Randomized clinical trial of groin hernia repair with titanium-coated lightweight mesh compared with standard polypropylene mesh

BACKGROUND

Groin hernia repair is one of the commonest operations in general surgery. Existing techniques have very low and acceptable recurrence rates, but chronic pain and discomfort remain a problem for many patients. New mesh materials are being developed to increase biocompatibility, and the aim of this study was to compare a new titanium-coated lightweight mesh with a standard polypropylene mesh.

METHODS

A randomized controlled single-centre clinical trial was designed, with the basic principle of one unit, one surgeon, one technique (Lichtenstein under general anaesthesia) and two meshes. Pain before and after surgery, and during convalescence (primary outcomes) was estimated in 317 patients. At 1-year clinical follow-up, recurrence, pain, discomfort and quality of life (secondary outcomes) were evaluated.

RESULTS

Patients with the lightweight mesh returned to work after 4 days, compared with 6.5 days for the standard mesh (P = 0.040). The lightweight group returned to normal activity after 7 days, versus 10 days for the standard group (P = 0.005). There was no difference in postoperative pain or recurrence at the 1-year follow-up.

CONCLUSION

Patients with the lightweight mesh had a shorter convalescence than those with the standard heavyweight mesh.

REGISTRATION NUMBER

ISRCTN36979348 (http://www.controlled-trials.com).

Quality of life is impaired in patients with peristomal bulging of a sigmoid colostomy

OBJECTIVE

Peristomal bulging caused by hernia or prolapse is common in patients with a sigmoidostomy. It is not known whether and to what extent peristomal bulging influences various daily activities. The purpose of this study was to evaluate the effects of bulging by using a general and disease-specific health scale (Short Health Scale, SHS) and a stoma-specific quality of life (Stoma-QoL) questionnaire in patients with and without peristomal bulging.

MATERIAL AND METHODS

Seventy patients with sigmoidostomies were examined to identify peristomal bulging. The mean (SD) age was 71.7 (13.7) years and the patients had had their sigmoidostomies for a mean of 8.1 (7.9) years. Bulging was noticed in 46 patients (66%) while 24 had no bulging.

RESULTS

It was found that patients with bulging were at a disadvantage. In the SHS, patients with bulging reported significantly impaired QoL in 3 out of 4 scales regarding symptom load, worry and general sense of well-being. Also, in the Stoma-QoL questionnaire there was a significant difference between patients with and those without bulging.

CONCLUSIONS

QoL evaluated with a general and disease-specific instrument (SHS) was significantly impaired in patients with bulging around a sigmoidostomy. The Stoma-QoL questionnaire showed a small but statistically significant difference between patients with and those without bulging but the clinical significance is uncertain. Further studies are required to evaluate the role of some of the individual items in the Stoma-QoL questionnaire.

Characterization of antigen and bacterial transport in the follicle-associated epithelium of human ileum

The follicle-associated epithelium (FAE), covering Peyer's patches, provides a route of entry for antigens and microorganisms. Animal studies showed enhanced antigen and bacterial uptake in FAE, but no study on barrier function of human FAE has been reported. Our aim was to characterize the normal barrier properties of human FAE. Specimens of normal ileum were taken from 30 patients with noninflammatory colonic disease. Villus epithelium (VE) and FAE were identified and mounted in Ussing chambers. Permeability to 51Cr-EDTA, transmucosal flux of the protein antigen, horseradish peroxidase (HRP), and transport of fluorescent Escherichia coli (chemically killed K-12 and live HB101) were measured. Uptake mechanisms were studied by confocal- and transmission electron microscopy, and by using pharmacological inhibitors in an in vitro coculture model of FAE and in human ileal FAE. HRP flux was substantially higher in FAE than in VE, and was reduced by an amiloride analog. Electron microscopy showed HRP-containing endosomes. Transport of E. coli K-12 and HB101 was also augmented in FAE and was confirmed by confocal microscopy. In vitro coculture experiments and electron microscopy revealed actin-dependent, mainly transcellular, uptake of E. coli K-12 into FAE. 51Cr-EDTA permeability was equal in FAE and VE. Augmented HRP flux and bacterial uptake but similar paracellular permeability, suggest functional variations of transcellular transport in the FAE. We show for the first time that FAE of human ileum is functionally distinct from regular VE, rendering the FAE more prone to bacterial-epithelial cell interactions and delivery of antigens to the mucosal immune system.

Prospective evaluation of 6895 groin hernia repairs in women

Background

Although 8 per cent of groin hernia repairs are performed in women, there is little published literature relating specifically to women. This study compared differences in outcome between women and men after groin hernia repair.

Methods

Data collected prospectively in the Swedish Hernia Register between 1992 and 2003 were analysed, including 6895 groin hernia repairs in women and 83 753 in men.

Results

A higher proportion of emergency operations was carried out in women (16·9 per cent) than men (5·0 per cent), leading to bowel resection in 16·6 and 5·6 per cent respectively. During reoperation femoral hernias were found in 41·6 per cent of the women who were diagnosed with a direct or indirect inguinal hernia at the primary operation. The corresponding proportion for men was 4·6 per cent. The hernia repair was not classified as a standard operation (e.g. Shouldice, Lichtenstein, Plug/Mesh, TAPP/TEP) in 38·2 per cent of women and 11·2 per cent of men. Women had a significantly higher risk of reoperation for recurrence than men, and techniques associated with the lowest risk for reoperation in men had the highest risk in women.

Conclusion

A greater proportion of women than men require emergency groin hernia repair, with consequently higher rates of bowel resection, complications and death. Surgical techniques developed for use in men may put women at unnecessary risk.

Influence of suture material and surgical technique on risk of reoperation after non-mesh open hernia repair

BACKGROUND

Although mesh techniques are used with increasing frequency, sutured repair still has a place in groin hernia surgery. Studies relating suture material to recurrence rate have yielded conflicting results. The aim of the present study was to analyse the influence of suture material and sutured non-mesh technique on the risk of reoperation in open groin hernia repair using data from the Swedish Hernia Register.

METHODS

The relative risk of reoperation after sutured repair using non-absorbable, late absorbable and early absorbable sutures was compared in multivariate analyses, taking into account known confounding factors.

RESULTS

Between 1992 and 2000, 46,745 hernia repairs were recorded in the Swedish Hernia Register. Of these, 18,057 repairs were performed with open non-mesh methods and were included in the analysis. Using non-absorbable suture as reference, the relative risk of reoperation after repair with early absorbable suture and late absorbable suture was 1.50 (95 per cent confidence interval (c.i.) 1.22 to 1.83) and 1.03 (95 per cent c.i. 0.83 to 1.28) respectively. Using the Shouldice repair as reference, other sutured repairs were associated with a significantly higher relative risk of reoperation (1.22, 95 per cent c.i. 1.03 to 1.44).

CONCLUSION

A non-absorbable or a late absorbable suture is recommended for open non-mesh groin hernia repair. The Shouldice technique was found to be superior to other open methods.

Outcome of repair of bilateral groin hernias: a prospective evaluation of 1,487 patients

OBJECTIVE

To find out whether simultaneous repair of bilateral hernias increases the risk of recurrence compared with unilateral repair.

DESIGN

Prospective study.

SETTING

Swedish hospitals participating in the Swedish Hernia Register (SHR).

INTERVENTIONS

Prospective collection of data from the SHR, 1992-1999 inclusive. The Cox proportional hazard test was used for calculating odds ratio (OR).

MAIN OUTCOME MEASURES

Hernia repairs were followed up in a life table fashion until re-operation for recurrence or death of the patient.

RESULTS

33416 unilateral and 1487 bilateral operations on 2974 groin hernias were found. Direct hernias were more common in the bilateral than in the unilateral group, 1,825, 61% compared with 13,336, 40%, (p < 0.0001). A laparoscopic method was used for 1774 (60%) of bilateral and 3285 (10%) unilateral repairs, and 455 bilateral operations (31%) were done as day cases compared with 18376 (55%) unilateral ones (p < 0.0001 for both comparisons). The cumulative incidence of reoperation at three years for groin hernias after bilateral and unilateral repair was 4.1% (95% confidence interval 3.1% to 5.1%) and 3.4% (95% Cl 3.1% to 3.7%, respectively. After adjustment for other risk factors, the OR for reoperation for recurrence after bilateral repair was 1.2 (95% CI 0.9 to 1.5) with unilateral repair as reference. The OR for reoperation after laparoscopic bilateral repair compared with open bilateral repair was 0.9 (95% CI 0.6 to 1.4).

CONCLUSIONS

Simultaneous repair of bilateral hernias does not increase the risk of reoperation for recurrence and there is no significant difference in the risk of reoperation after bilateral repair using open or laparoscopic techniques.

Mesh repair of parastomal hernias: new aspects of the Onlay technique

When a hernia becomes symptomatic with pain, obstruction, or mechanical distortion, need for a repair is likely. In this short note are new aspects on the Onlay mesh repair technique of parastomal hernias presented. The satisfactory results achieved in 5 patients are reported. One recurrence required a further successful repair.

Is a dissection balloon beneficial in bilateral, totally extraperitoneal, endoscopic hernioplasty? A randomized, prospective, multicenter study

SUMMARY

Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to gain the initial working space in totally extraperitoneal endoscopic (TEP) hernioplasty, but this increases its cost. Forty-four men with bilateral, primary or recurrent inguinal hernias were randomized to undergo TEP with or without dissection balloon. There were two conversions to transabdominal preperitoneal hernioplasty, or open herniorrhaphy, in the group with balloon and four in the group without balloon. There was no difference in the postoperative morbidity or operation time between the two groups, and there were no major complications in either group. The recurrence rate was 4.3% in the group with the balloon and 7.1% in the group without the balloon. There were no statistically significant differences between the groups. Although our study population is too small to detect small differences between the groups, it seems that the use of a dissection balloon is not beneficial in a bilateral TEP.

Is a dissection balloon beneficial in totally extraperitoneal endoscopic hernioplasty (TEP)? A randomized prospective multicenter study

BACKGROUND

Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to facilitate the creation of the initial working space in totally extraperitoneal endoscopic hernioplasty (TEP), but their use adds to the cost of the operation.

METHODS

A total of 322 men with unilateral, primary, or recurrent inguinal hernias were randomized to undergo TEP with or without a dissection balloon.

RESULTS

In the group with the balloon, three of 161 patients (2.5%) required conversion to transabdominal preperitoneal hernioplasty (TAPP), or open herniorraphy, whereas 17 of 161 patients (10.6%) were converted to TAPP or open herniorraphy in the group without the balloon (p = 0.002). The mean operation time was 55 min in the group with the balloon and 63 min in the group without the balloon (p = 0.004). There was no difference between them in postoperative morbidity, and there were no major complications in either group. The recurrence rate was 3.1% in the group with the balloon and 3.7 % in the group without the balloon (p = 0.8).

CONCLUSION

The use of a dissection balloon in TEP reduces the conversion rate and may be especially beneficial early in the learning curve.

Laparoscopic hernia repair in patients with bilateral groin hernias

OBJECTIVE

To compare outcome of unilateral and bilateral laparoscopic hernia repair.

DESIGN

Prospective consecutive trial.

SETTING

University hospital, Sweden.

SUBJECTS

380 patients who had unilateral hernias repaired laparoscopically and 64 patients who had bilateral hernias repaired. The median (range) age in the two groups was 56 (21-86) and 61 (30-85) years, respectively and the median (range) follow-up was 42 (24-58) months.

MAIN OUTCOME MEASURES

Operating time, hospital stay, complications, and time to recovery.

RESULTS

The median (range) operating time was 70 (25-240) minutes in the unilateral and in the bilateral group 113 (55-330) minutes. The complication rate, recurrence rate, and time to full recovery did not differ between the groups.

CONCLUSION

The laparoscopic approach seems to be a good option for patients with bilateral inguinal hernias.

[Laparoscopic sigmoid resection in diverticulitis]

It is still difficult to determine the exact indication for a laparoscopic sigmoid resection for diverticular disease. Frequently, the severity of diverticulitis is not sufficiently defined. For this reason a modification of the Hinchey classification is proposed to which a stage II b for fistula formation and a differentiation between acute and chronic disease have been added. Another problem is the lack of criteria which define a "laparoscopic" resection. A sigmoid resection should be called "laparoscopic" if the mobilization of the sigmoid colon, the transsection of the mesenteric vein and artery and the mesentery itself and the distal transsection of the bowel are done laparoscopically. The resection of the bowel and the introduction of the anvil of the stapler device can be done extraabdominally, however, the anastomosis again should be performed laparoscopi-cally. A so defined sigmoid resection can be done in the chronic stage I. In the chronic stage II a there will be significant problems due to adhesion formation, and in the acute stages II a and II b as well as in the chronic stage II b a laparoscopic resection should not be attempted.

Audit and recurrence rates after hernia surgery

OBJECTIVE

To study the effect of quality assurance on the recurrence rate after hernia repair.

DESIGN

A prospective longitudinal cohort study.

SETTING

District hospital, Sweden.

SUBJECTS

All (n = 1232) patients aged 15-80 years operated upon for inguinal or femoral hernia in Motala 1984, 1986-1988, 1990, and 1992-1994.

INTERVENTION

A questionnaire enquiring about pain or a lump in the operated area was sent 3-6 years postoperatively to all patients, excluding those who had already been operated on for recurrence and those who had died. Selected cases were examined depending on the answers to the questionnaire.

MAIN OUTCOME MEASURES

Recurrence rate estimated by adding already confirmed recurrences to those found at the clinical examination; reoperation for recurrence; hospital stay; and number of day cases. Cumulative incidence of reoperation was analysed by actuarial analysis of all patients operated on from 1986-1997.

RESULTS

The recurrence rate decreased from 18% in 1984 and 1986 to 3% in 1993 and 1994. The reoperation rate for recurrence at three years was 10.8% (95% confidence interval, CI: 9.3 to 12.2%), 3.6% (2.6 to 4.4%) and 2.2% (1.7 to 2.7%) for patients operated on between 1986-1988, 1989-1991 and 1992-1997, respectively. Differences between the first and the second and between the first and the third period were both highly significant (p < 0.001) whereas the difference between the second and third period was not (p = 0.09). Mean hospital stay decreased from 3.5 days in 1984 to 0.9 days in 1994.

CONCLUSION

By recording recurrence rate or its surrogate endpoint, reoperation rate for recurrence, or both, hospital stay, and number of day cases, and presenting these results to participating surgeons, we provided incentives to improve outcome. This has resulted in a rapid decrease in recurrence rate and a shortened hospital stay, thereby improving cost-effectiveness.

Cost-minimisation analysis of laparoscopic and open appendicectomy

OBJECTIVE

To compare the direct and indirect costs of laparoscopic and open appendicectomy.

DESIGN

Randomised study.

SETTING

University hospital, Sweden.

MAIN OUTCOME MEASURES

Total costs for a defined period of time for each option.

RESULTS

102 patients were randomised and 99 were included in the final analysis. All patients had completely recovered within two months of operation. Disposable extra material used for the laparoscopic operation and longer operating time raised its median cost by SEK 912 and 1785, respectively. The mean duration of hospital stay, period off work (indirect costs), and time to complete recovery did not differ between the groups.

CONCLUSION

Laparoscopic appendicectomy has higher direct costs than open operation and is not as cost-effective when the longterm outcome is the same in both groups.

Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies

OBJECTIVE

Analysis of reoperation and recurrence rates three years after repair of groin hernias.

DESIGN

Prospective audit by questionnaire and selective follow-up.

SETTING

Eight Swedish hospitals.

SUBJECTS

All groin hernia operations done during 1992 on patients between the ages of 15 and 80 years.

MAIN OUTCOME MEASURES

Postoperative complications, reoperation for recurrence, and recurrence.

RESULTS

During 1992, 1565 hernia operations were done. The postoperative complication rate was 8% (125/1565). At 36 months postoperatively 108 recurrences had already been reoperated on, six patients with recurrences were on the waiting list for reoperation and a further 36 recurrences had been detected at follow-up. The interhospital variation in recurrence rate ranged from 3% to 20%. Postoperative complications, recurrent hernia, direct hernia and hospital catchment area over 100000 inhabitants were all factors associated with an increased relative risk of recurrence.

CONCLUSIONS

The recurrence rate exceeded the reoperation rate for recurrence by almost 40% which should be taken into account if the reoperation rate is used as the endpoint after repairs of groin hernia. An audit scheme, based on prospective recording, reoperation rate, and (periodic) calculation of the recurrence rate may be used to identify risk factors for recurrence and areas in need of improvement.

Hernia surgery in a defined population: a prospective three year audit

OBJECTIVE

To establish a register of inguinal hernia surgery that allows audit and analyses of data from several centres.

DESIGN

Prospective recording of data on a common protocol.

SETTING

Eight Swedish hospitals.

SUBJECTS

All groin hernia operations done for patients over 15 years old from January 1992 to December 1994.

MAIN OUTCOME MEASURES

Methods of repair, postoperative complications including mortality, day surgery rate, and reoperations for recurrence.

RESULTS

During the three years studied 4879 hernia operations were undertaken in 4474 patients. Postoperative mortality within 30 days of operation for emergency and elective hernia repairs was 3.5% and 0.07%, respectively. Of all herniorrhaphies 798 (16%) were done for recurrences, 142 of these after operations between 1992 and 1994. At 24 months 4% of all operations had been redone because of recurrences with highly significant variations among hospitals ranging from 1.5% to 6.7%. Postoperative complications within 30 days after operation, direct hernia, recurrent hernia, and the use of absorbable sutures were associated with an increased risk of reoperation.

CONCLUSIONS

A quality register recorded voluntarily can identify significant interhospital differences in outcome as well as variables associated with an increased risk of reoperation, thereby raising quality awareness and facilitating the process of improvement.

Surgical outcome and cost-minimisation-analyses of laparoscopic and open hernia repair: a randomised prospective trial with one year follow up

OBJECTIVE

To compare outcome and costs between laparoscopic and open hernia repair.

DESIGN

Prospective randomised study.

SETTING

One university and two district hospitals in Sweden.

SUBJECTS

200 men aged 25-75 years.

MAIN OUTCOME MEASURES

Operating time, hospital stay, complications, and time to recovery. A cost-minimisation-analysis was used in which the total costs were calculated for a defined period of time for each option.

RESULT

The one year follow-up rate was 98%. Mean (SD) operation times in the laparoscopic and open groups were 72 (30) and 62 (25) minutes, respectively (p = 0.009). Hospital stay and complication rates did not differ between the groups. Among employees the mean (SD) periods off work in the laparoscopic and open groups were 10 (8) and 23 (21) days, respectively (p = 0.0001). The mean direct costs of the laparoscopic operation were increased by SEK 4037 (US$ 483) but the savings in indirect costs resulting from earlier return to work were SEK 11392 (US$ 1364).

CONCLUSIONS

Laparoscopic hernia repair gave the employed patients faster recovery and return to work, and was the most cost-effective strategy provided that both direct and indirect costs were included.

Abdominoperineal excision of the rectum--an endangered operation. Norman Nigro Lectureship

PURPOSE

This study was undertaken to test the efficacy of an extreme policy of sphincter conservation by combining precise total mesorectal excision with low stapling techniques and endoluminal lavage to guard against implantation.

METHODS

A total of 136 consecutive operations for cancer below 5 cm from the anal verge has been prospectively documented and followed for a mean of 7.7 (range, 1-18) years. A total of 105 of the operations were anterior resections (77 percent), and 31 were abdominoperineal excisions (23 percent).

RESULTS

The oncologic results in the 105 patients who underwent anterior resections appear greatly superior to those of the patients who underwent abdominoperineal excisions, although the number of abdominoperineal excisions was small (31). Actuarial local recurrence at six years for anterior resection and total mesorectal excision was 1 percent for 85 curative procedures and 4 percent for all cases (n = 100), compared with 33 and 47 percent for abdominoperineal excisions (n = 15 and 31). Only four recurrences were observed below the level of the levators, three in the wound of an abdominoperineal excision and one in a stapled anastomosis after a palliative excision. No cases of nodal metastasis in the ischiorectal fossa were observed.

CONCLUSION

In a unit specializing in sphincter conservation, precise total mesorectal excision from above appears oncologically superior to abdominoperineal excision. Three-fourths of patients with carcinoma of the lower one-third of the rectum can be offered sphincter-conserving surgery, although temporary defunctioning is probably prudent in such cases. The wound of an abdominoperineal excision may be a prerequisite for perineal recurrence, which may often be caused by implantation.

Laparoscopic bowel mobilization combined with intraoperative colonoscopic polypectomy in patients with an inaccessible polyp of the colon

BACKGROUND

The purpose of this report was to describe a simple technique suitable for polyps where circumstances of the bowel anatomy prevent complete access and control of the colonoscopic procedure.

METHODS

By combining laparoscopic mobilization of the bowel with colonoscopic polypectomy, previously inaccessible polyps could be snared in two patients.

RESULTS

Both patients had 3-cm large sessile adenomas in the sigmoid colon safely removed, and they returned home within a day.

CONCLUSIONS

The described procedure increases the safety of the otherwise difficult polypectomy and also avoids laparotomy with enterotomy or bowel resection as the alternative.

Transperitoneal or totally extraperitoneal approach in laparoscopic hernia repair: results of 491 consecutive herniorrhaphies

Laparoscopic hernia surgery was introduced in this unit in May 1992. Up to November 1995, 426 patients with 491 inguinal and femoral hernias have undergone surgery. A transabdominal preperitoneal (TAPP) approach was used in 339 patients with 393 hernias. After June 1994 a totally extraperitoneal (TEP) technique was used in 87 patients with 98 hernias. This prospective nonrandomized study deals with the learning curve, complications, and early results. The mean (SD) follow-up times in the TAPP and TEP groups were 23 (9) and 7 (4) months, respectively. Mean operating times and hospital stays did not differ between the TAPP and TEP patients, but the period off work was shorter in the TEP group. Fifteen major complications, including one postoperative death, two bowel obstructions, one severe neuralgia, three trocar hernias, one epigastric artery bleeding episode, and seven recurrences, were recorded; all except one was in the TAPP group. The TEP operation may be the method of choice in laparoscopic hernia surgery.

Absorption profiles for polyethylene glycols after regional jejunal perfusion and oral load in healthy humans

The study aimed at applying closed segmental intestinal perfusion with a multichannel tube (Loc-I-Gut) for studies of regional small bowel permeability to different-sized polyethylene glycols and to compare jejunal absorption with absorption after oral load in healthy subjects. Intestinal perfusion was performed in 10 healthy volunteers and recovery of (14)C-labeled polyethylene glycol 4000 was used to detect leakage. Absorption of polyethylene glycols 546-942 was measured as urinary recovery after perfusion and oral load, and as disappearance from the lumen during steady-state perfusion. Steady-state conditions were obtained during the second hour of perfusion. Absorption of polyethylene glycols during perfusion was size-selective for molecular weights 546-766, but not for 810-942. After oral load, absorption was size-selective throughout 546-942. Segmental perfusion with Loc-I-Gut may be used to study regional jejunal permeability. Our data support the hypothesis of a dual pore system for absorption of hydrophilic molecules in the human jejunum.

Laparoscopic groin hernia repair: results of 200 consecutive herniorraphies

Laparoscopic hernia surgery was introduced in this unit in May 1992. Up to September 1993, 175 patients with 200 inguinal and femoral hernias were treated using this approach. This prospective study deals with intraoperative and postoperative complications, patient recovery and early operative results. The median (range) age was 58 (21-87) years and the median (range) follow-up was 12 (5-24) months. A laparoscopic transabdominal preperitoneal technique was used. The median (range) operation time was 67 (23-160) min for unilateral hernias and the median (range) hospital stay was 1 (0-27) day. Major complications were two postoperative bowel obstructions and seven recurrences, six of these in the first 31 patients. Overall, 17 minor complications were recorded; 52 per cent of the patients were back at work within 1 week, and 94 per cent within 1 month. The value of laparoscopic hernia repair remains to be determined and randomized controlled trials will be necessary.

Release of platelet-activating factor in acute experimental pancreatitis

This study demonstrates the formation of platelet-activating factor (PAF) in rats with acute experimental pancreatitis (AEP). The AEP was induced by infusing sodium taurodeoxycholate and trypsin into the bile-pancreatic duct. The PAF content was increased in blood samples and in pulmonary and pancreatic tissue as compared with control animals. Significant amounts of PAF were also found in peritoneal fluid. The PAF content did increase in blood samples and in pulmonary tissue after administration of endotoxin intravenously. The effects of intraperitoneal PAF administration were also studied and showed an increase of polymorphonuclear cells in blood samples. These findings suggest that acute pancreatitis might generate and release PAF. Whether PAF release is associated with the pathophysiology of complications in acute pancreatitis remains to be elucidated.

Spontaneous rupture of the spleen

A 40-year-old woman with bronchial asthma was admitted as a medical emergency with suspected myocardial infarction. Spontaneous splenic rupture was diagnosed during hospitalization and splenectomy successfully performed. No histopathologic changes or signs of previous injury or adhesions were found.

Quality assessment in hernia surgery

Questionnaires were sent five years postoperatively to all patients between 15 and 80 years old at operation who were treated for inguinal or femoral hernia in 1984 at Motala Hospital. Patients were asked about pain or a lump in the operation area and a clinical examination was offered. Of 137 patients with 142 hernias, 92% answered the questionnaire and 88% came to the examination. Among patients who answered the questionnaire and attended the examination the cumulated recurrence rate was 19%, when recurrence was defined as an indication for reoperation or a bulge in the operation area that appeared or increased during abdominal straining. Predictive values for positive and negative questionnaire answers in relation to hernia recurrence were 69% and 95%, respectively. In 14% of hernia operations a reoperation had been performed or was needed. Testicular atrophy was found in 2.7% of male patients. A questionnaire follow-up may be appropriate for identifying patients with symptomatic recurrencies, but it is inadequate as a single indicator of quality assessment in hernia surgery.

Major amputation in a defined population: incidence, mortality and results of treatment

Medical records of all patients, from a defined population of 88,000 inhabitants, who underwent major lower limb amputation during 1980-82 were retrospectively scrutinized. The records showed 131 amputations were performed in 106 patients at the district hospital and 22 amputations on 17 patients at the local university hospital, referral centre, altogether 57 men and 66 women. This gave an amputation incidence of 46 per 10(5) inhabitants per year. Of the amputees 47 per cent were older than 80 years. Only two patients underwent reconstructive vascular surgery (at the university hospital) before surgery. Final amputation level was above-knee in 61 per cent of the patients treated at the district hospital. Mortality rates at 30 days and 2 years after the amputation were 23 and 56 per cent, respectively, and the age-corrected survival after 2 years was 55 per cent. For patients who came from and eventually returned to their own homes the mean hospital stay amounted to 184 days (postoperative deaths excluded). After amputation 26 patients were trained to wear a prosthesis and 16 of these used the prosthesis 2 years after amputation. The present study underlines the need for prospective and parallel studies of vascular surgery and amputation as well as analyses of the risk factors involved in lower limb ischaemia in defined populations.