Repair of large midline incisional hernias with polypropylene mesh: Comparison of three operative techniques

Polypropylene mesh is widely used for the reconstruction of incisional hernias that cannot be closed primarily. Several techniques have been advocated to implant the mesh. The objective of this study was to evaluate, retrospectively, early and late results of three different techniques, onlay, inlay, and underlay. The records of 53 consecutive patients with a large midline incisional hernia — 25 women and 28 men, mean age 60.4 (range 28–94) — were reviewed. Polypropylene mesh was implanted using the onlay technique in 13 patients, inlay in 23 patients, and underlay in 17 patients. Either the greater omentum or a polyglactin mesh was interponated between the mesh and the viscera. The records of these 53 patients were reviewed with respect to: size and cause of the hernia, pre- and postoperative mortality and morbidity, with special attention to wound complications. Patients were invited to attend the outpatient clinic at least 12 months after implantation of the mesh for physical examination of the abdominal wall. Postoperative complications occurred in 14 (26.4%) patients. The onlay technique had significantly more complications, as compared to both other techniques. Reherniation occurred in 15 (28.3%) patients. The reherniation rate of the inlay technique was significantly higher than after the underlay technique (44% vs 12%, P=0.03) and tended to be higher than the onlay technique (44% vs 23%, P=0.22). Repair of large midline incisional hernias with the use of a polypropylene mesh carries a high risk of complications and has a high reherniation rate. The underlay technique seems to be the better technique.     

Carotenoids up-regulate connexin43 gene expression independent of their provitamin A or antioxidant properties.

Epidemiological evidence and studies in whole animals and cell culture have indicated that carotenoids have cancer chemopreventive action. In mouse C3H10T1/2 cells, this activity is highly correlated with the ability of carotenoids to up-regulate gap junctional intercellular communication. Here, we report that in mouse cells, carotenoids increase the expression of connexin43, a gene that encodes a major gap junction protein. This effect appears unrelated to their provitamin A or antioxidant properties, since carotenoids with and without provitamin A activity increased levels of connexin43 mRNA and protein, whereas the antioxidants methyl-bixin and alpha-tocopherol were inactive. Moreover, the active carotenoid canthaxanthin did not induce the vitamin A-inducible gene retinoic acid receptor-beta. Connexin43 is the first carotenoid-inducible gene described in mammals. By indicating an additional pathway through which carotenoids function, these data provide a mechanistic basis for cancer chemoprevention by carotenoids and may lead to a re-evaluation of carotenoid physiology.     

Imaging Barrett's oesophagus

Eight patients who had Barrett's oesophagus confirmed by histology are presented. All had barium swallow examinations and technetium-99m sodium pertechnetate (99Tcm-pertechnetate) scintigraphy, the findings of which are reviewed and discussed. The most valuable diagnostic signs on barium swallow examination related to the site of the stricture and the presence of mucosal outpouchings. Scintigraphy was positive in all eight cases. Patients suspected of having Barrett's oesophagus on barium swallow examination should undergo scintigraphy. When the latter is positive, the endoscopist should be alerted to obtain biopsies not only at the site of stricture but serially as far as the gastrooesophageal junction.     

Biomechanics of the golf swing in players with pathologic conditions of the forearm, wrist, and hand

Golf is an activity generally stressful to the hands and wrists and particularly can produce increasing symptoms in players with underlying problems such as hand and wrist arthritis or tendinitis. The purpose of this study was to quantitate wrist motion and club head/ball impact force in subjects with pathologic conditions of the hand, wrist, or forearm, within a laboratory environment. A regular straight-handled golf club was compared to a new BioCurve handle design that has a 19 degrees ulnar bend. We measured and compared the effect of the two grips on wrist motion, club head velocity, ball impact force, ball impact location, and isometric torsional strength in 20 subjects who had a variety of upper extremity disorders. This data was then compared to data collected in an identical fashion from golfers without such conditions. The results of our study show that there were no differences related to club handle design on impact force or impact location, club head velocity, or club head path and face angle. Wrist kinematic differences were minimal between handle designs. The differences that were significant (P less than 0.05) centered around the decreased ulnar deviation of the left hand that resulted when subjects used the BioCurve handle design, which also allowed greater resistance to torque than the straight grip club. In addition to collecting objective data, we asked subjects for their opinions of the two grips. As a whole, the normal group and the group with pathologic conditions noted more comfort, improved grip, and less shock transmission with the BioCurve handle.     

Free flap reconstruction of the lower extremity in the elderly

Summary Over a four year period, thirteen patients over the age of 60 (mean 69 years) underwent reconstruction of lower extremity defects with free tissue transfers. Ten latissimus dorsi, one tensor facia lata, and two rectus abdominus free flaps were used. Despite significant risk factors which included previous tobacco use, hypertension, diabetes mellitus, and angiographic vessel abnormalities, ten of thirteen cases had successful outcomes. There was one acute flap failure secondary to arterial thrombosis. Four flaps had delayed healing, with one patient eventually requiring amputation secondary to persistent pain and wound drainage. This experience demonstrates that free flap reconstruction of lower extremity defects in the elderly patient is a reasonable alternative to amputation when other options are limited.From the Section of Plastic and Reconstructive Surgery at the Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA Requests for reprints: J. Fisher, M.D.     

The Scimitar syndrome: CT findings in partial anomalous pulmonary venous return

An anomalous pulmonary vein draining into the subdiaphragmatic inferior vena cava was initially demonstrated on computed tomographic (CT) scans. The diagnosis of scimitar syndrome was confirmed with digital subtraction angiography. In retrospect, the anomalous vein and dextroposition of the heart were shown on chest radiographs.