Non-operative treatment as a strategy for patients with parastomal hernia: a multicentre, retrospective cohort study.

AIM: Parastomal hernia is the most common complication following stoma construction. Surgical treatment is usually chosen over non-operative treatment, but a clear rationale for the choice of management is often lacking. This study aims to investigate the reasons for non-operative treatment, cross-over rates and postoperative complications. METHOD: A multicentre, retrospective cohort study was conducted. Patients diagnosed with a parastomal hernia between January 2007 and December 2012 were included. Data on baseline characteristics, primary surgery and hernias were collected. For non-operative treatment, reasons for this treatment and cross-over rates were evaluated. For all patients undergoing surgery (surgical treatment and cross-overs), complication and recurrence rates were analysed. RESULTS: Of the 80 patients included, 42 (53%) were in the surgical treatment group and 38 (48%) in the non-operative treatment group. Median follow-up was 46 months (interquartile range 24-72). The reasons for non-operative treatment were absence of symptoms in 12 patients (32%), comorbidities in nine (24%) and patient preference in three (7.9%). In 14 patients (37%) reasons were not documented. Eight patients (21%) crossed over from non-operative treatment to surgical treatment, of whom one needed emergency surgery. In 23 patients (55%), parastomal hernia recurred after the original surgical treatment, of whom 21 (91%) underwent additional repair. CONCLUSION: Parastomal hernia repair is associated with high recurrence and additional repair rates. Non-operative treatment has a relatively low cross-over and emergency surgery rate. Given these data, non-operative treatment might be a better choice for patients without complaints or with comorbidities.

[PROPHYLAXIS OF INFILTRATIVE-INFLAMMATORY COMPLICATIONS OF THE WOUNDS HEALING IN PATIENTS, OPERATED ON FOR NONCOMPLICATED HERNIA OF ANTERIOR ABDOMINAL WALL].

The results of investigation of the inflammatory processes dynamics in operative wounds in 238 patients after surgical intervention, performed for noncomplicated hernias of anterior abdominal wall of various localization, as well as the impact of polarized light on correction of the vegetative nervous system disorders, for prophylaxis of infiltrative-purulent complications were analyzed.

Abdominal hernias: a clinical review of their assessment and management in the Naval Service.

Hernias are a relatively common occurrence in the armed forces community and may affect an individual's fitness for duty and impact on operational capability, particularly in specialist occupations. Their early identification and management will allow appropriate treatment and minimise any impact on operational capability. This article aims to summarise the assessment and management of simple hernias and considers occupational considerations in their management for personnel serving in the Royal Navy and Royal Marines.

Understanding noninguinal abdominal hernias in the athlete.

Abdominal hernias are common with over 20 million hernia repairs performed worldwide. Inguinal hernias are the most common type of hernia. Inguinal and sports hernia have been discussed at length in recent literature, and therefore, they will not be addressed in this article. The noninguinal hernias are much less common but do occur, and knowledge of these hernias is important when assessing the athlete with abdominal pain. Approximately 25% of abdominal wall hernias are noninguinal, and new data show the order of frequency as umbilical, epigastric, incisional, femoral, and all others (i.e., Spigelian, obturator, traumatic). Return-to-play guidelines need to be tailored to the athlete and the needs of their sport. Using guidelines similar to abdominal strain injuries can be a starting point for the treatment plan. Laparoscopic repair is becoming more popular because of safety and efficacy, and it may lead to a more rapid return to play.

Early intervention, parastomal hernia and quality of life: a research study.

Parastomal hernia continues to be a common and distressing problem for stoma patients. But are they preventable? In 2005 and again in 2007, Thompson and Trainor reported that by introducing a simple prevention programme that advised the wearing of support garments for heavy lifting for 1 year after stoma surgery, they significantly reduced the incidence of parastomal hernias. They also found that most of the hernias occurred in the early months after stoma surgery (their intervention programme started 3 months after surgery). The current study builds on Thompson and Trainor's work by introducing an intervention programme at a much earlier stage, with specific advice to wear a lightweight support garment on discharge from hospital in place of normal underwear. Advice was also given about lifting and participants were started on an abdominal exercise programme. Quality of life was monitored at discharge, 3 months, 6 months and 1 year. The results show reduced hernia rates and an increased quality of life for these patients. The aim was to improve on the results of Thompson and Trainor in reducing parastomal hernias, improving quality of life and reducing costs to the NHS through fewer complications associated with hernias, and wasted prescriptions for unused, inappropriate or ill-fitting support wear.

Atypical clinical presentation of internal herniation after laparoscopic Roux-en-Y gastric bypass.

A 60-years old women with history of Roux-en-Y gastric bypass presented with progressive abdominal pain, mainly at the left loin. Imaging was aspecific. Exploratory laparoscopy showed an internal herniation trough the Petersen space.

Modification of collagen formation by mesenchymal stem cells isolated from human adipose tissue in culture and after autotransplantation for abdominal hernia plasty.

Mesenchymal stem cells from the adipose tissue of patients with postoperative hernias produce excessive amounts of collagen III, which shifts the balance between type III and type I collagens. The proposed technique of pretransplantation preparation allows in vitro stimulation collagen formation processes with predominant activation of collagen I synthesis and normalization of proportion between different collagen types. Abdominal wall repair with polypropylene surgical mesh in combination with autotransplantation of mesenchymal stem cells reduced the collagen III to collagen I ratio due to activation of collagen I synthesis and suppression of collagen III production, which had a positive effect on the structure of in vivo formed connective tissue.

[Factors affecting morbidity in urgent repair of abdominal wall hernia with intestinal incarceration in adults]. / Intestinal inkarserasyon için acil karin duvari fitik onarimi yapilan eriskinlerde morbiditeyi etkileyen faktörler.

BACKGROUND: The aim of this study was to investigate factors that affect morbidity in adults with incarcerated intestinal hernia of the abdominal wall. METHODS: 124 patients with a mean age of 61 ± 13.87 years (73 males) underwent emergency surgery for incarcerated intestinal hernia between March 1999 and March 2008. The median duration of the hernia was 5 years (0.1-30). Type and duration of hernia, accompanying diseases, surgical procedure, and operation-related complications were retrospectively evaluated. RESULTS: Twenty-five patients (20%) had complications. Twelve patients (10%) had surgical site infection and 10 patients (8%) had septic complications. Four patients (3%) died in the postoperative period. Out of 40 patients developing strangulation, 18 underwent bowel resection. The only independent variable concerning bowel resection other than inguinal hernia was found to be ventral hernia (p=0.039). There was no statistical significance between duration of hernia and incarceration and complications. The rate of complications was significantly high in the patients with accompanying diseases (p<0.001). The relation between age and complications was also significant (p=0.034). Multivariate analyses showed high ASA scores as the only independent variable for development of complications (p<0.001). CONCLUSION: Patients with comorbid diseases and high ASA scores should be informed about the elevated risk of complications, and scheduled surgery before the development of incarceration should be recommended.

[Right obstructive pyelonephritis due to supra-piriform herniation of the pelvic ureter: a clinical case]. / Pyélonéphrite obstructive droite par étranglement herniaire supra-piriforme de l'uretère pelvien: cas clinique.

Ureteric herniations are extremely rare. We are reporting the case of a 57-year-old female presenting with an upper urinary tract sepsis due to a pelvic ureteral herniation into the supra-piriform sciatic foramen. The diagnosis was made by the CT scan and the treatment was performed in two steps: first the upper urinary tract was drained, and then the hernia was surgically treated. Although ureteral hernias are exceptional causes for nephritic colic, urologists must be aware of the specificity of the diagnosis and of the treatment in order to avoid complications.

[The operations of the abdominal hernias with the use propylene material in patients operated due to abdominal aortic aneurysm]. / Stosowanie siatek propylenowych w operacjach przepuklin brzusznych u chorych, operowanych z powodu tetniaka aorty brzusznej.

The correlation between abdominal hernias and aortic aneurysm has been well documented in literature. The pathophysiology of aneurysm and hernia formation is seen within the abnormal collagen metabolism, resulting in extracellular matrix defects. This study presents a group of 8 men in the age of 36 to 78 years old (average 63, 5 years old) who underwent both an operation for the aneurysm and for the abdominal hernia. Of the reported 8 patients, 7 had postoperative hernias, where 4 of the cases there were recurrent postoperative hernias. The remaining patient had an inguinal hernia. In 7 cases patients underwent an abdominal aortic aneurysm (AAA) operation and in one case a hepatic artery aneurysm endovascular operation was performed. Due to the fact that postoperative hernias are an immense problem, especially within the group of patient with collagen defects, the area of research and improvement of the materials that are used in prosthetic hernia surgery today needs to progress. This study also presents a short review of the various types of prosthetic materials used in the production of hernial meshes. This is to emphasize the necessity of improving operational techniques to minimize the risk of herniation, especially within a group of patients with collagen defects.

Abdominal weakness, bulge, or hernia after DIEP flaps: An algorithm of management, prevention, and surgical repair with classification.

BACKGROUND: This study analyzes abdominal weakness, hernia, and bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Abdominal wall morbidities are categorized, and an algorithm for management is provided. METHODS: A retrospective review of 644 patients who underwent abdominal based flap breast reconstruction between 2009 and 2018 and met selection criteria was performed. Bulge and hernia were evaluated on exam and then by imaging and/or operative exploration. The incidence of abdominal weakness was evaluated by BREAST-Q™ data. Risk factors were analyzed. RESULTS: Of the 644 patients, 23 (3.6%) had a clinically significant bulge or hernia on exam postoperatively. Developing an abdominal wound postoperatively and sacrificing nerves both correlated with an increased incidence of bulge or hernia (p < 0.05). The use of lateral row perforators, keeping the umbilicus, higher BMI, and the use of biological mesh in the initial abdominal wall repair trended toward an increased incidence of bulge or hernia; however, these data were not statistically significant. Seven percent of patients who answered the BREAST-Q™ reported abdominal weakness. Patients in the umbilicus sacrificing cohort had an increased incidence of weakness (p < 0.05). Abdominal wounds, nerve sacrificing procedures and obesity correlated with an increased incidence of weakness; these data were not statistically significant. CONCLUSIONS: A classification and algorithm for treatment of functional abdominal wall morbidity after DIEP flap is provided. Abdominal wall morbidity is classified as: type 1 - abdominal weakness; type 2 - smaller, unilateral abdominal bulge; and type 3 - true abdominal hernia or large bilateral bulge. An algorithm of treatment is presented, which includes physical therapy and surgical repair recommendations.

Herpes zoster-induced trunk muscle paresis presenting with abdominal wall pseudohernia, scoliosis, and gait disturbance and its rehabilitation: a case report.

Herpes zoster (HZ)-induced abdominal wall pseudohernia has been frequently reported, but there has been no report describing HZ-induced trunk muscle paresis leading to functional problems. We describe a 73-year-old man with T12 and L1 segmental paresis caused by HZ presenting with abdominal wall pseudohernia, scoliosis, and standing and gait disturbance who responded well to a systematic rehabilitation approach. He first noticed a right abdominal bulge in the 6th postherpetic week, which was gradually accompanied by right convex thoracolumbar scoliosis, pain, and standing and gait disturbance in the 12th week. Needle electromyography revealed abnormal spontaneous activities at rest in the right T12 myotomal muscles, and motor unit recruitment was markedly decreased. We arranged an outpatient rehabilitation program consisting of using a soft thoracolumbosacral orthosis for pain relief and trunk stability, muscle reeducation of the paretic abdominal muscles, strengthening of the disused trunk and extremity muscles, and gait exercise. Based on electromyographic findings, we instructed him in an effective method of muscle reeducation. After 4 months of rehabilitation, he showed marked improvement and became an outdoor ambulator. We suggest that electromyography is a useful tool to evaluate clinical status and devise an effective rehabilitation program in patients with HZ trunk paresis.

[Current trends in the treatment of incisional hernia in patients after kidney transplantation]. / Aktualne trendy w leczeniu przepukliny pooperacyjnej po przeszczepieniu nerki.

The incidence of incisional hernia following abdominal surgery varies between 2 and 13%, the rate of incisional hernia after renal transplantation varies between 1.1 and 3.8%. There are no evidence based guidelines regarding the treatment of incisional hernias in renal transplant recipients. The aim of this study was to compare results of surgical repair of incisional hernia in patients after renal transplantation depending on the treatment method. A Pubmed was searched for articles related to the treatment of patients with incisional hernia after renal transplantation. Finally five articles were used for review. The analyzed papers report a total of 5606 patients in a time period between 1965-2004. Hernia mesh repairs were similar - primary approximation of the fascial borders and polypropylene mesh reinforcement, mainly by on lay technique or by suturing the mesh to fascial edges. Hernia repairs without mesh were diverse: simple closure, component separation technique, tensor fascia late grafts, split thickness skin grafting. Although all authors are concerned about prosthetic mesh use for hernia repair in transplant patients, four of them advise this method. Surprisingly, the incidence of incisional hernia in transplant recipients (1.83%) is no higher than in normal population (2-13%). Hernia recurrence in the analyzed group was 2% for prosthetic mesh repair, and 25% for no mesh repair. Prosthetic mesh repair of incisional hernias after kidney transplantation is a safe technique and starting to displace other methods of treatment.

Internal hernias in pregnant females with Roux-en-Y gastric bypass: a systematic review.

Improved fertility following a Roux-en-Y gastric bypass (RYGB) can lead to pregnancy and increase the risk of internal herniation. A developing fetus and symptoms of pregnancy can mask the diagnosis and delay intervention, leading to deleterious maternal and fetal consequences. The aim of this systematic review is to summarize the literature regarding internal hernias during pregnancy, their management, and patient outcomes. A comprehensive literature search was undertaken on PubMed and Google Scholar to identify cases of internal hernias presenting during pregnancy after RYGB. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for eligibility and inclusion of articles. Twenty-seven articles, with a total of 59 patients, regarding internal herniation during pregnancy after RYGB were identified. Epigastric pain and nausea and vomiting was the most common presentation. Regardless of orientation of the Roux limb and despite previous closure of mesenteric defects, internal herniation can still occur. A triad of epigastric pain, pregnancy, and a history of RYGB should be a red flag for clinicians to consider internal hernias as a top differential diagnosis. Prompt bariatric consultation and rapid intervention will improve maternal and fetal outcomes.

[A woman with a lumbar swelling]. / Een vrouw met een lumbale zwelling.

We present the case of a 57-year-old woman with a large (7 x 5 cm), asymptomatic lumbar swelling. A lumbar MRI scan revealed a hernia of the superior lumbar triangle (Grynfeltt-Lesshaft hernia). Thus far, 300 cases have been described in the literature. Therapeutic options include surgical and conservative treatment.

Fibrin glue mesh fixation combined with mesenchymal stem cells or exosomes modulates the inflammatory reaction in a murine model of incisional hernia.

Surgical meshes are effective and frequently used to reinforce soft tissues. Fibrin glue (FG) has been widely used for mesh fixation and is also considered an optimal vehicle for stem cell delivery. The aim of this preclinical study was to evaluate the therapeutic effect of MSCs and their exosomes combined with FG for the treatment of incisional hernia. A murine incisional hernia model was used to implant surgical meshes and different treatments with FG, MSCs and exo-MSCs were applied. The implanted meshes were evaluated at day 7 by anatomopathology, cellular analysis of infiltrating leukocytes and gene expression analysis of TH1/TH2 cytokines, MMPs, TIMPs and collagens. Our results demonstrated a significant increase of anti-inflammatory M2 macrophages and TH2 cytokines when MSCs or exo-MSCs were used. Moreover, the analysis of MMPs, TIMPs and collagen exerted significant differences in the extracellular matrix and in the remodeling process. Our in vivo study suggests that the fixation of surgical meshes with FG and MSCs or exo-MSCs will have a beneficial effect for the treatment of incisional hernia in terms of improved outcomes of damaged tissue, and especially, in the modulation of inflammatory responses towards a less aggressive and pro-regenerative profile. STATEMENT OF SIGNIFICANCE: The implantation of surgical meshes is the standard procedure to reinforce tissue defects such as hernias. However, an exacerbated and persistent inflammatory response secondary to this implantation is frequently observed, leading to a strong discomfort and chronic pain in the patients. In many cases, an additional surgical intervention is needed to remove the mesh. This study shows that mesenchymal stem cells and their exosomes, combined with a fibrin sealant, can be used for the successful fixation of these meshes. This new therapeutic approach, assayed in a murine model of incisional hernia, favors the modulation of the inflammatory response towards a less aggressive and pro-regenerative profile.

Diagnosis and treatment of chronic abdominal pain 5 years after Roux-en-Y gastric bypass.

BACKGROUND: Knowledge of optimal diagnostic workup, etiology, and response to treatment of chronic abdominal pain after Roux-en-Y gastric bypass (RYGB) is limited. OBJECTIVE: To define the etiology of chronic abdominal pain presenting at the 5-year follow-up after RYGB and to evaluate response to treatment. SETTING: Oslo University Hospital (tertiary referral center for obesity surgery). METHODS: Of 234 patients operated during a randomly selected 12-month period, 165 (71%) returned for 5-year follow-up, and 160 responded to study questionnaires. Of these, 54 (34%) reported chronic abdominal pain and were invited to participate in a structured diagnostic and treatment algorithm. These patients were contacted for the evaluation of their response to treatment. RESULTS: Fifty-one of 54 patients (94%) reporting chronic abdominal pain at the 5-year follow-up were included in the study. Of the 45 patients with onset of symptoms post-RYGB, 28 (62%) underwent one or more radiologic evaluations, 10 (22%) underwent endoscopy, and 13 (29%) underwent laparoscopy. Diagnosis and treatment were established for 34 patients (76%), whereas 11 (24%) had abdominal pain of unknown cause. The most common etiology was internal herniation (n = 6), dumping (n = 6), food intolerance (n = 6), gallstones (n = 5), and irritable bowel syndrome (n = 4). After a median follow-up of 13.0 months (standard deviation, 11.5), 37 (82%) patients reported remission or improvement of symptoms, 6 had unchanged symptoms, and 2 patients were lost to follow-up. CONCLUSIONS: The etiology of long-term chronic abdominal pain post-RYGB is diverse. A multidisciplinary team can help most patients with dedicated follow-up, but a subset of patients has symptoms of unknown etiology.