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Maine RG, Kajombo C, Purcell L, Gallaher JR, Reid TD, Charles AG. Effect of in-hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi. BJS Open 2019; 3:367-375. [PMID: 31183453 PMCID: PMC6551403 DOI: 10.1002/bjs5.50152] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 01/22/2019] [Indexed: 12/14/2022] Open
Abstract
Background In sub‐Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care‐seeking by patients. Delays in treatment can result from delayed presentation (pre‐hospital), delays in transfer (intrafacility) or after arrival at the treating centre (in‐hospital delay; IHD). This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD. Methods Utilizing Malawi's Kamuzu Central Hospital Emergency General Surgery database, data were collected prospectively from September 2013 to November 2017. Included patients had a diagnosis considered to warrant urgent or emergency intervention for surgery. Bivariable analysis and Poisson regression modelling was done to determine the effect of IHD (more than 24 h) on mortality, and identify factors associated with IHD. Results Of 764 included patients, 281 (36·8 per cent) had IHDs. After adjustment, IHD (relative risk (RR) 1·68, 95 per cent c.i. 1·01 to 2·78; P = 0·045), generalized peritonitis (RR 4·49, 1·69 to 11·95; P = 0·005) and gastrointestinal perforation (RR 3·73, 1·25 to 11·08; P = 0·018) were associated with a higher risk of mortality. Female sex (RR 1·33, 1·08 to 1·64; P = 0·007), obtaining any laboratory results (RR 1·58, 1·29 to 1·94; P < 0·001) and night‐time admission (RR 1·59, 1·32 to 1·90; P < 0·001) were associated with an increased risk of IHD after adjustment. Conclusion IHDs were associated with increased mortality. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed.
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Affiliation(s)
- R. G. Maine
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - C. Kajombo
- Department of SurgeryKamuzu Central HospitalLilongweMalawi
| | - L. Purcell
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - J. R. Gallaher
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - T. D. Reid
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - A. G. Charles
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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2
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Karran A, Blake P, Chan D, Reid TD, Davies IL, Kelly M, Roberts SA, Crosby T, Lewis WG. Propensity score analysis of oesophageal cancer treatment with surgery or definitive chemoradiotherapy. Br J Surg 2014; 101:502-10. [PMID: 24615406 DOI: 10.1002/bjs.9437] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND The role of treatments involving surgery versus definitive chemoradiotherapy (dCRT) for oesophageal cancer remains controversial. METHODS Consecutive patients with oesophageal cancer were studied. Those whose treatment involved surgery alone or who received neoadjuvant chemotherapy or chemoradiotherapy were compared with those receiving dCRT. Multiple regression models, including propensity scores, were developed to assess confounding factors associated with undergoing surgery or dCRT, and the risk-adjusted association between treatment and survival. RESULTS From a total of 727 patients, regression adjustment to control for bias created a cohort of 521 patients available for comparison (277 in the surgery group and 244 in the dCRT group). Local and distant recurrence rates were 10·1 and 22·0 per cent respectively after surgery, compared with 26·2 and 11·9 per cent following dCRT (P < 0·001). Median survival, and 2- and 5-year survival rates after surgery were 27 months, 53·8 and 31·0 per cent respectively, compared with 28 months, 54·2 and 31·9 per cent after dCRT (P = 0·918). On multivariable analysis, disease-free survival was related to endosonographic tumour category (hazard ratio (HR) 0·76, 95 per cent confidence interval 0·10 to 6·04 for T1; HR 1·57, 0·21 to 11·58 for T2; HR 2·12, 0·29 to 15·49 for T3; HR 3·07, 0·41 to 23·16 for T4; P = 0·003, in relation to T0 as reference), lymph node metastasis count (HR 1·10, 1·04 to 1·15; P < 0·001) and total disease length (HR 0·96, 0·93 to 1·00; P = 0·041). CONCLUSION There was no difference in survival after oesophageal cancer treatment involving surgery or dCRT.
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Affiliation(s)
- A Karran
- South East Wales Cancer Network, Department of Surgery, University Hospital of Wales, Cardiff, UK
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3
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Rutka O, Rees MD, Caparrotta TM, Mant S, Reid TD, Williams GL. Management of suspected appendicitis: a one-year audit. Ann R Coll Surg Engl 2013. [DOI: 10.1308/rcsann.2013.95.5.e13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- O Rutka
- Aneurin Bevan Health Board, UK
| | - MD Rees
- Aneurin Bevan Health Board, UK
| | | | - S Mant
- Aneurin Bevan Health Board, UK
| | - TD Reid
- Aneurin Bevan Health Board, UK
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4
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Chan DSY, Reid TD, Howell I, Lewis WG. Systematic review and meta-analysis of the influence of circumferential resection margin involvement on survival in patients with operable oesophageal cancer. Br J Surg 2013; 100:456-64. [DOI: 10.1002/bjs.9015] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2012] [Indexed: 12/26/2022]
Abstract
Abstract
Background
The prognostic role and definition of circumferential resection margin (CRM) involvement in operable oesophageal cancer remain controversial. The College of American Pathologists (CAP) and Royal College of Pathologists (RCP) define CRM involvement as tumour found at the cut resection margin and within 1 mm of the cut margin respectively. This systematic review and meta-analysis was performed to determine the influence of CRM involvement on survival in operable oesophageal cancer.
Methods
PubMed, MEDLINE and the Cochrane Library (January 1990 to June 2012) were searched for studies correlating CRM involvement with 5-year mortality. Statistical analysis of dichotomous variables was performed using the odds ratio (OR) as the summary statistic.
Results
Fourteen studies involving 2433 patients with oesophageal cancer who had undergone potentially curative oesophagectomy were analysed. Rates of CRM involvement were 15·3 per cent (173 of 1133) and 36·5 per cent (889 of 2433) according to the CAP and RCP criteria respectively. Overall 5-year mortality rates were significantly higher in patients with CRM involvement compared with CRM-negative patients according to both CAP (OR 4·02, 95 per cent confidence interval (c.i.) 2·25 to 7·20; P < 0·001) and RCP (OR 2·52, 1·96 to 3·25; P < 0·001) criteria. CRM involvement between 0·1 and 1 mm was associated with a significantly higher 5-year mortality rate than CRM-negative status (involvement more than 1 mm from CRM) (OR 2·05, 95 per cent c.i. 1·41 to 2·99; P < 0·001).
Conclusion
CRM involvement is an important predictor of poor prognosis. CAP criteria differentiate a higher-risk group than RCP criteria, but overlook a patient group with similar poor outcomes.
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Affiliation(s)
- D S Y Chan
- Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK
| | - T D Reid
- Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK
| | - I Howell
- Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK
| | - W G Lewis
- Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK
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5
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Saeed ZM, Lloyd-Evans J, Reid TD, Williams R, Robinson M, Williams GL, Stephenson BM. CT evaluation for 'quiescent' herniation following closure of diverting loop ileostomy. Colorectal Dis 2012; 14:1528-30. [PMID: 22471312 DOI: 10.1111/j.1463-1318.2012.03039.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AIM The prevalence of abdominal wall herniation at the site of a previous temporary stoma is uncertain. This cohort study investigated the frequency of radiological abnormalities at the site of a closed diverting loop ileostomy. METHOD All patients in whom an ileostomy was raised and later closed during a 5-year period formed the study group. When colorectal cancer surveillance computed tomography (CT) was undertaken the images were scrutinized and graded as to defined anatomical abnormalities. RESULTS One hundred and seventy-nine patients had an ileostomy, of which 92 were diverting. Fifty-nine (64%) were closed at various intervals (median time to closure 6 (2-22) months and 43 underwent a surveillance CT at 1-3 (median 2) years. At 1 year an abnormality (atrophy or defect) at the site of closure was seen in 16 (37%) CT scans. These were more frequent with increasing duration of follow-up. One asymptomatic hernia was detected at 2 years but there was no deterioration in the abdominal wall at 3 years when compared with that at 2 years. CONCLUSION Abnormalities in the abdominal wall at the site of a closed diverting ileostomy are common but true herniation is unusual. The routine use of prophylactic mesh at ileostomy closure may be unnecessary.
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Affiliation(s)
- Z M Saeed
- Departments of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
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Reid TD, Carenzo M, Pellicciotti F, Brock BW. Including debris cover effects in a distributed model of glacier ablation. ACTA ACUST UNITED AC 2012. [DOI: 10.1029/2012jd017795] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Chan DSY, Fielding P, Roberts SA, Reid TD, Ellis-Owen R, Lewis WG. Prognostic significance of 18-FDG PET/CT and EUS-defined tumour characteristics in patients with oesophageal cancer. Clin Radiol 2012; 68:352-7. [PMID: 22981727 DOI: 10.1016/j.crad.2012.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 08/01/2012] [Accepted: 08/06/2012] [Indexed: 12/25/2022]
Abstract
AIM To determine the correlation between 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography/computed tomography (PET/CT) defined maximum standardized uptake value (SUVmax) and endoluminal ultrasound-defined tumour volume (EDTV) in patients with oesophageal cancer (OC) and their relative prognostic significance. MATERIALS AND METHODS One hundred and eighty-five consecutive patients with OC were staged using CT, endoscopic ultrasound (EUS), and PET/CT. The maximum potential EDTV was calculated (πr(2)L, where r = tumour thickness and L = total length of disease including proximal and distal lymph node metastases). Primary outcome measure was survival from diagnosis. RESULTS Ninety-one percent of patients (168/185) had FDG-avid tumours on PET/CT. SUVmax correlated positively and significantly with EDTV (Spearman's rho = 0.339, p = 0.001). On univariate analysis, survival was inversely related to the PET/CT lymph node metastasis count (LNMC, p = 0.015), EUS N stage (p = 0.002), EDTV (<48 cm(3), p = 0.001), EUS total length of disease (p = 0.001), SUVmax (p = 0.002), PET/CT N stage (p < 0.0001), and EUS LNMC (p < 0.0001). On multivariate analysis two factors were significantly and independently associated with survival: EDTV (HR, 3.118; 95% CI: 1.357-7.167; p = 0.007), and PET/CT N stage (HR, 0.496; 95% CI: 0.084-1.577; p = 0.022). CONCLUSION EDTV and PET/CT N stage were important predictors of survival and further research is needed to identify critical prognostic values.
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Affiliation(s)
- D S Y Chan
- Department of Surgery, University Hospital of Wales, Cardiff, UK.
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8
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Davies L, Mason JD, Roberts SA, Chan D, Reid TD, Robinson M, Gwynne S, Crosby TD, Lewis WG. Prognostic significance of total disease length in esophageal cancer. Surg Endosc 2012; 26:2810-6. [PMID: 22534739 DOI: 10.1007/s00464-012-2250-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND This study tested the hypothesis that endoluminal ultrasound (EUS) defined total length of disease (including both the primary tumor and the position and number of proximal and distal lymph nodes-ELoD) and the associated EUS lymph node metastasis count (ELNMC) are better predictors of outcome than endoscopic esophageal cancer (OC) length and radiological tumor node metastasis stage in patients who undergo potentially curative treatment with surgery or definitive chemoradiotherapy (dCRT). METHODS A total of 645 consecutive patients diagnosed with OC and managed by a multidisciplinary team were staged by CT and EUS. The primary outcome measure was survival from date of diagnosis. RESULTS A total of 323 patients received surgery (208 neoadjuvant chemotherapy), and 322 who were deemed unsuitable for surgery received dCRT. Univariable analysis revealed that survival was related to EUS T (p < 0.0001), N (p < 0.0001), EUS primary tumor length (p = 0.037), ELoD (p = 0.011), ELNMC (p < 0.0001), and treatment type (p = 0.001). Multivariable analysis revealed two factors: ELoD (hazard ratio (HR), 0.961; 95 % confidence interval (CI), 0.925-0.998; p = 0.041) and ELNMC (HR, 1.08; 95 % CI, 1.015-1.15; p = 0.016) were independently associated with survival. CONCLUSIONS ELoD and ELNMC should become part of routine OC radiological staging to optimize stage-directed therapeutic outcomes.
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Affiliation(s)
- L Davies
- South East Wales Cancer Network, Department of Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK.
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9
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Abstract
Worldwide internet access is increasing exponentially. The UK Government Office for National Statistics reported that between 2002 and 2009 the proportion of UK households with internet access increased from 46% to 70%. Between 2007 and 2009 the proportion of UK adults using the internet to access health information rose from 27% to 42%. Similar situations exist in Continental Europe and the USA, where 52% of internet users and 61% of adults respectively search online for medical information. In 2003 it was estimated that 4.5% of all internet searches globally were for health related information. Moreover, patients now frequently choose to seek health information online. Indeed Hesse et al reported that almost one in two patients search the internet before consulting a physician.
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Affiliation(s)
- TD Reid
- Specialist Registrar in General Surgery, University Hospital of Wales, Cardiff
| | - C Beaton
- Specialist Registrar in General Surgery, University Hospital of Wales, Cardiff
| | - IL Davies
- Clinical Research Fellow in General Surgery, University Hospital of Wales, Cardiff
| | - D Arnold
- Medical Student, University Hospital of Wales, Cardiff
| | - JBM Ward
- Medical Student, University Hospital of Wales, Cardiff
| | - WG Lewis
- Consultant Surgeon, University Hospital of Wales, Cardiff
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10
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Abstract
A case report of spontaneous omental bleeding attributed to a combination of vigorous abdominal exercise and antiplatelet agents. This case serves to high-light the bleeding risks associated with antiplatelet therapy.
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Affiliation(s)
- T D Reid
- Department of General Surgery, West Wales General Hospital, Carmarthen, UK.
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11
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Abstract
INTRODUCTION Timing of intervention in symptomatic carotid disease is critical. The UK Department of Health's National Stroke Strategy published in December 2007 recommends urgent carotid intervention within 48 h, in appropriate patients, who have suffered a transient ischaemic attack (TIA), amaurosis fugax or minor stroke. Despite the running of a rapid-access clinic for patients with symptoms of TIA, the time from symptom to surgery is rarely less than 2 weeks. To date, there has been little published research on the UK public response to the symptoms of TIA, and no study at all of the response of primary care to such patients. The aim of this study was to ascertain both these responses to see whether a 48-h target is achievable. PATIENTS AND METHODS A total of 402 men attending our aortic aneurysm screening sessions were asked to complete a questionnaire requesting their most likely response to an episode of amaurosis fugax or TIA. All 45 GP practices in the hospital catchment area were asked how they would respond to patients requesting to be seen with the symptoms used in the questionnaire. RESULTS Nearly one in six patients would ignore the symptom unless it recurred, approximately half would request a GP appointment and a third would see an optician if they had amaurosis fugax. The mean waiting time to see a GP was 2 days for a routine appointment and within 24 h for an emergency appointment. CONCLUSIONS It is clear that a significant number of people would ignore the first symptom of carotid ischaemia; for those with amaurosis fugax, nearly a third would initially seek help from their optician. Those given a routine GP appointment would have to wait a minimum of 2 days. If the Department of Health is serious about reducing the incidence of stroke and introducing a target of 48 h from symptom to treatment, then there needs to be a wide-spread public and healthcare education programme, in particular alerting opticians and GP receptionists that these symptoms constitute a medical emergency.
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Affiliation(s)
- T D Reid
- Department of General Surgery, Princess of Wales Hospital, Coity Road, Bridgend CF31 1RQ, UK.
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12
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Sanjay P, Reid TD, Bowrey DJ, Woodward A. Defining the position of deep inguinal ring in patients with indirect inguinal hernias. Surg Radiol Anat 2006; 28:121-4. [PMID: 16636774 DOI: 10.1007/s00276-006-0105-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Accepted: 11/28/2005] [Indexed: 10/24/2022]
Abstract
A preliminary survey of surgeons of all grades in our hospital revealed confusion about the position of the deep inguinal ring. Standard teaching is that the deep inguinal ring is lateral to the femoral artery. The aim of this study was to define the position of the deep ring in patients undergoing elective inguinal hernia repair. Thirty consecutive male patients undergoing indirect inguinal hernia repair under local anaesthesia were studied. The following landmarks were marked on the patient with a felt pen: anterior superior iliac spine (ASIS), femoral artery (FA), deep inguinal ring (DR), pubic tubercle (PT) and pubic symphysis (PS). The distance of each point from the ASIS was measured in centimetres. The relation of the femoral artery to the deep inguinal ring was confirmed by palpation through the deep ring during surgery. The femoral artery was consistently identified midway between the anterior superior iliac spine and pubic symphysis (mid-inguinal point). The deep inguinal ring was located medial (22/30) or above (8/30) the femoral artery, but never lateral. The mean distances from the anterior superior iliac spine to the deep ring and femoral artery were 8.8 and 7.7 cm, respectively. Contrary to standard teaching, this study demonstrates that the deep inguinal ring lies medial, not lateral, to the femoral artery. This may clarify some of the variations in textbook anatomy, and explain the difficulty in distinguishing direct and indirect inguinal hernias pre-operatively.
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Affiliation(s)
- P Sanjay
- Royal Glamorgan Hospital, Llantrisant, CF72 8XR, S Wales, UK
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Sanjay P, Reid TD, Davies EL, Arumugam PJ, Woodward A. Retrospective comparison of mesh and sutured repair for adult umbilical hernias. Hernia 2005; 9:248-51. [PMID: 15891810 DOI: 10.1007/s10029-005-0342-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2004] [Accepted: 03/28/2005] [Indexed: 12/14/2022]
Abstract
Adult umbilical and paraumbilical hernia repair is associated with a high recurrence rate of 10-30%. Mesh repair has been reported to be associated with low recurrence rates. This study aims to compare sutured repair with prosthetic mesh repair to evaluate recurrence and infection rates. A retrospective study was conducted over an 8-year period including all the umbilical and paraumbilical hernia repairs performed by one consultant surgeon. The hernias were repaired using interrupted suture, Mayo overlap, flat mesh and mesh plug techniques. The study was based on case-note review, telephone and postal questionnaire survey. A total of 100 patients were studied, of which 70 had paraumbilical hernias, 28 had umbilical hernias and 2 had both types of hernia. Median age was 56 years (range 19-90 years). A total of 61 patients had suture repair (50 interrupted suture repair, 11 Mayo) and 39 had prosthetic mesh repair (33 mesh plug, 6 flat mesh). The median body mass index (BMI) was 31.2 (range 23.4-44.5) in the suture repair group and 33.3 (range 24.1-59.1) in the mesh group, with no significant statistical difference in BMI between the two groups (P>0.05). Median follow-up was 4.5 years (range 1-8 years). Recurrence rates for the suture and mesh repair groups were 11.5 and 0%, respectively (P=0.007). Infection rates for the suture and mesh repair groups were 11.5 and 0%, respectively (P=0.007). Our data suggest that prosthetic mesh repair is ideal for managing primary and recurrent umbilical hernias in both obese and non-obese patients.
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Affiliation(s)
- P Sanjay
- Department of General Surgery, Royal Glamorgan Hospital, Llantrisant, Wales CF72 8XR, UK
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Beddard T, Ebrahimzadeh M, Reid TD, Sibbett W. Five-optical-cycle pulse generation in the mid infrared from an optical parametric oscillator based on aperiodically poled lithium niobate. Opt Lett 2000; 25:1052-1054. [PMID: 18064270 DOI: 10.1364/ol.25.001052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
We describe an optical parametric oscillator based on aperiodically poled lithium niobate that generates nearly transform-limited 53-fs duration pulses at a center wavelength of 3mum, corresponding to only 5 optical cycles. Results are presented illustrating the effect of pump- and grating-period chirp on the idler pulses, and a configuration capable of producing idler bandwidths in excess of 700 nm is discussed.
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