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Certain stress-induced ancillary findings on myocardial perfusion scintigraphy increase the likelihood that the patient has coronary artery disease (CAD); furthermore, among CAD patients, they indicate more severe and extensive disease, placing these patients at higher risk for future cardiac events. Indeed, in studies with no obvious perfusion defect yet with serious CAD--for example, balanced ischemia--it can be these high-risk findings that necessitate invasive intervention.Besides reversible perfusion defects, such findings include increased pulmonary radiotracer uptake, transient cavity dilatation, increased end-diastolic or end-systolic volume, decreased post-stress ejection fraction, and increased right ventricular tracer uptake on stress images. The pathophysiology underlying these findings is clearly different as they do not always occur together, and each independently predicts more severe and extensive CAD. In the current review, these findings are defined and their significance in diagnosing patients with suspected or known CAD is discussed.

The article by Janes et al. [1] is thought-provoking, although we cannot agree with the conclusion expressed by Schafer in his invited commentary [2] in which he stated that based on current evidence prophylactic mesh should be implanted in all patients having a permanent colostomy. This series [1] has demonstrated a clinical parastomal hernia rate of 13% (2/15 patients) when prophylactic mesh was employed versus 81% (17/21 patients) when mesh was not used. The results of this cohort of patients have now been reported three times at differing stages of follow-up (1, 2, and 5 years) (Table 1) [1, 3, 4]. At 5 years of follow-up, the observed parastomal hernia rate of 81% when mesh is not used far exceeds previously reported results, where herniation rates without the routine use of mesh have typically been between 30% and 50% [5]. The reader is thus left to wonder why herniation in the nonmesh group is so much more prevalent than previously reported? It is also noteworthy that most of the patients underwent colostomy because of a malignancy (47/54 patients), and yet no data regarding the radiologic (computed tomography, CT) hernia rate is presented from either arm of the study, despite one of the authors commenting in a recent review article that more parastomal hernias can be detected using CT than with clinical examination alone [5]. Presumably, some of these patients will have had imaging as part of routine follow-up or because of the development of disseminated disease at a later date. In the literature, the most frequently reported parastomal herniation rate is 30%, of whom only 20% or so would develop sufficient symptoms to be considered for further surgery. This means that only 6% of patients who have a colostomy develop a hernia symptomatic enough to warrant repair. This figure may indeed be lower, as most colostomies are formed because of malignant disease where the overall long-term survival is likely to be around 60%, with most deaths during the first 2 years or so. In other words, possibly only 4% of patients are likely to survive long enough to develop significant parastomal herniation. Finally, in this series it is important to note that no mesh-related complications were observed. However, previous reports have reported complication rates of 10% [6], suggesting that the excellent results achieved by Janes et al. [1] may not be reproducible in the hands of all surgeons. Therefore, whether it is acceptable to place mesh in all patients having a colostomy to prevent the 4% to 6% of hernias that may require repair, when complications might be expected in * 10% of patients must be questioned—or are we missing something?

Dear Sir, There is now increasing clinical evidence that protecting the oval-shaped myopectineal oriWce (MPO), through which groin herniation occurs, is the goal of modern day hernia surgery. This is now often accomplished with the use of mesh, but does both sides of the MPO need to be protected [1]? We have used a plug and patch approach for 9 years [2] but have found large direct hernias diYcult and often troublesome to deal with. Whilst our recurrence rates are acceptable, recurrence at a median follow-up of 5 years after repair of primary direct defects (0.64%) is twice that of indirect repairs (0.29%). With this in mind we have placed other prosthetics in the preperitoneal plane using an open anterior approach with favourable short-term results. However, the ease with which the diVerent devices can be placed means there is a learning curve even for experienced surgeons [3], which raise issues regarding the training of junior surgeons as in the laparoscopic debate. Of those devices used to date the ‘memory-ring patch’ described by Pelissier [4, 5] is by far the easiest to use and correctly deploy in the pre-peritoneal space. We Wrmly endorse its use but do not feel that it is necessary when managing those indirect hernias where the deep defect is not particularly wide.