Philip E. Donahue

The preperitoneal approach and prosthetic buttress repair for recurrent hernia. The evolution of a technique.

Repair of recurrent groin hernias is associated with a high incidence of repeat recurrences (2-19%). Reported herein is a 10-year experience of the management of recurrent groin hernias through the use of the preperitoneal approach with the addition of a reinforcing prosthetic mesh buttress. Two hundred and three recurrent groin hernias in 195 patients (192 men, three women) were treated between July 1975 and October 1986. The preperitoneal approach to the inguinal region was performed under regional anesthesia to define the nature of the recurrent hernia. Initial experience in a randomized trial between the use of local endogenous tissue repair versus endogenous repair with a prosthetic polypropylene mesh buttress demonstrated superiority of the latter in reducing repeat recurrences of anatomically defined direct or combined recurrent hernias. Pure indirect and femoral recurrences did not mandate mesh reinforcement. Long-term follow-up was available for 115 hernias (56%) in 102 patients (52.3%) over a period of 6 months to 10 years. Eight patients had repeat recurrences a mean of 30 +/- 22 months after repair. Six recurrences (four direct, two indirect) occurred in an early experience, when no mesh was used. Two recurrences (one indirect and one lateral to the mesh) representing 1% of all hernias (1.7% of those followed-up) have occurred after routine use of the mesh buttress, with the last re-recurrence seen in December 1982. Three ventral hernias (1.5%) occurred at the wound of entry, but none have occurred since placement of the mesh was modified to cover this wound. There were five (2.5%) wound infections and one (0.5%) hydrocele with no re-recurrences. It is concluded that the preperitoneal approach to recurrent groin hernias, together with the appropriate use of a reinforcing mesh buttress, is safe, allows anatomic definition of the hernial defect, and is followed by few repeated recurrences. The evolution of this approach during the last 10 years has made it the procedure of choice for the management of all recurrent groin hernias at the University of Illinois College of Medicine.

Limitations of 24-hour intraesophageal pH monitoring in the hospital setting*

Prolonged intraesophageal pH monitoring is considered by some to be the most sensitive and specific test of gastroesophageal reflux. We prospectively examined the ability of the test to discriminate 64 hospitalized patients with typical reflux symptoms from 20 age-matched hospitalized control subjects. Patients were subdivided based on endoscopic findings into two groups: group 1, normal endoscopy (n = 30); group 2, erosive esophagitis (n = 34). Six different individual reflux variables and a scoring system were evaluated. Total esophageal acid exposure time and the number of reflux episodes requiring longer than 5 min to clear were each found to have greater discriminatory power than other variables and the scoring system. Although the 64 patients had significantly more acid reflux than controls, only 48% had abnormal results (defined as 2 SD from the control mean). Group 1 patients had significantly more reflux than controls, though only 21% had abnormal results. Group 2 patients were significantly different than both controls and group 1, but 29% had normal studies. Ninety-three percent of the group 1 patients with normal studies responded to antireflux therapy, and only 1 patient had another explanation for the symptoms. The finding that 24-h pH monitoring was normal in half of the individuals presenting with reflux symptoms and in 29% of the patients with erosive esophagitis indicates that negative test results must be interpreted with caution. The insensitivity of the test may relate to the manner in which the study has traditionally been performed in the hospital, and outpatient ambulatory monitoring may improve its reliability.

The role of imaging ultrasound during pancreatic surgery.

Real-time ultrasound imaging was employed at 122 operations for the complications of pancreatitis, adenocarcinoma, and islet cell tumors. Ultrasound was found to be useful in 69% of the operations for pancreatitis and 66% of the operations for tumor. Assistance was provided in diagnosis or definition of pathology. Help in diagnosis consisted in detecting conditions that were not found on preoperative testing or at exploration and excluding conditions that were suspected on the basis of previous diagnostic studies or findings at operation. Better definition of pathology was provided by precise localization of structures, assessment of their size and surrounding anatomy, and distinction of tissue features that helped to recognize their identity. Ultrasound was usually more helpful in defining pathology than in diagnosis. Ultrasound enabled early orientation to important landmarks, reduced the need for contrast x-ray studies, and yielded unique information about the etiology of abnormalities. Although ultrasound has a slow learning curve, we believe that its use during pancreatic operations can significantly aid the surgeon and we recommend its wider application in surgical practice.

Endoscopic sclerosis of the gastric cardia for prevention of experimental gastroesophageal reflux

Surgical anti-reflux therapy appears to involve the muscles of the proximal gastric cardia and those of the lower esophageal sphincter. In an experimental canine reflux model, we injected sclerosant solution into the submucosa of the proximal gastric cardia, hypothesizing that the subsequent fibrotic reaction might exert an anti-reflux effect. Reflux was induced by atropine infusion, and the amount of reflux was quantitated by pH monitoring. Endoscopic sclerosis was effective in preventing reflux induced by high-dose atropine. Because the length and pressure of the lower esophageal sphincter were unaffected by endoscopic treatment, reflux prevention was possibly related to enhancement of the gastric component of the reflux barrier.

Computerized axial manometry of the esophagus: a new method for the assessment of antireflux operations

This is a presentation of a new manometric parameter of the mechanical competence of the lower esophageal sphincter (LES), the lower esophageal sphincter vector volume (LESVV). It is determined by computer analysis of continuous-pressure measurements during constant speed pullback of a radially oriented 4–6− or 8-channel manometry catheter across the LES. Patients were studied with this method both before aggressive medical therapy for esophagitis and before and after Nissen fundoplication. LESVV accurately predicted failure of medical therapy and success of the fundoplication. In patients with successful fundoplication, LESVV demonstrated a 100-fold increase in mechanical competence of the LES, even in the absence of increased LES pressure or length, increasing from 113 ± 63 mm3 to 11357 ± 3733 mm3.

Achalasia of the esophagus: treatment controversies and the method of choice

During a 15-year period, 62 patients were treated for achalasia of the esophagus. Pneumatic dilation (PD) had been performed initially in 46 and was successful in 23; failures were due to acute perforation of the esophagus, persistent dysphagia, or pathologic gastroesophageal reflux. Esophagomyotomy alone (EM) was performed in 19 individuals resulting in definite improvement in 12; four patients had moderate reflux or dysphagia, and three of these required another surgical procedure. An extended myotomy with an antireflux procedure (M-NF) was performed in 13 patients with symptomatic relief in 12; one patient required reconstruction of a too-tight fundoplication that caused persistent dysphagia. The advantages of pneumatic dilation were the ease of performance, patient acceptability, and an overall efficacy of 50%. Definitive surgical therapy, while more predictably effective in relieving dysphagia, was considerably more expensive in terms of patient discomfort and time. When pathologic reflux was present following a previous procedure, the M-NF was performed; obstruction of the esophagus did not occur if the fundoplication was “floppy.” The M-NF deserves consideration as the surgical procedure of choice for achalasia.

Trovafloxacin in the treatment of intra-abdominal infections: results of a double-blind, multicenter comparison with imipenem/cilastatin

BACKGROUND Trovafloxacin, a new broad-spectrum fourth-generation quinolone, has in vitro activity against most gram-negative and gram-positive anaerobes and aerobes. Trovafloxacin is available as both an intravenous formulation, alatrofloxacin, and a single daily oral tablet. Excellent tissue pharmacokinetics and oral bioavailability suggest usefulness in the treatment of complicated intra-abdominal infections. Thus, the efficacy of alatrofloxacin followed by oral trovafloxacin was compared with the standard regimen of intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in this prospective, multicenter, double-blind trial. METHODS Patients were randomized to receive either 300 mg alatrofloxacin daily followed by 200 mg oral trovafloxacin daily or 1 g imipenem/cilastatin intravenously thrice daily followed by 500 mg oral amoxicillin/clavulanic acid thrice daily for up to 14 days following surgical intervention of a documented intra-abdominal infection. Efficacy was assessed at the end of therapy and at follow-up (day 30). RESULTS At the end of the study, cure or improvement occurred in 83% (129/156) and 84% (127/152) of clinically evaluable patients in the trovafloxacin and comparative groups, respectively. Pathogen eradication rates, adverse-event profiles, and significant laboratory abnormalities were comparable between groups. CONCLUSION Intravenous alatrofloxacin with or without oral trovafloxacin was as effective as intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in complicated intra-abdominal infections.

Parietal Cell Vagotomy versus Vagotomy-antrectomy: Ulcer Surgery in the Modern Era

Patients with peptic ulcer occasionally develop complications that require surgical intervention, despite the advances in medical treatment and changes in the natural history of disease. The clinical surgeon must make a decision about performing “selective vagotomy antrectomy versus highly selective vagotomy,” based on the information discussed herein. The goals for operative treatment remain safe correction of the presenting problem, avoidance of perioperative morbidity and mortality, and freedom from disabling postoperative side effects. This paper addresses broad aspects of the details of surgical interventions; because most operative procedures are performed in urgent circumstances in patients who often have a variety of conditions, it is not surprising that there is no best operation suited to every complication of ulcer.

Ultrasonic imaging during biliary and pancreatic surgery

Real-time ultrasound scanning was used during operations on the biliary tract and pancreas. The principal application in biliary surgery was to evaluate the common bile duct for presence of calculi. Our initial experience indicates that operative ultrasonography compares favorably with operative cholangiography. In pancreatic operations, ultrasound has been helpful in the management of pseudocysts and chronic pancreatitis. For pseudocysts, ultrasonography has indicated cyst wall thickness and the presence of adjacent anatomic structures. Ultrasound has distinguished the fluid loculations of the pseudocyst from swelling due to inflammatory edema. In surgery for chronic pancreatitis, ultrasonography has revealed the size and location of pancreatic ducts. This information has been useful in helping select sites for internal drainage of pseudocysts and in chronic pancreatitis with ductal dilatation. Operative ultrasonography is a relatively simple procedure which has the potential for providing the surgeon with early information and decreasing the need for dissection and radiographic imaging.

Labeling of nerve cells in the dorsal motor nucleus of the vagus of rats by retrograde transport of Fluoro-Gold

Nerve cells in the dorsal motor nucleus of the vagus (dmnX) were identified by retrograde axonal transport after injections of a fluorescent tracer, Fluoro-Gold, into the anterior gastric wall. The intramural injection resulted in labeling of cells in the medial half of the left dmnX. These observations were contrasted with the diffuse (mediolateral and rostrocaudal) and bilateral distribution of labeled cells after Fluoro-Gold solution was dripped onto the stomach. In comparison with other neurotracers, the advantages of Fluoro-Gold are that (1) it can be visualized without the chemical reaction with chromogen, thereby allowing better reproducibility, and (2) it does not fade up to one year.