Ventral hernia recurrence in women of childbearing age: a systematic review and meta-analysis.

BACKGROUND: There is no consensus agreement on the optimal management strategy for ventral hernia in women of childbearing age. The theoretical increased risk of ventral hernia recurrence can impact management strategies. We conducted a systematic review of the literature to report the ventral hernia recurrence rate in women of childbearing age who underwent hernia repair prior to their pregnancy and propose a management algorithm. METHODS: We systematically searched multiple databases including MEDLNE, PubMed, and the Cochrane Library sources from inception to August, 2017. Two reviewers independently identified 314 primary studies, assessed methodological quality, and extracted data. Quality of included studies was assessed by employing the Newcastle Ottawa quality assessment tool for cohort studies. A separate tool was utilized for assessing the methodological quality of case series. A meta-analysis of proportions was conducted of studies reporting incidence of recurrence using STATA, employing a random effects model, to calculate a pooled weighted incidence rate (with 95% confidence interval). Descriptive statistics were employed to report the findings of studies which did not report any ventral hernia recurrence. RESULTS: Five retrospective studies were included in our review, enrolling a total of 14,638 female participants. Upon stratifying patients according to pregnancy status after primary hernia repair, 13,494 were found to be in the non-pregnant cohort whereas 1,144 were included in the pregnant cohort. Overall, 9% (95% CI 8-9%) of the non-pregnant patients experienced a recurrence whereas 12% (95% CI 10-15%) of patients that became pregnant subsequent to a ventral hernia repair experienced a recurrence. No major adverse events were recorded throughout the course of pregnancy. CONCLUSIONS: Ventral hernias in women of childbearing age have a pooled recurrence rate of 12%. Pregnancy may be considered a risk factor for ventral hernia recurrence. Female patients of childbearing age with asymptomatic or minimally symptomatic ventral hernias that do not pose a significant strain on the patients' quality of life could be provided with the option of watchful waiting, with appropriate education of risks while discussing management.

Effect of Insulin Therapy using Hyper-insulinemic Normoglycemic Clamp on Inflammatory Response in Brain Dead Organ Donors.

BACKGROUND: Brain death is a major stress that is associated with a massive inflammatory response and systemic hyperglycemia. Severe inflammation leads to increased graft immunogenicity and risk of graft dysfunction; while acute hyperglycemia aggravates the inflammatory response and increases the risk of morbidity and mortality. Insulin therapy not only controls hyperglycemia but also suppresses inflammation. The present study is to investigate the anti-inflammatory properties and the normoglycemia maintenance of high dose insulin on brain dead organ donors. DESIGN: 15 brain dead organ donors were divided into 2 groups, insulin treated (n=6) and controls (n=9). Insulin was provided for a minimum of 6 h using the hyperinsulinemic normoglycemic clamp technique. The changes of serum cytokines, including IL-6, IL-10, IL-1ß, IL-8, TNFα, TGFα and MCP-1, were measured by suspension bead array immunoassay and glucose by a glucose monitor. RESULTS: Compared to controls, insulin treated donors had a significant lower blood glucose 4.8 (4-6.9) vs. 9 (5.6-11.7) mmol/L, p<0.01); the net decreases of pro-inflammatory cytokines, such as IL-6 and MCP-1, and the net increase of anti-inflammatory cytokine, such as IL-10, reached significant level in insulin treated donors compared with those in controls. CONCLUSION: High dose insulin therapy decreases the concentrations of inflammatory cytokines in brain dead donors and preserves normoglycemia. High dose of insulin may have anti-inflammatory effects in brain dead organ donors and therefore, improve the quality of donor organs and potentially improve outcomes.