Clinician preferences in the treatment of acutely symptomatic hernia: the 'MASH' survey.

INTRODUCTION: There is limited high-quality evidence to guide the management of acute hernia presentation. The aim of this study was to survey surgeons to assess current trends in assessment, treatment strategy and operative decisions in the management of acutely symptomatic hernia. METHODS: A survey was developed with reference to current guidelines, and reported according to Checklist for Reporting Results of Internet E-Surveys guidelines. Ethical approval was obtained from the University of Sheffield (UREC:034047). The survey explored practice in groin, umbilical/paraumbilical and incisional hernia presenting acutely. It captured respondent demographics, and preferences for investigations, treatment strategies and repair techniques for each hernia type, using a five-point Likert scale. RESULTS: Some 145 responses were received, of which 39 declared a specialist hernia practice. Essential investigations included urea and electrolytes (58.6%) and inflammatory markers (55.6%). Computed tomography scan of the abdomen was essential for assessment of incisional hernia (90.9%), but not for other hernia types. Bowel compromise drives early surgery, and increasing American Society of Anesthesiology score pushes towards non-operative management. Type of repair was driven by hernia contents, with increasing contamination associated with increased rates of suture repair. Where mesh was proposed in contaminated settings, biological types were preferred. There was variation in the potential use of laparoscopy for groin hernia. CONCLUSIONS: This survey provides a snapshot of current trends in the management of acutely symptomatic hernia. It demonstrates variation across aspects of assessment and repair technique. Additional data are required to inform practice in these areas.

Spontaneous haemorrhage from a left gastric artery aneurysm as a cause of acute abdominal pain.

Visceral artery aneurysms are rare, with a reported incidence of less than 2% in the general population. 1,2 Aneurysms of the left gastric artery are particularly uncommon, accounting for 4% of all visceral aneurysms. 3,4 Although the majority are discovered incidentally and can be managed conservatively, prompt treatment of those ruptured or at risk of rupture is crucial to reduce the associated morbidity. Increasing awareness of visceral artery aneurysms as a cause of spontaneous intraperitoneal haemorrhage will improve early recognition and impact on survival. We present a rare case of spontaneous rupture of a left gastric artery aneurysm.

Outcomes of regional transfers of ruptured abdominal aortic aneurysm in a UK vascular network.

INTRODUCTION Rupture of abdominal aortic aneurysm is a surgical emergency. In order to improve operative outcomes, vascular services have been centralised in the United Kingdom. This means that a patient may present to a hospital with a ruptured aneurysm, but require transfer to a vascular centre for definitive treatment. METHODS This retrospective cohort study identified patients who underwent surgery for ruptured abdominal aortic aneurysm in a tertiary vascular centre over a 2-year period. Data on demographics and originating unit were recorded. Outcomes assessed included 30-day mortality, operative mortality and postoperative morbidity. RESULTS We identified 70 patients who underwent surgery for ruptured abdominal aortic aneurysm in the 2-year period; 36 presented directly to the vascular unit (VU), 14 to referral unit 1 (RU1) and 20 to referral unit 2 (RU2); 30-day mortality rates were 27.7% (VU), 35.5% (RU1) and 30.0% (RU2), respectively. There was no statistical difference in mortality between units. Postoperative complications were seen in 35.9% of VU patients, 78.6% of RU1 patients and 70% of RU2 patients. This was statistically significant between VU and RU1 (P = 0.006) and VU and RU2 (P = 0.02). Direct operative complications were seen in 9 patients, gastrointestinal complications in 9, limb complications in 6 and systemic complications in 40. CONCLUSION This study found that site of presentation does not affect mortality but is associated with increased morbidity. This is a complex issue, which will require a prospective multicentre study to investigate further.

IL 1 and bacterial lipopolysaccharide increase the ability of human endothelial cells to bind peripheral blood monocytes.

Human endothelial cells (EC) exposed to human recombinant IL 1 and to bacterial lipopolysaccharide (LPS) demonstrated a time dependent increase in their ability to bind peripheral blood monocytes (M0). The enhancement of endothelial-M0 interactions was shown to represent a direct alteration of EC and was not explained by IL 1 and LPS affecting M0. Other experiments indicated that the enhancement represented an acceleration in EC binding of M0 suggesting that EC may play a role in initiating proinflammatory events prior to the recruitment of inflammatory cells by chemotactic peptides.

Modulation of human monocyte chemotaxis and procoagulant activity by human C-reactive protein (CRP).

Experiments were performed to determine whether the acute phase reactant C reactive protein (CRP) influences the chemotactic and procoagulant activity (PCA) of human peripheral blood monocytes (MO). The results show that concentrations of CRP between 2.5 and 10 ug/ml increased MO chemotaxis approximately 3-fold in a serum free assay system. By contrast 25 and 50 ug/ml CRP did not result in MO chemotaxis. In other experiments MO preincubated for 18 hours with 50 ug/ml CRP demonstrated increased PCA compared to MO preincubated in medium alone. MO preincubated with CRP also displayed an additive increase in PCA when subsequently exposed to low concentrations of lipopolysaccharide (LPS) or immune complexes. However, CRP did not increase the PCA of MO exposed to high concentrations of LPS or immune complexes, which triggered greater PCA. These data suggest that CRP may modulate these early host responses to inflammatory stimuli.