Sven Bringman

Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia

This randomized trial examined whether lightweight (LW) polypropylene mesh (large pore size, partially absorbable) could have long‐term benefits in reducing chronic pain and inflammation after inguinal hernia repair.

The association of human adipose angiotensinogen gene expression with abdominal fat distribution in obesity.

OBJECTIVE: To investigate in obese subjects the relationship between angiotensinogen gene expression in the abdominal omental and subcutaneous adipose tissue on the one hand and body fat distribution as measured by waist-to-hip ratio (WHR) on the other hand and to compare angiotensinogen gene expression between the two adipose tissue regions.SUBJECTS: Twenty obese subjects undergoing weight reduction surgery with adjustable gastric banding (12 men, eight women; WHR 0.89–1.09; body mass index (BMI) 29–51 kg/m2, age 26–54 y).MEASUREMENTS: Omental and subcutaneous adipose angiotensinogen mRNA and 18S ribosomal RNA (reference gene) levels were measured by competitive quantitative reverse transcriptase–polymerase chain reaction.RESULTS: Angiotensinogen mRNA levels were one-third higher in the omental than in the subcutaneous adipose tissue region (P=0.02). The 18S rRNA levels did not differ significantly between the two adipose tissue regions. WHR correlated positively and significantly with angiotensinogen mRNA in both the subcutaneous and the omental adipose tissue (r=0.5). This relationship was independent of age and BMI. However, WHR did not correlate with 18S rRNA in any of the adipose tissue regions.CONCLUSION: The angiotensinogen gene in adipose tissue might be involved in the development of upper-body obesity.

Short-term Outcomes for Open and Laparoscopic Midline Incisional Hernia Repair: A Randomized Multicenter Controlled Trial: The ProLOVE (Prospective Randomized Trial on Open Versus Laparoscopic Operation of Ventral Eventrations) Trial.

Objective:The aim of the trial was to compare laparoscopic technique with open technique regarding short-term pain, quality of life (QoL), recovery, and complications. Background:Laparoscopic and open techniques for incisional hernia repair are recognized treatment options with pros and cons. Methods:Patients from 7 centers with a midline incisional hernia of a maximum width of 10 cm were randomized to either laparoscopic (LR) or open sublay (OR) mesh repair. Primary end point was pain at 3 weeks, measured as the bodily pain subscale of Short Form-36 (SF-36). Secondary end points were complications registered by type and severity (the Clavien-Dindo classification), movement restrictions, fatigue, time to full recovery, and QoL up to 8 weeks. Results:Patients were recruited between October 2005 and November 2009. Of 157 randomized patients, 133 received intervention: 64 LR and 69 OR. Measurements of pain did not differ, nor did movement restriction and postoperative fatigue. SF-36 subscales favored the LR group: physical function (P < 0.001), role physical (P < 0.012), mental health (P < 0.022), and physical composite score (P < 0.009). Surgical site infections were 17 in the OR group compared with 1 in the LR group (P < 0.001). The severity of complications did not differ between the groups (P < 0.213). Conclusions:Postoperative pain or recovery at 3 weeks after repair of midline incisional hernias does not differ between LR and OR, but the LR results in better physical function and less surgical site infections than the OR does. (ClinicalTrials.gov Identifier: NCT00472537)

Early results of a randomised trial comparing Prolene and VyproII-mesh in endoscopic extraperitoneal inguinal hernia repair (TEP) of recurrent unilateral hernias

The purpose of this study was to compare a lightweight mesh to a standard polypropylene hernia mesh in endoscopic extraperitoneal hernioplasty in recurrent hernias. A total of 140 men with recurrent unilateral inguinal hernias were randomised to a totally extraperitoneal endoscopic hernioplasty (TEP) with Prolene or VyproII in a single-blinded multi-center trial. The randomisation and all data handling were performed through the Internet. 137 patients were operated as allocated. Follow-up was completed in 88% of the patients. The median operation times were 55 (24–125) min and 53.5 (21–123) min for the Prolene and VyproII groups, respectively. The meshes had comparable results in the surgeon’s assessment of the handling of the mesh, return to work, return to daily activities, complications, postoperative pain and quality of life during the first 8 weeks of rehabilitation, except in General Health (GH) SF-36, where the VyproII-group had a significantly better score (P=0.045). The use of Prolene and VyproII-meshes in endoscopic repair of recurrent inguinal hernia seems to result in similar short-term outcomes and quality of life.

Increased expression of eNOS protein in omental versus subcutaneous adipose tissue in obese human subjects

OBJECTIVE: To investigate the expression of eNOS and iNOS mRNA and protein in adipose tissue from subcutaneous (s.c.) and omental adipose tissue of obese subjects.DESIGN: Subcutaneous and omental adipose tissue was obtained from subjects undergoing weight reduction surgery. Messenger RNA and protein levels were measured in tissue extracts and related to basal lipolysis, which was measured in isolated adipocytes from the same subjects.SUBJECTS: Eight overweight but otherwise healthy male subjects (age 43.4±10.3 y, BMI 39±3.5 kg/m2, mean±s.e.m.).MEASURESMENTS: For mRNA detection a competitive reverse transcription polymerase chain reaction method was used while protein was detected by Western blot. Glycerol release was determined in isolated adipocytes using a standard luminometric assay.RESULTS: Tissue mRNA levels for eNOS in s.c. tissue were 6098±1969 amol/mg RNA and in omental tissue 6987±2914 amol/mg RNA (mean±s.e.m., P=0.75). iNOS mRNA levels were substantially lower; in s.c. tissue 227±127 amol/mg RNA and in omental tissue 245±162 amol/mg RNA (P=0.8). In Western blot, eNOS protein levels in s.c. and omental tissue were 1.88±2.0 and 7.47±4.11 (OD/mm2 100 µg total protein, P=0.0063), respectively. iNOS protein was expressed at significantly lower levels and barely detectable in both s.c. and omental tissue. Basal rate of lipolysis was two times higher in s.c. compared to omental fat cells (P=0.028).CONCLUSIONS: eNOS protein is markedly increased in omental compared to s.c. adipose tissue in human obese subjects, probably due to post-transcriptional mechanisms. Since basal lipolysis is much lower in omental vs s.c. adipose tissue it is possible that regionally increased NO production, primarily by eNOS, may be involved in the site difference of basal lipolysis in obese subjects.

Early results of a randomized multicenter trial comparing Prolene and VyproII mesh in bilateral endoscopic extraperitoneal hernioplast (TEP)

BackgroundThe use of mesh in inguinal hernia surgery has become increasingly popular despite the potentially harmful effects that foreign material may exert on human tissue. The purpose of this study was to compare the use of a lightweight mesh vs a standard hernia mesh in bilateral endoscopic hernioplasty.MethodsThis single-blinded multicenter trial, 140 men with bilateral inguinal hernias were randomized to undergo totally extraperitoneal endoscopic hernioplasty (TEP) with either Prolene or VyproII. The randomization and all data management were done via the Internet.ResultsA total of 139 patients were operated on as allocated. The follow-up was complete in 94% of the patients. The median (range) operating times were 85 min (45-140) and 73min (35-165) for the Prolene and VyproII groups, respectively. (p = 0.01). The difference was due to uneven distribution of the allocated patients to study groups among individual surgeons. The time to return to work was similar (11 vs 9 days, p = 0.08). The time to return to normal daily activities was 19 days (1-133) in the Prolene group and 12.5 days (0-237) in the VyproII group (p = 0.06). There were no significant differences between the groups in their scores on the Visual Analogue Scale or SF-36 Health Scores during the 8-week follow-up.ConclusionsThe use of Prolene and VyproII meshes in bilateral endoscopic repair of inguinal hernia seems to result in similar short-term outcome and quality of life. However, there was a tendency toward faster return to normal activity among VyproII patients.

The Arg 389 Gly β1-adrenergic receptor gene polymorphism and human fat cell lipolysis

BACKGROUND: The β1-adrenoceptor is a candidate gene for obesity because of its role in catecholamine-induced energy homeostasis. A common Arg 389 Gly variant polymorphism has been shown in recombinant cells to influence its-coupling properties.OBJECTIVE: To investigate the effect of the Arg 389 Gly β1-adrenoceptor polymorphism on catecholamine-induced lipolysis in native human fat cells obtained by subcutaneous biopsy.SUBJECTS: Two-hundred and ninety-eight apparently healthy male and female subjects with a wide variation in body mass index (BMI, 18–60 kg/m2).MEASURES: The lipolytic sensitivities and maximum lipolytic action of noradrenaline and the selective adrenoceptor agonists dobutamine (β1), terbutaline (β2) and CGP 12177 (β3) were determined in isolated subcutaneous adipocytes and related to β-adrenoceptor radioligand binding parameters.RESULTS: No differences in the sensitivity or maximum lipolytic capacity of the agonists were found between the genotypes. This was true both when all subjects were analyzed together and when subgroups (lean, obese, men, women) were analyzed separately. Radioligand binding to β1- or β2-adrenoceptors was also similar between genotypes. The polymorphism had no important influence on either BMI or the distribution of obese and non-obese subjects between the genotypes.CONCLUSION: The distribution of the Arg 389 Gly polymorphism is similar in lean and obese subjects and has no apparent effect on the lipolytic response to β-adrenergic stimulation in native human adipocytes. This suggests, despite the altered coupling properties reported in recombinant cells, that the Arg 386 Gly polymorphism has no important influence on human obesity.

Quality-of-life and Surgical Outcome 1 Year After Open and Laparoscopic Incisional Hernia Repair: PROLOVE: A Randomized Controlled Trial.

Objective:Patients suffering from an incisional hernia after abdominal surgery have an impaired quality of life (QoL). Surgery aims to improve QoL with a minimum risk of further complications. The aim was to analyze QoL, predictors for outcome, including recurrence and reoperation rates during the first postoperative year. Methods:In a randomized controlled trial comparing laparoscopic and open mesh repair, 133 patients were assessed preoperatively and after 1 year with regard to QoL using the Short Form-36 (SF-36), visual analog scale (pain, movement limitation, and fatigue), and questions addressing abdominal wall complaints. Factors concerning recurrence, reoperations, satisfaction, and improved QoL were analyzed. Results:A total of 124 patients remained for analysis. All SF-36 scores except mental composite score increased, reaching and maintaining levels of the Swedish norm already after 8 weeks with no difference between groups. Event-free recovery was seen in 85% in the laparoscopic group and in 65% of the open cases (P < 0.010). Five recurrences occurred after laparoscopic surgery and 1 in the open group (P < 0.112). Overall, abdominal wall complaints decreased from 82% to 13% of the patients; and 92% were satisfied with the result after 1 year.In univariable logistic regression analyses laparoscopic surgery and male sex predicted an event-free recovery. Obesity (BMI > 30) predicted better outcome with regard to QoL. No predictors for recurrence or satisfaction were identified. Conclusions:Patients with incisional hernia benefit substantially from surgery concerning QoL, independent of surgical technique. An event-free recovery occurred frequently after laparoscopic surgery. SF-36 seems well suited for assessing surgical outcome in patients after incisional hernia repair.

Outpatient laparoscopic cholecystectomy. A prospective study with 100 consecutive patients.

One hundred patients with cholelithiasis were included in a prospective consecutive follow-up study to evaluate laparoscopic cholecystectomy in a day surgical setting. The median operating time was 70 min. In 96% of the patients, it was possible to perform peroperative cholangiography. The median time off work was 7 days and the median time to full recovery was 14 days. Five patients were admitted due to weakness/nausea. Six patients were admitted due to conversion to open surgery or choledocholithiasis. Eighty-nine patients were treated in ambulatory surgery. We conclude that laparoscopic outpatient cholecystectomy can be performed safely with a low unplanned admission rate.

Introduction of Herniorraphy with Mesh Plug and Patch

OBJECTIVE To evaluate the introduction of the Perfix mesh plug and patch system for inguinal hernia repair. DESIGN Prospective consecutive follow-up study. SETTING Teaching hospital, Sweden. SUBJECTS 139 patients with 145 hernias who were operated on for inguinal hernia with the Perfix mesh plug and patch technique during 1997. MAIN OUTCOME MEASURES Operating time, sick leave, time to full recovery, morbidity, recurrence rate. RESULTS The median operating time was 35 minutes (range 15-105) and the mean follow-up was 9 months (range 4-13). Office workers required a mean of 7 days off work (range 0-43) and manual workers 15 days (range 0-90). Retired patients took 21 days (0-30) to recover fully, office workers 22 days (7-70), manual workers 30 days (7-90), students 34 days (0-60) and unemployed patients 60 days (21-150). There were 17 minor complications within 30 days and 2 recurrences during the follow up period. CONCLUSION Herniorraphy with a mesh plug and patch can easily be introduced with good short-term results.