Abdominal binders after laparotomy: review of the literature and French survey of policies.

BACKGROUND AND AIM: The use of abdominal binders after laparotomy is a question of habit. Scientific evidence of their usefulness is limited. The aims of this work were to review the scientific literature and to depict the practices of French surgeons regarding the use of these devices. METHODS: A systematic review of the literature about the use of abdominal binders after laparotomy was conducted. In order to depict surgeons' habits, an anonymous questionnaire was sent to all surgical departments affiliated to the FRENCH network (Federation of Surgical Research) and their surgical contacts. They were all asked about their use of binders, the type of binders they ordered, the expected benefit, the cost and the need for a randomized trial in this field. RESULTS: Only four trials have been published regarding the use of abdominal binders after laparotomy, all with a small number of patients. Some authors suggested that wearing binders procured a benefit in terms of postoperative comfort, but no significant difference was found. One study also suggested an improvement in respiratory volumes. No study focused on incisional hernia. Regarding the survey of practices, 50 questionnaires were retained for the final analysis (one questionnaire per department of surgery). The use of this device is really very frequent in France (94 % of surgeons order them), a habit usually acquired during the training in surgery. The main expected benefit is the prevention of abdominal wall dehiscence (83 %), but also an improvement in patients' postoperative comfort and pain (66 %). Although some surgeons order an abdominal binder for all their patients, most use them in selected patients (according to the operation and the patients' characteristics). CONCLUSION: Abdominal binders are frequently ordered by French surgeons after laparotomy. The expected benefit is the prevention of abdominal-wall complications, even though no data actually support this practice. Binders might have a benefit in terms of postoperative pain relief, but this needs to be analyzed. A prospective randomized trial is warranted.

Practice patterns in complex ventral hernia repair and place of biological grafts: a national survey among French digestive academic surgeons.

BACKGROUND: Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications. METHODS: A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals. RESULTS: Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%). CONCLUSIONS: Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications.

A self-adhering mesh for inguinal hernia repair: preliminary results of a prospective, multicenter study.

BACKGROUND: Prosthetic reinforcement is the gold standard treatment for inguinal hernia and reduces the risk of recurrence. Yet up to one-third of patients complain of post-surgical pain due to irritation and inflammation caused by the mesh and the fixation materials. Of these patients, 3-4% will experience severe and disabling chronic pain. We performed a prospective multicenter clinical study of a self-adhering prosthesis, consisting of a lightweight polypropylene mesh (40 g/m²) coated on each side with synthetic glue, to evaluate early postoperative complications and patient outcomes. PATIENTS AND METHODS: Between August 2008 and June 2010, 186 patients underwent hernia repair using the Lichtenstein technique and the self-adhering prosthesis. Primary endpoints were the frequency of disabling complications and quality of life (QoL) at 3-month follow-up. Pain, numbness, and groin discomfort were evaluated pre- and postoperatively (1 week, 1 and 3 months) using a visual analogue scale (VAS). Patients' pre- and postoperative QoL were measured using the SF12 questionnaire. Secondary endpoints were number of complications and recurrence rate, use of analgesic drugs, length of hospital stay, delay to return to normal activities, and patient satisfaction. The quality of the self-adhering mesh and its clinical utility were also evaluated by the participating surgeons. RESULTS: A total of 186 patients were enrolled and followed for at least 3 months after inguinal hernia repair. A total of 174 (95%) primary hernias and 12 (5%) recurrent hernias were treated. There were no intraoperative complications, no recurrences, and no repeat interventions performed during the study. The post-surgical complication rate was 4.5%. The mean delay to recover normal physical activity was 4 days. For the primary endpoint of pain, a VAS of zero was reported by 93/184 (50.5%) patients at 1 week, 130/171 (76.0%) patients at 1 month and 119/132 (90.2%) patients at 3 months' follow-up (P < 0.0001). The postoperative SF12 scores showed a significant improvement in patient QoL following surgery (P < 0.0001). CONCLUSIONS: Adhesix( ® ) self-adhering mesh for prosthetic reinforcement following inguinal hernia repair is atraumatic and associated with infrequent post-surgical complications or pain, a rapid recovery rate, and a high patient-reported QoL. A longer follow-up is underway to assess the frequency of post-surgical recurrence.

Appropriateness of colonoscopy in Europe (EPAGE II). Surveillance after polypectomy and after resection of colorectal cancer.

BACKGROUND AND STUDY AIMS: To summarize the published literature on assessment of appropriateness of colonoscopy for surveillance after polypectomy and after curative-intent resection of colorectal cancer (CRC), and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. METHODS: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of surveillance colonoscopy after polypectomy and after resection of CRC was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. RESULTS: Most CRCs arise from adenomatous polyps. The characteristics of removed polyps, especially the distinction between low-risk adenomas (1 or 2, small [< 1 cm], tubular, no high-grade dysplasia) vs. high-risk adenomas (large [> or = 1 cm], multiple [> 3], high-grade dysplasia or villous features), have an impact on advanced adenoma recurrence. Most guidelines recommend a 3-year follow-up colonoscopy for high-risk adenomas and a 5-year colonoscopy for low-risk adenomas. Despite the lack of evidence to support or refute any survival benefit for follow-up colonoscopy after curative-intent CRC resection, surveillance colonoscopy is recommended by most guidelines. The timing of the first surveillance colonoscopy differs. The expert panel considered that 56 % of the clinical indications for colonoscopy for surveillance after polypectomy were appropriate. For surveillance after CRC resection, it considered colonoscopy appropriate 1 year after resection. CONCLUSIONS: Colonoscopy is recommended as a first-choice procedure for surveillance after polypectomy by all published guidelines and by the EPAGE II criteria. Despite the limitations of the published studies, colonoscopy is also recommended by most of the guidelines and by EPAGE II criteria for surveillance after curative-intent CRC resection.

[Lymphadenectomy in the treatment of colon cancer]. / La chirurgie ganglionnaire dans le cancer du côlon.

Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging of the cancer at the time of intervention; 2) improving the chances for complete resection and cure; 3) evaluating the thoroughness and quality of a particular surgical procedure. The prognostic value of lymphadenectomy is evident from the direct practical decisions it entails: evidence-based recommendations (Level A) have proposed adjuvant chemotherapy for all patients with Stage III colon cancer since 1990. Studies have shown a statistically significant correlation between the number of nodes examined in an operative specimen and long-term survival in patients with Stage II disease. The more closely lymph nodes are examined, the more metastasis is found; one can then see the aberrations of stage migration described as the "Will Rogers Phenomenon." Without randomized studies, it is impossible to say whether resection of a larger number of lymph nodes actually improves the prognosis or whether that number is simply a marker of better surgical management including the quality of the surgical gesture, the careful pathologic examination of the specimen, and subsequent choices for adjuvant chemotherapy. The recovery of 12 lymph nodes correlates with a better global prognosis. At the very least, it is an effective marker for the quality of the surgical resection and can be used in the evaluation of professional practice.

[Not Available]. / La chirurgie ganglionnaire dans le cancer du côlon.

F. Lacaine Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging of the cancer at the time of intervention; 2) improving the chances for complete resection and cure; 3) evaluating the thoroughness and quality of a particular surgical procedure. The prognostic value of lymphadenectomy is evident from the direct practical decisions it entails: evidence-based recommendations (Level A) have proposed adjuvant chemotherapy for all patients with Stage III colon cancer since 1990. Studies have shown a statistically significant correlation between the number of nodes examined in an operative specimen and long-term survival in patients with Stage II disease. The more closely lymph nodes are examined, the more metastasis is found; one can then see the aberrations of stage migration described as the "Will Rogers Phenomenon." Without randomized studies, it is impossible to say whether resection of a larger number of lymph nodes actually improves the prognosis or whether that number is simply a marker of better surgical management including the quality of the surgical gesture, the careful pathologic examination of the specimen, and subsequent choices for adjuvant chemotherapy. The recovery of 12 lymph nodes correlates with a better global prognosis. At the very least, it is an effective marker for the quality of the surgical resection and can be used in the evaluation of professional practice.

[Not Available]. / La chirurgie ganglionnaire dans le cancer du côlon.

F. Lacaine Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging of the cancer at the time of intervention; 2) improving the chances for complete resection and cure; 3) evaluating the thoroughness and quality of a particular surgical procedure. The prognostic value of lymphadenectomy is evident from the direct practical decisions it entails: evidence-based recommendations (Level A) have proposed adjuvant chemotherapy for all patients with Stage III colon cancer since 1990. Studies have shown a statistically significant correlation between the number of nodes examined in an operative specimen and long-term survival in patients with Stage II disease. The more closely lymph nodes are examined, the more metastasis is found; one can then see the aberrations of stage migration described as the "Will Rogers Phenomenon." Without randomized studies, it is impossible to say whether resection of a larger number of lymph nodes actually improves the prognosis or whether that number is simply a marker of better surgical management including the quality of the surgical gesture, the careful pathologic examination of the specimen, and subsequent choices for adjuvant chemotherapy. The recovery of 12 lymph nodes correlates with a better global prognosis. At the very least, it is an effective marker for the quality of the surgical resection and can be used in the evaluation of professional practice.

[Inguinal hernia repair: time interval between surgical repair and recurrence]. / Hernies inguinales: délais d'apparition des récidives.

This study seeks to evaluate the time interval between initial inguinal hernia repair and the appearance of recurrent hernia in patients undergoing re-operation. Recurrent hernia was identified in 94 (6.4%) of 1,474 patients having undergone initial hernia repair at our institution. Recurrence appeared within two years in 40 patients (42%). Recurrences were noted beyond five years in 32 patients (34%), and after 20 years in 18 patients (19%). 75% of recurrences had occurred within 15 years. We conclude that almost two-thirds of recurrences occur later than five years after the initial intervention and a quarter occur at an interval of more than fifteen years. Most studies underestimate hernia recurrence due to an insufficient period of post-operative observation.

[Are physicians and their relatives at risk of postoperative complications when they are scheduled for surgery? Case control study from a prospective survey of 11,756 patients]. / Le risque opératoire est-il majoré chez les médecins ou leurs proches? Etude cas-témoin à partir du suivi prospectif des suites opératoires de 11,756 patients.

AIM AND METHODS: Are physicians and their relatives at risk of postoperative complications when they are scheduled for surgery? With the aim to answer this question, a case control study was performed from a cohort of 11,756 patients scheduled for surgery from 01/01/1987 to 12/31/2002. Fourty seven patients were physicians and 122 were a close relative to a physician. The percentage of physicians in the current series is comparable to that in the general urban population in France. Each of these patients was matched with 5 patients as controls regarding sex, age, diagnosis, procedure, and date of surgery. RESULTS: No statistically significant difference was observed between the 47 physicians and their 235 controls in the occurence of postoperative complications: 6% vs 6% (Odds ratio (OR)=1,07; CI(95%): 0,28-3,74), unplanned return to the operative room: 2% vs 2% (OR=1,00; CI: 0,11-8,8), and postoperative mortality: 0% vs 0,5% (p=0,07). No stastistically significant difference was observed between the 122 close relatives to a physician and their 610 controls in the occurence of postoperative complications: 6% vs 6% (OR=1,00; CI: 0,43-2,3), unplanned return to the operative room: 2% vs 3% (OR=0,55; CI: 0,18-3,4), and postoperative mortality: 1% vs 0,5% (OR=1,67; CI: 0,13-12,12). CONCLUSION: this study does not confirm the widespread opinion that postoperative course would be worse in physicians as patients and in their close relatives. Their recovery is not different from that to other patients if they are treated as well as other patients.

Prognosis of stage II colon cancer by non-neoplastic mucosa gene expression profiling.

We have assessed the possibility to build a prognosis predictor (PP), based on non-neoplastic mucosa microarray gene expression measures, for stage II colon cancer patients. Non-neoplastic colonic mucosa mRNA samples from 24 patients (10 with a metachronous metastasis, 14 with no recurrence) were profiled using the Affymetrix HGU133A GeneChip. Patients were repeatedly and randomly divided into 1000 training sets (TSs) of size 16 and validation sets (VS) of size 8. For each TS/VS split, a 70-gene PP, identified on the TS by selecting the 70 most differentially expressed genes and applying diagonal linear discriminant analysis, was used to predict the prognoses of VS patients. Mean prognosis prediction performances of the 70-gene PP were 81.8% for accuracy, 73.0% for sensitivity and 87.1% for specificity. Informative genes suggested branching signal-transduction pathways with possible extensive networks between individual pathways. They also included genes coding for proteins involved in immune surveillance. In conclusion, our study suggests that one can build an accurate PP for stage II colon cancer patients, based on non-neoplastic mucosa microarray gene expression measures.

[Is the laparoscopic approach appropriate for porcelain gallbladder?]. / Faut-il opérer les vésicules porcelaine par laparoscopie?

Contrary to the fears raised in surgical publications of the 1950's and 60's, the prognosis of porcelain gallbladder is not automatically associated with an increased risk of gallbladder carcinoma. Two recent cohort studies have allowed a better definition of the appropriate therapeutic attitude for a patient with a calcified gallbladder. In cases of "true" porcelain gallbladder, i.e., the presence of complete transmural calcification of the entire gallbladder wall, indications for cholecystectomy are based on biliary symptoms, all the more so since choledocholithiasis is often associated with porcelain gallbladder. In the case of partial calcification of the gallbladder, i.e., focal plaques of calcification involving the mucosa, prophylatic operative treatment is indicated. In these cases, the incidence of malignancy is markedly increased (14 times that of a control population). Cholecystectomy can still be performed laparascopically as long as the rules for prevention of peritoneal dissemination of tumor cells are scrupulously observed--the gallbladder should not be opened nor bile spilled, the specimen should be placed in a bag for removal through the abdominal wall, the pneumoperitoneum should be evacuated with the trocars still in place and the specimen should be opened and examined after removal with immediate frozen section pathologic exam if there is any question of tumor.