Evaluating postoperative hernia incidence and risk factors following pelvic exenteration.

Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251-1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre. METHOD: A retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination. RESULTS: A total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative. CONCLUSION: This study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.

Surgical management of abdominal desmoids: a systematic review and meta-analysis.

BACKGROUND: Desmoid tumours are benign fibromatous tumours arising from dysregulated myofibroblast proliferation within musculoaponeurotic structures. They can occur sporadically but more commonly are associated with genetic syndromes such as familial adenomatous polyposis (Sakorafas et al. in Surg Oncol 16(2):131-142, 2007) (FAP). Mutations in either the Wnt, ß-catenin or APC genes are 'key' triggers for the development of these tumours (Howard and Pollock in Oncol Ther 4(1):57-72, 2016). Classically, these tumours do not metastasise; however, they are associated with significant morbidity and mortality due to their infiltrative pattern and/or local invasion. Historically, surgical resection was the cornerstone of treatment. There remains paucity of data regarding outcomes following the surgical management of abdominal desmoid tumours in terms of success, recurrence and morbidity. OBJECTIVES: The aim of this review was to assess the current evidence for surgical management of abdominal desmoid tumours in terms of success, recurrence and morbidity. METHODS: A systematic search of articles in PubMed, EMBASE and The Cochrane Library databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the period from January 2000 to November 2020. RESULTS: Twenty-three studies were included, of which, 749 patients had surgical resection (696 for primary and 53 for recurrent desmoids), 243 patients (18.8%) were medically managed and 353 patients (27.3%) underwent surveillance. Median follow-up was 51.4 months (range 1-372). Six-hundred and ninety-six of the 749 resections (92.9%) underwent primary desmoid resection, with the remaining 53 (7.1%) undergoing resection for recurrence. One-hundred and two surgically managed patients (19%) developed a (re)recurrence, with mesenteric involvement the commonest site for recurrence (55%). When comparing recurrence post-surgery to progression following medical therapy, there was a trend towards better outcomes with surgery, with 25% of surgical patients having a recurrence versus 50.5% having progression with medical therapy [OR 0.40 (95% CI 0.06-2.70), p = 0.35]. Major morbidity following surgery was 4.4% (n = 33) with 2% (n = 14) mortality within 30 days of resection. CONCLUSION: The management of desmoids has considerable heterogeneity. Surgical resection for abdominal desmoids remains a valid treatment option in highly selective cases where negative margins can be obtained, with low major morbidity and/or mortality.

Short-term outcomes in older patients with peritoneal malignancy treated with cytoreductive surgery and HIPEC: Experience with 245 patients from a national centre.

BACKGROUND: Cytoreductive Surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly accepted as the optimal management of selected patients with peritoneal malignancy. There is limited published evidence on outcomes in older patients treated by this complex therapeutic strategy. METHODS: A retrospective review of a prospective database of all patients who underwent CRS with HIPEC in a single institution over seven years. A comparative analysis of outcomes in patients under 65 undergoing CRS and HIPEC with patients ≥65 years was performed. The key endpoints were morbidity, mortality, reintervention rate and length of stay in the high dependency/intensive care (HDU/ICU) units. RESULTS: Overall, 245 patients underwent CRS and HIPEC during the study period, with 76/245 (31%) ≥65 years at the time of intervention. Tumour burden measured by the peritoneal carcinomatosis index (PCI) score was a median of 11 for both groups. Median length of hospital stay in the ≥65-year-old group was 14.5 days versus 13 days in the <65-year-old group (∗p = 0.01). Patients aged ≥65-years spent a median of one more day in the critical care unit ∗(p = 0.001). Significant morbidity (Clavien-Dindo ≥ Grade IIIa) was higher in the ≥65-year than the <65-year group (18.4% versus 11.2%). There were no perioperative deaths in the ≥65-year group. CONCLUSION: This study demonstrates higher perioperative major morbidity in ≥65-year group, but with low mortality in patients undergoing CRS/HIPEC for disseminated intraperitoneal malignancy. This increased morbidity does not translate into higher rates of re-interventions and highlights the importance of optimal patient selection.

Use of Mini-Percutaneous Nephrolithotomy Technique to Remove Extra-Peritoneal Foreign Bodies.

BACKGROUND Foreign bodies (FBs) in the intra- or extra-peritoneal cavity are relatively rare. The aim of treatment is to remove the FB to prevent chronic inflammation and/or infection. Traditionally, surgical management is necessary, as the detection and localization of FBs can be difficult. Mini-percutaneous nephrolithotomy (Mini-PCNL) under the guidance of ultrasonography (US-guided) has recently been used as an alternative to conventional therapeutic options for FB removal. CASE REPORT In this article, we report the cases of 2 patients with an extra-peritoneal wooden toothpick FB treated using the mini-percutaneous nephrolithotomy technique as an effective treatment for removing the FBs. These patients recovered quickly and were discharged uneventfully. CONCLUSIONS Using ultrasound to guide mini-PCNL represents a potential alternative to laparoscopic surgery for the detection and removal of FBs, allowing the patient to recover quickly. This approach is simple, minimally invasive, and feasible under local anesthesia and should be considered as an alternative to surgery.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases: outcomes from a national centre in the current era.

BACKGROUND: Multimodal therapy incorporating cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) improve survival for selected patients with colorectal peritoneal metastases (CPMs). Many countries have centralised management of these patients, aiming to improve outcomes. There is ongoing debate on the need for and complications associated with HIPEC administration. We report indications and outcomes after CRS/HIPEC treated in a national centre in the modern era. METHODS: A retrospective review of all CPM patients who underwent CRS and HIPEC since the initiation of an Irish national program in 2013. The primary endpoint was the overall survival associated with CRS/HIPEC. RESULTS: During the study period (April 2013-June 2020), 123 patients proceeded to planned CRS/HIPEC for CPM. Median age was 58 (IQR 47-67) and 55 patients (44.7%) were male. In 65 patients (52.8%), CPM was synchronous. In 7/123 (5.8%), disease was unresectable. The median peritoneal cancer index (PCI) was 10 (IQR 5-17). Overall, 104/123 (84.5%) underwent a complete cytoreduction (CC0/CC1). Thirteen out of 123 (10.5%) patients also had a synchronous liver resection. Forty out of 123 (32.5%) patients had adverse pathological features (poorly differentiated or signet ring cells). The median survival in patients after CC0, CC1 and CC2/3 resection was 50, 18 and 11 months respectively (*p = < 0.0001, Log-rank Mantel-Cox). In total, 14/123(11.4%) had a major post-operative complication and 4/123 (3.3%) required re-operation. There was one (0.8%) post-operative death. The median length of stay was 14 days (IQR 9-19). CONCLUSION: This study reports encouraging outcomes in patients with CPM undergoing CRS and HIPEC, especially when complete cytoreduction is achieved.

Magnetic Sphincter Augmentation Placement for Recalcitrant Gastroesophageal Reflux Disease Following Bariatric Procedures: A Systematic Review and Bayesian Meta-Analysis.

Background: This study aims to consolidate all available articles on this topic and evaluate MSA effectiveness in the management of gastroesophageal reflux disease (GERD). Matherials and Methods: We conducted an electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science. An electronic systematic search of articles comparing preoperative and postoperative health-related quality of life (GERD-HRQL) scores in patients who underwent MSA placement for management of GERD following bariatric surgery was performed. Three retrospective studies totaling 33 patients met the inclusion criteria and were included in this meta-analysis. Results: The pooled mean difference in change from preoperative GERD-HRQL score was 17.5 (95% CrI; -22.88 to -12.20) and it was statistically significant. The between-study variability is 3.621 (95% HPD; 1.39 4.99) with low heterogeneity (I2 = 15%; 95% HPD; 2.1 26.2%). Conclusions: MSA for refractory GERD following bariatric surgery appears feasible. Prospective randomized controlled with standardized surgical technique and objective follow-up evaluation is needed to better assess short- and long-term efficacy.

Sarcopenia and Inflammatory Bowel Disease: A Systematic Review.

Background: Sarcopenia is associated with increased morbidity and mortality in oncologic and transplant surgery. It has a high incidence in chronic inflammatory states including inflammatory bowel disease (IBD). The validity of existing data in IBD and of sarcopenia's correlation with surgical outcomes is limited. Methods: We performed a systematic review to assess the correlation of sarcopenia with the requirement for surgery and surgical outcomes in patients with IBD. Observational studies of patients with IBD in whom an assessment of sarcopenic status/skeletal muscle index was undertaken, a proportion of whom proceeded to surgical management, were selected. Results: A total of 5 studies with a combined 658 IBD patients met the inclusion criteria. The majority (70%) had a diagnosis of Crohn's disease. Median (range) body mass index and skeletal muscle index were reported in 4 studies and were 16.58 (13.66-22.50) kg/m2 and 44.52 (42.90-50.64) cm2/m2, respectively. Forty-two percent of IBD patients had sarcopenia. Notably, none of the studies assessed both the anatomical and functional component required for a correct assessment of sarcopenia. Three studies noted that sarcopenic IBD patients had a higher probability of requiring surgery. The rate of major complications (Clavien-Dindo grade ≥IIIa) was significantly higher in patients with sarcopenia. Improved perioperative nutrition management may mitigate the risk of complications. Conclusion: Many IBD patients are young, may be malnourished, and commonly require emergent surgery. There is considerable heterogeneity in the assessment of sarcopenia. Sarcopenia is common in the IBD population and can predict the need for surgical intervention. Sarcopenia correlates with an increased rate of major postoperative complications. Improved perioperative intervention may diminish this risk. A formal assessment, screening by a dedicated IBD dietician, and preoperative physical therapy may facilitate early intervention.

Open Inguinal Hernia Repair: A Network Meta-analysis Comparing Self-Gripping Mesh, Suture Fixation, and Glue Fixation.

The most troublesome complications of inguinal hernia repair are recurrent herniation and chronic pain. A multitude of technological products dedicated to abdominal wall surgery, such as self-gripping mesh (SGM) and glue fixation (GF), were introduced in alternative to suture fixation (SF) in the attempt to lower the postoperative complication rates. We conducted an electronic systematic search using MEDLINE databases that compared postoperative pain and short- and long-term surgical complications after SGM or GF and SF in open inguinal hernia repair. Twenty-eight randomized controlled trials totaling 5495 patients met the inclusion criteria and were included in this network meta-analysis. SGM and GF did not show better outcomes in either short- or long-term complications compared to SF. Patients in the SGM group showed significantly more pain at day 1 compared to those in the GF group (VAS score pain mean difference: - 5.2 Crl - 11.0; - 1.2). The relative risk (RR) of developing a surgical site infection (RR 0.83; Crl 0.50-1.32), hematoma (RR 1.9; Crl 0.35-11.2), and seroma (RR 1.81; Crl 0.54-6.53) was similar in SGM and GF groups. Both the SGM and GF had a significantly shorter operative time mean difference (1.70; Crl - 1.80; 5.3) compared to SF. Chronic pain and hernia recurrence did not statistically differ at 1 year (RR 0.63; Crl 0.36-1.12; RR 1.5; Crl 0.52-4.71, respectively) between SGM and GF. Methods of inguinal hernia repair are evolving, but there remains no superiority in terms of mesh fixation. Ultimately, patient's preference and surgeon's expertise should still lead the choice about the fixation method.

Right hemicolectomy: a network meta-analysis comparing open, laparoscopic-assisted, total laparoscopic, and robotic approach.

BACKGROUND: There are a variety of surgical approaches for the management of right-sided colonic neoplasms. To date, no method has been shown superior in terms of surgical and perioperative outcomes. This meta-analysis compared open (ORH), laparoscopic-assisted (LRH), total laparoscopic (TLRH), and robotic right hemicolectomy (RRH) to assess surgical outcomes and perioperative morbidity and mortality. STUDY DESIGN: We conducted an electronic systematic search using PubMed, EMBASE, and Web of Science that compared RRH, TLRH, LRH, and ORH. Forty-eight studies met the inclusion criteria: 5 randomized controlled trials, 25 retrospective, and 18 prospective studies totalling 5652 patients were included. RESULTS: The overall complication rate was similar between RRH and TLRH (RR 1.0; Crl 0.66-1.5). The anastomotic leak rate was higher in LRH and ORH compared to RRH (RR 1.9; Crl 0.99-3.6 and RR 1.2; Crl 0.55-2.6, respectively), whereas it was lower in TLRH compared to RRH (RR 0.88 Crl 0.41-1.9). The risk of reoperation was significantly higher in ORH compared to TLRH (RR 3.3; Crl 1.3-8.0). Operative time was similar in RRH compared to LRH (RR - 27.0; Crl - 61.0 to 5.9), and to TLRH (RR - 24.0; Crl - 70.0 to 21.0). The hospital stay was significantly longer in LRH compared to RRH (RR 3.7; Crl 0.7-6.7). CONCLUSION: The surgical management of right-sided colonic disease is evolving. This network meta-analysis observed that short-term outcomes following RRH and TLRH were superior to standard LRH and ORH. The adoption of more advanced minimally invasive techniques can be costly and have associated learning phases, but will ultimately improve patient outcomes.

Acute Appendicitis in the Adult Population: Modelled Decision Analysis Supports a Conservative Approach.

INTRODUCTION: Acute appendicitis represents the commonest cause of acute intra-abdominal pathology. Appendectomy and antibiotics are the mainstay of therapy for appendicitis. Evidence is emerging that antibiotics alone may adequately treat most cases of appendicitis. Decision analysis is a quantitative method of examining alternate treatment strategies. This study describes a modelled decision analysis comparing operative and conservative management of appendicitis. METHODS: The base case patient is a healthy, 23-year-old male presenting with migratory pain to the right iliac fossa (RIF) and elevated inflammatory markers. A decision tree was constructed comparing operative and conservative treatment. Rates of complications, failure of conservative therapy, recurrence and utilities were calculated via a systematic literature review. Variables were tested for sensitivity. RESULTS: Overall, conservative management gives a significantly better outcome (51.51 vs 49.87 QALYs). Three variables proved sensitive. Once operative complication rates are lower than 11.5 %, surgical treatment becomes the optimal strategy. If rates of failure of conservative management exceed 12.9 %, surgery becomes optimal. If the utility assigned to a post-operative complication exceeds 0.44, surgery becomes optimal. CONCLUSIONS: This decision analysis supports a conservative strategy, albeit with caveats. If operative complications are low or rates of failure of conservative management remain high, surgery is the preferable strategy.