Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair.

BACKGROUND: The optimal treatment for recurrent inguinal hernia is of concern due to the high frequency of recurrence. METHODS: This randomized multicenter study compared the short- and long-term results for recurrent inguinal hernia repair by either the laparoscopic transabdominal preperitoneal patch (TAPP) procedure or the Lichtenstein technique. RESULTS: A total of 147 patients underwent surgery (73 TAPP and 74 Lichtenstein). The operating time was 65 min (range, 23-165 min) for the TAPP group and 64 min (range, 25-135 min) for the Lichtenstein group. Patients who underwent TAPP reported significantly less postoperative pain and shorter sick leave (8 vs 16 days). The recurrence rate 5 years after surgery was 19% for the TAPP group and 18% for the Lichtenstein group. CONCLUSION: The short-term advantage for patients who undergo the laparoscopic technique is less postoperative pain and shorter sick leave. In the long term, no differences were observed in the chronic pain or recurrence rate.

Postoperative convalescence after inguinal hernia surgery: prospective randomized multicenter study of laparoscopic versus shouldice inguinal hernia repair in 1042 patients.

Interest in inguinal hernia surgery has increased significantly with the introduction of new operating techniques during the past decade. This multicenter study compared short-term results in patients treated by the laparoscopic transabdominal preperitoneal patch technique (TAPP; n = 518) and the Shouldice technique (n = 524). We evaluated demographics, operative data, complications, hospital stay, postoperative pain, use of cs, functional status, sick leave, and complaints up to 3 months postoperatively. The median operating time was shorter in the Shouldice group (55 vs. 65 min), but there were no significant differences in complication rates, and major complications were rare. The hospital stay was 1 day or less in over 98% of cases in both groups, but more operations were performed on outpatient basis in the Shouldice group. In the TAPP group postoperative pain and analgesic consumption were less, postoperative functional status was better, and sick leave was shorter (10 vs. 14 days). These results show that the two methods are equally safe and have few major complications. The TAPP operation is associated with less postoperative pain, better postoperative functional status, and shorter sick leave, but at the price of a longer operating time.

Myoelectric activity in the stomach and duodenum after epidural administration of morphine or bupivacaine.

BACKGROUND: Gastric emptying is delayed in patients receiving postoperative pain relief with epidural morphine compared to patients receiving epidural bupivacaine. The electrophysiological basis for this effect is unknown. The aim of this study was to compare the effects of epidural morphine with epidural bupivacaine on gastroduodenal myoelectric activity (EMG) in patients after surgery. METHODS: Fourteen patients with epidural analgesia who underwent open cholecystectomy were randomly assigned to receive either epidural morphine (EM) or epidural bupivacaine (EB) for postoperative pain relief. During surgery EMG electrodes were placed in the subserosa in the antrum and duodenum and the EMG registration started 3.5 hours after the end of surgery. Gastric emptying measured with the acetaminophen test was studied in the morning the day after surgery. RESULTS: The spike activity in the antrum was significantly lower 160-340 minutes after the administration of morphine in the EM-group compared to the activity in the EB-group (P < 0.04). The incidence of regular slow wave rhythm in the antrum was significantly lower 160-520 minutes after the administration of morphine in the EM-group compared to the EB-group (P < 0.03). Duodenal Phase III activity measured with EMG was significantly more frequent during 160-520 minutes after the morphine administration in the EM-group compared to the EB-group (P < 0.02). The acetaminophen absorption was significantly delayed in the epidural morphine group compared to the epidural bupivacaine group. CONCLUSIONS: Gastroduodenal electromyographic activity was significantly changed during epidural morphine compared to epidural bupivacaine. The delayed gastric emptying during epidural morphine may be explained by decreased and uncoordinated contractile activity in the antrum, shown by decreased spike activity and irregular slow wave rhythm. The increased pressure activity in the duodenum, shown by increased Phase III activity, may also impair gastric emptying.

Obstructing inflammatory fibroid polyp in pelvic ileal reservoir after restorative proctocolectomy in ulcerative colitis. Report of a case.

PURPOSE: This study was designed to describe clinical, endoscopic, and histopathologic features of an inflammatory fibroid polyp occurring in the pelvic ileal reservoir after restorative proctocolectomy in ulcerative colitis. METHOD: A case report describing the clinical course of such a patient is presented. RESULTS: Three years postoperatively, the patient developed diarrhea, anemia, weight loss of 10 kg, and symptoms of obstructed defecation. Ileoscopy showed pouchitis and a polypoid tumor filling the pouch. Biopsies revealed chronic inflammation without signs of malignancy. At laparotomy, a 5 cm x 3.5 cm x 3.5 cm submucosal, solid, circumscribed tumor was found within the pouch, and histopathologic examination yielded the diagnosis. The pelvic pouch was resected and replaced by a Brooke ileostomy. During 18 months of follow-up, the course has been uneventful. CONCLUSION: Inflammatory fibroid polyp is a rare, reactive, non-neoplastic lesion, which, for the first time, is reported in a pelvic ileal reservoir. It may cause pouch dysfunction. It is always benign but may masquerade as a malignant tumor.

Formula diet is a preventive factor in experimentally induced ideal ulcers in rats. A bacteriological study.

We earlier described an experimental model to create recurring chronic ileal inflammation with ulceration in the rat. A 2 cm segment of the distal ileum is excised but left attached to its intact mesentery; the ileum is reanastomosed. The ileal segment will seal off its open ends and a cyst-like structure of varying size will be formed, containing mucus, cell debris and bacteria. Approximately two thirds of the animals develop chronic inflammation with ulceration proximal to the ileal anastomosis. The ileal cyst and the surgical procedure on the distal ileum were shown to be prerequisites of the rat model for the development of lesions. We recently described that, in contrast to rats fed a standard diet, rats fed a hydrolyzed formula diet never developed inflammation or ulceration when subjected to the experimental procedure. In the present study we confirmed these observations and showed that the normal ileal flora (NIF) and the ileal cyst flora (ICF) were significantly influenced by the diets. The bacterial counts of both the aerobic and anaerobic NIF were 2 10log lower, i.e. > or = 99%, in rat fed the formula diet as compared to in those fed standard rat pellets. The NIF of the former group was represented by more aerobic species than the NIF of rats on the standard diet. Compared to the NIF there was a parallel increase in the bacterial counts of the ICF by approximately 2 10log CFU values in both groups of rats. The mean number of anaerobic species, mainly Gram-negative rods of the ICF, increased by approximately 70% in the rats on the standard diet that developed ileal ulceration, whereas identified aerobic species of the ICF decreased by 61% in rats on the formula diet and by 46% in those on the standard diet that did not develop ileal ulceration. The number of anaerobes in those groups of rats remained unchanged. The significant bacteriological differences between the rats that developed ileal ulcers and those which did not indicate that bacteria may be involved, directly or indirectly, in the development of chronic ileal ulceration.

Experimentally induced ileal ulcers in rats. Formula diet is a preventive factor.

We recently described an experimental model in the rat to create recurring chronic ileal inflammation including ulceration. This model is dependent on an "in vivo culture" of normal intestinal contents. In the present experimental study we examined the effect of a polymeric and a hydrolyzed formula diet on the formation of ulcerating lesions using our rat model. Two groups of rats (twenty in each group) were fed either one of these formula diets eight weeks prior to the experimental procedure and this diet was continued until sacrifice eight weeks later. Twenty control rats also underwent the experimental procedure but were fed standard rat pellets for the same time periods. At sacrifice 60% of the control rats had developed ileal ulcers. None of the rats fed the formula diets developed macroscopic ileal inflammation or ulceration. The effectiveness of formula diets in inducing remission in Crohn's disease in humans may be linked to alterations in the intestinal microflora. We hypothesize that the formula diets in this experiment exerted a protective effect against ileal ulceration by altering the ileal microflora. Preliminary studies support this hypothesis but need to be expanded.

Experimentally induced ileal ulcers in rats. A model to study non-specific inflammatory bowel disease.

A surgical technique was used to establish chronic intestinal ulcers in Sprague-Dawley rats. A 2-cm-long segment of the distal ileum was excised and left attached on the mesentery. The ileum was reanastomosed. The excluded ileal segment formed a 'cyst' of various sizes. Initially, the anastomoses healed well, but after 6-8 weeks para-anastomotic ulcers developed in more than 50% of the rats. Histopathology showed a chronic inflammatory reaction with a predominance of mononuclear cells and increased numbers of eosinophilic granulocytes. The surface of the ulcers was covered with bacteria. Penetrating ulcers with fistula formation occurred. It is concluded that this experimental model may be useful for time sequential studies of the development of chronic and ulcerative ileitis. It may also be used to study the effect of medical and surgical regimens for the treatment of non-specific chronic inflammatory bowel disease.

The role of feces, necrotic tissue, and various blocking agents in the prevention of adhesions.

Ischemic tissue and intraperitoneal bacteria have been ascribed an etiologic role in the production of intra-abdominal adhesions. To further elucidate the role of these stimuli and to evaluate the potential protective effect of various agents, peritonitis was induced in 160 Sprague-Dawley rats. The experiment was stratified into those animals with peritonitis plus necrotic tissue, solid feces, both, or neither. The agents tested were a nonsteroidal anti-inflammatory (ibuprofen), free radical scavenger (SOD), and an anticoagulant (heparin). Death was less likely to occur in animals treated with heparin (3 of 40 vs. 12 of 40, p less than 0.01) or SOD (4 of 40 vs. 12 of 40, p less than 0.05). Ibuprofen did not increase survival in this model. Heparin protected against adhesions in animals with an ischemic ileum of limb and without solid feces. In animals with a nonischemic isolated segment of ileum and solid feces, adhesion formation was increased in both the ibuprofen and the heparin treatment groups (p less than 0.05).

A prospective randomized comparison of gastric bypass and gastroplasty. Complications and early results.

Fifty-seven morbidly obese patients were randomized to gastric bypass (29) or gastroplasty (28) and observed for 24 months postoperatively. Operating time and hospital stay were longer and peroperative and postoperative complications somewhat more common in the bypass than in the gastroplasty group. But weight loss at 1 year was significantly greater and failures significantly fewer after gastric bypass. Four gastroplasties were converted to bypass after 18-24 months because of failure to lose weight. Gastric bypass was judged to be much the preferable of the two operations. Dumping occurred in some patients with bypass but not after gastroplasty. Dumping was not associated with greater weight loss. Peroperatively measured pouch volume showed significant correlation with weight loss after gastroplasty, but not after bypass. Peroperative pouch volume and postoperatively measured stoma diameter were co-acting factors, which in multiple regression analysis could explain observed variance in weight loss to about 40% after gastroplasty, but to a negligible degree after gastric bypass.

Clinical and epidemiological aspects of Crohn's disease in children and adolescents.

Between 1971 and 1980 34 children (18 boys and 16 girls) were diagnosed as having Crohn's disease in Orebro county, Sweden, corresponding to a yearly incidence of 6.1 and a prevalence of 41 per 100,000 children. Classical gastrointestinal symptoms were common, but initially only five patients presented with extraintestinal symptoms and had a normal ESR. Of the patients 13 have only been treated medically and 21 have been operated on. Nine of the children have had a quiescent course, whereas 13 had a recurrent and 11 a chronic course. Most of the children have a good quality of life, which we think is the result of a carefully individualized therapy. One child died.

Sedation for fibreoptic gastroscopy: a comparative study of midazolam and diazepam.

Midazolam, a water-soluble benzodiazepine, was compared with diazepam in fat emulsion (Diazemuls) as sedation for outpatient gastroscopy in a randomized double-blind fashion. Midazolam 0.05 mg kg-1 was found to be approximately equipotent to Diazemuls 0.15 mg kg-1. There were no differences concerning speed of recovery and all patients were considered ready for discharge after 2 h. Venous tolerance was good for both drugs. With the same degree of sedation, midazolam produced a higher frequency of amnesia (60% v. 7%; P less than 0.001) for the endoscopic procedure. Although the patients appeared to prefer midazolam to Diazemuls, this difference was significant only in patients who had not previously undergone gastroscopy (P less than 0.05). The high degree of amnesia with midazolam may be an advantage in sedation for unpleasant procedures like gastroscopy.

C-peptide concentration in pancreatic juice obtained during endoscopic pancreatography in patients with and without insulinoma.

ERCP was performed in three patients with insulinoma. One had a large malignant tumor, while the remaining two had small tumours. In two of these patients pancreatic juice was collected for C-peptide determination. Pancreatography was performed and pancreatic juice was obtained in seven other subjects comprising: five control subjects and two patients in whom insulinoma was suspected because of symptoms suggestive of hypoglycaemia. Pancreatography was normal in all subjects except the patient with a large insulinoma in whom an obstruction of the main pancreatic duct was found. The maximal C-peptide concentrations in pancreatic juice of patients with insulinoma were found to be several-fold higher than in the control subjects and in one of the patients in whom insulinoma was suspected but unproven. The remaining patient with suspected insulinoma had a maximal C-peptide concentration comparable with those found in patients with proven insulinoma. Thus remarkable differences in maximal C-peptide concentrations obtained in patients with and without insulinoma were found. However, the clinical significance of the findings needs further evaluation. The value of ERP in patients with suspected insulinoma may be twofold: an obstruction of the main pancreatic duct may indicate a large, hardly resectable tumour; in patients in whom the duct is unaffected the relation between the tumour as visualized by angiography, and the duct, is of value for the surgeon when planning the operation.

Computed tomographic illustration of cavum vergae.

This paper presents 3 examples of cavum vergae, a normal variant in cranial computed tomography (CCT) and pneumoencephalography. The CCT appearance of cavum vergae is illustrated in both axial and coronal planes, and the means of distinguishing cavum vergae from cavum velum interpositum and cystic lesions of the third ventricle by reference to normal anatomical landmarks is discussed.