Five hundred and sixty-four patients reviewed 1 year after major abdominal surgery have been studied prospectively by a single observer for 10 years to determine the incidence and significance of incisional hernia. Of 337 (60 per cent) patients completing the 10 year follow-up 37 (11 per cent) developed an incisional hernia and 13 (35 per cent) of these first appeared at 5 years or later. One in three hernias caused symptoms. The late appearing hernias were smaller than the early ones, and caused little trouble. Of the 18 patients who consulted their general practitioner, 11 had symptoms and of these six (55 per cent) were referred for surgical opinion. Many hernias were diagnosed at routine outpatient follow-up and were likely to receive treatment from the surgeon. Most symptomatic patients were offered surgery with the remainder usually being offered a corset. In about half our patients (mainly those without symptoms) surgery was refused or advised against although the patients would have accepted it. Recurrence is common after surgical repair (40 per cent) but seems to be related to surgical technique. The possibility of complications occurring from an incisional hernia does not appear to be discussed with patients although obstruction occurred in 14 per cent of our patients with troublesome hernia.

From six to 89 months after surgery 82 patients who had been treated by radical surgery (118 excisions) for intractable hidradenitis suppurativa were reviewed. Local recurrence rates varied greatly with the disease site, being low after axillary (3%) and perianal surgery (0%) and high after inguinoperineal (37%) and submammary (50%) excision. Recurrence results from inadequate excision or an unusually wide distribution ofapocrine glands, but physical factors such as obesity, local pressure, and skin maceration played a part in a few patients. Recurrence due to inadequate surgery tended to be the most troublesome. At follow up 75 (91%) ofthe patients were pleased with the results of their operation. A quarter of the patients developed disease at a new anatomical site after operation.Radical surgery gives good symptomatic control of severe hidradenitis suppurative of the axilla, inguinoperineal, and perianal regions but is less satisfactory for submammary disease.

No abstract

She presented to the emergency unit some five hours later, still suffering from chest pain; pulse rate was 105 beats/min and blood pressure 140/80 mm Hg. Jugular venous pressure was not raised, and her chest was clear. The apical impulse was normal in position and contour, and normal heart sounds with a grade 3/6 late systolic murmur maximal at the fourth left intercostal space were heard at auscultation. Electrocardiography (figure a) showed sinus tachycardia, a normal PR interval and axis, and extensive 1-5 mm planar ST-segment depression while the QT interval corrected for rate was prolonged (0-62 s): this reaction has been reported after administration of adrenaline.2 Total plasma calcium and protein concentrations measured at the same time were within the normal range.She was admitted to the coronary care unit, and the chest pain continued to be severe despite treatment with sublingual nitroglycerine (1.5 mg) and oral nifedipine (60 mg). The pain was relieved by an intravenous infusion of nitroglycerine (50 ,ug/min), with a simultaneous decrease in the degree of ST-segment depression. Subsequent electrocardiograms showed progressive normalisation of the ST segments and the development of tall, peaked T waves in the chest leads (figure b).Her condition remained stable after her pain had been relieved, and the nitroglycerine infusion was subsequently stopped. Serial estimations of the creatinine phosphokinase MB fraction were all within the normal range.Results of a submaximal effort stress test incorporating a multigated equilibrium blood pool scan were normal. M mode and two dimensional Ele't.o.ardiogram a. ,,.t _t-imeof ad isionk (a n fe diitaino intr 1 -AVe nitI rolyerne(b.Electrocardiogram at time of admission (a) and after administration of intravenous nitroglycerine (b).echocardiography disclosed normal left ventricular wall motion and size with evidence of mild prolapse of the mitral valve. No risk factors for ischaemic heart disease could be found. She remained asymptomatic with a normal electrocardiogram six months later. CommentTypical ischaemic chest pain with appropriate electrocardiographic changes in a young woman with no risk factors for ischaemic heart disease after intravenous injection of adrenaline indicates that the adrenaline was almost certainly the cause of the subsequent myocardial ischaemia. This supposition was further substantiated by the results of subsequent investigations, which largely excluded the presence of preexisting ischaemic heart disease. The mechanism of myocardial ischaemia lasting for more than five hours after a single bolus of adrenaline is unclear.The ability of catecholamines to cause myocardial damage is well established, and these hormones have also been implicated in the myocardial necrosis occurring in patients with phaeochromocytoma.3 The mechanism is thought to be either a direct effect on the myocardial cell or myocardial damage resulting from ischaemia caused by, among other things, constriction of the coronary artery. An additional mechanism whereby adre...

Five hundred and sixty-four patients undergoing abdominal surgery, who were carefully assessed at the time of operation for evidence of venous thrombosis, have been followed up to determine the incidence of leg symptoms, varicose veins and post-thrombotic syndrome. Patients are frequently troubled by pain, swelling and phlebitis, which can persist for up to a year after operation. New varicose veins developed by 1 year in 20 per cent of patients. These occurred with increased frequency in patients who also developed a deep vein thrombosis, but they were also seen in patients who showed no clinical or isotopic evidence of thrombosis. The post-thrombotic syndrome was present in 26 patients by 3 years after the operation; half of these patients had suffered the syndrome before the definitive operation. Assessment of the long term effects of venous thrombosis must be carried out against the background of similar effects seen in patients without thrombi, and the development of the post-thrombotic syndrome may best be considered as the summation of a number of incidents, overt or occult, occurring throughout a lifetime.