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Background: Chronic groin pain in athletes presents often a diagnostic and therapeutic challenge. Sportsman's hernia (also called "athletic pubalgia") is a deficiency of the posterior wall of the inguinal canal, which is often repaired by laparoscopic mesh placement. Endoscopic mesh repair may offer a faster recovery for athletes with sportsman's hernia than nonoperative therapy., Methods: A randomized, prospective study was conducted on 60 patients with a diagnosis of chronic groin pain and suspected sportsman's hernia. Clinical data and MRI were collected on all patients. After 3 to 6 months of groin symptoms, the patients were randomized into an operative or a physiotherapy group (n = 30 patients in each group). Operation was performed using a totally extraperitoneal repair in which mesh was placed behind the symphysis and painful groin area. Conservative treatment included at least 2 months of active physiotherapy, including corticosteroid injections and oral anti-inflammatory analgesics. The outcome measures were pre- and postoperative pain using a visual analogue scale and partial or full recovery to sports activity at 1, 3, 6, and 12 months after randomization., Results: The athletes in both treatment groups had similar characteristics and pain scores. Operative repair was more effective than nonoperative treatment to decrease chronic groin pain after 1 month and up to 12 months of follow-up (P < .001). Of the 30 athletes who underwent operation, 27 (90%) returned to sports activities after 3 months of convalescence compared to 8 (27%) of the 30 athletes in the nonoperative group (P < .0001). Of the 30 athletes in the conservatively treated group, 7 (23 %) underwent operation later because of persistent groin pain., Conclusion: This randomized controlled study indicated that the endoscopic placement of retropubic mesh was more efficient than conservative therapy for the treatment of sportsman's hernia (athletic pubalgia)., (Copyright © 2011 Mosby, Inc. All rights reserved.)

To study the possible benefits of N2O pneumoperitoneum, 40 patients scheduled for laparoscopic cholecystectomy for symptomatic cholelithiasis were randomized into either CO2-induced (n = 20) or N2O-induced (n = 20) pneumoperitoneum groups. The intensity of postoperative pain was assessed by the patients themselves using an visual analogue pain score scale. CO2 insufflation caused respiratory acidosis. The total amount of anesthetic enflurane needed was lower in the N2O than in the CO2 group (p < 0.041). The N2O group experienced less pain 1 hour (p < 0.040) and 6 hours (p < 0.017) postoperatively and the next morning. Serum cortisol and plasma adrenaline concentrations in the N2O group did not differ from those in the CO2 group. Patients with N2O pneumoperitoneum seem to have less pain without the side effects caused by CO2. The N2O pneumoperitoneum is a good alternative to the CO2 pneumoperitoneum, especially for prolonged laparoscopic operations in patients with chronic cardiopulmonary diseases.

Background and Aims: Before choosing between open and laparoscopic preperitoneal tension-free repair, a study comparing their safety and short-term outcome was needed. No randomised studies comparing the two hernia repair techniques have hitherto been published., Material and Methods: A prospective randomised study was carried out comparing laparoscopic transabdominal preperitoneal mesh herniorrhaphy (n = 24) to open preperitoneal mesh herniorrhaphy (n = 25)., Results: When comparing unilateral repairs, the mean operation time was significantly (P < 0.01) shorter in the open group (55 min) than in the laparoscopic group (66 min). Pain on movement (P < 0.05) and pain on coughing (P < 0.01) receded more rapidly in the laparoscopic group. The median time before return to work or normal activity was 7 days (range 1-60) in laparoscopic and 5 days (1-30) in open repair. There were five (21%) complications associated with the laparoscopic procedure, while the open procedure resulted in two (8%) complications. After a median follow-up of 18 months the recurrence rate in the laparoscopic group was 13% and in the open group 8%., Conclusions: In this study the open method was associated with fewer complications and recurrences than the laparoscopic technique. Despite the decreased postoperative discomfort after laparoscopic repair, there was no significant difference in median time before return to work or normal activity. These results together with the higher cost of the laparoscopic procedure suggest that the open method is more suitable at least for unilateral hernias.

Background/aims: Our aim was to review the results of one trocar staging laparoscopies performed under local anesthesia in out patients with intra-abdominal cancer., Materials and Methods: Two hundred fifteen patients with intra-abdominal cancer (predominantly esophagogastric and pancreatohepatobiliary) underwent one trocar staging laparoscopy on lidocain infiltration anesthesia under conscious sedation. In 43 patients computed tomography (CT) or ultrasonography (US) had raised a suspicion of hepatic metastases, but percutaneous needle biopsy had failed to confirm it; 172 patients had negative CT or US. Peritoneum and liver were examined and biopsies were taken under direct laparoscopic control., Results: Fourteen patients (7%) received narcotics during the 2-6 hour observation. Mortality was zero. Complications occurred in 5 patients (2%): 1 small bowel perforation (operated), 1 bleeding from the abdominal wall, 1 acute atrial fibrillation, and 2 wound infections. In 79 patients histology demonstrated hepatic or peritoneal metastases. Out of 136 patients 123 were operated in whom laparoscopy did not demonstrate metastases. Thirty-eight of these were unresectable at laparotomy: Five patients (4%) had peritoneal or liver metastases and 33 (27%) proved locally inoperable. The sensitivity of laparoscopy to ascertain peritoneal or liver metastases was 94%., Conclusions: We conclude that one trocar local anesthesia outpatient laparoscopy is a fairly safe and effective method to detect peritoneal and liver metastases in abdominal cancer.

Between January 1992 and December 1994, 5,742 patients were treated by laparoscopic cholecystectomy in 35 Finnish hospitals. The operation was converted to open laparotomy in 360 (6.3%) patients, the most common causes for conversion being technical difficulties in dissection of the gall bladder (2.8%), bleeding (0.9%) and bile duct injury (0.48%). Intraoperative cholangiography was performed selectively in 18%, and common bile duct stones were found in 10.2% of these cases. Postoperative complications occurred in 208 (3.6%) patients, of whom 65 (1.1%) required reoperation. Twenty-eight (0.48%) of these patients had common bile duct injury. In eighteen patients bilio-digestive Roux-en-Y reconstruction was performed, whereas 10 cases could be handled by endoscopic drainage or suturing and T-tube drainage. Thus, the total number of patients with bile duct injury was 56 (0.96%). The reported hospital mortality was 0.08%. The mean hospital stay and the mean sick leave were three days (range 1-41) and 13 days (range 1-60), respectively. These data demonstrate that laparoscopic cholecystectomy can be performed with acceptable morbidity and mortality rates as a routine method in various different hospitals.

Objective: To study the efficacy, safety and timing of endoscopic retrograde cholangiography (ERC) and sphincterotomy in patients with acute gallstone pancreatitis., Design: Open study in Tampere University Hospital, Finland., Subjects: 45 consecutive patients with acute gallstone pancreatitis who underwent ERC, with or without sphincterotomy., Main Outcome Measures: The results of early, compared with late, ERC with or without sphincterotomy., Results: ERC was successful in all 45 patients. Ampullary impacted stone was found in eight. Common duct stones were found in 21 (47%) and sphincterotomy was successful in 19 of these (90%). Nine patients developed complications (20%), five of the nine in whom severe disease had been predicted (56%) and four of the 36 in whom mild disease had been predicted (11%, p < 0.01). Three patients required operations for necrotising pancreatitis, in two of whom sphincterotomy had failed. There was no difference in outcome between the 21 patients who had ERC with or without sphincterotomy within 72 hours (median 48 h) of the onset of symptoms and the 24 in whom it was delayed for a median of 144 hours., Conclusion: ERC and sphincterotomy may be done safely as a routine in patients with acute gallstone pancreatitis, and delay for a median of six days (range 3-14) from the onset of symptoms did not seem to affect the outcome in our patients.

This prospective study consisted of 32 patients. In each patient, bile was collected during two separate endoscopic retrograde cholangiopancreatographies (ERCP) to study changes in biliary bacteriology and cytology. The mean interval between ERCPs was 20 months (15-29 months). Twenty-three patients had gallstones in the gallbladder, bile ducts, or both. Nineteen of them had bactibilia compared to none of the 9 patients with normal ERCP (P less than 0.001). Fifteen patients had normal bile ducts in ERCP (Group 1). Four of these patients (27%) had bactibilia initially and 9 (60%) at follow-up (P = 0.069). Seventeen patients had bile duct stones and underwent endoscopic sphincterotomy (Group II). Fifteen of these patients (88%) had bactibilia initially, and 15 (88%) also had bactibilia at follow-up. Initially, anaerobic bacteria were detected in 37 per cent of Group I patients with bactibilia and in 50 per cent of Group II patients with bactibilia. At follow-up, the bile in Group I patients infrequently (11%) contained anaerobes, whereas in Group II patients anaerobes predominated (67%; P less than 0.011). Clear correlation between the biliary cytology and bacteriology could not be observed. The authors conclude that ERCP may result in increased incidence of long-term bactibilia and suggest that contamination occurred during ERCP. The bactibilia associated with bile duct stones does not subside after endoscopic treatment of the common duct stones.

Objective: To see if tumour associated antigens CA 195 and CA 19-9 were able to differentiate between patients with pancreatic carcinoma, and those with chronic pancreatitis or stones in the common bile duct., Design: Prospective, open, clinical study., Setting: 47 patients with histologically confirmed pancreatic adenocarcinoma, 38 with chronic pancreatitis diagnosed by endoscopic retrograde cholangiopancreatography (ERCP), and 26 with stones in the common bile duct diagnosed and treated by ERCP., Interventions: Samples of serum taken from all patients just before ERCP, and samples of pancreatic juice obtained from 18, 11, and 12 patients, respectively during ERCP., Results: Assay of the two tumour markers in pancreatic juice failed to differentiate between patients with benign and malignant disease. When assayed in serum, however, CA 195 detected those with carcinoma with a sensitivity of 72% and a specificity of 92%, and CA 19-9 with a sensitivity of 81% and a specificity of 88%. The patients with unresectable tumours had significantly higher concentrations of both markers in serum than patients with resectable tumours (p less than 0.05)., Conclusions: CA 195 and CA 19-9 concentrations in serum are equally successful in differentiating between benign and malignant pancreatic disease. Assay of markers in pancreatic juice does not provide useful diagnostic information.

An analysis of acute necrotizing pancreatitis (ANP) after endoscopic retrograde cholangiopancreatography (ERCP) was carried out. The incidence of ANP was 0.5% (5/914) for ERCP and 0.5% (2/370) for endoscopic sphincterotomies (EST). All the five patients were obese, middle-aged or older women. Four had a suspicion of common bile duct stones and the fifth a pancreatic tumour as an indication for ERCP. Two had most probably a functional sphincteric disorder and the third was without clear pathological findings. In the remaining two cases the bile duct cannulation failed and repeated pancreatic duct cannulation occurred; while in one case the pancreatic duct was not cannulated. The four pancreatographies were normal and without parenchymal opacification. Symptoms of acute pancreatitis started within 6 hours after ERCP. The pancreatitis was severe by Ranson criteria and necrotizing by evaluation at laparotomy. All the patients showed bacterial growth either in bile, blood or ascitic fluid early in the course of pancreatitis (E. coli, Str. faecalis or Klebsiella pneumoniae). The possible pathogenetic factors of post-ERCP ANP are discussed.

A comparative study of 158 patients laparotomized for abdominal trauma is presented. 96 had a penetrating and 62 patients a blunt abdominal injury. 95% of the former group was stabbed with a knife and 56% had signs of alcohol intoxication. The blunt trauma patients were in all the studied respects more difficult to handle than those with a penetrating injury. They were older, arrived later at the hospital, were often in shock, more difficult to diagnose and therefore, operated on later, had more severe and associated injuries, had to be given more blood, were more often treated in the I.C.U., developed more severe postoperative complications, were hospitalized longer and had a higher mortality rate.

We analysed the results of 437 endoscopic retrograde cholangiopancreatographies (ERCP) and 126 endoscopic sphincterotomies (EST) after gastric diversion surgery collected from the literature and from our hospital. The most difficult step in the procedure was duodenal intubation (90% success; range 33-95%). This greatly depended on the method of intestinal reconstruction. Poorest results were related to a long jejunal loop with entero-enterostomy (Braun's anastomosis). A final ERCP success rate was 74% (46-95%). EST could be performed in most of the cases (93%) indicated. Extraction of biliary calculi succeeded only infrequently. Insertion of biliary stents was possible. Special techniques of the procedure are discussed. It is concluded that ERCP and EST may also be performed after gastric surgery with varying success depending on the method of intestinal reconstruction. Both doctor and patient should be prepared to the possible use of alternative methods.

Twenty-three patients, mean age of 65 years, planned for emergency surgery because of upper gastrointestinal bleeding, were electrocoagulated with an endoscopic Storz monopolar flushing electrode. Nineteen patients were managed successfully. Two out of twelve patients with gastric ulcer and both patients with gastrojejunal ulcer bleeding needed an operation. The overall success rate was 82% and the mortality was 9%. According to this study endoscopic monopolar flushing liquid electrocoagulation is a good alternative to surgery in upper gastrointestinal bleedings except gastrojejunal ulceration.