Adipose tissue imaging as nutritional predictors in patients undergoing enterocutaneous fistula repair.

OBJECTIVES: The management of enterocutaneous fistulae (ECF) is complex, challenging, and often associated with metabolic, septic, and nutritional complications. Radiographic quantification of body composition such as fat or lean body mass distribution is a potentially valuable preoperative assessment tool to optimize nutritional status. The aim of this study was to investigate the correlation between total adipose tissue (fat) area (TFA), assessed by computed tomography and magnetic resonance imaging radiology tests, with body weight, body mass index (BMI), various biochemical parameters, need for nutritional support, and survival in patients undergoing ECF repair. METHODS: Biochemical and anthropometric parameters at the time of ECF surgery were retrospectively collected for adult patients undergoing ECF repair at University College London Hospital, UK. Visceral and subcutaneous adiposity was measured at the level of the third lumbar vertebra (Image J) at computed tomography or magnetic resonance imaging. Statistical analysis included descriptives, univariate and multivariate analysis between TFA and various parameters, and their influence on postoperative survival. RESULTS: A complete set of data was available for 85 patients (51 women, 56.9 ± 14.5 y of age) who underwent ECF repair. ECF originated mainly as a surgical complication (86%) while 14% were undergoing a second ECF repair. Median BMI was 22.8 kg/m2 and mean TFA was 361 ± 174.9 cm2, with a higher visceral fat content in men than in women (183.8 ± 99.2 versus 99 ± 59.7 cm2, P < 0.001). BMI, body weight, and creatinine were significantly positively correlated with TFA (ρ = 0.77, 0.73, and 0.50, respectively, P < 0.001); no correlation was noted between TFA and preoperative albumin levels. Patients in the low TFA group had a higher use of parenteral nutrition (P = 0.049). Hospital length of stay was longer in patients receiving artificial nutrition support (70 versus 22 d, P < 0.001). A TFA cutoff point of 290 cm2 discriminated patients who required artificial nutrition versus no nutritional support with moderate sensitivity (75%) but poor specificity (45%). At multivariate analysis, only >60 y of age (hazard ratio [HR], 2.69, P < 0.02) and use of parenteral nutrition (HR, 3.90, P < 0.02) were associated with worse overall survival. CONCLUSION: Abdominal adiposity was strongly correlated with anthropometric parameters at the time of surgery. Earlier identification of patients requiring artificial nutrition at standard preoperative imaging might allow integration of nutritional optimization into initial clinical management plans reducing length of stay and improving clinical outcomes.

Definitions for Loss of Domain: An International Delphi Consensus of Expert Surgeons.

BACKGROUND: No standardized written or volumetric definition exists for 'loss of domain' (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons. METHODS: A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed. RESULTS: Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery. CONCLUSIONS: Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.

Imaging complex ventral hernias, their surgical repair, and their complications.

Complex ventral hernia (CVH) describes large, anterior, ventral hernias. The incidence of CVH is rising rapidly due to increasing laparotomy rates in ever older, obese and co-morbid patients. Surgeons with a specific interest in CVH repair are now frequently referring these patients for imaging, normally computed tomography scanning. This review describes what information is required from preoperative imaging and the surgical options and techniques used for CVH repair, so that radiologists understand the postoperative appearances specific to CVH and are aware of the common complications following surgery. KEY POINTS: • Complex ventral hernia (CVH) describes large abdominal wall hernias (e.g. width ≥10cm). • CVH patients are being referred increasingly for preoperative and postoperative imaging. • Imaging is pivotal to characterise preoperative morphology and quantify loss of domain. • Postoperative imaging appearances are contingent on the surgical methods used for CVH repair. • Postoperative complications are depicted easily by imaging.

Nomenclature in Abdominal Wall Hernias: Is It Time for Consensus?

Abdominal wall reconstruction is a rapidly evolving area of surgical interest. Due to the increase in prevalence and size of ventral hernias and the high recurrence rates, the academic community has become motivated to find the best reconstruction techniques. Whilst interrogating the abdominal wall reconstruction literature, we discovered an inconsistency in hernia nomenclature that must be addressed. The terms used to describe the anatomical planes of mesh implantation 'inlay', 'sublay' and 'underlay' are misinterpreted throughout. We describe the misinterpretation of these terms and give evidence of where it exists in the literature. We give three critical arguments of why these misinterpretations hinder advances in abdominal wall reconstruction research. The correct definitions of the anatomical planes, and their respective terms, are described and illustrated. Clearly defined nomenclature is required as academic surgeons strive to improve abdominal wall reconstruction outcomes and lower complication rates.

Short-term outcome of fertility-sparing laparoscopic excision of deeply infiltrating pelvic endometriosis performed in a tertiary referral center.

OBJECTIVE: To examine the short-term surgical outcomes in women undergoing fertility-sparing laparoscopic excision of deeply infiltrating pelvic endometriosis. DESIGN: Retrospective cohort study. SETTING: Tertiary referral center for treatment of endometriosis, a university teaching hospital, London, United Kingdom. PATIENT(S): A total of 177 women who underwent fertility-sparing laparoscopic excision of deeply infiltrating endometriosis between January 1, 2006, and December 31, 2007. INTERVENTION(S): Eligible women were identified from the surgeons' database, and their medical notes were reviewed. Data from preoperative assessment, surgery, and postoperative outcomes were analyzed. MAIN OUTCOME MEASURE(S): Complication rate. RESULT(S): One hundred seventy-seven women underwent fertility-sparing laparoscopic excision of deeply infiltrating endometriosis including excision of uterosacral ligaments (43, 24.3%), excision of rectovaginal septum (56, 31.6%), rectal shave (56, 31.6%), disk excision (7, 4%) or bowel resection (15, 8.5%). The median operative time was 95 minutes with a range of 30 to 270 minutes (interquartile range 75-120 minutes). Overall, complications developed in 18 women (10.2%). In 12 (6.8%) of these only uncomplicated pyrexia developed whereas significant intraoperative and/or postoperative complications developed in the remaining 6 (3.4%). Women spent a median of 2 days recovering in hospital (range 1-7, interquartile range 2-3 days). CONCLUSION(S): Fertility-sparing laparoscopic excision of deeply infiltrating endometriosis appears to be safe with a low short-term complication rate.

Colorectal cancer in the young patient.

Colorectal cancer is the second most common cause of death from cancer in the UK. It is estimated that between 2 to 3 per cent of colorectal cancer occurs in patients younger than the age of 40 years. It remains unclear from the literature whether this group of patients has a worse prognosis from colorectal cancer than the population as a whole. There are no large series that report a 10-year survival in young patients diagnosed with colorectal cancer. The authors' objective was to assess patients diagnosed with colorectal cancer younger than the age of 40 years to determine whether the 5- and 10-year survival rates in a tertiary referral center compares favorably with survival rates obtained at other centers and the population as a whole. A retrospective observational study was conducted and an analysis of the patient's notes was made, specifically looking at age at diagnosis, nature and duration of symptoms, predisposing risk factors for colorectal cancer, the site within the bowel of the colorectal cancer, the type of curative resection performed, Dukes' stage, and details of 5- and 10-year follow-up to assess survival. Forty-nine patients age 40 years or younger received treatment for colorectal cancer at St. Mark's Hospital from 1982 to 1992. The overall 5- and 10-year survival was 58 per cent and 46 per cent respectively. The study provides more evidence to support the fact that young patients with colorectal cancer seem to present with more advanced disease. Despite this, the overall 5-year relative survival rate is comparable if not better than other studies, supporting recent evidence that the prognosis in this group of patients is no worse than for colorectal cancer in the population as a whole.

Perinodal adipose tissue and fatty acid composition of lymphoid tissues in patients with and without Crohn's disease and their implications for the etiology and treatment of CD.

The physiological bases for roles of adipose tissue and fatty acids in the symptoms and dietary treatments of Crohn's disease are poorly understood. The hypothesis developed from experiments on rodents that perinodal adipocytes are specialized to provision adjacent lymphoid tissues was tested by comparing the composition of triacylglycerol fatty acids in homologous samples of mesenteric adipose tissue and lymph nodes from patients with or without Crohn's disease. Mesenteric perinodal and other adipose tissue, and lymph nodes, were collected during elective surgery for Crohn's disease and other conditions. Fatty acids were extracted, identified, and quantified by thin-layer and gas-liquid chromatography. Perinodal adipose tissue contained more unsaturated fatty acids than other adipose tissue in controls, as reported for other mammals, but site-specific differences were absent in Crohn's disease. Lipids from adipose and lymphoid tissues had more saturated fatty acids, but fewer polyunsaturates in Crohn's disease patients than controls. In adipose tissue samples, depletion of n-3 polyunsaturates was greatest, but n-6 polyunsaturates, particularly arachidonic acid, were preferentially reduced in lymphoid cells. Ratios of n-6/n-3 polyunsaturates were higher in adipose tissue but lower in lymphoid cells in Crohn's disease patients than in controls. Site-specific differences in fatty acid composition in normal human mesentery are consistent with local interactions between lymph node lymphoid cells and adjacent adipose tissue. But these site-specific properties are absent in Crohn's disease, causing anomalies in composition of lymphoid cell fatty acids, which may explain the efficacy of elemental diets containing oils rich in n-6 polyunsaturates.