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Abstract. A series of 68 primary midline incisional hernias with a verticalMayo repair was evaluated retrospectively. Patients without documented hernia recurrence following this repair were invited for physical examination. Life-table methods were used for statistical analysis. The 1-, 3-, 5-, and 10-year cumulative recurrence rates were 35%, 46%, 48%, and 54%, respectively. Also, generally accepted risk factors were studied. Multivariate analysis identified the size of the hernia (p ‫؍‬ 0.02) and the use of steroids (p ‫؍‬ 0.04) as the most important independent risk factors of first time recurrent incisional hernia. Considering the high recurrence rates found, the results of this study strongly suggest that the vest-over-pants repair should no longer be used for closure of midline incisional hernias.Incisional hernias appear in at least 10% of patients with midline laparotomies [1]. Patients with an incisional hernia often complain of the aesthetic appearance or suffer from discomfort, pain, or intestinal obstruction [2]. A variety of operative procedures for incisional hernia repair have been in use, but the results are often disappointing. Five-year cumulative recurrence rates as high as 41% have been reported [3].Mayo believed that a scar in one plane, from within out, was an important risk factor for developing a hernia [4, 5]. He therefore advocated an overlapping repair in which each line of sutures is protected by normal structures. These sutures hold the structures in apposition, and the intraabdominal tension itself prevents displacement [4]. Mayo's technique is considered to be a major step in the history of hernia repair. Formerly, surgeons attempted to unite extensively dissected rectus muscles vertically in the midline, with poor results [4].The present study was performed to evaluate the results of the vertical "vest-over-pants" Mayo repair. In addition, various potential risk factors for recurrent incisional hernia were analyzed. Patients and MethodsThe records of all patients with a vertical Mayo repair operated at the Department of Surgery of the Sint Franciscus Gasthuis Rotterdam between 1981 and 1990 were reviewed retrospectively. Because recurrent hernias are known to have higher recurrence rates [3, 6] and incisional hernias occur more often in the midline than in other vertical [1,[7][8][9] or transverse [7, 10 -14] incisions, only patients with a primary hernia of the midline were selected for analysis. Patient-related factors of sex, age, obesity, chronic cough, prostatism, constipation, diabetes mellitus, history of oncologic disease, and use of steroids were noted. Obesity was measured using the Quetelet index. Operation-related factors, including surgical technique, suture materials, wound hematoma, wound infection, and the surgeon's experience (resident, consultant), were also analyzed. Hernia-related factors, such as the hernia-free interval, type of incision, previous hernia repairs, and the size and number of the hernias, were evaluated as well. Midline hernias were divided in...

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Due to the ageing of the general population, the proportion of elderly patients with colorectal cancer has increased. In a registry-based study, we evaluated the influence of age and other variables on resection rates and operative risk. Resection rates and postoperative mortality rates (30-day) were analysed in 6457 patients with colorectal cancer, diagnosed from 1985 through 1992 in hospitals connected to the Rotterdam Cancer Registry. Overall, 87% of the patients underwent resection but resection rates were lower for patients older than 89 years (67%) and for patients with rectal cancer (83%). The postoperative mortality rate was 1% for patients younger than 60 years and steadily increased with age. For patients 80 years and older the operative risk was 10%. According to multivariate analysis gender, age, subsite and stage were defined as independent prognostic factors. In view of the lack of alternatives, elderly patients with colorectal cancer should not be denied surgery on account of chronological age alone. Even in patients over 90 years of age resections can be performed with acceptable risk.

This prospectively randomized clinical trial was carried out in four Dutch hospitals to reduce the development of metachronous liver metastases and to get a better survival in patients with colorectal malignancies after surgically radical en bloc resection of the primary tumor and the regional lymph nodes. Three hundred seventeen patients were randomized to participate in three trial arms. One group of patients was treated by surgery alone (control group); in the other patients a catheter was placed in the dilated umbilical vein and advanced until the tip was lying in the left branch of the portal vein. Fifty percent of these patients got immediate postoperative portal infusion with 1 g 5-flnorouracil (5-FU) and 5000 U heparin daily for 7 days; the others received portal vein infusion with urokinase 10.000 U/honr for 24 hours only. Three hundred four patients were eligible. Overall hospital mortality was 3.6% (11 patients) and was not influenced by adjuvant treatment. After a median follow-up of 44 months 66 patients have died with relapse and 21 as a result of other causes. The chance of developing liver metastases and other distant metastases after portal infusion with 5-FU/heparin was one third of the chance in the control group (P < 0.001). Only an insignificant reduction of the average death rate in the 5-FU/heparin group was found.In the urokinase group no significant effect in reducing metastases or in survival was noted. Before recommending cytotoxic portal infusion as an adjuvant treatment in patients with colorectal cancer, detailed analysis of other ongoing portal infusion studies has to be awaited and careful calculations have to be made regarding how many patients really can be saved by this treatment.Cancer 65425-432, 1990.N AUTOPSY STUDIES of patients who died from colo-I rectal cancer, liver metastases were found in about 50% to 80%.' At time of surgery up to 25% of patients with primary colorectal cancer already have macroscopic liver metastases2 The number of patients with microscopic metastases is unknown.Tumor invasion into mesenteric veins causes spread of The authors thank Mrs. Mirjam Linskens for help in data collection and preparation of the manuscript, and Mr. P. J. van Assendelft for assistance in data management and analysis. The authors also thank all of the patients who were willing to cooperate in this study and who had the patience to undergo the multiple sometimes unpleasant investigations.Address for reprints: Jack C. J. Wereldsma, MD, PhD, Department of Surgery, Sint Franciscus Gasthuis, Kleiweg 500,3045 PM Rotterdam, The Netherlands.Accepted for publication July 2 1, 1989.circulating malignant cells to the portal vein.3 These tumor cells surrounded by fibrin and platelets may form tumor clots which can adhere at the vascular endothelium of the liver capillaries. These microfoci can develop into macroscopic metastases initiated by, until now, unknown factors. This tumor cell embolus theory sounds reasonable, the unknown factors being the induction of anesthesia, operative stress...

Due to the ageing of the general population, there has been a relative increase of elderly patients with rectal cancer. The relation between age and the risk of local recurrence after apparently curative surgery for cancer of rectum and rectosigmoid was studied in a retrospective study of 902 patients, diagnosed from 1984 through 1991 in the southwestern part of the Netherlands. Three age-groups were defined: 15-64 (n = 328), 65-74 (n = 327) and 75 and over (n = 247). After exclusion of postoperative deaths and controlling for unrelated causes of death, 5-year survival rates were similar in the three age-groups (70%, 71% and 75%, respectively). Local recurrence rates, however, decreased with age from 23% to 18% and 14%, respectively. In multivariate analysis, the hazard ratios were 1, 0.84 and 0.66, respectively. These results suggest that local recurrence occurs less frequently in the elderly, which needs confirmation from prospective studies and warrants consideration in decisions about the use of adjuvant treatment.

Due to the ageing of the general population, the proportion of elderly patients with colorectal cancer has increased. In a registry-based study, we evaluated the influence of age and other variables on resection rates and operative risk. Resection rates and postoperative mortality rates (30-day) were analysed in 6457 patients with colorectal cancer, diagnosed from 1985 through 1992 in hospitals connected to the Rotterdam Cancer Registry. Overall, 87% of the patients underwent resection but resection rates were lower for patients older than 89 years (67%) and for patients with rectal cancer (83%). The postoperative mortality rate was 1% for patients younger than 60 years and steadily increased with age. For patients 80 years and older the operative risk was 10%. According to multivariate analysis gender, age, subsite and stage were defined as independent prognostic factors. In view of the lack of alternatives, elderly patients with colorectal cancer should not be denied surgery on account of chronological age alone. Even in patients over 90 years of age resections can be performed with acceptable risk.

The authors assessed the potential benefit of postoperative radiation therapy for rectal cancer in a two-arm, prospective multicenter trial. One hundred seventy-two patients who had undergone surgical resection for rectal adenocarcinoma were randomly assigned to either treatment consisting of external irradiation to a dose of 5000 cGy in 5 weeks or a control group (no adjuvant therapy). It was assumed that the number of cells remaining after radical surgery would be low and that the dose of 5000 cGy would be adequate in eradicating the majority of those cells. The number of local recurrences was lower in the treated group of patients, but the difference was not statistically significant. It was assumed that if a significant reduction in the number of local recurrences could be obtained, improved (disease-free) survival would result. No influence on disease-free or overall survival could be detected. These results were in agreement with those reported in Europe and the US, and it was concluded that postoperative radiation therapy alone cannot be justified as a routine procedure in the primary management of resectable rectal cancer.