Causes of recurrences after open inguinal herniorrhaphy.

PURPOSE: One of the most important measures of success of open inguinal herniorrhaphy is the incidence of recurrence. Reports suggest that up to 13% of all inguinal hernia repairs worldwide, irrespective of the approach, are repaired for recurrence. The reason as to why inguinal hernias recur is most likely multifactorial. The aim of this review is to evaluate the risk factors responsible for these recurrences in open suture and mesh techniques. METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified English language, peer-reviewed articles on the causes of recurrence following open inguinal herniorrhaphy published between 1990 and 2018. The search terms included 'Inguinal hernia'; 'Open methods'; 'Suture repair'; 'Mesh repair', 'Recurrence', 'Causes', 'Humans'. RESULTS: The literature revealed several contributing modifiable and non-modifiable risk factors that were responsible for recurrence following open suture and mesh inguinal herniorrhaphy. These included perioperative, patient and hernia factors. CONCLUSIONS: Despite the advent of laparoscopic techniques, open inguinal herniorrhaphy remains one of the most common surgical operations. With open inguinal hernia repairs, risk factors for recurrence can be broadly classified into perioperative, patient and hernia factors. Certain patient and technical risk factors are modifiable and could reduce the recurrence rate. However, many others factors are non-modifiable. It is therefore imperative that the outcome of open inguinal herniorrhaphy must be optimised by careful planning and education for both surgeons and patients to achieve the lowest possible risk of subsequent surgery for recurrence.

Integrative veterinary medical education and consensus guidelines for an integrative veterinary medicine curriculum within veterinary colleges.

Integrative veterinary medicine (IVM) describes the combination of complementary and alternative therapies with conventional care and is guided by the best available evidence. Veterinarians frequently encounter questions about complementary and alternative veterinary medicine (CAVM) in practice, and the general public has demonstrated increased interest in these areas for both human and animal health. Consequently, veterinary students should receive adequate exposure to the principles, theories, and current knowledge supporting or refuting such techniques. A proposed curriculum guideline would broadly introduce students to the objective evaluation of new veterinary treatments while increasing their preparation for responding to questions about IVM in clinical practice. Such a course should be evidence-based, unbiased, and unaffiliated with any particular CAVM advocacy or training group. All IVM courses require routine updating as new information becomes available. Controversies regarding IVM and CAVM must be addressed within the course and throughout the entire curriculum. Instructional honesty regarding the uncertainties in this emerging field is critical. Increased training of future veterinary professionals in IVM may produce an openness to new ideas that characterizes the scientific method and a willingness to pursue and incorporate evidence-based medicine in clinical practice with all therapies, including those presently regarded as integrative, complementary, or alternative.

Meta-analysis and systematic review of laparoscopic versus open mesh repair for elective incisional hernia.

CONTEXT: The utility of laparoscopic repair in the treatment of incisional hernia repair is still contentious. OBJECTIVES: The aim was to conduct a meta-analysis of RCTs investigating the surgical and postsurgical outcomes of elective incisional hernia by open versus laparoscopic method. DATA SOURCES: A search of PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1993 and September 2013 was performed using medical subject headings (MESH) "hernia," "incisional," "abdominal," "randomized/randomised controlled trial," "abdominal wall hernia," "laparoscopic repair," "open repair", "human" and "English". STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS: Prospective RCTs comparing surgical treatment of only incisional hernia (and not primary ventral hernias) using open and laparoscopic methods were selected. STUDY APPRAISAL AND SYNTHESIS METHODS: Data extraction and critical appraisal were carried out independently by two authors (AA and MAM) using predefined data fields. The outcome variables analyzed included (a) hernia diameter; (b) operative time; (c) length of hospital stay; (d) overall complication rate; (e) bowel complications; (f) reoperation; (g) wound infection; (h) wound hematoma or seroma; (i) time to oral intake; (j) back to work; (k) recurrence rate; and (l) postoperative neuralgia. These outcomes were unanimously decided to be important since they influence the practical and surgical approach towards hernia management within hospitals and institutions. The quality of RCTs was assessed using Jadad's scoring system. Random effects model was used to calculate the effect size of both binary and continuous data. Heterogeneity amongst the outcome variables of these trials was determined by the Cochran Q statistic and I (2) index. The meta-analysis was prepared in accordance with PRISMA guidelines. RESULTS: Sufficient data were available for the analysis of twelve clinically relevant outcomes. Statistically significant reduction in bowel complications was noted with open surgery compared to the laparoscopic repair in five studies (OR 2.56, 95 % CI 1.15, 5.72, p = 0.02). Comparable effects were noted for other variables which include hernia diameter (SMD -0.27, 95 % CI -0.77, 0.23, p = 0.29), operative time (SMD -0.08, 95 % CI -4.46, 4.30, p = 0.97), overall complications (OR -1.07, 95 % CI -0.33, 3.42, p = 0.91), wound infection (OR 0.49, 95 % CI 0.09, 2.67, p = 0.41), wound hematoma or seroma (OR 1.54, 95 % CI 0.58, 4.09, p = 0.38), reoperation rate (OR -0.32, 95 % CI 0.07, 1.43, p = 0.14), time to oral intake (SMD -0.16, 95 % CI -1.97, 2.28, p = 0.89), length of hospital stay (SMD -0.83, 95 % CI -2.22, 0.56, p = 0.24), back to work (SMD -3.14, 95 % CI -8.92, 2.64, p = 0.29), recurrence rate (OR 1.41, 95 % CI 0.81, 2.46, p = 0.23), and postoperative neuralgia (OR 0.48, 95 % CI 0.16, 1.46, p = 0.20). CONCLUSIONS: On the basis of our meta-analysis, we conclude that laparoscopic and open repair of incisional hernia is comparable. A larger randomized controlled multicenter trial with strict inclusion and exclusion criteria and standardized techniques for both repairs is required to demonstrate the superiority of one technique over the other.

Reproductive Performance of Arabian and Thoroughbred Mares under Subtropical Conditions of Pakistan.

Breeding records of 57 Arabian and 66 Thoroughbred mares were analysed to assess their reproductive performance under the subtropical conditions of Pakistan. The Arabian mares showed significantly higher conception rates (p<0.05) in second mated oestrus and foal heat mated oestrus compared to Thoroughbred mares. However, conception rates for first lifetime mated oestrus were similar in both breeds of mares. Age at first mating (1,301±40 vs 1,500±32 days) was significantly (p<0.05) less in Arabian compared to Thoroughbred mares. Both breeds of mares showed significantly (p<0.05) higher frequencies of oestrous cycles and conception rates during the winter (October to March) compared to summer (June to August) months. Age of mares affected the conception rates, as mares at ages 3 to 7 and 8 to 12 years of ages had significantly higher conception rates (p<0.05) than those ≥18 years old in both breeds. This study demonstrates that i) reproductive performance in Arabians is better than Thoroughbred mares under the subtropical conditions of Pakistan, ii) mares remain cyclic throughout the year and iii) conception rates were higher in mares bred during winter compared to summer months.

Emergency intraperitoneal onlay mesh repair of incarcerated spigelian hernia.

BACKGROUND AND OBJECTIVES: Spigelian hernia is a rare cause of incarcerated ventral abdominal hernia that may pose a diagnostic dilemma. However, with the increasing utilization of double contrast computed tomography (CT) for undiagnosed small bowel obstruction in a virgin abdomen, more such cases are being diagnosed with increasing confidence. Furthermore, with the rapid expansion of the indications for minimal access surgery in emergency situations, these rare emergencies are increasingly tackled using a laparoscopic approach leading to swift patient recovery and discharge. METHODS: We present the case of an emergency intraperitoneal onlay mesh (IPOM) repair of Spigelian hernia, causing acute small bowel obstruction in a 55-year-old man with liver disease and ascites that was diagnosed using a CT scan. We conducted a search of Medline, Embase, Science Citation Index, Current Contents, PubMed, and the Cochrane Database to review the history of laparoscopic repair of Spigelian hernia and its various advancements, which are briefly presented here. RESULTS: The hernia was successfully reduced using laparoscopy, revealing a moderate-size defect in the linea semilunaris. The hernial defect was repaired with a composite mesh that was tacked into position. The patient was discharged from the hospital on the second postoperative day. CONCLUSIONS: Spigelian hernia in an emergency setting can be easily and swiftly repaired using the IPOM method utilizing a composite mesh.

Gallstone ileus: a difficult emergency diagnosis!

Gallstone ileus (GSI) is a rare cause of mechanical small bowel obstruction. It occurs when a fistula between the gallbladder and the small bowel facilitates the migration of gallstone(s) into the small bowel. The commonest site of impaction is in the terminal ileum. We report the case of a 71-year-old female presenting with GSI diagnosed on CT scan. She was surgically explored and gallstones extracted by a simple enterotomy leading to full recovery of the patient.

Outcome of palliative esophageal stenting for malignant dysphagia: a retrospective analysis.

Greater than 50% of patients with esophageal carcinoma are found to be incurable at the time of diagnosis, leaving only palliative options. Self-expanding metal stents (SEMs) are effective for relieving symptoms and complications associated with esophageal carcinoma and improving quality of life. We undertook a retrospective analysis to evaluate the experience of palliative esophageal stenting for symptomatic malignant dysphagia in our institution over a period of 7 years. Between January 1999 and January 2006, 126 patients who received SEMs for malignant dysphagia were identified using an upper gastrointestinal specialist nurse clinician database. Data were obtained from patient case notes, endoscopy, histopathology, radiology, and external agency databases. Of the 126 identified, 36 patients were excluded from the analysis. A number of variables including age, sex, presenting complaints, type of stent, indications of stenting, success or failure of stent insertion, survival rate, and complication rate were analyzed. Of the 90 patients, 55 (61%) were male and 35 (39%) were female. The mean age of patients was 70.79 (range 40-97) years. The predominant presenting complaints were dysphagia (n = 81) and weight loss (n = 48). The indication for stenting was worsening dysphagia in all patients. Tumors were confined to the distal esophagus and esophagogastric junction in 73 patients (81%), and the mid-esophagus in 17 (19%). Adenocarcinoma was identified in 61 patients (67.8%) and squamous cell carcinoma in 29 (32.2%). Stenting numbers were comparable in endoscopic and radiologic groups (47 vs. 43), with successful stent deployment in 89 patients. The 7- and 30-day mortality was 9% (n = 8) and 28% (n = 25), respectively. Comparable numbers of early deaths were seen in both radiologic (n = 13) and endoscopic (n = 12) groups. Causes of early inpatient death included hemorrhage (n = 5), pneumonia (n = 7), exhaustion (n = 2), cardiac causes (n = 3), perforation (n = 1), and sepsis (n = 1). The number of patients with complications was 41 (45.6%), 25 in the surgical group and 15 in the radiologic group; the difference was not significant (P = 0.13). The mean survival time was 92.5 (0-638) days and median survival time was 61 days. A subgroup of patients with complete dysphagia (score 4) gained a mean survival of 59 days. Those patients receiving adjuvant chemotherapy or radiotherapy survived significantly longer than those receiving stenting alone (152.8 days vs. 71.8 days). There is no significant difference in complications or survival when using endoscopic or radiologic methods to deploy SEMs in patients with inoperable esophageal cancer. Mortality is low; however, the morbidity rate is significant. Patients receiving adjuvant chemotherapy or radiotherapy, in addition to stenting, survived significantly longer than those with a stent only.

Time saving modified BCR sequential extraction procedure for the fraction of Cd, Cr, Cu, Ni, Pb and Zn in sediment samples of polluted lake.

The mobility, availability and persistence of heavy metals (Cd, Cr, Cu, Ni, Pb and Zn) in contaminated lake sediment samples were evaluated by means of sequential extraction scheme, proposed by the Community Bureau of Reference protocol (BCR). The metal content in the extracts was measured by atomic absorption spectrometry. The precision and accuracy of the proposed procedure were evaluated by using a certified reference material BCR 701. The maximum recoveries for heavy metals (HMs) were observed for all three steps of BCR protocol at 32h total shaking period instead of previously reported 51h, with p>0.05. The lixiviation tests (DIN 38414-S4) were used to evaluate the leaching of HMs from sediment samples and it was observed that levels of water extractable HMs were low as compared to those values obtained by acid-soluble fraction of the BCR protocol.

Syndromic management training for non-formal care providers in Pakistan improves quality of care for sexually transmitted diseases STD care: a randomized clinical trial.

We conducted a randomized, controlled, three-armed trial to assess whether training in syndromic management, with provision of packets, could improve the quality of STD services provided among non-formal care providers. The quality of STD case management service, observed by "incognito patients" in both intervention groups, improved substantially compared to the control group (p < 0.05). The training-and-packets group performed better in service delivery, HIV-testing referral, and condom provision when compared to the training-only group (all p < 0.05). The training-and-packets group also retained more knowledge and practiced more skillfully at six months post-intervention when compared to the training-only group (p < 0.05). Exit interviews of clients suggested that 81% of providers in the intervention groups offered advice on condom use when compared to none of those in the control group (p < 0.001). Syndromic management training and free syndrome packets for non-formal providers had a positive impact on the quality of STD care among the trained providers.

Common causes of male dog infertility.

A complete breeding soundness evaluation is essential for assessment of the infertile male dog. Cryptorchidism, a sex-limited autosomal recessive trait, is more common as a unilateral condition. Azoospermia is an ejaculate consisting of seminal plasma but lacking sperm; repeated semen collections in the presence of an estrual bitch will rule out inadequate experience and lack of sexual stimulation. Both carnitine and alkaline phosphatase (AP) are produced in the epididymis; seminal plasma AP concentrations>5000 U/L indicate a normal ejaculate, whereas <5000 U/L is associated with incomplete ejaculation. Benign prostatic hypertrophy (BPH), the most common age-related condition in intact male dogs, is characterized by a sanguineous urethral discharge, hematuria, or hemospermia; diagnosis is based on prostatic enlargement and confirmed by a transabdominal biopsy. Although castration is recommended, valuable breeding dogs can be given finasteride. Prostatitis is more common in older dogs with BPH. Culture of the third fraction of the ejaculate or urine obtained by cystocentesis is indicated. Bacterial prostatitis is treated with antibiotics with high lipid solubility. Some dogs with bacterial prostatitis may develop prostatic abscesses (a medical and surgical emergency). Prostatic cysts are often asymptomatic. Approximately, 5-7% of dogs with prostatic disease have prostatic neoplasia, most commonly adenocarcinoma (it occurs in both intact and castrated dogs), which often metastasizes and has a very poor prognosis. Although a specific diagnosis can be made in many cases of male dog infertility, not all causes are amenable to treatment.

De Garengeot hernia: an analysis of our experience.

AIM: The presence of a vermiform appendix in a femoral hernia sac is termed De Garengeot hernia. It may present as a tender and/or erythematous groin swelling and is often misdiagnosed as an incarcerated or strangulated femoral hernia. The purpose of this study is to review the management of De Garengeot hernia at a single institution since 1991. MATERIALS AND METHODS: A retrospective analysis of seven consecutive patients operated upon at our institution from 1991 to 2006 with De Garengeot hernia was undertaken. Patients' demographics, treatment performed and postoperative outcome were analysed. RESULTS: There were three men and four women. The median age was 55 years. None of the patients were diagnosed preoperatively. The commonest presenting symptom was painful groin swelling. All patients therefore underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated femoral hernia. Operative findings included four normal appendices, two inflamed appendices and one perforated appendix in the femoral hernial sac. Patients with normal appendix (n = 4) had mesh hernia repair without an appendicectomy. The rest of the patients (n = 3) with abnormal appendix underwent emergency open appendicectomy followed by sutured hernia repair. We had no deaths in this series and one minor wound infection. No recurrent hernia has been detected to date. CONCLUSION: Inflammation of the appendix determines the type of hernia repair and surgical approach. Incidental appendicectomy in the case of a normal appendix is not preferred.

A novel technique for nonoperative removal of round rectal foreign bodies.

Extraction of rectal foreign bodies is challenging. The medical literature confirms the diversity of the problem and equally some ingenious solutions, the majority of which requires either an anesthetic agent or a laparotomy to remove them. This case report presents a simple nonoperative technique to deal with one such situation.

Unusual presentation of acute pancreatitis: an irreducible inguinoscrotal swelling mimicking a strangulated hernia.

We report an unusual presentation of acute pancreatitis as a tender, irreducible, inguinoscrotal swelling mimicking a strangulated hernia. Lack of abdominal symptoms or signs can lead to misdiagnosis and unnecessary surgery.

Amyand's hernia: a report of 18 consecutive patients over a 15-year period.

AIM: The presence of a vermiform appendix in an inguinal hernia sac is termed Amyand's hernia. It may present as a tender inguinal or inguino-scrotal swelling and is often misdiagnosed as an incarcerated or strangulated hernia. The purpose of this study was to review the management of Amyand's hernia at a single institution since 1991. MATERIAL AND METHODS: A retrospective analysis was undertaken of 18 consecutive patients with an Amyand's hernia operated upon at our institution from 1991 to 2005. Patients' demographics, treatment and postoperative outcome were analysed. RESULTS: There were 17 men and one woman. Their median age was 42 years. None of the patients was diagnosed preoperatively. The commonest presenting symptom was painful inguinal or inguino-scrotal swelling (83%). All patients, therefore, underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated inguinal hernia. Operative findings included 11 normal appendices, four inflamed appendices and three perforated appendices in the inguinal hernial sac. Patients with a normal appendix (n = 11) had a mesh hernia repair without an appendicectomy. The rest of the patients (n = 7) with an abnormal appendix underwent emergency open appendicectomy followed by Bassini's sutured hernia repair. One patient died in the postoperative period of pneumonia. Only one recurrent hernia has been detected, with a median follow-up time of 6.4 years. CONCLUSION: The inflammatory status of the appendix determines the type of hernia repair and the surgical approach. Incidental appendicectomy in the case of a normal appendix is not favoured.

Role of a probiotic (Saccharomyces boulardii) in management and prevention of diarrhoea.

AIM: To assess the efficacy and safety of Saccharomyces boulardii (S. boulardii) in acute watery diarrhoea and its role in reducing the frequency of episodes of diarrhoea in subsequent two months. METHODS: Children from 2 mo to 12 years of age, with acute diarrhoea were selected according to inclusion criteria and randomised in S. boulardii group (treated with ORS, nutritional support and S. boulardii, 250 mg bid) and in control group (treated with ORS and nutritional support only). Active treatment phase was 5 d and each child was followed for two months afterwards. Frequency and consistency of stools as well as safety of drug was assessed on every visit. A comparison of two groups was done in terms of number of diarrhoeal episode in subsequent two months. RESULTS: There were fifty patients in each group. Baseline characteristics such as mean age and the average frequency of stools were comparable in S. boulardii and control group at the time of inclusion in the trial. By d 3 it reduced to 2.7 and 4.2 stools per d respectively and by d 6 it reduced to 1.6 (S. boulardii Group) and 3.3 (control group). The duration of diarrhoea was 3.6 d in S. boulardii group whereas it was 4.8 d in control group (P = 0.001). In the following two months, S. boulardii group had a significantly lower frequency of 0.54 episodes as compared to 1.08 episodes in control group. The drug was well accepted and tolerated. There were no reports of the side effects during treatment period. CONCLUSION: S. boulardii significantly reduces the frequency and duration of acute diarrhoea. The consistency of stool also improves. The drug is well-tolerated.

Induction of canine pyometra by inoculation of Escherichia coli into the uterus and its relationship to reproductive features.

To characterize oestrus-related factors affecting the induction of and recovery from pyometra in bitches, 60 clinically healthy beagle bitches were used for induction of pyometra by inoculation of Escherichia coli into the uterus during oestrous and metoestrous stages. The animals were classified into the following six groups according to inoculation time: Days 1-10, 11-20, 21-30, 31-40, 41-50 and 51-60 after LH surge. The incidence of pyometra during the periods Days 11-20 and 21-30 after LH surge was 90.9% and 78.9% respectively, while that during Days 1-10 and 51-60 after LH surge was less than 20%, and the patterns of the incidence of pyometra and the serum progesterone levels were similar. There was no difference in the incidence of pyometra induced in bitches less than 5 years old compared to bitches over 6 years old. Oestrus in all of the bitches with pyometra induced by E. coli returned with or without PGF 2alpha treatment, unlike in bitches with spontaneous pyometra. The duration of the oestrous cycle in the non-treated and PGF 2alpha-treated groups was 231.4+/-55.2 days and 162.1+/-40.6 days (P < 0.001), respectively, and there was no difference in the rate of return of oestrus between the two groups. The conception rate in all of the bitches in which oestrus had returned was 81.8%. The above findings indicate that the period during which severe pyometra could be induced was limited to the early stage in metoestrus.

Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair.

BACKGROUND: The aim was to conduct a meta-analysis of the randomized evidence to determine the relative merits of laparoscopic (LIHR) and open (OIHR) inguinal hernia repair. METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified all randomized clinical trials that compared OIHR and LIHR and were published in the English language between January 1990 and the end of October 2000. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The six outcome variables analysed were operating time, time to discharge from hospital, return to normal activity and return to work, postoperative complications and recurrence rate. Random effects meta-analyses were performed using odds ratios and weighted mean differences. RESULTS: Twenty-nine trials were considered suitable for meta-analysis. Some 3017 hernias were repaired laparoscopically and 2972 hernias were repaired using an open method in 5588 patients. For four of the six outcomes the summary point estimates favoured LIHR over OIHR; there was a significant reduction of 38 per cent in the relative odds of postoperative complications (odds ratio 0.62 (95 per cent confidence interval (c.i.) 0.46 to 0.84); P = 0.002), 4.73 (95 per cent c.i. 3.51 to 5.96) days in time to return to normal activity (P < 0.001), 6.96 (95 per cent c.i. 5.34 to 8.58) days in time to return to work (P < 0.001) and 3.43 (95 per cent c.i. 0.35 to 6.50) h in time to discharge from hospital (P = 0.029). There was a significant increase of 15.20 (95 per cent c.i. 7.78 to 22.63) min in the mean operating time for LIHR (P < 0.001). The relative odds of short-term recurrence were increased by 50 per cent for LIHR compared with OIHR, although this result was not statistically significant (odds ratio 1.51 (95 per cent c.i. 0.81 to 2.79); P = 0.194). CONCLUSION: LIHR was associated with earlier discharge from hospital, quicker return to normal activity and work, and significantly fewer postoperative complications than OIHR. However, the operating time was significantly longer and there was a trend towards an increase in the relative odds of recurrence after laparoscopic repair.

Laparoscopic surgery in the elderly patient.

BACKGROUND: Elderly patients represent a unique surgical challenge because of the associated complex comorbidity and diminished cardiopulmonary reserve. Therefore, minimally invasive surgery in the elderly may have a larger impact compared to the younger population. The aim of this study was to prospectively evaluate the experience of laparoscopic surgery in patients >or=70 years of age in our unit. METHODS: Two hundred and thirty-two patients (34 females and 98 males) older than 70 years who underwent various elective and emergency laparoscopic procedures between 1992 and 1997 were assessed prospectively. Preoperative comorbidity, operative results, and postoperative outcomes were analyzed. RESULTS: The median age of the patients was 76 years. The majority of patients were ASA class II. The mean hospital stay was 3.4 days. The overall morbidity and mortality rates were 10.8% and 3.4% respectively, and the conversion rate was 4.3%. CONCLUSIONS: Our experience suggests that laparoscopic surgery in the elderly is safe, is associated with short hospital stay, and produces less morbidity and mortality. Therefore, it should be adopted widely if the expertise in the area of laparoscopic surgery is available for this group of patients.

Accidental ingestion of cotton bud stick during alcohol intoxication: an unusual cause of caecal perforation.

A first reported case of caecal perforation by an ingested blunt foreign body is described. This 31-year-old female did not relate a history of accidental swallowing of a cotton bud stick on admission. The cause of her right iliac fossa pain (i.e. caecal perforation by a cotton bud stick) became only apparent when she underwent operation for suspected appendicitis. A simple closure of this caecal perforation was undertaken. The patient made a complete recovery from this ordeal. Caecal perforation by an ingested blunt foreign body can occur after it has safely negotiated the ileocaecal valve.