Systemic immune response after open tension-free inguinal hernia repair under different anesthetic alternatives: a prospective comparative study

PURPOSE

The purpose of the present study was a comparison of the systemic inflammatory response intensity through the estimation of C- reactive protein and albumin levels before and after open tension free inguinal hernia repair performed under different anesthetic alternatives.

PATIENTS AND METHODS

Totally, 125 inguinal hernia patients scheduled for unilateral primary open tension free inguinal repair unRomader local (50 patients), spinal (50 patients) and general anesthesia (25 patients) have been included in this prospective study.

RESULTS

The group of local anesthesia was associated with the higher postoperative serum levels of albumin compared to the group of general anesthesia (P 0.013). Local anesthesia was also associated with higher postoperative serum albumin levels compared to regional anesthesia but however the difference was not statistically significant (P 0.282). The group of local anesthesia was also associated with the lower postoperative levels of CRP compared to the regional (P 0.0094) and general anesthesia (P 0.0009) groups.

CONCLUSION

Local anesthesia proved superior to regional or general anesthesia for open tension free inguinal hernia repair in the given patient sample from the standpoint of the inflammatory and acute phase response.

A prospective randomized comparison of testicular functions, sexual functions and quality of life following laparoscopic totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) inguinal hernia repairs

BACKGROUND

There is very scant literature on the impact of inguinal hernia mesh repair on testicular functions and sexual functions following open and laparoscopic repair. The present randomized study compares TAPP and TEP repairs in terms of testicular functions, sexual functions, quality of life and chronic groin pain.

METHODS

This study was conducted from April 2012 to October 2014. A total of 160 patients with uncomplicated groin hernia were randomized to either trans-abdominal pre-peritoneal (TAPP) repair or totally extra-peritoneal (TEP) repair. Testicular functions were assessed by measuring testicular volume, testicular hormone levels preoperatively and at 3 months postoperatively. Sexual functions were assessed using BMSFI, and quality of life was assessed using WHO-QOL BREF scale preoperatively and at 3 and 6 months postoperatively. Chronic groin pain was evaluated using the VAS scale at 3 months, 6 months and at 1 year.

RESULTS

The median duration of follow-up was 13 months (range 6-18 months). The mean preoperative pain scores (p value 0.35) as well as the chronic groin pain were similar between TEP and TAPP repairs at 3 months (p value 0.06) and 6 months (p value 0.86). The testicular resistive index and testicular volume did not show any significant change at follow-up of 3 months (p value 0.9) in the study population. No significant difference was observed in testicular resistive index and testicular volume when comparing TEP and TAPP groups at at follow-up of 3 months (p value >0.05). There was a statistically significant improvement in the sexual drive score, erectile function and overall satisfaction over the follow-up period following laparoscopic inguinal hernia repair. However, sexual function improvement was similar in patients undergoing both TEP and TAPP repairs. All the domains of quality of life in the study population showed a significant improvement at a follow-up of 3 and 6 months. Subgroup analysis of all the domains of quality of life in both TAPP and TEP groups showed a similar increment as in the study population (p value <0.001); however, the mean scores of all the domains were comparable between the two subgroups (p value >0.05), preoperatively and 3 and 6 months follow-up.

CONCLUSIONS

Laparoscopic groin hernia repair improves the testicular functions, sexual functions and quality of life, but TEP and TAPP repairs are comparable in terms of these long-term outcomes.

Biochemical changes following succinylcholine administration after pretreatment with rocuronium at different intervals

OBJECTIVE

To evaluate the biochemical changes associated with succinylcholine administration after pretreatment with rocuronium at different time intervals.

METHOD

The prospective, randomised, single-blinded study was conducted at the Combined Military Hospital, Rawalpindi, from January to May 2010. Ninety male, aged 18-60 years, American Society of Anaesthesiology I or II patients undergoing elective inguinal herniotomy or external haemorrhoidectomy were included. The patients were randomly divided into three equal groups. Group A received a normal saline 5 ml as placebo 1 minute before succinylcholine; Group B received rocuronium 0.06 mg/kg 1 intravenously minute before succinylcholine, while Group C received intravenous injection of rocuronium 0.06 mg/kg 5 minute before succinylcholine. Venous blood samples for creatinine phosphokinase, lactate dehydrogenase and myoglobin plasma concentrations were obtained at 0, 30 minutes, 6 hours and 24 hours after succinylcholine administration.

RESULTS

Mean serum creatinine phosphokinase and myoglobin concentrations were significantly decreased in Groups B and C compared to Group A at 30 minutes and 24 hours (p < 0.05). However, no significant difference in the enzyme levels at any time interval was observed among the rocuronium groups. There was a significant rise in lactate dehydrogenase concentrations at 6 hours and 24 hours in Group A compared to Groups B and C (p < 0.05).

CONCLUSION

Pretreatment with rocuronium effectively reduces the biochemical changes associated with succinylcholine-induced muscle fasciculations. However, whether it is given 1 minute or 5 minutes before succinylcholine does not make much difference.

Circulating matrix metalloproteinases and their inhibitors in inguinal hernia and abdominal aortic aneurysm

AIM

There is evidence supporting the role of matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) in aortic and abdominal wall connective tissue degeneration, resulting in aneurysm and hernia formation. Furthermore, clinical association studies have demonstrated increased prevalence of abdominal wall hernias in patients with aortic aneurysms. Our objective was to estimate the levels of MMPs and TIMPs in the blood of patients with aortic aneurysm and inguinal hernia, in order to investigate whether there is potential pathogenic linkage of impaired collagen metabolism.

METHODS

Plasma concentrations of MMP-9, MMP-2, TIMP-1 and TIMP-2 were quantified using ELISA in 33 male patients with abdominal aortic aneurysm and 91 male patients with inguinal hernia. They were consecutive patients undergoing repair during the study period. The same substances were measured in 35 healthy male controls.

RESULTS

MMP-9 and MMP-2 concentrations were lower in the plasma of patients with inguinal hernia and abdominal aortic aneurysm than controls, with hernia patients having the lowest circulating levels. The levels of TIMP-2 were significantly elevated in patients with inguinal hernia and significantly reduced in patients with aortic aneurysm, whereas opposite correlations were found for circulating TIMP-1.

CONCLUSION

Different patterns of circulating MMP and TIMP levels were found in patients with aneurysm and hernia compared with controls. Underlying pathogenic processes implicating MMPs and TIMPs in connective tissue metabolism are expressed by differing plasma levels in the two disease states. Further research including combined plasma and tissue analyses is required to further investigate potential common pathogenesis of these diseases.

Coagulation, inflammatory, and stress responses in a randomized comparison of open and laparoscopic repair of recurrent inguinal hernia

BACKGROUND

In previous comparisons of inflammatory and stress responses to open (OR) and laparoscopic (LR) hernia repair, all operations were performed under general anesthesia. Since local anesthesia is widely used for OR, a comparison of this approach with LR seemed relevant.

METHODS

Patients with recurrent inguinal hernia were randomized to OR under local anesthesia (n = 30) or LR under general anesthesia (n = 31). The magnitude of the surgical trauma was assessed by measuring markers of coagulation (prothrombin fragment 1 + 2), endothelial activation (von Willebrand factor), inflammation [leukocytes, interleukin-6, -8 and -10, granulocyte macrophage colony-stimulating factor, and C-reactive protein (CRP)], and endocrine stress (cortisol) in blood collected before operation, 4 h postincision, and on postoperative day 2.

RESULTS

Leukocyte counts and interleukin-6 and CRP levels increased in both groups, with the CRP increase being significantly greater in the OR group. The other markers did not increase significantly.

CONCLUSION

The acute phase response was more pronounced after OR, even when this was done under local anesthesia. Both techniques seemed rather atraumatic.

Combined spinal-propofol anesthesia with noninvasive positive-pressure ventilation

Twenty-three adult patients undergoing repair of inguinal hernia under spinal anesthesia received propofol infusion for sedation with the assist of noninvasive positive-pressure ventilation (NPPV). Circulatory and respiratory parameters, such as percutaneous oxygen saturation, transcutaneous carbon dioxide tension, respiratory rate, tidal volume, blood pressure, and heart rate, were maintained within physiological ranges during the anesthesia. There were no adverse effects. These findings suggest that the application of NPPV in patients receiving propofol infusion for sedation is clinically practicable during anesthesia.

Serum VEGF and b-FGF profiles after tension-free or conventional hernioplasty

BACKGROUND

Angiogenesis is strongly influenced by vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (b-FGF), whose production is also regulated by interferon (IFN)-gamma and interleukin (IL)-10. The aim of this study was to evaluate the modifications of serum VEGF, b-FGF, IFN-gamma and IL-10 levels in patients with inguinal hernia undergoing hernioplasty with the Lichtenstein technique (LH) using polypropylene mesh or with Bassini open conventional inguinal hernia repair (BH).

MATERIALS AND METHODS

Randomly, 16 patients underwent BH, and 16 were treated with the LH technique using polypropylene mesh. Blood samples were collected 24 h prior to surgery and then 6, 24, 48 and 168 h postoperatively. The serum concentrations of VEGF, b-FGF, IFN-gamma and IL-10 were evaluated.

RESULTS

In BH patients, a peak of VEGF synthesis at 6 h with a normalization of this parameter 24 h after surgery has been observed. In the same subjects, b-FGF synthesis increased after surgery reaching significant levels 48 h later. On the contrary, in LH patients, a decrease in the serum VEGF and b-FGF concentrations was detected after surgery and their increase afterwards. IL-10 was increased in both groups 6 h after operation and declined to preoperative levels 24 h afterwards. IFN-gamma enhanced in LH patients 6 h after surgery, whereas no modifications were detected in BH subjects.

CONCLUSIONS

This preliminary study shows that VEGF and b-FGF modifications, associated with alterations of cytokine secretion, are detectable in human undergoing hernioplasty, and suggests that they could somehow influence in the wound-healing process.

Comparison of the plasma and hernia sac tissue copper levels in direct and indirect inguinal hernia patients

Although the inguinal hernia is among the most commonly encountered and well-described health problems all over the world, the etiology is still controversial. The aim of this study was to compare the plasma and hernia sac tissue copper levels in direct and indirect inguinal hernia patients. Plasma and hernia sac tissue copper levels obtained from patients operated under spinal anesthesia with primary direct (group I, n = 55, 45 male, mean age = 45.68 yr) and indirect (group II, n = 55, 40 male, mean age = 38.57 yr) hernias were detected by atomic absorption spectrophotometer. Significantly lower plasma and hernia sac tissue copper levels were detected in group I in comparison to group II (p < 0.001). Both plasma and hernia sac tissue copper levels were significantly lower in males when we compare the patients according to their sex characteristics, including both direct and indirect hernia groups (p < 0.05 and p < 0.01, respectively). Age was not a significant factor. The plasma and hernia sac tissue copper levels were significantly lower in direct hernia patients in comparison to indirect hernia patients. Copper is a cofactor of lysyl oxidase, an important enzyme in collagen tissue metabolism, so there might be a defect in the collagen synthesis of direct hernia patients because of the decreased activity of the lysyl oxidase. Further investigations are necessary to clarify this concept.

Lipid peroxidation and inguinal hernia repair. Tension-free vs. Andrews technique

AIM OF THE STUDY

To evaluate the early effect of inguinal hernia repair by the tension-free method compared to the conventional Andrew's technique on lipid peroxidation.

PATIENTS-METHODS

Thirty-four patients subjected to elective hernia repair were enrolled in the study divided in two groups. Group A (n=18) underwent hernia repair by the tension-free method using a polypropylene mesh. Group B (n=16) underwent hernia repair by the Andrew's technique (i.e. a modification of the Bassini's technique). Venous blood samples were drawn preoperatively and at 12, 24 and 48 h postoperatively. Malondialdehyde (MDA) was estimated by the thiobarbiturate assay.

RESULTS

Neutrophil counts were significantly higher in patients of group B compared to group A at 12 and 48 h postoperatively. Concentrations of fibrinogen were similar between the two groups. MDA was significantly higher in patients of group B hours compared to group A at 12, 24 and 48 h postoperatively. Positive correlation was found between neutrophil counts and MDA at 12 h (r: +0.43, P: 0.015) and 48 h (r: +0.496, P: 0.005) but not at 24 h. No correlation was found between serum fibrinogen and MDA.

CONCLUSION

Hernia repair by the Andrews's technique elicits a sustained triggering of lipid peroxidation, compared to the tension-free method.

Inguinal hernias, endometriosis, and other adverse outcomes in rhesus monkeys following lead exposure

The Harlow Center for Biological Psychology (HCBP) has a cohort of rhesus monkeys that were exposed to low concentrations of lead acetate in utero or as infants. The lead-exposed animals have been followed for 19 years and have developed four cases of inguinal hernia (males), three cases of endometriosis (females), and one case of immunoblastic lymphoma (male). Retrospective analysis of the data from the original lead-exposed cohort indicates that there is a significant association between lead exposure and the development of inguinal hernia (P=.04). Endometriosis was not significantly associated with lead exposure (P=.36). A case control study also was done to determine the significance of neonatal lead exposure as a risk factor for the development of inguinal hernia and endometriosis. The risk of developing inguinal hernia was significantly increased in lead-exposed animals (OR=20.0, P=.009). The association between endometriosis and lead exposure was also strong (OR=10.13, P<.001). No unmatched variables were associated with inguinal hernia, including body weight, history of diarrhea, constipation, or intussusception. No unmatched variables were highly associated with endometriosis, including body weight, age at first parity, and history of stillbirths. However, parity and the number of stillbirths were associated with lead exposure (P=.011 and P=.041, respectively). There was an association between endometriosis and a history of hysterotomy (OR=2.09) but it was not statistically significant (P=.38). No other cases of lymphoma in unexposed animals were identified using HCBP animal health records. These data indicate that early lead-exposed rhesus monkeys may develop illnesses later in life, especially inguinal hernia and endometriosis, more frequently than unexposed monkeys. Studies of human populations with early lead exposure are warranted to determine their incidence of inguinal hernia, endometriosis, and hematologic neoplasia.

A comparison of the oxidative stress response and antioxidant capacity of open and laparoscopic hernia repairs

BACKGROUND

Free radical-induced lipid peroxidation that is associated with a decrease in the antioxidant status of plasma occurs in many kinds of surgical procedures. In this study, we aimed to investigate markers of oxidative stress--malondialdehyde (as thiobarbituric acid reactive substances), protein carbonyls, and protein sulfhydryls--in patients undergoing Lichtenstein tension-free hernioplasty (LH) or laparoscopic preperitoneal hernia (LPPH) repair.

METHODS

Seventeen patients with unilateral inguinal hernia and no complications or recurrence were included in this study. Ten were randomized to undergo LH and seven to LPPH repair. Heparinized blood samples were taken to measure the levels of oxidative stress markers in the patients undergoing hernia repair. Levels of malondialdehyde, protein carbonyls, and protein sulfhydryls were measured preoperatively and at 6 and 24 hours postoperatively in all patients.

RESULTS

Both types of hernia repair caused a significant increase in the oxidative stress response and a decrease in antioxidant activity. Plasma levels of malondialdehyde and carbonyls (indicators of oxidant activity) were significantly higher in the LH than in the LPPH repair group (P<.05), and plasma sulfhydryl levels (indicators of antioxidant activity) were significantly lower in the LH than in the LPPH group (P<.05). In both groups, significant differences were also found between the preoperative levels and the postoperative levels 6 and 24 hours (P<.05).

CONCLUSIONS

These data demonstrate that both LH and LPPH repair cause a significant increase in markers of oxidative stress; however, the oxidative stress response associated with LH is greater than that associated with LPPH repair.

Nuclear factor kappaB activation in acute appendicitis: a molecular marker for extent of disease?

Nuclear factor-kappaB (NF-kappaB) has been demonstrated to regulate the transcription of target genes and stimulate inflammatory cytokine responses in a variety of inflammatory diseases. Preliminary studies have demonstrated that NF-kappaB is activated early in acute inflammation and sepsis and may serve as an indicator of clinical severity. The present study was designed to evaluate the degree of activation of NF-kappaB in patients with acute appendicitis and correlate activation with clinical extent of disease. Ten patients with acute appendicitis and five control patients (elective inguinal hernia repair) were evaluated by assaying NF-kappaB activity preoperatively and 12 to 18 hours postoperatively. Assaying of NF-kappaB was determined by binding activity for consensus probes in nuclear extracts from peripheral mixed white blood cells obtained by venous puncture. The bands of NF-kappaB activity from gel electrophoresis were quantified with a phosphor imager and reported as units of integrated intensity. The preoperative NF-kappaB activity was increased in all patients with appendicitis versus the controls [mean 151 (range 97-189) vs mean 50.3 (range 13.7-77); P < 0.0001]. The increased NF-kappaB activity also correlated with length of time of symptoms before operation. The patients who were symptomatic for less than 24 hours had an average NF-kappaB value of 103 (range 97-105) versus 171.4 (range 152-189) (P < 0.0001) in those who were symptomatic 24 or more hours. The NF-kappaB activity did not correlate with the white blood cell count. Postoperative NF-kappaB binding activity in the appendicitis patients dropped to minimal levels (mean 50.3), even lower than the control patients' baseline values (mean 55.6). Control patients demonstrated low baseline values preoperatively and a slight rise postoperatively [mean 50.3 (range 13.7-77) vs mean 100 (range 45-186)]. We conclude the following: (1) NF-kappaB binding activity is elevated in patients with acute appendicitis and correlates with symptoms longer than 24 hours. (2) This increased activity returns to baseline values within 18 hours after appendectomy. (3) Molecular indicators of inflammation may have a role in both staging surgical inflammatory conditions and predicting ultimate outcome.

Systemic inflammatory responses during laparoscopic and open inguinal hernia repair: a randomised prospective study

OBJECTIVE

To see if the inflammatory responses during and after laparoscopic and open inguinal hernia repairs differed.

DESIGN

Randomised prospective study.

SETTING

County hospital, Denmark.

PATIENTS

18 men aged 25-77 years with unilateral inguinal hernias.

INTERVENTIONS

Ten patients had a laparoscopic repair and 8 an open tension-free repair.

MAIN OUTCOME MEASURES

Serum concentrations of interleukin (IL)-2 receptors (R) of the alpha group (IL-2Ralpha), IL-6, anti-IL-6, IL-10, tumour necrosis factor (TNF)-alpha, sTNF-RI and sTNF-RII before and 2, 6, 12, and 24 hours after the repairs. Duration of operation and time for return to normal activities or work were also recorded.

RESULTS

Serum IL-6 concentrations increased significantly after operation in both groups (p < 0.0001), but the increase was significantly higher after open than after laparoscopic surgery at all sampling times (p = 0.00) at 6 hours postoperatively). Anti-IL-6 and IL-10 remained undetectable at all time points. There were no significant differences or increases in the concentrations of TNF-alpha or sTNF-RII. However, sTNF-RI concentrations increased significantly in both groups (p < 0.001) though there was no difference in between the two groups. IL-2Ralpha decreased significantly in both groups (p < 0.01) with no differences between the groups. The median operation time was 85 min (range 55-100 min) in the laparoscopic group and 52 min (range 45-79 min) in the "open" group (p < 0.01). Median time to return to normal activities/work were 2 and 13 days after laparoscopic and open operations, respectively (p < 0.01).

CONCLUSION

The surgical trauma of laparoscopic inguinal hernia repair is less than that of open tension-free hernia operations as assessed by circulating mediators of the postoperative inflammatory response. The clinical relevance of this finding must be evaluated in larger randomised studies.

Tissue factor assays as diagnostic tools for cancer? Correlation between urinary and monocyte tissue factor activity

Monocyte and urinary tissue factors (mTF and uTF) are both elevated in a number of pathologic conditions, including cancer. This study validates the best available uTF and mTF assays as diagnostic tools for cancer and examines if uTF levels reflect monocyte activation. Using kinetic chromogenic assays for uTF and mTF (measured on fresh resting cells [baseline], unstimulated cells, and lipopolysaccharide [LPS]-stimulated cells), we assessed TF levels in normal individuals, surgical controls, and patients with benign and malignant diseases. Each benign disease group was stratified as inflammatory or noninflammatory. Controls and benign noninflammatory results were indistinguishable. The malignant and inflammatory groups showed raised uTF levels over controls (p < 0.001). mTF levels differ similarly. For mTF and uTF assays, there was no significant difference between the malignant and inflammatory groups. The relative operating characteristic (ROC) curve plots sensitivity against false positive rate (1-specificity) for all possible cutoff values of a diagnostic test. Assay performance is assessed as the area under the curve (AUC). The ROC curve for the uTF assay displayed both sensitivity and specificity for cancer, the AUC being 0.83. Of the three mTF levels, LPS-stimulated cells gave the optimum curve (AUC = 0.71). uTF showed a weak to moderate association with mTF levels but correlated best and was statistically significant when compared with levels in the LPS-stimulated cells. uTF represents an intrinsic, kidney-derived, physiologic concentration rather than that of preactivated or postactivated monocytes. In conclusion, both uTF and LPS-stimulated mTF levels showed sensitivity and specificity in detecting cancer and inflammatory diseases. However, the two forms of TF appear to be independently derived.

Pharmacokinetics and pharmacodynamics of ropivacaine 2 mg/mL, 5 mg/mL, or 7.5 mg/mL after ilioinguinal blockade for inguinal hernia repair in adults

The aim of our study was to evaluate the pharmacokinetics and pharmacodynamics of ropivacaine in ilioinguinal-iliohypogastric blocks (IIB). After ethics committee approval and informed consent, 80 male adults scheduled for inguinal hernia repair were enrolled and randomized into four groups. After induction of general anesthesia, an IIB was performed double blinded in Groups 1, 2, and 3 with 0.25 mL/kg ropivacaine 2 mg/mL, 5 mg/mL, or 7.5 mg/mL and with saline in the Control group. Plasma concentration of ropivacaine was determined in venous blood using reversed-phase high-performance liquid chromatography. IIB with ropivacaine resulted in peak plasma concentrations of 0.3+/-0.15 microg/mL (Group 1) (mean +/- SD), 0.75+/-0.45 microg/mL (Group 2), or 1.57+/-0.82 microg/mL (Group 3). These concentrations occurred after 30 (15-60) min, median (range), 30 (10-60) min, and 45 (15-60) min, in the respective groups. Three of 19 patients in Group 1, 6 of 18 in Group 2, and 5 of 20 in Group 3 did not need any additional analgesics within 24 h postoperatively, but all 20 control patients did. Time to the first demand for analgesia was significantly shorter in the Control group (median 0.3 h [range 0-2.8]) compared with 1.5 h (0.5-24 h), 2 h (0.5-24 h), and 2 h (1.0-24 h) in Groups 1, 2, and 3, respectively. Three patients in Group 3 had a postoperative motor block of the femoral nerve. In conclusion, a ropivacaine dose of 0.25 mL/kg of 5 mg/mL seems adequate for IIB accompanying general anesthesia for postoperative pain relief. However, the pharmacokinetic results obtained suggest that even larger doses (0.25 mL/kg of 7.5 mg/mL ropivacaine) for IIB do not result in plasma concentrations in a toxic range.

IMPLICATIONS

Ropivacaine, a new local anesthetic, proved to be effective for pain relief after hernia repair in ilioinguinal blocks accompanying general anesthesia. Plasma concentrations peaked after 30-45 min, and were within safe limits after application of 0.25 mL/kg of 2, 5, or 7.5 mg/mL ropivacaine.

Increased serum angiogenin concentration in colorectal cancer is correlated with cancer progression

We have previously demonstrated that the increased expression of angiogenin (ANG) in pancreatic cancer is related to cancer aggressiveness; however, the relationship between ANG expression and its clinical relevance in colorectal cancer has not been demonstrated. We therefore investigated the correlation between serum ANG (sANG) concentration and colorectal cancer progression or the changes in sANG concentrations before and after cancer resection. To determination sANG concentration by ELISA, sera were obtained from colorectal cancer patients (the cancer group) preoperatively (n = 34) and postoperatively (n = 25), from hernia patients (the nonneoplastic group) preoperatively (n = 9) and postoperatively (n = 4), and from 23 healthy volunteers. The amount of ANG in the colorectal cancer tissues (n = 19) was determined by the same method. Before surgery, the mean sANG concentration in the cancer group (411.8 +/- 106.3 ng/ml) was significantly higher than that in both the nonneoplastic group (344.0 +/- 60.7 ng/ml; P = 0.04) and in the healthy volunteers (321.7 +/- 59.7 ng/ml; P = 0.0001). The degree of elevation of sANG concentration in the cancer group was more significant in the more progressed subgroups as compared with that in the normal group (versus T(is) + T1 + T2 cancer, P = 0.01; versus T3 + T4 cancer, P = 0.002; versus stage 0 + I cancer, P = 0.02; versus >stage III cancer, P = 0.001; versus Dukes' A cancer, P = 0.02; versus Dukes' C cancer, P = 0.006). After cancer resection, the mean sANG concentrations in each subgroup decreased to the same levels as those of the normal group; the degrees of reduction were more significant in the more progressed subgroups. The tissue ANG amount correlated significantly with sANG concentration (P = 0.007). These results suggest that the increased concentration of sANG that is derived from colorectal cancer correlates with cancer progression.

[Male reproductive function after inguinal hernia]

Reproductive function and treatment results have been analysed for 59 patients aged 17 to 32 years after herniotomy. 28 and 31 of them underwent standard and endosurgical interventions, respectively. The control group consisted of 30 healthy males matched for age. As shown by 6-month follow-up, the endosurgical herniotomy was not associated with such complications as hydroscheocele, hydrocele, testicular atrophy, diminution of blood flow along the testicular arteries. Ejaculate, levels of sex hormones in the blood, cremasteric reflex remained intact. After routine herniotomy there appeared defects in scrotal and testicular microcirculation with partial testicular atrophy in 25% of cases, testicular circulation fell 2.2-2.5-fold, deterioration of spermogram and cremasteric reflex parameters, reduction of serum testosterone were observed.

The inflammatory response to open tension-free inguinal hernioplasty versus conventional repairs

BACKGROUND

The tension-free inguinal hernioplasty is now a popular method because of less postoperative disability and low recurrence rate. The laboratory evaluation of the inflammatory response to the injury is an objective approach to determine the stress status of a surgical procedure. The aim of this study is to evaluate and to compare inflammatory responses to open tension-free and conventional repairs of inguinal hernias.

METHODS

Forty-eight male patients with primary indirect inguinal hernias were treated with elective operations, and separated into three groups according to surgical procedure: 12 pediatric patients treated with dissection of hernia sac in group 1, 16 adult patients with open tension-free hernioplasty in group 2, and 20 adult patients with conventional repairs in group 3. Ten healthy adult volunteers formed group 4 as control. The repair was performed with polypropylene mesh and suture as the Lichtenstein technique in group 2, and with polypropylene suture as one of Bassini, McVay, or Shouldice techniques in group 3. The inflammatory response was evaluated with serum interleukin-6 (IL-6) levels at 12 hours and serum C-reactive protein (CRP) levels at 48 hours postoperatively. Serum levels of IL-6 and CRP were measured in group 4 as control. Patient characteristics, operating time, and IL-6 and CRP levels were compared among the four groups.

RESULTS

There were no significant differences in mean age and operating time between the two groups of adult patients with hernia repair. Mean serum IL-6 levels of 12.1 +/- 5.2 and 8.2 +/- 2.7 pg/mL, and CRP levels of 34.3 +/- 13.8 and 7.5 +/- 4 mg/L in pediatric and control groups, respectively, were significantly lower than in the other two hernia groups. Mean serum IL-6 levels were 58.9 +/- 25.4 pg/mL in group 2 (tension-free repair) and 44.3 +/- 18.1 pg/mL in group 3 (conventional repair) (P > 0.05). Mean serum CRP levels were 111.3 +/- 41.3 and 83 +/- 43.2 mg/L in groups 2 and 3, respectively (P > 0.05). The differences not being statistically significant, a similar and considerable inflammatory response was noted in patients with either prosthetic mesh repair or with conventional repairs of indirect inguinal hernias.

CONCLUSIONS

The reinforcement of the posterior wall of the inguinal canal induces significant cytokine response regardless of tension-free or conventional repair. Open tension-free hernioplasty offered no advantages over conventional repairs from the standpoint of the inflammatory and acute phase response.

Plasma concentration profiles after pre-operative rectal administration of a solution of paracetamol in children

An exploratory study in paediatric surgical patients was performed to describe the behaviour of a rectal solution of paracetamol at 20 mg/kg. Four of six patients were able to complete the study. Peak concentration (Cmax) and time to peak concentration (tmax) found in the children are comparable to adults studied earlier. After 1.6 hrs (tmax) a peak concentration of 11.7 mg/l (Cmax) was reached. The area under the curve (AUC t = 6) and the mean residence time (MRT) were respectively 48.3 mghr/l and 5.2 hrs. The solution appears promising for further study in daily clinical practise.

Inflammatory markers following laparoscopic and open hernia repair

Laparoscopic surgery may reduce the inflammatory response to surgery by the avoidance of a skin incision which is frequently the site of maximum tissue trauma. We hypothesized that the inflammatory response is less with minimally invasive procedures. The aim of this study was to evaluate the response of inflammatory mediators following laparoscopic and open hernia repair. Thirty-four patients undergoing unilateral primary inguinal hernia repair were prospectively assigned to either laparoscopic mesh hernia repair (n = 14), open mesh hernia repair (n = 11), or a Bassini repair (n = 9). Serum samples withdrawn prior to surgery, 6 h after surgery, and then again at 24 h after surgery were assayed for interleukin-6 and C-reactive protein content. Interleukin-6 levels at 24 h in the laparoscopic (13.1 +/- 3.1 pg/ml), open mesh (15.5 +/- 2.5 pg/ml), or Bassini group) (15.4 +/- 2.0 pg/ml) did not differ significantly. Neither did C-reactive protein levels at 24 h in the laparoscopic (12.4 +/- 2.7 pg/ml), open mesh (23.0 +/- 7.8 pg/ml), or Bassini group 18.6 +/- 6.6 pg/ml) differ significantly. The response of inflammatory mediators to hernia repair is not modified by undertaking the procedure laparoscopically.

[Effect of vascular surgery on values of thrombin-antithrombin III complexes in patients with atherosclerosis of lower limb arteries]

In 25 patients with atherosclerosis of lower limb arteries (ALLA) in whom vascular operation was performed, the level of thrombin-antithrombin III (TAT) complexes and antithrombin III (AT III) activity were determined in comprehensive studies of the blood clotting system. The comparative group for the assessment of operation effect on primarily not disturbed haemostasis in humans included 10 men operated on for inguinal hernia, while the control group consisted of 54 healthy people. Blood for the determinations was taken before the operation, on the day of the operation (0-30 minutes after the operation), on the first day after it, and also on the third day in patients with hernia, and on the 7th day in patients with ALLA. In the patients with ALLA, blood hypercoagulation features were found, expressed as increased level of TAT complexes in spite of lack of abnormalities in comprehensive coagulation studies, while in the patients with hernia only increased AT III activity was found. The surgical operation caused in the patients with ALLA enhancing of hypercoagulation which was evidenced by over threefold increase of TAT complexes on the day of the operation.

CRP levels as a measure of surgical trauma: a comparison of different general surgical procedures

Acute phase proteins are released into the circulation as part of the metabolic response to trauma. C reactive protein (CRP) has been shown to be the most specific and sensitive indicator of trauma. We measured pre- and postoperative CRP levels in patients undergoing varicose vein surgery, inguinal herniorrhaphy, laparoscopic cholecystectomy and open cholecystectomy. A significant difference is shown between the levels found in those undergoing varicose vein, hernia surgery or open cholecystectomy; however, there is no significant difference in the CRP levels between open and laparoscopic cholecystectomy.

A comparison of pulmonary functions and oxygenation following local, spinal or general anaesthesia in patients undergoing inguinal hernia repair

In order to compare the pulmonary effects of various anaesthetic techniques, 49 otherwise healthy patients needing inguinal hernia repair were randomized to general, spinal or local anaesthesia. Blood gases were drawn and spirometry performed pre- and postoperatively at fixed intervals. Results showed a superior ventilation and oxygenation pattern for local anaesthesia (p < 0.05). No statistically significant differences were found between the groups with respect to forced vital capacity (FVC) or forced expiratory volume per second (FEV1) but patients who had spinal anaesthesia performed worse, and for the group as a whole there was a significant reduction compared to preoperative values. We conclude that local anaesthesia is less detrimental to pulmonary function in inguinal hernia operations than spinal or general anaesthesia.

Evaluation of the safety of inguinal hernia repair in the elderly using lignocaine infiltration anaesthesia

Repair of inguinal hernia using local anaesthesia is becoming increasingly popular as it avoids many of the systemic side effects associated with general or spinal/epidural anaesthesia and provides excellent early postoperative pain relief. Dosages of local anaesthetic approaching the recommended maximum are frequently required for adequate anaesthesia of the inguinal region. The present study describes the disposition and safety of lignocaine with adrenaline in 14 elderly patients to ascertain its safety with a view to more widespread application of the technique in more complicated hernia repairs. Serial plasma lignocaine concentrations were determined for up to 24 h following doses approaching the recommended maximum for infiltration (7 mg/kg). Peak lignocaine concentrations (normalized to 7 mg/kg) ranged from 0.23 to 0.90 mg/L (mean of 0.54 mg/L); that is, the maximum recorded concentration was less than one-fifth the toxicity threshold for lignocaine of 5 mg/L. The study suggested that the majority of patients tolerated the local anaesthetic approach very well and that the wide safety margin allowed ample scope to develop the local anaesthetic approach for the repair of more complex hernia repairs (e.g. large, bilateral or strangulated herniae, or those in obese patients) without risk of exposing patients to lignocaine concentrations which may cause toxic side effects.

Systemic cytokine response after major surgery

The systemic cytokine response to major surgical trauma was studied in 20 patients undergoing elective aortic surgery and five patients after inguinal hernia repair. Tumour necrosis factor alpha and interferon gamma were not detected in these patients. An early and short-lived interleukin 1 beta (IL-1 beta) response to major surgery was detected only by intensive sampling in the perioperative period. The IL-1 beta peak preceded a more marked interleukin 6 (IL-6) response that peaked 4-48 h after surgery. IL-6 levels had fallen sharply by 48-72 h in all patients who had an uneventful postoperative course. The IL-6 peaks were significantly lower after hernia surgery than after major aortic operations (P < 0.001); IL-1 beta was not detected in any samples. Three patients undergoing aortic surgery developed unexpected major postoperative complications. IL-6 levels in this group were significantly higher than those of the other patients undergoing aortic surgery within 6-8 h of skin incision, and remained elevated for longer. These rises in plasma IL-6 levels preceded the clinical onset of major complications by 12-48 h. The systemic IL-1 beta and IL-6 response to surgical trauma increased with the severity of the surgical insult. An early, exaggerated IL-6 response was associated with the subsequent clinical development of major complications.

Vasopressin and haemostatic responses to inguinal hernia repair under local anaesthesia

Major abdominal surgery is accompanied by intra-operative increases in factor VIII (FVIII), plasminogen activator activity (PAA) and fibrinopeptide A (FPA). Vasopressin (aVP) released during surgery mediates some of the effects but the mechanisms involved in this response are unclear. To investigate the role of the operative procedure, 20 subjects were studied during inguinal hernia operation under local anaesthesia. Venous blood samples were taken for FVIII coagulant activity (FVIII:C), euglobulin clot lysis time (ECLT), FPA, crosslinked FDPs (XL-FDP) and a VP. In six patients, aVP rose from (median) 0.5 to 38.3 pg/ml at bowel manipulation and fell to 4.1 pg/ml post-operatively. PAA rose from 33 units to 377 and 316 units (P less than 0.01), FVIII:C from 1.58 to 2.4 IU/ml (P less than 0.01) and FPA from 5.0 to 6.8 and 11.0 pmol/ml intra-operatively (P less than 0.002). XL-FDP rose from a median value of 34 ng/ml pre-operatively to 230 ng/ml post-operatively. In 14 patients plasma aVP levels remained constant and both FVIII:C and PAA remained unchanged. FPA rose from 2.6 pmol/ml to 5.9 pmol/ml intra-operatively (P less than 0.05) and XL-FDP fell from 110 to 60 ng/ml. Between groups, the changes were significantly different for FVIII:C (P less than 0.05) and PAA (P less than 0.03) with no differences in blood pressure, pulse or symptoms. These results support the hypothesis that aVP secretion during surgery mediates increases in FVIII and PAA. FPA tended to be higher in the aVP secreting group which indicates that aVP mediated activation of coagulation results in a hypercoagulable state.

Age-dependent variation of lymphocyte function in the postoperative child

Circulating lymphocyte profiles and reactivity normally vary with age. Operation results in depression of both lymphocyte counts and blastogenesis but the relationship of age to these alterations has not been previously evaluated in the pediatric surgical patient. This report analyzes the relationship of age to lymphocyte alteration in the postoperative child. Thirty-five healthy children (age range 1 mo to 12 yr), admitted for elective herniorrhaphy, underwent perioperative lymphocyte assay. Anesthesia consisted of halothane and NO2, and operative time averaged 54 minutes. Three milliliters of heparinized whole blood was obtained at induction of anesthesia and at 2 hours postoperatively. Lymphocytes were separated by Histopaque gradient and assayed for absolute count, total T-cells, and total B-cells. Lymphocyte reactivity was determined by 3H-Thymidine incorporation during incubation with the mitogens phytohemagglutinin (PHA), pokeweed (PWM), and/or concanavalin A (Con A) and results expressed as the logarithm of scintillation counts per minute. Differences in preoperative and postoperative values were analyzed for significance by paired T-test. The same differences were evaluated for relationship to age by regression analysis. Operation resulted in significant decreases in all lymphocyte counts (absolute, T- and B-cells), and the operative-induced alteration in both absolute and total B-cell counts were significantly correlated with age (P less than .03, P less than .007, respectively). Similarly, operation resulted in significant depression of lymphocyte reactivity and alteration in B-cell response (PWM) was significantly correlated with age (P less than .008). In all instances of significant correlation, lymphocyte alterations were inversely related to age.(ABSTRACT TRUNCATED AT 250 WORDS)

Spermatic and peripheral oestradiol levels in patients affected by azoospermia due to seminiferous tubular damage

Plasma levels of testosterone, androstenedione and oestradiol were determined in the spermatic venous blood of both testes of 17 patient affected by azoospermia due to tubular damage (Group I). The results were compared with those found in 5 patients affected by azoospermia of obstructive origin and 5 patients with an inguinal hernia (Group II). Mean spermatic levels of testosterone and androstenedione were not significantly different in the two groups, while the mean (+/- SE) oestradiol spermatic level was significantly higher in patients of Group I (5.02 +/- 0.75 nM/l vs. 2.20 +/- 0.365 nM/l; P less than 0.05). Moreover, while the testosterone/androstenedione and the androstenedione/oestradiol ratios were not significantly different in the two groups, the mean (+/- SE) testosterone/oestradiol ratio was significantly lower in patients of Group I (552.71 +/- 80.94 vs. 939.86 +/- 129.45; P less than 0.025). Peripheral testosterone and androstenedione mean levels were not significantly different between the two groups while the mean peripheral oestradiol level (+/- SE) was significantly higher in Group I (0.107 +/- 0.021 nM/l vs. 0.038 +/- 0.05 nM/l; P less than 0.025). Peripheral oestradiol was not significantly related to peripheral FSH, nor to spermatic oestradiol in both groups. These results suggest the possibility that oestradiol may be involved in the pathogenesis of some cases of male infertility.

Testosterone concentrations in spermatic venous blood plasma of prepubertal boys

Testosterone concentration has been measured in spermatic and peripheral venous plasma obtained during surgery from a total of 25 prepubertal boys affected either by inguinal hernia (Group I; N = 6; age range 2-8 years) or unilateral undescended testis (Group II; N = 19; age range 5-11 years). Median spermatic venous testosterone level was 58.7 ng/dl) (range 14.0--120.8 ng/dl) in Group I and 43.2 ng/dl (range 12..2-267.5 ng/dl) in Group II; median peripheral testosterone level was 4.9 ng/dl (range 2.3-15.4 ng/dl) and 5.6 ng/dl (range 1.1-89.3 ng/dl) in Group I and II, respectively. The difference between the spermatic and peripheral level was statistically significant in both groups (P less than 0.01 in Group I and P less than 0.001 in Group II). These results indicate that the prepubertal human testis secretes testosterone, even if in a very low amount. It is also suggested that this secretion can be responsible for LH inhibition in prepubertal boys.

Influence of age on the endocrine-metabolic response to surgery

The pathogenesis of the increased operative risk in elderly patients is unknown. From a theoretical point of view, a change in endocrine-metabolic response might be involved. In the present study, a battery of hormonal and metabolic variables were measured in eight young and eight elderly healthy males undergoing elective inguinal hernial repair under general anesthesia. Blood was drawn before induction of anesthesia, at skin incision, and one, two, and six hours after skin incision. The findings were: 1) Plasma cortisol increase was significantly higher in elderly than in young controls. 2) Plasma renin level was lower in old age, but renin-aldosterone and electrolyte response patterns were alike in the two groups. 3) Thyroid parameters, in terms of serum T4, serum T3, serum rT3, and T3-resin uptake, responded normally to surgery and showed no age-related differences. 4) The hyperglycemic response was not significantly influenced by age indicating unchanged glycoregulatory mechanisms also verified by determinations of plasma catecholamines, cAMP, and insulin. 5) Blood lymphocyte count was constantly lower in elderly than in young and decreased with time, but the age-related difference was not significant. 6) Blood polymorphonuclear leukocytes showed an increase of the same magnitude in both age groups, although at a significantly slower rate in the elderly. It is concluded that age affects some aspects of the initial endocrine-metabolic response to surgery.

Evaluation of alpha-fetoprotein in early infancy

Serum AFP concentrations of normal subjects were statistically analyzed in order to obtain the normal ranges in early infancy. The 95% prediction band would seem to offer a convenient means of evaluating serum AFP in the age range 0-300 days of life. Some illustrative cases, whose AFP values were formerly considered to be abnormally high but later proved to be within normal range, are presented.