Five-year outcome of laparoscopic and Lichtenstein hernioplasties

BACKGROUND

Laparoscopic hernia repair has been proved superior to open repairs in terms of short-term results, but long-term results of laparoscopic and open mesh repairs have been lacking until recently.

METHODS

A total of 123 patients were randomly allocated to two treatment groups comparing laparoscopic and Lichtenstein hernioplasties in three separate trials. The first and second trials compared small and large mesh used in transabdominal preperitoneal repairs, and the third study compared totally extraperitoneal hernioplasty with the Lichtenstein operation. A 5-year follow-up visit was scheduled to assess recurrencies, symptoms, and patient satisfaction.

RESULTS

For the follow up evaluation, 121 (98.4%) of the patients were reached. There were five hernia recurrences in the laparoscopic group (small mesh) and two in the Lichtenstein group (difference, 5%; 95% confidence interval, -4-13%; p = 0.3). One patient who underwent the transabdominal preperitoneal polypropylene procedure underwent reoperation 3 years later because of dense small bowel adhesions at the inguinal surgical site. Chronic groin pain was more common after open operation (0 vs 4) patients (difference 7%; confidence interval, -0.4-16%; p = 0.04). Ten patients (16%) in the laparoscopic group and 12 (20%) in the open group reported discomfort or pain at the surgical site.

CONCLUSIONS

Both laparoscopic and Lichtenstein hernioplasties have a low risk for hernia recurrence if proper mesh size is used. The patients who undergo hernioplasty with open mesh hernioplasty seem to experience chronic symptoms and pain more often than those managed with the laparoscopic procedure.

Short-term symptomatic outcome and quality of life after laparoscopic versus open Nissen fundoplication: a prospective randomized trial

BACKGROUND

Laparoscopic operation has replaced conventional operation in the treatment of reflux disease. This change has been mostly based on excellent results from highly experienced antireflux surgeons rather than on randomized clinical trials.

AIMS

The objective of this study was to compare the short-term symptomatic outcome and patient quality of life costs after laparoscopic (LNF) or open Nissen fundoplication (ONF) in a community hospital setting with less experienced surgeons.

METHODS

Forty-two patients with documented gastroesophageal reflux disease (GERD) were randomized to either LNF or ONF. Symptomatic outcome using a custom questionnaire and the Gastrointestinal Quality of Life Index (GIQLI) were measured pre- and postoperatively at one and three months.

RESULTS

Esophagitis was cured among all patients in LNF group compared to 90% in the ONF group. The symptoms observed preoperatively were significantly improved in both groups, except for dysphagia and flatulence. Dysphagia was more common after LNF. The GIQLI (scale 0-144) was equally normalized in both groups. The mean GIQLI-change among all patients was 37.9 points. Patient satisfaction did not differ between the groups.

CONCLUSIONS

LNF and ONF are effective methods in the operative treatment of GERD in short-term and result in a significant improvement in patients gastrointestinal symptoms and quality of life.

Risk factors for recurrent stress fractures in athletes

Our aim was to identify factors predisposing athletes to multiple stress fractures, with the emphasis on biomechanical factors. Our hypothesis was that certain anatomic factors of the ankle are associated with risk of multiple stress fractures of the lower extremities in athletes. Thirty-one athletes (19 men and 12 women) with at least three separate stress fractures each, and a control group of 15 athletes without fractures completed a questionnaire focusing on putative risk factors for stress fractures, such as nutrition, training history, and hormonal history in women. Bone mineral density was measured by dual-energy x-ray absorptiometry in the lumbar spine and proximal femur. Biomechanical features such as foot structure, pronation and supination of the ankle, dorsiflexion of the ankle, forefoot varus and valgus, leg-length inequality, range of hip rotation, simple and choice reaction times, and balance in standing were measured. There was an average of 3.7 (range, 3 to 6) fractures in each athlete, totaling 114 fractures. The fracture site was the tibia or fibula in 70% of the fractures in men and the foot and ankle in 50% of the fractures in women. Most of the patients were runners (61%); the mean weekly running mileage was 117 km. Biomechanical factors associated with multiple stress fractures were high longitudinal arch of the foot, leg-length inequality, and excessive forefoot varus. Nearly half of the female patients (40%) reported menstrual irregularities. Runners with high weekly training mileage were found to be at risk of recurrent stress fractures of the lower extremities.

Comparison of laparoscopic and open Nissen fundoplication 2 years after operation. A prospective randomized trial

BACKGROUND

Laparoscopic operation has replaced the conventional open procedure in the treatment of gastroesophageal reflux disease (GERD) in spite of the fact that long-term results based on controlled clinical trials have been lacking. The objective of this study was to compare outcome, quality of life, and patient satisfaction after laparoscopic and open Nissen fundoplication in a community hospital setting with a 2-year follow-up.

METHODS

Forty-two patients with GERD were randomized to either laparoscopic (LNF) or open (ONF) Nissen fundoplication. Outcome evaluation included reflux symptoms, gastrointestinal quality of life (GIQLI), and upper GI endoscopy.

RESULTS

Esophagitis was cured among all patients in the LNF group and in 90% of the ONF group. There were two patients (10%) in both groups who had medicine-dependent recurrent reflux together with significant worsening in the GIQLI scores. One patient in the LNF group has been reoperated due to a suture granuloma in the left epigastric port. Two patients in the LNF group needed esophageal dilatation due to persistent dysphagia. GIQLI scores (scale, 0-144) were equally normalized in both groups. Overall, 90% in the LNF and 100% in the ONF group were either satisfied or very satisfied with the operation. There was only one patient (LNF) who would not choose to have the operation again.

CONCLUSIONS

Laparoscopic and open Nissen fundoplication seem to be equally effective methods for improving reflux symptoms and quality of life, resulting in a high rate of satisfaction among patients with an intermediate follow-up period of 2 years.

Comparison of costs between laparoscopic and open Nissen fundoplication: a prospective randomized study with a 3-month followup

BACKGROUND

Laparoscopic antireflux surgery has replaced conventional operation despite the fact that currently no randomized trials have been published regarding its cost effectiveness. The objective of the present study was to compare costs and some short-term outcomes of laparoscopic and open Nissen fundoplication.

STUDY DESIGN

Forty-two patients with documented gastroesophageal reflux disease were randomized between October 1995 and October 1996 to either laparoscopic (LNF) or open (ONF) Nissen fundoplication. Some short-term outcomes, Gastrointestinal Quality of Life Index (GIQLI) hospital costs, and costs to society were assessed. Followup was 3 months.

RESULTS

Medians of operation times in the LNF and ONF groups were 98 min and 74 min, respectively. Hospital stay was 2.5 days shorter after laparoscopic operation (LNF 3 days versus ONF 5.5 days). Both operations were equally safe and effective, but the LNF group experienced significantly less pain and fatigue during the first 3 postoperative weeks. Improvement in the GIQLI and overall patient satisfaction were comparable between the methods. Convalescence was faster in the LNF group: return to normal life being 14 versus 31 days and return to work being 21 versus 44 days in the LNF and ONF groups, respectively. Hospital costs were similar, $2,981 and $3,140 in the LNF and ONF groups, respectively, but total costs were lower ($7,506 versus $13,118) in the LNF group as a result of an earlier return to work.

CONCLUSIONS

LNF is superior in cost effectiveness, assuming that the longterm results between the methods are comparable.

A prospective randomized outcome and cost comparison of totally extraperitoneal endoscopic hernioplasty versus Lichtenstein hernia operation among employed patients

Laparoscopic hernia operations have been criticized in regard to their high hospital costs. This study was designed to compare the costs and some outcome features of totally extraperitoneal endoscopic hernia operation (TEP) and Lichtenstein mesh repair (OPN) among 45 randomized employed patients. The medians of operative time in the TEP and OPN groups were 67.5 and 53 min, respectively. Return to normal life was 14 days in the TEP group and 20 days in the OPN group. The hospital costs per patient were $1,239 (all costs are in US dollars) in the TEP group and $782 in the OPN group. The median total costs were $3,912 and $4,661 in the TEP and OPN groups, respectively. The Lichtenstein operation is cheaper for the hospital. The total costs for working patients are lower with the endoscopic technique because fewer working days are lost.

A cost and outcome comparison between laparoscopic and Lichtenstein hernia operations in a day-case unit. A randomized prospective study

BACKGROUND

Laparoscopic hernia repair has often been criticized for its high costs.

METHODS

To compare the costs of laparoscopic and open hernia repair, 40 patients were randomized for either transabdominal laparoscopic or Lichtenstein mesh repair (under local anesthesia) in a day-case surgery unit.

RESULTS

Median operative times for the laparoscopic and open groups were 62 and 65 min, respectively. Postoperative pain was comparable for the two groups. The period before return to normal life was 14 days in the laparoscopic group and 21 days in the open group. The hospital costs were 2051 FIM ($1 US = 4.6 FIM) higher in the laparoscopic group, but the total costs for employed patients (including expenses due to lost work days) were lower.

CONCLUSION

Although the Lichtenstein operation is cheaper for the hospital, the total costs for working patients are lower with the laparoscopic technique, when the cost of lost work days is factored into overall expense.

Cost-effective appendectomy. Open or laparoscopic? A prospective randomized study

BACKGROUND

The aim of this study was to compare the outcome and cost-effectiveness of laparoscopic (LA) and open appendectomy (OA).

METHODS

Forty consecutive patients were randomized to either the LA (n = 19) or OA (n = 21) group.

RESULTS

The medians of operative times in the LA and OA groups were 31.5 and 41 min, respectively. The total operation room times were 91 and 82 min, respectively. There was no significant difference in postoperative pain or fatigue, but return to normal life was faster in the LA group (14 versus 26. 5 days). The median hospital costs per patient were 8,538 and 6,788 FIM ($1 US = 4.6 FIM) in the LA and OA groups, respectively; but the total costs among working patients were lower in the LA group (20, 963 versus 27,778 FIM) due to faster return to work.

CONCLUSIONS

Laparoscopic appendectomy is as safe as open appendectomy. The hospital costs are higher, but LA offers significant cost savings to the payer for working patients.

Total costs of laparoscopic and lichtenstein inguinal hernia repairs: a randomized prospective study

In a prospective, randomized study, laparoscopic (n = 20) and Lichtenstein (n = 18) inguinal hernia repairs were compared in relation to operative time, operative costs, hospital stay, postoperative pain, return to work, patient satisfaction, complications, and total costs. All the operations were performed with the patient under general anesthesia. The median operative times in the laparoscopic and Lichtenstein groups were 71.5 (range, 43-140) and 45 (16-83) min, respectively (p < 0.001). Postoperative pain and use of analgesics was less in the laparoscopic group. The median time to return to work was 14 (8-26) days in the laparoscopic group and 19 (5-40) days in the Lichtenstein group. More complications occurred in the Lichtenstein group. The median of the operative costs, in U.S. dollars, was $1,395 and $878, respectively, and the median total costs (including community expenses resulting from lost workdays) were $4,796 in the laparoscopic and $5,320 in the Lichtenstein groups.

Diagnosis and treatment of stress fracture of the patella in athletes

Five cases of stress fracture of the patella in athletes are presented. Four of these occurred transversally in the lower part and one longitudinally in the lateral part of the patella. Three of the patients were females (endurance runner, high jumper, and orienteerer) and two males (volleyball and soccer player). The diagnosis was made 2-8 months from the onset of the symptoms. Conservative treatment was successful in only one patient; all others were treated surgically, with good end result. Drilling of the fracture line was performed twice with metal wire cerclage fixation, excision of the lateral fragment was carried out once, and a bone graft with K wires and cerclage compression (tension band) was performed once. In all cases the patellar retinaculum was intact, indicating a stress injury. Stress fracture of the patella is a rare overuse injury, and therefore difficulties and delays in the diagnosis and treatment may occur. In cases with delayed diagnosis we recommend operative treatment.

[Stress fractures in athletes and military recruits. An overview]

Stress fracture is an overuse injury caused by muscle forces together with bending and impact forces acting on the bone, which has not adapted to the loading. The localization of stress fractures is more common in lower extremities. They are found in many other bones of the body as well. In the history of these patients a considerable amount of running exercise is usually found. The symptoms are stress pain and aching at rest after training. Typical findings are local palpation pain and edema. Sometimes tender resistance is felt. Clinically used radiological imaging methods are radiographs, scintigraphy and in some cases magnetic resonance imaging and computed tomography. The radiographs are not usually positive until 2 weeks after the onset of symptoms. With a typical history and clinical findings the radiological diagnosis causes no further problems. The corner stones of the treatment are: early identification of the symptoms, early diagnosis, a sufficiently long training pause and in special cases consultation of experts in the field. There are rare stress fractures with increased risk of a delayed union, non-union or complete fracture. Surgical treatment may be needed in some cases. The prevention of stress fractures has proved to be difficult. The risk of acquiring stress fractures is increased by running with improper shoes and in female athletes with menstrual irregularities. If running is changed to some other kind of sport, the incidence stress fractures is lower.

Stress fracture of the medial malleolus

We studied eight patients who had a stress fracture of the medial malleolus. The main symptom was localized pain on the medial side of the ankle. The initial radiographs revealed the lesion for only three patients; for the other patients, the diagnosis was made with the use of isotope scans and was confirmed with computerized tomography scans, magnetic resonance images, or subsequent plain radiographs. One vertical fracture was treated initially with compression with AO screws. On the basis of our experience with stress fractures in other bones, drilling was performed to enhance the formation of bone in two patients who had delayed healing and who had had symptoms for eight and twelve months. The fractures healed four and five months after the drilling. The five patients who were managed non-operatively had to avoid running and jumping for at least three months (average, four months) so that healing could take place. All five of these fractures healed within five months.

Diagnosis and treatment of stress fractures located at the mid-tibial shaft in athletes

Anterior mid-tibial stress fractures are a clinical problem. The diagnosis can be delayed because the normal radiographic anteroposterior and side views may only show thickening of the anterior cortex. Oblique views and tomography are often required. Isotope scan confirms the diagnosis and is the method of choice. The treatment varies from rest to operational intervention. A delayed union of this area of the tibia is a potential complication and is a high risk for an athlete, a complete fracture being the most serious complication. We present the results of conservative and operative treatment of 17 patients. Of these cases, nine progressed to a delayed union and operation was performed using transversal drilling with a 2.0-2.5 drill. We recommend a period of rest up till six months and surgical intervention with drilling of the hypertrophied cortex if there is any suspicion of a possibility of a delayed union. Also, if there is a long delay in the diagnosis, operative treatment is recommended. Biopsy is recommended during surgery for differential diagnosis.

Stress avulsion fracture of the tarsal navicular. An uncommon sports-related overuse injury

We report nine cases of stress-related avulsion fracture of the tarsal navicular in athletes. This uncommon over-use injury is thought to occur following repetitive cyclic compressive loading secondary to an impingement of the tarsal navicular. The small dorsal triangular fragment is best seen in weightbearing lateral view radiographs and isotope scan and/or tomography help confirm the diagnosis. We feel that operative treatment is the method of choice in highly symptomatic cases and among top athletes because of the shorter recovery time.

Delayed unions and nonunions of stress fractures in athletes

From 1971 to 1985, 369 athletes presented to us with stress fractures. Of these patients, 10% (37) were treated for development of delayed unions or nonunions. Twenty-seven of the patients were male and 10 were female. Their mean age was 23.1 years (range, 17 to 39). About half of the athletes were involved in endurance sports. The diagnostic criteria for a delayed union or nonunion were clinical and radiological evidence. There was a diagnostic delay of about 3.5 months in the series. Plain radiographs, tomography, and isotope scans were used in the diagnosis. Special radiographic views were also used. In 15 cases (10 hallux sesamoid bone fractures, 1 midtibial shaft fracture, 1 metatarsal V base fracture, 1 tarsal navicular fracture, 1 olecranon fracture, and 1 proximal tibial shaft fracture) nonoperative treatment was used. Operative treatment was used 22 times (5 sesamoid fractures, 5 midtibial fractures, 5 metatarsal V base fractures, 3 tarsal navicular fractures, 3 olecranon fractures, and 1 proximal tibial shaft fracture). Results were good or excellent in 32 cases (86.5%), moderate in 4 cases, and poor in 1 case.

Stress fractures in athletes

During the 14-year period of 1971-1985, 368 stress fractures in 324 athletes were treated. The series contained 268 fractures in males and 100 fractures in females; 32 fractures occurred in children (less than 16 years), 117 in adolescents (16-19 years), and 219 in adults. Forty-six fractures were incurred by athletes at an international level, 274 by athletes at a national or district level and 48 by recreational athletes. Of the total cases, 72% occurred to runners and a further 12% to athletes in other sports after running exercises. The distribution of the stress fractures by site was: tibia 182, metatarsal bones 73, fibula 44, big toe sesamoid bones 15, femoral shaft 14, femoral neck 9, tarsal navicular 9, pelvis 7, olecranon 5 and other bones 10. Of the total fractures, 342 were treated conservatively and 26 fractures required surgical treatment. The operative indication was dislocation in 5 cases and delayed union/nonunion in 21 cases. The sites most often affected by delayed union were: anterior midtibia, sesamoid bones of the big toe, base of the fifth metatarsal, olecranon, and tarsal navicular. The athletes at an international level experienced the greatest risk of multiple separate fractures, protracted healing, or fractures requiring surgery.

Stress fractures of the olecranon in javelin throwers

Between the years 1977 and 1984, four javelin throwers with a stress fracture of the olecranon were seen and treated. In one patient, acute painful dislocation of the fracture occurred during a competitive throw. Two patients had stress fracture of the tip. The fracture treated conservatively healed in 18 months. The patient treated by excision of the tip was able to throw after 2 months. Two patients had slightly oblique, more distally located stress fractures, which were treated with a tension band and 2 Kirschner wires. The fractures healed in 4 months. One of the patients had a refracture 11 months after the primary operation. It was successfully treated with a compression screw and two bone pegs. Because of the high risk of delayed union and nonunion, stress fractures of the olecranon should be treated operatively in javelin throwers.

Stress fracture of the navicular bone. Nine cases in athletes

Nine cases of stress fractures of the tarsal navicular bone were treated in athletes. The diagnosis was made with radiographs and bone scan within 6 months. Only two patients were treated surgically. The only poor result was seen in a patient in whom the fracture was only explored.

Overuse injuries in cross-country skiing

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Stress fractures of the sesamoid bones of the first metatarsophalangeal joint in athletes

Over a period of 11 years 15 cases of stress fractures of the sesamoid bones of the first metatarsophalangeal (MTP) joint were treated in athletes. The mean age of the patients was 22.3 years, and there were 9 males and 6 females in the series. All patients were athletes, who began to suffer from the symptoms during training without any trauma. Eight fractures were located in the medial, six in the lateral sesamoid bone, and in one case both sesamoids were affected. The diagnosis was performed on the basis of the history, symptoms, clinical examination, and radiological, or isotope scanning findings. Ten of the patients were treated conservatively by prescribing an avoidance of excessive physical activity and better training shoes. In five cases surgical excision of the fragmented painful sesamoid bone was performed. There were no complications in the series and the athletes could start gradually training 6-8 weeks after the operation. The histology showed fibrotic non-union at the fracture site and supported the diagnosis of stress fracture. Three of the conservatively treated athletes had mild symptoms in intensive training, others had a good end result.

Stress fracture of the mid-tibial shaft

In a series of 151 tibial stress fractures in athletes and joggers, seven were located at the mid-third of the diaphysis. The diagnosis was made radiographically several months after the onset of symptoms; a transverse fissure line or gap was noted in the middle of the hypertrophied anterior tibial cortex. Histologic examination of a biopsy of the fracture line showed features resembling pseudoarthrosis. All the patients returned to physical activities.

Exertion injuries in female athletes

Because sports injuries in men form most of the available statistics, the reportage of injuries in female athletes is sparse. We describe exertion injuries and disorders in 281 women athletes, all of which hampered athletic training or performances. Sixty per cent of the injuries occurred to girls ages between 12-19 years, and about forty-eight per cent were track and field athletes. The most common sites of injury were the ankle, foot, heel and leg. Osteochondritic disorders were the most typical injuries in the series, and the chronic medical tibial syndrome was the injury that needed surgical treatment most frequently. Overuse injuries seem to differ very little from each other in the events included in this survey.

Stress fractures in young athletes

In a series of 16 cases of stress fractures in 15-year-old and younger athletes 8 fractures occurred in boys and 8 in girls. There were no differences between the sexes in the athletes' training habits. Ten of the fractures were located at the tibia, seven at its upper third and three at the lower part of the bone. Three fractures were found in the fibula, in the metatarsal bones two stress fractures and in the femur one stress fracture. Most stress fractures were caused by endurance type sports. The daily training distances were not particularly high at the time of the onset of the symptoms. In most cases the diagnosis was based on a radiological evaluation. A sufficiently long pause from all athletic activity was enough treatment. Stress fractures in children are very uncommon.

Comparison of dextranomer and streptokinase-streptodornase in the treatment of venous leg ulcers and other infected wounds

The clinical efficacy of dextranomer (Debrisan) and streptokinase-streptodornase (Varidase) was compared in a controlled randomized in-patient study. There were two patient groups: Group A consisting of 28 patients with a total of 31 venous leg ulcers and Group B consisting of 56 patients with other infected wounds (posttraumatic and postoperative wounds, amputation stumps, burn wounds, arteriosclerotic ulcers, decubital ulcers, ulcers due to bone disease, rheumatic ulcers, ulcers due to erysipelas and wounds of mixed aetiology). Both agents have a good cleansing effect as well as a good effect on infection and wet necrosis. Dextranomer stimulates the formation of granulation tissue faster than streptokinase-streptodornase.

Regulation of the glycosylations of collagen hydroxylysine in chick embryo tendon and cartilage cells

The regulation of the glycosylations of hydroxylysine was studied in isolated chick-embryo cells by labelling with a [14C]lysine pulse. The course of the procollagen lysyl modifications was compared in tendon and cartilage cells, and the effect on the gycosylations of the degree of lysyl hydroxylation and the concentration of Mn2+ and Fe2+ were also studied, in tendon cells. Procollagen triple helix formation was inhibited in most experiments in order to eliminate the effect of this process on the continuation of the reactions. Both in the tendon and cartilage cells the intracellular lysyl modifications proceeded in a biphasic fashion. After an initial sharp linear increase, the reactions did not cease but were protracted at a slower but constant rate. Lysyl hydroxylation was followed by rapid galactosylation in both cell types and this was followed almost immediately by rapid glucosylation, suggesting a close association of the corresponding enzymes. The data further suggest that other factors must also exist, in addition to the differences in the timing of triple helix formation and the actual hydroxylysine content, which are responsible for the different amounts of galactose in the collagens synthesized by these cell types. The amount of glucosylgalactosylhydroxylysine nevertheless seemed to be determined by the available acceptor sites, i.e., the amount of galactosylhydroxylysine. In further experiments with tendon cells the oxygen participating in lysyl hydroxylation was displaced by nitrogen at various points in time. When the degree of lysyl hydroxylation was reduced to less than one-third of the original, the total amounts of glycosylated residues decreased correspondingly, but their proportion relative to total hydroxylysine remained unchanged. Extra Mn2+ increased the proportion of galactosylated hydroxylysine, suggesting that the activity of hydrosylysyl galactosyltransferase is not saturating in respect of the catalyzed reaction. Experiments on the addition of Fe2+ or its chelation by alpha, alpha'-dipyridyl gave indications that the presence of this co-factor is not required for either glycosylation reaction in isolated tendon cells.