study was to assess the effects of age on whole-body amino acid turnover in response to eccentric exercise and hyperglycemia-induced hyperinsulinemia. 16 healthy men were divided into young (N=8) and older (N=8) groups. Protein metabolism was assessed using a [1-13C]-leucine isotopic tracer approach. Measures were obtained under fasted basal conditions and during 3-h hyperglycemic clamps that were performed without (control) and 48 h after eccentric exercise. Exercise reduced leucine oxidation in the younger men (P<0.05), but not in older men. Insulin sensitivity was inversely correlated with leucine oxidation (P<0.05), and was lower in older men (P<0.05). Healthy aging is associated with an impaired capacity to adjust protein oxidation in response to eccentric exercise. The decreased efficiency of protein utilization in older men may contribute to impaired maintenance, growth, and repair of body tissues with advancing age.

Incidence of and potential risk factors for gallstone disease in a general population sample.

BACKGROUND: Several epidemiological studies have been published, but there are few reports on relations between gallstone incidence, symptomatology and risk factors. METHODS: Of 621 randomly selected individuals aged 35-85 years in a general population who had been screened previously with ultrasonography and found to have no gallbladder stones, 503 (81.0 per cent) were re-examined after a minimum interval of 5 years. At baseline and re-examination, heredity for gallstone disease was explored and body mass index, digestive symptoms including abdominal pain, quality of life, alcohol and smoking habits, use of non-steroidal anti-inflammatory drugs and oestrogen, parity and blood lipid levels were recorded. RESULTS: Forty-two (8.3 per cent) of the 503 subjects developed stones. Subjects were followed for a total of 3025.8 person-years, yielding an incidence for newly developed gallstones of 1.39 per 100 person-years. A positive association for gallstone development was found only for length of follow-up and plasma low-density lipoprotein-cholesterol levels at baseline. Weekly alcohol consumption was inversely related to gallstone development. CONCLUSION: The incidence of gallstones in this population was 1.39 per 100 person-years. Gallstone development was related to length of follow-up and LDL-cholesterol levels, and inversely related to alcohol consumption.

Defined indications for elective cholecystectomy for gallstone disease.

BACKGROUND: This study examined symptomatology and quality of life following elective cholecystectomy for symptomatic gallstone disease with defined indications for surgery. METHODS: In this prospective study of 200 consecutive patients (161 women; median age 46.5 (range 24-79) years), strict indications for elective cholecystectomy were stipulated. Digestive symptoms and quality of life were recorded with a self-administered questionnaire before and at 3 and 12 months after surgery. RESULTS: Of 149 patients who experienced abdominal pain with typical location before surgery, 136 (91.3 per cent) reported total remission or reduced frequency of that type of pain 12 months later. Of 35 patients who reported atypical or multiple pain location before operation, 27 (77 per cent) experienced reduced frequency or disappearance of that type of pain. Frequency of pain episodes, atypical or multiple pain location, specific food intolerance and frequency of disturbing abdominal gas at baseline correlated positively with the frequency of abdominal pain episodes at 12 months after surgery. There was a tendency towards an inverse relation to age. CONCLUSION: The frequency of persistent abdominal pain after elective cholecystectomy was low among patients with typical pain location before surgery. Atypical pain location, and frequent pain episodes before operation significantly reduced the chance of becoming pain-free.

Development of symptoms and complications in individuals with asymptomatic gallstones.

BACKGROUND: Gallbladder stones are common in the developed world. Complications of gallstones contribute substantially to healthcare costs and may be life threatening. The identification of individuals likely to develop complications would be of benefit in clinical practice as elective cholecystectomy could then be performed. METHODS: Seven hundred and thirty-nine subjects aged 35-85 years from the general population were screened for gallbladder problems by ultrasonography and questionnaire assessment of putative risk factors and digestive symptoms. Gallstones, cholesterolosis or sludge in the gallbladder were diagnosed in 123 (16.3 per cent) of 739 subjects, 120 of whom were followed for a median of 87 (range 3-146) months to May 2003 or until treatment was required. RESULTS: Fourteen patients were admitted to hospital and treated for gallstone-related complications or symptoms. The cumulative risk of being treated during the first 5 years after detection of asymptomatic gallstones was 7.6 per cent and there was no indication of this risk levelling off. There were no significant differences between treated and untreated subjects with regard to digestive symptoms or any of the risk factors monitored at the initial screening, although treated subjects were significantly younger than those who were not treated. CONCLUSION: Nearly one in ten individuals with asymptomatic gallbladder stones in the general population may be expected to develop symptoms or complications that require treatment within 5 years. Age may be inversely related to the incidence of complications.

Gastric bile monitoring: an in vivo and in vitro study of Bilitec reliability.

BACKGROUND: It has been claimed that the combination of bile and hydrochloride acid (HCl) has a noxious effect on intestinal mucosa. The aim was to study the reliability of the Bilitec 2001 method inmonitoring the presence of bile in repeated tests and at different pH and water dilutions. METHODS: 24-h esophageal pH and gastric Bilitec monitoring were performed twice with an interval of 6 weeks in 23 patients with symptomatic gastroesophageal reflux (GER). In vitro tests of pH and Bilitec recordings were peformed with different mixtures of bile, HCl and water. RESULTS: Gastric bile was present in 37% of the recording time, 28% during day time and 47% during nights. No significant difference was found between the two test occasions. The maximum bile concentration in the stomach was significantly lower in patients with severe pathological GER than in those with normal GER. When concentrated bile was diluted with the same volume of HCl, the pH level fell below 4. The maximum absorption limit with Bilitec in concentrated bile was gradually reduced with decreasing pH. The Bilitec technique recorded the presence of bile even at a pH of 1.4, but not if the bile was diluted with water at a ratio of 1:100 or more. CONCLUSIONS: Bilitec gastric recordings show the same clinical result when repeated under standardized conditions. The Bilitec technique is not reliable for monitoring the amount and concentration of bile in the stomach. Bile reflux cannot be monitored with the pH recording technique.

Dual versus triple therapy in eradication of Helicobacter pylori.

BACKGROUND/AIMS: Duodenal ulcers should be treated by eradication of Helicobacter pylori. This study compared the efficacy of a proton pump inhibitor together with one or two antibiotics in eradication therapy. METHODOLOGY: 177 patients who were H. pylori positive were randomized to receive 14 days of either: lansoprazole 30 mg bd and amoxicillin 1 g bd (LA), omeprazole 20 mg bd and amoxicillin 1 g bd (OA) or lansoprazole 30 mg bd, amoxicillin 1 g bd and clarithromycin 500 mg bd (LAC). The efficacy was assessed at four weeks and at six months after the end of treatment. Biopsies were taken for culture and bacterial sensitivity testing at inclusion and at four weeks after the end of treatment. RESULTS: 149 patients were evaluated for efficacy. The eradication rate was significantly higher in LAC (96%) compared to LA (51%) and OA (64%) treatments (P < 0.001). At baseline 17%, 21% and 19% of the patients in the LA, OA and LAC groups, respectively, were resistant to metronidazole and only one patient was resistant to clarithromycin. Post-treatment, four patients had acquired metronidazole resistance. CONCLUSIONS: LAC is more effective than LA and OA for eradication of H. pylori in duodenal ulcer disease.