Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement vs. primary suture only in midline laparotomies (PRIMA): long-term outcomes of a multicentre, double-blind, randomised controlled trial

Background

Incisional hernia occurs approximately in 40% of high-risk patients after midline laparotomy. Prophylactic mesh placement has shown promising results, but long-term outcomes are needed. The present study aimed to assess the long-term incisional hernia rates of the previously conducted PRIMA trial with radiological follow-up.

Methods

In the PRIMA trial, patients with increased risk of incisional hernia formation (AAA or BMI ≥27 kg/m2) were randomised in a 1:2:2 ratio to primary suture, onlay mesh or sublay mesh closure in three different countries in eleven institutions. Incisional hernia during follow-up was diagnosed by any of: CT, ultrasound and physical examination, or during surgery. Assessors and patients were blinded until 2-year follow-up. Time-to-event analysis according to intention-to-treat principle was performed with the Kaplan-Meier method and Cox proportional hazard models. Trial registration: NCT00761475 (ClinicalTrials.gov).

Findings

Between 2009 and 2012, 480 patients were randomized: 107 primary suture, 188 onlay mesh and 185 sublay mesh. Five-year incisional hernia rates were 53.4% (95% CI: 40.4-64.8), 24.7% (95% CI: 12.7-38.8), 29.8% (95% CI: 17.9-42.6), respectively. Compared to primary suture, onlay mesh (HR: 0.390, 95% CI: 0.248-0.614, p < 0.001) and sublay mesh (HR: 0.485, 95% CI: 0.309-0.761, p = 0.002) were associated with a significantly lower risk of incisional hernia development.

Interpretation

Prophylactic mesh placement remained effective in reducing incisional hernia occurrence after midline laparotomy in high-risk patients during long-term follow-up. Hernia rates in the primary suture group were higher than previously anticipated.

Funding

B. Braun.

O26 INFECTIOUS COMPLICATION IN RELATION TO THE PROPHYLACTIC MESH POSITION: THE PRIMA TRIAL REVISITED

Aim

Prophylactic mesh reinforcement has proven to reduce the incidence of incisional hernia (IH). Fear of infectious complications may withhold the widespread implementation of prophylactic mesh reinforcement, particularly in the onlay position.

Material and Methods

Patients scheduled for elective midline surgery were randomly assigned to a suture closure group, onlay mesh group, or sublay mesh group. The incidence, treatment, and outcomes of patients with infectious complications were assessed through examining the adverse event forms. Data were collected prospectively for 2 years after the index procedure.

Results

Overall, infectious complications occurred in 14/107 (13.3%) patients in the suture group and in 52/373 (13.9%) patients with prophylactic mesh reinforcement (p = 0.821). Infectious complications occurred in 17.6% of the onlay group and 10.3% of the sublay group (p = 0.042). Excluding anastomotic leakage as a cause, these incidences were 16% (onlay) and 9.7% (sublay), p = 0.073. The mesh could remain in-situ in 40/52 (77%) patients with an infectious complication. The 2-year IH incidence after onlay mesh reinforcement was 10 in 33 (30.3%) with infectious complications and 15 in 140 (9.7%) without infectious complications (p = 0.003). This difference was not statistically significant for the sublay group.

Conclusions

Prophylactic mesh placement was not associated with increased incidence, severity, or need for invasive treatment of infectious complications compared with suture closure. Patients with onlay mesh reinforcement and an infectious complication had a significantly higher risk of developing an incisional hernia, compared with those in the sublay group.

Infectious Complication in Relation to the Prophylactic Mesh Position: The PRIMA Trial Revisited

BACKGROUND

Prophylactic mesh reinforcement has proven to reduce the incidence of incisional hernia (IH). Fear of infectious complications may withhold the widespread implementation of prophylactic mesh reinforcement, particularly in the onlay position.

STUDY DESIGN

Patients scheduled for elective midline surgery were randomly assigned to a suture closure group, onlay mesh group, or sublay mesh group. The incidence, treatment, and outcomes of patients with infectious complications were assessed through examining the adverse event forms. Data were collected prospectively for 2 years after the index procedure.

RESULTS

Overall, infectious complications occurred in 14/107 (13.3%) patients in the suture group and in 52/373 (13.9%) patients with prophylactic mesh reinforcement (p = 0.821). Infectious complications occurred in 17.6% of the onlay group and 10.3% of the sublay group (p = 0.042). Excluding anastomotic leakage as a cause, these incidences were 16% (onlay) and 9.7% (sublay), p = 0.073. The mesh could remain in-situ in 40/52 (77%) patients with an infectious complication. The 2-year IH incidence after onlay mesh reinforcement was 10 in 33 (30.3%) with infectious complications and 15 in 140 (9.7%) without infectious complications (p = 0.003). This difference was not statistically significant for the sublay group.

CONCLUSIONS

Prophylactic mesh placement was not associated with increased incidence, severity, or need for invasive treatment of infectious complications compared with suture closure. Patients with onlay mesh reinforcement and an infectious complication had a significantly higher risk of developing an incisional hernia, compared with those in the sublay group.

Interventions that Facilitate Shared Decision-Making in Cancers with Active Surveillance as Treatment Option: a Systematic Review of Literature

PURPOSE OF REVIEW

Medical decisions concerning active surveillance are complex, especially when evidence on superiority of one of the treatments is lacking. Decision aids have been developed to facilitate shared decision-making on whether to pursue an active surveillance strategy. However, it is unclear how these decision aids are designed and which outcomes are considered relevant. The purpose of this study is to systematically review all decision aids in the field of oncological active surveillance strategies and outcomes used by authors to assess their efficacy.

RECENT FINDINGS

A search was performed in Embase, Medline, Web of Science, Cochrane, PsycINFO Ovid and Google Scholar until June 2019. Eligible studies concerned interventions aiming to facilitate shared decision-making for patients confronted with several treatment alternatives, with active surveillance being one of the treatment alternatives. Twenty-three eligible articles were included. Twenty-one articles included patients with prostate cancer, one with thyroid cancer and one with ovarian cancer. Interventions mostly consisted of an interactive web-based decision aid format. After categorization of outcomes, seven main groups were identified: knowledge, involvement in decision-making, decisional conflict, treatment preference, decision regret, anxiety and health-related outcomes. Although active surveillance has been implemented for several malignancies, interventions that facilitate shared decision-making between active surveillance and other equally effective treatment alternatives are scarce. Future research should focus on developing interventions for malignancies like rectal cancer and oesophageal cancer as well. The efficacy of interventions is mostly assessed using short-term outcomes.

Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis

Background

Incisional hernia is a frequent complication after abdominal surgery. The aim of this study was to assess the efficacy of prophylactic mesh reinforcement (PMR) after midline laparotomy in reducing the incidence of incisional hernia.

Methods

A meta‐analysis was conducted following PRISMA guidelines. The primary outcome was the incidence of incisional hernia after follow‐up of at least 12 months. Secondary outcomes were postoperative complications. Only RCTs were included. A random‐effects model was used for the meta‐analysis, and trial sequential analysis was conducted.

Results

Twelve RCTs were included, comprising 1815 patients. The incidence of incisional hernia was significantly lower after PMR compared with sutured closure (risk ratio (RR) 0·35, 95 per cent c.i. 0·21 to 0·57; P < 0·001). Both onlay (RR 0·26, 0·11 to 0·67; P = 0·005) and retromuscular (RR 0·28, 0·10 to 0·82; P = 0·02) PMR led to a significant reduction in the rate of incisional hernia. The occurrence of seroma was higher in patients who had onlay PMR (RR 2·23, 1·10 to 4·52; P = 0·03). PMR did not result in an increased rate of surgical‐site infection.

Conclusion

PMR of a midline laparotomy using an onlay or retromuscular technique leads to a significant reduction in the rate of incisional hernia in high‐risk patients. Individual risk factors should be taken into account to select patients who will benefit most.

[Correction added on 19 February 2020, after first online publication: J. García Alamino has been amended to J. M. Garcia‐Alamino]

Repair of complex abdominal wall hernias with a cross-linked porcine acellular matrix: cross-sectional results of a Dutch cohort study

BACKGROUND

The use of synthetic mesh in potentially contaminated and contaminated incisional hernias may lead to a higher morbidity and mortality. Biological meshes may provide a solution, but since these meshes are rarely used, little is known about long-term results. The aim of this cohort study was to evaluate the long-term clinical efficacy and patient satisfaction following Permacol™ in complex abdominal wall hernia repair (CAWHR) patients in a cross-sectional fashion.

MATERIALS AND METHODS

All patients were operated for CAWHR with Permacol™ in the Netherlands between 2009 and 2012. The design was a multicenter cross-sectional cohort study. The STROCSS statement was followed. Patients were interviewed, underwent abdominal examination, and completed quality-of-life questionnaires. ClinicalTrials.gov Identifier NCT02166112. Research Registry Identifier researchregistry4713.

RESULTS

Seventy-seven patients were seen in the outpatient clinic. Their hernias were classified as potentially contaminated in 25 patients (32.5%) and infected in 52 patients (67.5%). The mean follow-up was 22.2 ± 12.6 months. The most frequent postoperative complication was wound infection (n = 21; 27.3%), meshes had to be removed in five patients (6.5%). By the time of their visit to the outpatient clinic, 22 patients (28.6%) had a recurrence of whom ten (13%) had undergone reoperation. Thirty-nine patients (50.6%) had bulging of the abdominal wall. Quality-of-life questionnaires revealed that patients graded their health status with a mean 6.8 (± 1.8) out of 10 points.

CONCLUSION

Bulging and recurrence are frequently observed in patients treated with Permacol™ for CAWHR. Considering both recurrence and bulging as undesirable outcomes of treatment, a total of 46 patients (59.7%) had an unfavorable outcome. Infection rates were high, but comparable with similar patient cohorts. Quality-of-life questionnaires revealed that patients were satisfied with their general health, but scored significantly lower on most quality-of-life modalities of the Short Form-36 questionnaire.

Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement versus primary suture only in midline laparotomies (PRIMA): 2-year follow-up of a multicentre, double-blind, randomised controlled trial

BACKGROUND

Incisional hernia is a frequent long-term complication after abdominal surgery, with a prevalence greater than 30% in high-risk groups. The aim of the PRIMA trial was to evaluate the effectiveness of mesh reinforcement in high-risk patients, to prevent incisional hernia.

METHODS

We did a multicentre, double-blind, randomised controlled trial at 11 hospitals in Austria, Germany, and the Netherlands. We included patients aged 18 years or older who were undergoing elective midline laparotomy and had either an abdominal aortic aneurysm or a body-mass index (BMI) of 27 kg/m² or higher. We randomly assigned participants using a computer-generated randomisation sequence to one of three treatment groups: primary suture; onlay mesh reinforcement; or sublay mesh reinforcement. The primary endpoint was incidence of incisional hernia during 2 years of follow-up, analysed by intention to treat. Adjusted odds ratios (ORs) were estimated by logistic regression. This trial is registered at ClinicalTrials.gov, number NCT00761475.

FINDINGS

Between March, 2009, and December, 2012, 498 patients were enrolled to the study, of whom 18 were excluded before randomisation. Therefore, we included 480 patients in the primary analysis: 107 were assigned primary suture only, 188 were allocated onlay mesh reinforcement, and 185 were assigned sublay mesh reinforcement. 92 patients were identified with an incisional hernia, 33 (30%) who were allocated primary suture only, 25 (13%) who were assigned onlay mesh reinforcement, and 34 (18%) who were assigned sublay mesh reinforcement (onlay mesh reinforcement vs primary suture, OR 0·37, 95% CI 0·20-0·69; p=0·0016; sublay mesh reinforcement vs primary suture, 0·55, 0·30-1·00; p=0·05). Seromas were more frequent in patients allocated onlay mesh reinforcement (34 of 188) than in those assigned primary suture (five of 107; p=0·002) or sublay mesh reinforcement (13 of 185; p=0·002). The incidence of wound infection did not differ between treatment groups (14 of 107 primary suture; 25 of 188 onlay mesh reinforcement; and 19 of 185 sublay mesh reinforcement).

INTERPRETATION

A significant reduction in incidence of incisional hernia was achieved with onlay mesh reinforcement compared with sublay mesh reinforcement and primary suture only. Onlay mesh reinforcement has the potential to become the standard treatment for high-risk patients undergoing midline laparotomy.

FUNDING

Baxter; B Braun Surgical SA.

The idiosyncratic drug-induced gene expression changes in HepG2 cells

The inflammatory stress has been associated with an increase in susceptibility to idiosyncratic drug-induced liver injury (DILI). However, the molecular mechanisms of this inflammation-associated idiosyncratic drug hepatotoxicity remain unknown. We exposed HepG2 cells with high and low doses of three idiosyncratic (I) and three non-idiosyncratic (N) compounds, in the presence (I+ and N+) or absence (I− and N−) of a cytokine mix for 6, 12 and 24 h. To investigate the genome‐wide expression patterns, microarray was performed using the Agilent 4×44K Whole Human Genome chips. The data presented in this DIB include the expression of genes participating in the ceramide metabolism, ER stress, apoptosis and cell survival pathways. The functions of these genes were illustrated in our associated article (Jiang et al., 2017) [1]. Raw and normalized gene expression data are available through NCBI GEO (accession number GSE102006).

Omics-based identification of the combined effects of idiosyncratic drugs and inflammatory cytokines on the development of drug-induced liver injury

The mechanisms of idiosyncratic drug-induced hepatotoxicity remain largely unclear. It has demonstrated that the drug idiosyncrasy is potentiated in the context of inflammation and intracellular ceramides may play a role in this process. To study the mechanisms, HepG2 cells were co-treated with high and low doses of three idiosyncratic (I) and three non-idiosyncratic (N) compounds, with (I+ and N+) or without (I- and N-) a cytokine mix. Microarray, lipidomics and flow cytometry were performed to investigate the genome-wide expression patterns, the intracellular ceramide levels and the induction of apoptosis. We found that all I+ treatments significantly influenced the immune response- and response to stimulus-associated gene ontology (GO) terms, but the induction of apoptotic pathways, which was confirmed by flow cytometry, only appeared to be induced after the high-dose treatment. The ceramide signaling-, ER stress-, NF-kB activation- and mitochondrial activity-related pathways were biologically involved in apoptosis induced by the high-dose I+. Additionally, genes participating in ceramide metabolism were significantly altered resulting in a measurable increase in ceramide levels. The increases in ceramide concentrations may induce ER stress and activate the JNK pathway by affecting the expression of the related genes, and eventually trigger the mitochondria-independent apoptosis in hepatocytes. Overall, our study provides a potential mechanism to explain the role of inflammation in idiosyncratic drug reactions.

[Correlation between ICIQ-UI-SF score and personality testing results over a urinary incontinent population]

OBJECTIVE

We found out the personality pattern of an incontinent population and proceeded to a correlation between the personality inventory and the ICIQ-UI-SF (International Consultation Incontinence Questionnaire Urinary Incontinence Short Form) to demonstrate reliability and sincerity of the answers and to establish that a personality disturbance may impact the physiopathology of micturition.

MATERIALS AND METHODS

We performed an observational prospective study. It included patient's answers to a computed questionnaire combining a double ICIQ-UI-SF questionnaire and the 71 questions of the Minimult questionnaire. Forty-seven patients were asked to participate.

RESULTS

Over 37 patients included, Wilcoxon-Mann-Whitney non parametric test confirmed agreement of the two ICIQ-UI-SF questionnaires with P=0.1792. Twenty-three patients were validated to the Minimult inventory with F scale<70. We analysed variability of the two global ICIQ-UI-SF score in regard with the validity scale using ROC analysis. We observed an AUC of 0.559 with sensitivity 78.6% and specificity 43.5%. No L score was above 70 demonstrating absence of lie. No personality disturbance was found in 9 cases. We observed six cases with a high hypochondric value, five with a high depressive value, and four with a high hysteric value. This neurotic triad was found in two cases. We noticed five cases with psychopathic deviance relative to antisocial behaviour while values of paranoia and hypomania were high in one case without any association of these personality aspects, which demonstrated absence of behavioural problem. Psychotic profile associating schizophrenia, paranoia, depression and hypomania was not found. We outlined in half of the valid population a significant high psycho-asthenic pattern.

CONCLUSION

We conclude that a correlation between the personality inventory and the ICIQ-UI-SF is feasible. The comparative study demonstrate reliability of answers. Sincerity is established by the Minimult L scale. We confirm and precise literature information over clinical personality pattern of this population and observe relevant elements concerning the psycho-asthenic pattern which depicts an anxious personality with an important feeling of the problem. These elements permit to suspect that a personality disturbance may impact the physiopathology of the micturition.

LEVEL OF EVIDENCE

4.

A systematic review of the surgical treatment of large incisional hernia

PURPOSE

Incisional hernia (IH) is one of the most frequent postoperative complications. Of all patients undergoing IH repair, a vast amount have a hernia which can be defined as a large incisional hernia (LIH). The aim of this study is to identify the preferred technique for LIH repair.

METHODS

A systematic review of the literature was performed and studies describing patients with IH with a diameter of 10 cm or a surface of 100 cm2 or more were included. Recurrence hazards per year were calculated for all techniques using a generalized linear model.

RESULTS

Fifty-five articles were included, containing 3,945 LIH repairs. Mesh reinforced techniques displayed better recurrence rates and hazards than techniques without mesh reinforcement. Of all the mesh techniques, sublay repair, sandwich technique with sublay mesh and aponeuroplasty with intraperitoneal mesh displayed the best results (recurrence rates of <3.6%, recurrence hazard <0.5% per year). Wound complications were frequent and most often seen after complex LIH repair.

CONCLUSIONS

The use of mesh during LIH repair displayed the best recurrence rates and hazards. If possible mesh in sublay position should be used in cases of LIH repair.

Meta-analysis of primary mesh augmentation as prophylactic measure to prevent incisional hernia

BACKGROUND

Incisional hernia (IH) remains one of the most frequent postoperative complications after abdominal surgery. As a consequence, primary mesh augmentation (PMA), a technique to strengthen the abdominal wall, has been gaining popularity. This meta-analysis was conducted to evaluate the prophylactic effect of PMA on the incidence of IH compared to primary suture (PS).

METHODS

A meta-analysis was conducted according to the PRISMA guidelines. Randomized controlled trials (RCTs) comparing PMA and PS for closing the abdominal wall after surgery were included.

RESULTS

Out of 576 papers, 5 RCTs were selected comprising 346 patients. IH occurred significantly less in the PMA group (RR 0.25, 95% CI 0.12-0.52, I(2)0%; p < 0.001). No difference could be observed with regard to wound infection (RR 0.86, 95% CI 0.39-1.91, I(2) 0%; p = 0.71) or seroma (RR 1.22, 95% CI 0.64-2.33, I(2) 0%; p = 0.55). A trend was observed for chronic pain in favor of the PS group (RR 5.95, 95% CI 0.74-48.03, I(2)0%; p = 0.09).

CONCLUSION

The use of PMA for abdominal wall closure is associated with significantly lower incidence of IH compared to PS.

A double blind randomized controlled trial comparing primary suture closure with mesh augmented closure to reduce incisional hernia incidence

Background

Incisional hernia is the most frequently seen long term complication after laparotomy causing much morbidity and even mortality. The overall incidence remains 11-20%, despite studies attempting to optimize closing techniques. Two patient groups, patients with abdominal aortic aneurysm and obese patients, have a risk for incisional hernia after laparotomy of more than 30%. These patients might benefit from mesh augmented midline closure as a means to reduce incisional hernia incidence.

Methods/design

The PRImary Mesh Closure of Abdominal Midline Wound (PRIMA) trial is a double-blinded international multicenter randomized controlled trial comparing running slowly absorbable suture closure with the same closure augmented with a sublay or onlay mesh. Primary endpoint will be incisional hernia incidence 2 years postoperatively. Secondary outcomes will be postoperative complications, pain, quality of life and cost effectiveness.

A total of 460 patients will be included in three arms of the study and randomized between running suture closure, onlay mesh closure or sublay mesh closure. Follow-up will be at 1, 3, 12 and 24 months with ultrasound imaging performed at 6 and 24 months to objectify the presence of incisional hernia. Patients, investigators and radiologists will be blinded throughout the whole follow up.

Disccusion

The use of prosthetic mesh has proven effective and safe in incisional hernia surgery however its use in a prophylactic manner has yet to be properly investigated. The PRIMA trial will provide level 1b evidence whether mesh augmented midline abdominal closure reduces incisional hernia incidence in high risk groups.

Trial registration

Clinical trial.gov NCT00761475.

The principles of abdominal wound closure

BACKGROUND

Incisional hernia (IH) is a common complication of abdominal surgery. Its incidence has been reported as high as 39.9%. Many factors influence IH rates. Of these, surgical technique is the only factor directly controlled by the surgeon. There is much evidence in the literature on the optimal midline laparotomy closure technique. Despite the high level of evidence, this optimal closure technique has not met wide acceptance in the surgical community. In preparation of a clinical trial, the PRINCIPLES trial, a literature review was conducted to find the best evidence based technique for abdominal wall closure after midline laparotomy.

METHODS

An Embase search was performed. Articles describing closure of the fascia after midline laparotomy by different suture techniques and/or suture materials were selected.

RESULTS

Fifteen studies were identified, including five meta-analyses. Analysis of the literature showed significant lower IH rates with single layer closure, using a continuous technique with slowly absorbable suture material. No significant difference in IH incidence was found comparing slowly absorbable and non absorbable sutures. Furthermore, a suture length to wound length ratio of four or more and short stitch length significantly decreased IH rates.

CONCLUSIONS

Careful analysis of the literature indicates that an evidenced based optimal midline laparotomy closure technique can be identified. This technique involves single layer closure with a running suture, using a slowly absorbable suture with a suture length to wound length ratio of four or more and a short stitch length. We adopt this technique as the PRINCIPLES technique.

Meta-analysis of glue versus sutured mesh fixation for Lichtenstein inguinal hernia repair

Background

Chronic pain remains a frequent complication after Lichtenstein inguinal hernia repair. As a consequence, mesh fixation using glue instead of sutures has become popular. This meta-analysis aimed to clarify which fixation technique is to be preferred for elective Lichtenstein inguinal hernia repair.

Methods

A meta-analysis was conducted according to the PRISMA guidelines. Articles published between January 1990 and April 2012 were searched for in MEDLINE, Embase and the Cochrane Library. Randomized controlled trials (RCTs) comparing glue and sutured mesh fixation in elective Lichtenstein repair for unilateral inguinal hernia were included. The quality of the RCTs and the potential risk of bias were assessed using the Cochrane risk of bias tool.

Results

Of 254 papers found in the initial search, a meta-analysis was conducted of seven RCTs comprising 1185 patients. With the use of glue mesh fixation, the duration of operation was shorter (mean difference −2·57 (95 per cent confidence interval (c.i.) –4·88 to −0·26) min; P = 0·03), patients had lower visual analogue scores for postoperative pain (mean difference −0·75 (−1·18 to −0·33); P = 0·001), early chronic pain occurred less often (risk ratio 0·52, 95 per cent c.i. 0·31 to 0·87; P = 0·01), and time to return to daily activities was shorter (mean difference −1·17 (−2·30 to −0·03) days; P = 0·04). The hernia recurrence rate did not differ significantly.

Conclusion

Elective Lichtenstein repair for inguinal hernia using glue mesh fixation compared with sutures is faster and less painful, with comparable hernia recurrence rates.

Tissue adhesives in gastrointestinal anastomosis: a systematic review

BACKGROUND

Anastomotic leakage in gastrointestinal (GI) surgery remains a major problem. Although numerous studies have been undertaken on the role of tissue adhesives as GI anastomotic sealants, no clear overview has been presented. This systematic review aims to provide a clear overview of recent experimental and clinical research on the sealing of different levels of GI anastomosis with tissue adhesives.

METHODS

We searched MEDLINE and Embase databases for clinical and experimental articles published after 2000. We included articles only if these addressed a tissue adhesive applied around a GI anastomosis to prevent anastomotic leakage or decrease leakage-related complications. We categorized results according to level of anastomosis, category of tissue adhesive, and level of evidence.

RESULTS

We included 48 studies: three on esophageal anastomosis, 13 on gastric anastomosis, four on pancreatic anastomosis, eight on small intestinal anastomosis, and 20 on colorectal anastomosis; 15 of the studies were on humans.

CONCLUSIONS

Research on ileal and gastric/bariatric anastomosis reveals promising results for fibrin glue sealing for specific clinical indications. Sealing of pancreatico-enteric anastomosis does not seem to be useful for high-risk patients; however, research in this field is limited. Ileal anastomotic sealing was promising in every included study, and calls for clinical evaluation. For colorectal anastomoses, sealing with fibrin glue sealing seems to have more positive results than with cyanoacrylate. Further research should concentrate on the clinical evaluation of promising experimental results as well as on new types of tissue adhesives. This research field would benefit from a systematic experimental approach with comparable methodology.

The impact of mandibular advancement on articulation, resonance and voice characteristics in Flemish speaking adults: a pilot study

Bilateral saggital split osteotomy (BSSO) of the mandible is a frequently performed mandibular orthognathic procedure, used to resolve mandibular disharmonies. Literature review showed contradictory findings regarding the effect of the orthognathic surgery on speech characteristics. The purpose of the present study was to determine a detailed analysis of the articulation, resonance and voice characteristics after BSSO with mandibular advancement for the treatment of Class II malocclusions using objective and subjective assessment techniques (perceptual evaluations, Dysphonia Severity Index, nasalance scores) in eight subjects. The findings of the present study indicate that before and after BSSO with mandibular advancement three types of articulation disorders may predominate in the Flemish language: the incorrect production of the trill sound /r/ and the /s/ sound and devoicing of the /z/. After orthognathic surgery most patients showed an identical articulation pattern (normal or disturbed pattern) as in the presurgical condition. In this study the BSSO with mandibular advancement had no significant impact on the nasality characteristics and the nasalance values probably due to the competent velopharyngeal valving in the presurgical condition. And, as expected the vocal quality revealed no significant difference. The maxillofacial surgeon and the speech language pathologist must be aware of the persistency of these preoperative articulation errors in the postsurgical condition.

Identification and isolation of the indole-3-pyruvate decarboxylase gene from Azospirillum brasilense Sp7: sequencing and functional analysis of the gene locus

The root-associated bacterium Azospirillum brasilense Sp7 produces the growth-stimulating phytohormone indole-3-acetic acid (= IAA) via the indole-3-pyruvate pathway. The DNA region containing ipdC, the structural gene for indole-3-pyruvate decarboxylase, was identified in a cosmid gene library of strain Sp7 by hybridization and has been sequenced. Upstream of the gene, two other ORF homologous to gltX and cysS were sequenced that are transcribed in the opposite direction. A functional analysis of the cloned ipdC region has been performed. To test the expression of the gene, a lacZ-Km cartridge was introduced into the gene. By this construct, tryptophan-dependent stimulation of gene expression in A. brasilense Sp7 was observed. Evidences for the existence of another copy of the ipdC gene in the Azospirillum genome are also reported.

[Methodology of penile isotope imaging. Evaluation]

AIMS

Duplex ultrasonography and pulsed doppler analysis or dynamic infusion cavernosometry and cavernosography are used for functional evaluation of penile arterial or venous dynamics during a pharmacological erection. The accuracy of the echographic investigations is correlated to the investigator experience. Cavernosometry and cavernosography are more invasive technique than the radioisotope erection penogram, which is a reproductive and reliable test.

MATERIAL AND METHODS

We investigate 60 patients. Neurological, psychological and endocrinological etiology are excluded. The technique is described: thyroid is blocked by potassium perchlorate, bloodpool is labelled with Tc99m, a dynamic study is performed over 60 mn with intracavernous injection of PGE1 5g or Papaverine 30 mg at T10mn, ROIS are defined by computer processing, a phalogram curve is provided.

RESULTS

This noninvasive test sorts out arteriogenic, venogenic and psychogenic impotence by a qualitative curve analysis. The quantitative parameters depending on numerous time consuming variables have proved to be of poor clinical use and non significant. We objectivate 20 psychogenic impotence, 27 arteriogenic impotence, 7 venous leakage and 6 mixed (arteriogenic and venogenic) impotence. Statistic evaluation of arteriogenic lesions comparative by doppler technique reveals a sensitivity of 83% and a specificity of 87%. The advantages of the test are; ambulatory, objective, noninvasive and reliable investigation. In the same time, "qualitative" data evaluates the response to a pharmacological induced erection.

CONCLUSIONS

The radioisotope erection penogram is a noninvasive, reproductive and reliable screening test for vasculogenic impotence.

[Liposarcoma of the spermatic cord]

The liposarcoma is mainly located in the retroperitoneum and rarely involves the spermatic cord. Dissemination occurs more often via haematogenous way than by lymphatic way. The incidence of local recurrence is higher than distant metastases. The treatment of choice is the wide excision. Adjuvant radiotherapy is recommended in the well differentiated and myxoid type of tumors if the local control during excision is not complete or wide enough. Benefit of chemotherapy is still controversial and limited. Case report of a stage 1 liposarcoma of the spermatic cord, four years after excision of a large lipoma during a hernia repair. The treatment consisted in radical excision of this liposarcoma without any adjuvant therapy. Follow-up of 30 months without recurrence.

Actigraphic evaluation of handedness

The utility of an objective evaluation of motor activity, actigraphy, was examined in the evaluation of handedness. Hand preference was assessed in a homogeneous group of 190 young volunteers using the Edinburgh Inventory (EI). The EI distribution obtained in the population studied was comparable with distributions cited in the literature. Simultaneous actigraphic recordings from both wrists were made in 58 of these subjects for 20 h, starting at 1000 h, using an epoch length of 4 s. Care was taken to include comparable numbers of right- and left-handers (based on EI score) in this subgroup. Two actigraphic parameters were defined. One of these, the Activity Index (AI[x]), is a measure of the difference in total motor activity between right and left wrist. The other, Movement Index (MIy[x]) is a measure of the difference in movement pattern. AI[x] showed a moderate but significant correlation with EI (r = 0.36, P < 0.005). The correlation between MIy[x] and EI was high (r = 0.65, P < 0.0001). Rebinning of the data into 60 s epochs decreased the degree of linear correlation between MIy[x] and EI. We conclude, in contrast to a previous study, that actigraphy can be used to discriminate between dominant and non-dominant hands; that the difference in movement pattern between right and left hand is larger than the difference in total motor activity; and that epoch lengths shorter than the conventional 60 s are more sensitive for this kind of discrimination.

Technetium-99m HMPAO SPET in acute supratentorial ischaemic infarction, expressing deficits as millilitre of zero perfusion

A comparative interim analysis was performed of clinical parameters, computed tomographic (CT) scan results and technetium-99m hexamethylpropylene amine oxime single-photon emission tomography (SPET) findings obtained within 12 h of acute supratentorial ischaemic infarction. First, the applicability for SPET semiquantification in this study of the "method of Mountz", simultaneously accounting for extent and degrees of hypoperfusion by expressing deficits as millilitre of zero perfusion, was considered. Next, the relative contributions of perfusion SPET and CT scan in the acute stage of ischaemic infarction were compared in 27 patients (mean age 68.8 years). Finally, the correlation of SPET lesions with clinical parameters at onset was evaluated. The method of Mountz represents a workable, accurate virtual parameter, with the assumption that the contralateral brain region remains uninvolved. Interobserver reproducibility in 12 SPET studies, with lesions varying between 6 and 369 cc, showed a correlation coefficient r of 0.99. In practice, because of inconstant distribution of activities in the brain, the method can only be applied slice by slice and not on the total global volume. While the mean delay since the onset of symptomatology was approximately 7 h for both SPET and CT scan, SPET showed lesions concordant with the clinical neurological findings in 100% and CT scan in only 48%. One could hypothesize that SPET examinations performed later would show larger functional defects, because of the development of additional functional changes secondary to biochemical alterations. However, in this regard no statistically significant differences were found between two subproups, taking the median of delay before SPET examination as cut-off.(ABSTRACT TRUNCATED AT 250 WORDS)

[Immediate allergy to latex in urological practice]

Five cases of acute allergic reaction to latex are reported. Four of those were diagnosed during surgery and presented anaphylactic shock. One was suspected before surgery by systematic screening and dramatic presentation was avoided. Increasing frequency of latex allergy is reported in the literature and is usually seen in patients with extensive neurosurgical or urological histories, or by peoples currently exposed to natural rubber products (medical staff). Systematic screening in history before surgery is important so that exposure to latex should be avoided in suspected cases.

[Appendicular mucocele. Report of 2 cases]

We report two cases of mucocele of the appendix produced by a cystadenocarcinoma, with pseudomyxoma peritonei in one. The treatment consisted in appendectomy with partial resection of the caecum, for the first patient. It consisted in wide resection and in local chemotherapy for the second.

[Actinomycosis of the abdominal wall. Report of a case]

We report a primary case of Actinomycosis of the abdominal wall. The diagnosis is obtained on the basis of the CT-scan and the pathological examination. The treatment is a surgical excision and a long term administration of antibiotics.

[First elements of comparison between blood-tissue barriers at cerebral, genital and urinary levels]

Fluorescence microscope observations of Trypan Blue distribution gives the demonstration of the blood-tissue barriers. It reveals the similitude between the barriers in choroid plexus, in testis, epididymis and bladder and the difference with the blood-brain barrier. Electron microscope investigations afford a statistical view of relations between structure and vascular permeability and stress the opposition reported above. Membrane specializations of each epithelium often bring forward those which are involved in the barrier. This function is principally assigned to thight junctions. The different morphological aspects encountered lead to the problem of dynamic variations in the configuration of the junctions.