Adult hernia surgery in Wales revisited: impact of the guidelines of The Royal College of Surgeons of England

This study investigated the impact of the guidelines of The Royal College of Surgeons of England on the practice of hernia surgery in Wales. This was assessed by means of a postal survey to all consultant general surgeons in Wales in 1996-1997. The areas covered were: awareness of the guidelines of The Royal College of Surgeons of England and the impact of such guidelines on their practice, attendance at hernia courses, operative technique, materials used for repair and skin suture, proportion of day case hernias, length of inpatient stay, thromboembolic (TE) prophylaxis and postoperative advice to patients with regard to light work, heavy work and sport. In all, 79 replies were received (85%). Almost all the surgeons had read the guidelines; this changed the practice of 20% of respondents but did not in 32%. A further 48% did not answer the question. In contrast with our 1993 survey results, in Wales there is now a uniform surgical management of adult inguinal hernias: the most common operation is the Liechtenstein, with monofilament non-absorbable suture to secure the mesh, followed by the Shouldice repair. The Bassini and inguinal darn operations are becoming much less common and none now uses braided or absorbable sutures for the repair. Skin closure is still rather variable, with only 58% of respondents adhering to the recommended absorbable subcuticular suture. Postoperative advice is now uniform and in accordance with the guidelines. A trend towards more TE prophylaxis and more day case hernia surgery is also seen.

Chronic leg ulcers: beware the 'wolf in sheep's clothing!'

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Hyaluronic acid induces tumour necrosis factor-alpha production by human macrophages in vitro

Foetal wounds heal with minimal or no scar formation. High levels of hyaluronic acid (HA) have been implicated as a contributory factor. Macrophages are essential for normal wound healing, a role facilitated by secretion of an array of cytokines. Of these, tumour necrosis factor alpha (TNF-alpha) has been shown to reduce wound collagen levels and thus scarring. This study examines the ability of HA to stimulate TNF-alpha production by human macrophages. The human U937 myelomonocytic cell line was differentiated into DU937 adherent macrophages. DU937 monolayers were exposed to HA at concentrations of 0.1, 1, 10 and 100 micrograms/ml. Conditioned media from HA-exposed monolayers were assayed for TNF-alpha activity using a standard L929 fibroblast bioassay. TNF-alpha activities of HA-exposed DU937 culture supernatants were compared to those of controls and expressed as % cytotoxicity. Exposure of macrophages to HA at concentrations of 10 micrograms/ml and 100 micrograms/ml significantly stimulated TNF-alpha production, as demonstrated by % cytotoxicities expressed as median (interquartile range) of 33.5 (29-34.5)% (P = 0.03) and 77.5 (67-85)% (P = 0.029) respectively (Mann-Whitney U test). This effect was specifically associated with TNF-alpha generated during HA exposure, as these cytotoxic effects could be abolished by addition of anti-TNF-alpha antibody, reducing cytotoxicity to 9 (6.5-13.5)% and 8.5 (6-12)% respectively. These observations indicate that HA stimulates TNF-alpha production by human macrophages. TNF-alpha is known to downregulate fibroblastic collagen synthesis within experimental wounds. We suggest that the high levels of HA within foetal wounds may play a part in limiting fibroplasia, and thereby limit scarring, via an upregulation of TNF-alpha production from wound macrophages.

Transecting the rectum: the 'clean cut' approach

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Aspects of hernia surgery in Wales

The management of elective inguinal herniorrhaphy in Wales was assessed by means of a postal survey of consultant general surgeons. This included technique of repair, length of inpatient stay, follow-up, use of heparin thromboprophylaxis and advice regarding driving, strenuous activities and work. In all, 54 replies (77%) were received. The views of patients on their surgery was assessed by a questionnaire sent to 80 patients treated on a single surgical unit; 60 replies (75%) were received. Waiting times were relatively short among this group, 67.5% of patients being treated within 6 months of seeking medical advice; 16.25% suffered a complication. All wound infections occurred after discharge and 15% of patients had some groin discomfort 6 months after operation. Accuracy of clinical examination of 50 inguinal hernias by different grades of surgeon was assessed. Consultants were significantly more accurate when compared with house officers (P < 0.001). There is a wide range of repair techniques and postoperative advice practised by consultant general surgeons in Wales. Patients' main complaint was that of a sparsity of postoperative advice, although there also appears to be an appreciable postoperative morbidity. Clinical experience plays a significant role in assessment of the suitability of hernias for surgery.

Wet cement: a poorly recognized cause of full-thickness skin burns

Cement is a rare cause of full-thickness burns. We have examined the aetiology, frequency and severity of these burns, and assessed public awareness of the potential of cement as a caustic agent. Of patients, 95 per cent were unaware of the potential of cement to cause burns, and none had seen precautionary warnings on cement bags or delivery dockets. Factors important in burn production appear to be alkalinity, duration of contact and the abrasive nature of the cement particles. It is concluded that doctors, especially casualty officers, should know of the potential of progressive full-thickness burns from wet cement. General public awareness should be increased. The cement manufacturers were asked to comment on the content of this paper.

An unusual complication of laparoscopic cholecystectomy

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Health effects of atmospheric sulfur dioxide and dietary sulfites. The fallacy of typology

Some animal studies have shown that exposure to low levels of sulfur dioxide and dietary bisulfite is relatively harmless. To the contrary, sulfite oxidase deficiency is known in man, bisulfite is mutagenic for several test organisms, and the atmospheric SO2 level is positively correlated with death rates for several chronic diseases among some human populations. The studies reporting harmlessness for animals may be misleading because of the fallacy of typology.