Incarcerated hernia: to reduce or not to reduce?

Purpose  Before the advent of general anesthesia, taxis (hernia reduction) was the treatment of choice of incarcerated hernia but, over the years, its use subsided in favor of urgent herniorrhaphy. The role of taxis for incarcerated hernias in a growing geriatric population must be reexamined. Methods  We attempted taxis in 101 adult patients diagnosed with anterior abdominal wall incarcerated hernia. Following successful taxis, patients were hospitalized for a 24-h period of observation to obviate any complications of taxis. Upon their discharge, the patients were advised to follow with an elective hernia repair. Unsuccessful attempts at taxis were followed by emergency surgery. The gender of the patient, type of hernia, time lapse since incarceration, and signs of intestinal occlusion were recorded and mortality and morbidity rates were calculated. Results  Taxis was successful in 60.3% of cases. No taxis-related complication was observed, even though the mean delay in presentation since incarceration was 12 h. Mortality and morbidity within the taxis group were null. Conclusion  Taxis is a feasible and safe maneuver pending an eventual surgical treatment. By offering better conditions at a later repair, the mortality and morbidity may be considerably lowered. Further studies are needed in order to elucidate various aspects of this two-stage treatment of incarcerated hernia.     

Erectile dysfunction: to prescribe or not to prescribe?

Even with the help of modern pharmacology, treatment of erectile dysfunction often remains complex, and requires taking into account the social, psychological, and behavioral dimensions of the disorder. This brief report presents a case study highlighting this complexity.     

Urinary tract infections: to prophylaxis or not to prophylaxis?

Urinary tract infections, with or without reflux, are the most frequent reason for long-term antibacterial prophylaxis in infants and children. When one is considering the use of prophylaxis in these children, what is clear from existing published data? Up to 2006 there were a small number of poor quality studies, with no reliable evidence of the effectiveness of antibiotics in preventing recurrent symptomatic urinary tract infections (UTIs). Since then, four randomised controlled studies, to assess the benefits, or lack thereof, of antibiotic prophylaxis, have been published. None has demonstrated a clear benefit. The following conclusions can be drawn: antibiotic prophylaxis is not indicated for children following a first febrile UTI if no or mild grade I or II reflux is present; for higher grade reflux there is no definite conclusion.     

Internal thoracic artery: to skeletonize or not to skeletonize?

The internal thoracic artery has been the most reliable graft material used in coronary artery bypass grafting with an excellent long-term patency rate. Complete myocardial revascularization with internal thoracic arteries improves long-term survival and decreases the rate of repeat operations compared with vein grafts. Adequate length of the graft in coronary artery bypass graft surgery is essential for providing complete arterial revascularization. In the last decade or so, technique of skeletonization of internal thoracic artery has been proposed to achieve extra length. Skeletonization of the internal thoracic artery allows the preparation of longer conduits with a superior free flow and can reduce the incidence of postoperative pulmonary and sternal complications. However, concerns about vasoreactivity of skeletonized internal thoracic artery grafts, the functional consequences of surgical trauma, the possible loss of innervation, and vasa vasorum perfusion in the skeletonized conduits have prevented this technique from being universally accepted. Presently available evidence from retrospective studies (level 3 evidence) suggests that skeletonization is a safe and effective technique for myocardial revascularization. However, there is a need for conducting multicenter, randomized controlled trials comparing the skeletonized and pedicled internal thoracic arteries with special emphasis on long-term patency to conclusively validate the safety and efficacy of skeletonization technique.     

Good MRI images: to Gad or not to Gad?

Gadolinium-based magnetic resonance imaging (MRI) contrast agents (Gad-CA) were formerly considered as alternatives to X-ray-employed iodinated media. Although originally thought to be nonnephrotoxic and proven to be nonhazardous in a healthy population, the Gad-CA safety issue is progressively more controversial in the high-risk group of end-stage renal disease (ESRD) patients. Recently, Gad-CAs have not only been blamed for harmless side effects such as dizziness or nausea but also for much more severe complications such as acute renal failure, pancreatitis, or even the development of so-called “nephrogenic systemic fibrosis” in patients with renal failure, culminating in the prohibition of gadodiamide (Omniscan) administration in ESRD patients and, due to renal-organ immaturity, in newborns and infants up to 1 year old. This editorial is written to give insights into the molecular structure of Gad-CAs as well as into the potential biochemical pathomechanisms underlying the aforementioned severe clinical manifestations. Furthermore, a review about the latest literature on Gad-CA nephrotoxicity is provided. Potential risk factors are mentioned and strategies to avoid deterioration of renal function are presented. Cases with Gad-CA-associated adverse events should be adequately documented and reported appropriately. MRI professionals should collaborate closely with their colleagues from other medical specialties to identify patients with adverse events.     

The gastric cardia: to be or not to be?

The origin and biologic significance of cardiac gastric mucosa are controversial. Traditionally, it has been considered native mucosa and part of normal foregut development. It has been recently suggested that cardiac mucosa is present only as a metaplastic response to gastroesophageal reflux disease and therefore always abnormal. We evaluated the esophagogastric junction in 100 pediatric autopsy samples to determine the existence, characteristics, and length of pure cardiac mucosa at different ages. No patient had a history of gastroesophageal reflux disease. Cardiac mucosa immediately distal and contiguous to the esophageal squamous mucosa was identified in all 100 samples, varying in length from 0.1 to 3 mm; the mean length was 1 mm. There was an inverse correlation between patient age and length of cardiac mucosa; gender had no influence on measured length. Three patients had mild to moderate histologic esophagitis; two had gastritis. No metaplastic features or Helicobacter pylori were identified. These findings support the concept that there is a normal, variably narrow developmental zone at the esophagogastric junction covered by cardiac mucosa and is present at birth. When cardiac type mucosa is found in biopsy material, it does not necessarily represent evidence of a mucosal metaplastic response to gastroesophageal reflux disease.     

Tetralogy of Fallot: to patch or not to patch?

Angiograms of 11 patients with Tetralogy of Fallot were reviewed before and after total repair, and analyzed with respect to growth of the pulmonary valve annulus. At the operation none of the patients was more than 5-years-old, none received a transannular patch and all were asymptomatic at the last visit. The radiologic diameter of the pulmonary valve annulus was compared to the descending thoracic aorta at the level of the diaphragm. Preoperative ratio averaged 1.09 +/- 0.22 and increased postoperatively to 1.35 +/- 0.20 (p less than 0.02). A "catch-up" growth of small annuli could be demonstrated.     

To bridge or not to bridge?

Objective

Ventricular assist devices (VAD) are an important therapy that saves the lives of candidates a waiting heart transplantation (HTx). However, there are questions about posttransplantation effects of VADs.

Methods

Seventy-four patients with end-stage heart failure who underwent HTx in our clinic between February 2007 and July 2011 were divided into two groups; a bridge cohort (n = 28) and a nonbridge group comprising 46 who underwent HTx without mechanical circulatory support. There mean ages were 39.89 ± 15.66 and 38.33 ± 16.23 years respectively. Significantly more patients in the bridge group, were man displayed anemia, were treated with anticoagulation therapy, and underwent a resternotomy. In the nonbridge group, more patients needed preoperative inotropic support.

Results

Multiple logistic regression analysis revealed preoperative renal failure (P = .007, odds ratio [OR] 27) and inotropic support (P = .006, OR: 10,222) as well as longer cardiopulmonary bypasses (≥130 minutes, P = .001, OR: 11,24) to be risk factors for in-hospital mortality, which was 15.2% in nonbridge and 10.7% in bridge subjects, P = .733). Major adverse events, such as renal failure, pulmonary failure, right ventricular failure, neurological event, and reoperation due to bleeding, shown similar incidences between the groups. The amount of blood transfusion was significantly higher in the bridge group (2.34 U versus 3.56 U, P = .037). The preoperative incidence of human leukocyte antigen sensitization (panel reactive antibody ≥ 10%) and grade 2R were rejection episodes in the early period were similar.

Conclusion

Early posttransplant results were not adversely or beneficially influenced by the use of VADs. Similar to other types of cardiac surgery, a patients preoperative condition seemed to be the major factor affecting mortality.     

Moderate Ischemic Mitral Regurgitation: to Treat or not to Treat?

There is consensus of opinion that patients with moderately severe to severe (grade 3+ or 4+) ischemic mitral regurgitation (IMR) should undergo mitral valve surgery at the time of coronary artery bypass grafting (CABG), while trace to mild (grade 1+) IMR can probably be left alone. However, the management of moderate (grade 2+) IMR continues to be a subject of constant debate and controversy. In particular, as techniques of valvular repair continue to be refined; many surgeons have advocated mitral valve repair and concomitant CABG for these patients. Others, however, have continued to treat these patients with revascularization alone and close postoperative observation of the mitral valve. In their opinion, degree of concomitant mitral valve dysfunction in this group of patients does not justify the increased operative risks associated with simultaneous mitral valve correction. We are currently practicing in an era of evidence-based medicine (EBM) in which clinical decision-making has to be guided by current best available evidence from scientific, clinical studies. This review article attempts to tackle this controversial issue and find the best approach of dealing with moderate IMR at the time of CABG by evaluating current best available evidence.     

The long saphenous vein: to strip or not to strip?

As 80% of varicose veins stem from incompetence of the great saphenous system, surgeons must choose between simple high ligation of the saphenofemoral junction with avulsion of varicosities or the same procedure done with additional stripping of the long saphenous vein. Many surgeons strip the long saphenous vein by using variations of Keller's 1905 report of inversion stripping. Others may use other techniques. When surgical procedures for varicose veins are compared, they are often measured by the recurrence rate. This, of course, is difficult to define. Comparisons of saphenous vein stripping versus ligation favor the results achieved by stripping but patient satisfaction appears to be equal and while stripping appears to give better satisfaction with regard to quality of life scores, in fact, the risk of nerve damage and subsequent litigation is quite real when the operation of stripping is done.