Incisional Hernia: Early Complication of Abdominal Surgery

It has been suggested that early development of the incisional hernia is caused by perioperative factors, such as surgical technique and wound infection. Late development may implicate other factors, such as connective tissue disorders. Our objective was to establish whether incisional hernia develops early after abdominal surgery (i.e., during the first postoperative month). Patients who underwent a midline laparotomy between 1995 and 2001 and had had a computed tomography (CT) scan of the abdomen during the first postoperative month were identified retrospectively. The distance between the two rectus abdominis muscles was measured on these CT scans, after which several parameters were calculated to predict incisional hernia development. Hernia development was established clinically through chart review or, if the chart review was inconclusive, by an outpatient clinic visit. The average and maximum distances between the left and right rectus abdominis muscles were significantly larger in patients with subsequent incisional hernia development than in those without an incisional hernia (P < 0.0001). Altogether, 92% (23/25) of incisional hernia patients had a maximum distance of more than 25 mm compared to only 18% (5/28) of patients without an incisional hernia (P < 0.0001). Incisional hernia occurrence can thus be predicted by measuring the distance between the rectus abdominis muscles on a postoperative CT scan. Although an incisional hernia develops within weeks of surgery, its clinical manifestation may take years. Our results indicate perioperative factors as the main cause of incisional hernias. Therefore, incisional hernia prevention should focus on perioperative factors.     

Totally extraperitoneal repair for bilateral inguinal hernia: Does mesh configuration matter?

BACKGROUND: The endoscopic preperitoneal approach has numerous advantages for the reconstruction of bilateral inguinal hernias. Repair may be achieved using either one large or two small meshes. The aim of this study was to investigate whether one of the techniques was superior in terms of recurrence and complication rate. METHODS: Data obtained from 113 patients who underwent surgery between January 1998 and December 2001 was reviewed. For the sake of this study, 86% of all patients were examined for hernia recurrence at an additional outpatient visit. RESULTS: The findings showed recurrence rates, of 3.5% for single mesh and 3.7% for double mesh. This difference was not significant. Complication rates did not differ significantly between the groups. CONCLUSIONS: Endoscopic preperitoneal bilateral hernia repair is a safe and reliable technique in the hands of experienced surgeons. The rate of hernia recurrence and complications is low and independent of the mesh configuration (single or double). Mesh configuration based on personal preference is permissible.     

Surgical therapy of unspecific and specific Spondylodiscitis

AIM: The aim of this study was to evaluate the clinical and radiological results of surgical treatment of thoracic and lumbar vertebral osteomyelitis by means of one-stage extrafocal posterior stabilisation, anterior debridement, and anterior column reconstruction. METHOD: A retrospective analysis of the peri- and postoperative parameters of 62 patients with a clinical and radiographic follow-up of 2.6 years that were available for 46 patients was performed. In 42 cases, the anterior column was restored with structural bone grafts, in 20 patients, expandable titanium cages filled with morsellised autologous bone and antibiotic collagen sponges were used. To assess the course of spinal alignment a radiometric analysis was undertaken. Furthermore, the Roland-Morris score (RMS) was applied to evaluate the back pain-related disability. RESULTS: The diagnosis was made no earlier than 2.7 months after the first symptoms. Preoperatively, 40 % of the patients presented with neurological impairment, of these 76 % improved after surgery. Staphylococcus aureus was the most common pathogen isolated (32 %), Mycobacterium tuberculosis was found in 11 % of the patients. Except for one patient with revision for persistent infection and consecutive failure of the bone graft, primary eradication of the infection was achieved in all cases. At follow-up, bony fusion was radiographically observed in all patients. When using cages, the segmental loss of correction was significantly lower than when using bone grafts (1.0 vs. 4.1 degrees ). At follow-up the RMS averaged 6.6. CONCLUSION: One-stage extrafocal posterior stabilisation combined with anterior debridement and anterior column reconstruction with bone grafts or titanium cages is a safe and effective strategy for patients with vertebral osteomyelitis in need of surgery. Titanium cages have proven to be biomechanically advantageous, especially in cases of extensive destruction and are not associated with higher rates of persistence or recurrence of infection compared to autologous bone grafts.     

In vitro evidence and age-related changes for nicotinic but not muscarinic acetylcholine receptors in the central nervous system of Sepia officinalis

Binding putative muscarinic ([3H]-NMS and [3H]-QNB) or nicotinic ([3H]-cytisine) acetylcholine receptors was quantitatively studied through the use of in vitro binding experiments on either membrane preparations or brain sections of juvenile (3 months), mature (15 months) or senescent (23 months) cuttlefish. No specific binding could be detected with muscarinic receptor ligands under any of the experimental conditions employed (ligand concentrations, buffers, ionic charges, types of tissue, i.e., brain sections or membrane preparations). On the other hand, [3H]-cytisine demonstrated a specific and saturable binding with a single class of high affinity binding sites (Kd of 2.6-34.6 nM; Bmax of 128-1682 fmol/mg tissue equivalent, depending on the central structure). This binding was found to be heterogeneous throughout the central regions (optic lobe>pedal lobe; superior frontal lobe>...precommissural lobe; vertical lobe>...anterior basal lobe; subvertical lobe; inferior frontal lobe; median basal lobe). These results question the existence of muscarinic-like receptors in the cuttlefish brain, or at least of a pharmacological dissimilarity from vertebrate muscarinic receptors. In contrast, nicotinic-like receptors are widely present; interestingly, their density was found to be significantly reduced in most nervous central lobes of senescent cuttlefish when compared with mature animals. The most significant decrease (-71%) was found in the anterior part of the superior frontal lobe, which is involved in visual learning; this might be related to the changes, previously demonstrated, in cholinergic neurons in this lobe in the course of aging.     

Ethnic disparities in the treatment of stage I non-small cell lung cancer

RATIONALE: Important variations exist in the treatment of non-small cell lung cancer. Because resection is the most effective treatment for patients with early disease, disparities in surgical rates can generate considerable differences in outcomes. OBJECTIVE: We analyzed data from a national population-based registry to evaluate disparities in the treatment of Hispanic and white patients with stage I lung cancer and to assess the extent to which these inequalities explain survival differences. METHODS: This study included 16,036 Hispanic and white patients with stage I lung cancer diagnosed between 1991 and 2000. Cases were identified from the Surveillance, Epidemiology, and End Results registry. Survival was compared among white and Hispanics using Kaplan-Meier curves. Stratified survival curves and Cox regression were used to evaluate whether inequalities in stage (IA vs. IB) and resection could explain survival differences. RESULTS: Hispanics had worse overall and lung cancer-specific survival compared with whites (p = 0.04 and 0.008, respectively). Five-year lung cancer survival was 54% for Hispanics versus 62% for whites. Hispanics were more frequently diagnosed with stage IB disease (p = 0.0002) and less likely to undergo resection (p = 0.03). Among resected patients, survival was similar for the two groups, as it was among those who did not undergo unresection. After adjusting for surgery and stage, there was no difference in survival between groups. CONCLUSIONS: Hispanics with stage I lung cancer had worse survival as compared with whites. These disparities are largely explained by lower rates of resection and higher probability of diagnosis at stage IB. Future work must delineate why Hispanics are receiving less surgery.     

The donor kidney: I. Morphology of adequate preservation.

The structure of the dog kidney can be preserved in hypothermic intracellular-type solutions, but after 6 hours the appearance of pathologic focal changes such as mild oedema, lesions of the cellular elements, podocyte heteromorphism, vacuolization, disintegration of the basal membrane and of the cytomembrane structrues and even cell degeneration, is unavoidable.     

Enteropathogenic Escherichia coli: stimulating neutrophil migration across a cultured intestinal epithelium without altering transepithelial conductance

INTRODUCTION: Migration of neutrophils across the intestinal epithelium is the hallmark of inflammatory conditions of the bowel. In cultured intestinal epithelial monolayer models, neutrophils can be induced to migrate along a chemotactic gradient such as n-formyl-methionyl-leucyl-phenylalanine (fMLP). Physical passage of the neutrophils across the epithelium could disrupt the tight-junctions, possibly leading to a large increase in the transepithelial conductance (G(t)). The goal of this study is to determine whether transepithelial migration of neutrophils induced by enteropathogenic (EPEC) causes changes in G(t) comparable with those seen with fMLP. METHODS: The apical side of T84 monolayers were rapidly infected with EPEC E2348/69 or exposed to 1 microM fMLP. A third group of monolayers exposed to neither EPEC nor fMLP served as control. Indium-labeled neutrophils were added to the serosal side of monolayers grown on a cell culture insert membrane (12 microm pores). G(t) was measured at fixed intervals up to 4 hours. After a 150-minute incubation, radioactivity of the neutrophils that migrated to the apical side was assayed and the number of migrating neutrophils was calculated. RESULTS: At 150 minutes, EPEC induced similar neutrophil chemotactic capability compared to fMLP (231 +/- 34.10(3) and 193 +/- 48.10(3), respectively, n = 13, P > 0.05). However, EPEC-induced neutrophil migration was not associated with significant increase in G(t), 1.13 +/- 0.16 fold of baseline G(t), in distinction with fMLP groups, 13.3 +/- 0.48 fold, n = 7 (P< 0.05). G(t) changes with EPEC were seen after 4 hours of infection, but were not different in the presence or absence of neutrophil migration (1.37 +/- 0.12 fold and 1.42 +/- 0.17 fold of baseline G(t), respectively). CONCLUSIONS: The results indicate that EPEC-induced neutrophil migration can occur without significant disruption of barrier function. In addition, the chemo-attractant recruiting neutrophils during EPEC infection is unlikely to be fMLP; and, the G(t) increase seen with fMLP-driven recruitment may indicate a discretionary compromise of barrier function during neutrophil migration.     

Selective ventral derotation spondylodesis in idiopathic thoracic scoliosis: a prospective study

AIM: Radiometric curve analysis of instrumented primary and spontaneous secondary curve correction after anterior correction and fusion of idiopathic thoracic scoliosis. METHOD: Sixty-four patients with idiopathic thoracic scoliosis were prospectively evaluated. All patients were operated either with the Zielke-VDS or with a primary stable double rod instrumentation with selective fusion of the thoracic curve from end-to end-vertebra. Follow-up averaged 29 months (24 - 52 months). RESULTS: The Cobb angle of the primary curve averaged 63.2 degrees preoperatively and was corrected to 21.4 degrees postoperatively with an average loss of correction of 5.3 degrees (58 % final curve correction). Apical thoracic vertebral rotation was corrected by 48 %. The secondary lumbar curve measured 38.2 degrees preoperatively (72 % correction on the bending films) and was spontaneously corrected by 57 % to 16.4 degrees without significant loss of correction in the final follow-up. Apical vertebral rotation averaged 11.3 degrees in the lumbar curve and was corrected spontaneously by 24 % to 8.6 degrees without significant loss of correction. Lumbar apex vertebra deviation showed no significant reduction. There was no case of lumbar curve decompensation in either frontal or sagittal plane. Implant related complications were observed in 7 patients (rod breakage), but no pseudarthrosis occurred. There were no neurological complications noted. CONCLUSION: Selective anterior correction and fusion in idiopathic thoracic scoliosis enables a satisfactory correction of both primary and lumbar secondary curves. The advantage of selective anterior correction and fusion of thoracic scoliosis is the short fusion length, better derotation and satisfactory correction of the secondary lumbar curve. The disadvantages of single threaded rod techniques in terms of lack of primary stability and a kyphogenic effect have been eliminated by the development of a primary stable, small size double rod instrumentation.