Delphi consensus statement for understanding and managing the subcostal hernia: subcostal hernias collaborative report (scholar study).

INTRODUCTION: Subcostal hernias are categorized as L1 based on the European Hernia Society (EHS) classification and frequently involve M1, M2, and L2 sites. These are common after hepatopancreatic and biliary surgeries. The literature on subcostal hernias mostly comprises of retrospective reviews of small heterogenous cohorts, unsurprisingly leading to no consensus or guidelines. Given the limited literature and lack of consensus or guidelines for dealing with these hernias, we planned for a Delphi consensus to aid in decision making to repair subcostal hernias. METHODS: We adopted a modified Delphi technique to establish consensus regarding the definition, characteristics, and surgical aspects of managing subcostal hernias (SCH). It was a four-phase Delphi study reflecting the widely accepted model, consisting of: 1. Creating a query. 2. Building an expert panel. 3. Executing the Delphi rounds. 4. Analysing, presenting, and reporting the Delphi results. More than 70% of agreement was defined as a consensus statement. RESULTS: The 22 experts who agreed to participate in this Delphi process for Subcostal Hernias (SCH) comprised 7 UK surgeons, 6 mainland European surgeons, 4 Indians, 3 from the USA, and 2 from Southeast Asia. This Delphi study on subcostal hernias achieved consensus on the following areas-use of mesh in elective cases; the retromuscular position with strong discouragement for onlay mesh; use of macroporous medium-weight polypropylene mesh; use of the subcostal incision over midline incision if there is no previous midline incision; TAR over ACST; defect closure where MAS is used; transverse suturing over vertical suturing for closure of circular defects; and use of peritoneal flap when necessary. CONCLUSION: This Delphi consensus defines subcostal hernias and gives insight into the consensus for incision, dissection plane, mesh placement, mesh type, and mesh fixation for these hernias.

Fetal cardiac hypertrophy and cardiac function in diabetic pregnancies.

OBJECTIVE: Our purpose was to evaluate the relationship between fetal cardiac wall hypertrophy and ventricular function in fetuses of metabolically controlled, insulin-requiring diabetics. STUDY DESIGN: M-mode directed fetal echocardiography included measurements of left and right ventricular free wall and interventricular septal thickness and ventricular diastolic and systolic dimensions. Fetal measurements included biparietal diameter, estimation of fetal weight, and cardiac area/thoracic area. Cardiac size is expressed as a ratio of wall thickness/biparietal diameter, and function is expressed as ventricular shortening fraction (Ventricular diastolic dimension-Ventricular systolic dimension/Ventricular diastolic dimension). Fetuses of diabetics at 20 to 24, 28 to 31, and 32 to 36 weeks' gestation were compared with normal fetuses of nondiabetic mothers at similar gestational ages, which were used as a control group. RESULTS: Study and control groups were comparable in mean gestational age (22 vs 20, 29 vs 29, 35 vs 34 weeks) in each of groups 1, 2, and 3. All fetuses tested fell within these groups. Estimated fetal weight, cardiac area/thoracic area, right ventricular wall thickness/biparietal diameter, and interventricular septal thickness/biparietal diameter were greater in the study group between 32 and 36 weeks: 3227 +/- 430 versus 2235 +/- 176 gm (p < 0.05), 0.32 versus 0.29, (p < 0.05), 0.53 +/- 0.05 versus 0.44 +/- 0.05 mm (p < 0.05), and 0.50 +/- 0.3 versus 0.46 +/- 0.5 mm (p < 0.05), respectively. Right ventricular shortening fraction/left ventricular shortening fraction was significantly different from controls in this group (1.30 vs 0.89, p < 0.05). This change was a function of altered right ventricular shortening fraction in late diabetic pregnancy. Right ventricular shortening fraction in the study groups was 0.39, 0.36, and 0.52, respectively, versus 0.36, 0.41, and 0.33 in controls. Left ventricular shortening fraction in the group at 32 to 36 weeks and in controls in three groups was 0.42, 0.39, 0.40 and 0.44, 0.37. CONCLUSION: These findings reveal an increase in right ventricular shortening fraction associated with global cardiac enlargement. Myocardial hypertrophy involving right ventricular wall thickness and interventricular septal thickness in metabolically stable insulin-requiring diabetics revealed hypercontractility of the right ventricle.