Complex abdominal wall hernia repair with biologic mesh in elderly: a propensity matched analysis.

BACKGROUND: Complex abdominal wall reconstruction (CAWR) has become a common surgical procedure both in non-elderly and elderly patients. OBJECTIVE: The aim of this study is to analyze the outcomes of the elderly compared to nonelderly undergoing CAWR using propensity score matching. METHODS: All patients who underwent CAWR using porcine-derived, non-crosslinked acellular dermal matrix (ADM) (Strattice™) between January 2014 and July 2017 were studied retrospectively. Propensity matched analysis was performed for risk adjustment in multivariable analysis and for one-to-one matching. The outcomes were analyzed for differences in postoperative complications, reoperations, mortality, hospital length of stay and adverse discharge disposition. RESULTS: One hundred-thirty-six patients were identified during the study period. Non-elderly (aged 18-64 years) constituted 70% (n = 95) and elderly (aged ≥ 65 years) comprised 30% of the overall patient population (n = 41). Seventy-three (56.7%) were females. After adjustment through the propensity score, which included 35 pairs, the surgical site infection (p = 1.000), wound necrosis (p = 1.000), the need for mechanical ventilation (p = 0.259), mortality (p = 0.083), reoperation rate (p = 0.141), hospital length of stay (p = 0.206), and discharge disposition (p = 0.795) were similar. CONCLUSION: Elderly patients undergoing CAWR with biological mesh have comparable outcomes with non-elderly patients when using propensity matching score.

A novel tool to evaluate bias in literature on use of biologic mesh in abdominal wall hernia repair.

PURPOSE: Biologic meshes are being increasingly used for abdominal hernia repair in high-risk patients or patients with a previous history of wound infection, due to their infection-resistant properties. Several studies have been carried out to assess whether biologic mesh is superior to synthetic mesh, as well as to establish guidelines for their use. Unfortunately, most of these studies were not rigorously designed and were vulnerable to different types of bias. The systematic reviews that have been published so far on this topic contain the same biases and limitations of the primary articles that are analyzed. The lack of a literature review on the bias on the use of biological mesh prompted us to conduct the literature search, assessment and plan this article. METHODS: We performed a literature search in PubMed, Embase and Cochrane databases of systematic reviews on biologic mesh for ventral hernia repair. The literature review was conducted using the Population, Intervention, Comparisons, Outcomes and Design approach. We identified 40 studies that matched the stringent criteria we had set. We then created a 13-point instrument to assess for bias and applied it on the primary studies that we intended to analyze. RESULTS: Most primary studies are case series or case reports of patients undergoing abdominal hernia repair with biologic mesh, without any comparison group, and the inclusion of cases was only specified to be consecutive in 6 out of 40 cases. In terms of assessing outcomes, in none of the 40 articles were the outcome assessors blinded to the intervention or exposure status of participants. CONCLUSION: The instrument that we created could allow to assess the risk of bias in different kind of studies. Our assessment of the studies based on the criteria that we had set up in the instrument clearly identified that further research needs to be done due to the lack of unbiased studies regarding the use of biologic meshes for abdominal hernia repair.

Recurrence of infection and hernia following partial versus complete removal of infected hernia mesh: a systematic review and cohort meta-analysis.

BACKGROUND: The aim of this systematic review and meta-analysis was to determine whether complete removal of infected hernia mesh (CMR) provides better results as compared to partial removal (PMR). METHODS: PubMed, EMBASE, Cochrane Library, and MEDLINE via Ovid were systematically searched for records published from 1980 to 2018 by three independent researchers (GM, GS, and GG). Quality assessment, data extraction and analysis were performed according to the Cochrane Handbook for Systematic Reviews of Interventions. Mantel-Haenszel method with odds ratio and 95% confidence interval (OR (95% CI)) as the measure of effect size of dichotomous primary and secondary endpoints was utilized. Random-effects model was used for meta-analysis. RESULTS: Five observational studies totaling 421 patients were included in the meta-analysis. Rates of infection recurrence were 58.5% (62/106) in PMR and 25.5% (62/315) in CMR. The difference was statistically significant [OR (95% CI) 4.15 (2.30, 7.47); p < 0.001]. Rates of hernia recurrence were 9.7% (8/82) in PMR vs. 40.2% (41/102) in CMR. This difference was not statistically significant [OR (95% CI) 0.25 (0.04, 1.62); p = 0.15]. Low risk of publication bias was found using funnel plots and Egger's test. CONCLUSIONS: This meta-analysis found significantly increased rates of infection recurrence in patients undergoing partial removal of infected hernia mesh as compared to complete removal. Complete removal of infected hernia mesh may be associated with increased rates of hernia recurrence. Further longitudinal observational studies are needed to confirm these findings.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

The role of perioperative endoscopic retrograde cholangiopancreatography and biliary drainage in large liver hydatid cysts.

BACKGROUND: The best surgical technique for large liver hydatid cysts (LHCs) has not yet been agreed on. Objectives. The objective of this study was to examine the role of perioperative endoscopic retrograde cholangiopancreatography (ERCP) and biliary drainage in patients with large LHCs. MetHODS: A 20-year retrospective study of patients with LHCs treated surgically at the University Clinical Center of Kosovo (UCCK). We divided patients into 2 groups based on treatment period: 1981-1990 (Group I) and 2001-2010 (Group II). Demographic characteristics (sex, age), the surgical procedure performed, complications rate, and outcomes were compared. RESULTS: Of the 340 patients in our study, 218 (64.1%) were female with median age of 37 years (range, 17 to 81 years). 71% of patients underwent endocystectomy with partial pericystectomy and omentoplication, 8% total pericystectomy, 18% endocystectomy with capitonnage, and 3% external drainage. In Group I, 10 patients underwent bile duct exploration and T-tube placement; in Group II, 39 patients underwent bile duct exploration and T-tube placement. In addition, 9 patients in Group II underwent perioperative ERCP with papillotomy. The complication rate was 14.32% versus 6.37%, respectively (P = 0.001). CONCLUSION: Perioperative ERCP and biliary drainage significantly decreased the complication rate and improved outcomes in patients with large LHCs.

Occult hemopneumothorax following chest trauma does not need a chest tube.

BACKGROUND: The increasing use of thoracic computed tomography (CT) in trauma patients has led to the recognition of intrapleural blood and air that are not initially evident on admission plain chest X-ray, defining the presence of occult hemopneumothorax. The clinical significance of occult hemopneumothorax, specifically the role of the tube thoracostomy, is not clearly defined. OBJECTIVE: To identify those patients with occult hemopneumothorax who can be safely managed without chest tube insertion. DESIGN: Prospective observational study. METHODS: During the recent 24 month period ending July 2010, comprehensive data on trauma patients with occult hemopneumothorax were recorded to determine whether tube thoracostomy was needed and, if not, to define the consequences of nondrainage. Pneumothorax and hemothorax were quantified by computed tomography (CT) measurement. Data included demographics, injury mechanism and severity, chest injuries, need for mechanical ventilation, indications for tube thoracostomy, hospital length of stay, complications and outcome. RESULTS: There were 73 patients with hemopenumothorax identified on CT scan in our trauma registry. Tube thoracostomy was successfully avoided in 60 patients (83 %). Indications for chest tube placement in 13 (17 %) of patients included X-ray evidence of hemothorax progression (10), respiratory compromise with oxygen desaturation (2). Mechanical ventilation was required in 19 patients, five of them required chest tube insertion, and six developed ventilator associated pneumonia, while there were no cases of empyema. There was one death due to severe head injury. CONCLUSIONS: Occult hemopneumothorax can be successfully managed without tube thoracostomy in most cases. Patients with a high ISS score, need for mechanical ventilation, and CT-detected blood collection measuring >1.5 cm increased the likelihood of need for tube thoracostomy. The size of the pneumothorax did not appear to be significant in determining the need for tube thoracostomy.

Nutrition therapy for critically ill and injured patients.

BACKGROUND: Nutrition support has undergone significant advances in recent decades, revolutionizing the care of critically ill and injured patients. However, providing adequate and optimal nutrition therapy for such patients is very challenging: it requires careful attention and an understanding of the biology of the individual patient's disease or injury process, including insight into the consequent changes in nutrients needed. OBJECTIVE: The objective of this article is to review the current principles and practices of providing nutrition therapy for critically ill and injured patients. METHODS: Review of the literature and evidence-based guidelines. RESULTS: The evidence demonstrates the need to understand the biology of nutrition therapy for critically ill and injured patients, tailored to their individual disease or injury, age, and comorbidities. CONCLUSION: Nutrition therapy for critically ill and injured patients has become an important part of their overall care. No longer should we consider nutrition for critically ill and injured patients just as "support" but, rather, as "therapy", because it is, indeed, a key therapeutic modality.

Gastrointestinal tract access for enteral nutrition in critically ill and trauma patients: indications, techniques, and complications.

BACKGROUND: Enteral nutrition (EN) is a widely used, standard-of-care technique for nutrition support in critically ill and trauma patients. OBJECTIVE: To review the current techniques of gastrointestinal tract access for EN. METHODS: For this traditional narrative review, we accessed English-language articles and abstracts published from January 1988 through October 2012, using three research engines (MEDLINE, Scopus, and EMBASE) and the following key terms: "enteral nutrition," "critically ill," and "gut access." We excluded outdated abstracts. RESULTS: For our nearly 25-year search period, 44 articles matched all three terms. The most common gut access techniques included nasoenteric tube placement (nasogastric, nasoduodenal, or nasojejunal), as well as a percutaneous endoscopic gastrostomy (PEG). Other open or laparoscopic techniques, such as a jejunostomy or a gastrojejunostomy, were also used. Early EN continues to be preferred whenever feasible. In addition, evidence is mounting that EN during the early phase of critical illness or trauma trophic feeding has an outcome comparable to that of full-strength formulas. Most patients tolerate EN through the stomach, so postpyloric tube feeding is not needed initially. CONCLUSION: In critically ill and trauma patients, early EN through the stomach should be instituted whenever feasible. Other approaches can be used according to patient needs, available expertise, and institutional guidelines. More research is needed in order to ensure the safe use of surgical tubes in the open abdomen.

Age and traumatic chest injury: a 3-year observational study.

BACKGROUND: A quarter of trauma-related deaths are attributable to traumatic chest injury (TCI). OBJECTIVE: To outline the pattern and outcome of TCI in a rapidly developing country among different age groups. METHODS: We conducted a retrospective observational study for patients who sustained TCI and admitted between January 2008 and December 2010 to the Level I trauma center at Hamad General Hospital in Qatar. Patients were classified and analyzed in four age groups (group 1 ≤18, group 2 between 19-44, group 3 45-59, and group 4 >60 years). Multivariate regression analysis was performed for predictors of mortality. RESULTS: Of 5,118 cases admitted to the Section of Trauma Surgery, 1,355 (26.5 %) had TCI (12, 67, 16, and 5 % in groups 1-4, respectively), which was due to blunt trauma in 96 % of cases. The overall mean age was 33 ± 15 years and males comprised 94 % of cases. Children (≤18 years of age) had more traffic-related injury, intubation, high Injury Severity Score (ISS) (19 ± 12), and associated head and liver injuries in comparison to the other groups. The overall mortality rate was 13 % (24, 11, 12, and 16 % in groups 1-4, respectively). The death rate was higher in pedestrians, followed by motor vehicle crashes (MVCs) and fall-related injuries (24 vs. 13 vs. 7 %, respectively, p = 0.001). The highest mortality occurred within the first day (n = 115, 65 %). In comparison to old age, children were more likely to die early (on the first day) and the adult group died mostly within the first week of hospitalization. Independent predictors for mortality included associated head injury [odds ratio (OR) 2.3, 95 % confidence interval (CI) 1.48-3.62), ISS (OR 1.11, 95 % CI 1.09-1.13), and age (OR 0.37, 95 % CI 0.22-0.62). CONCLUSION: TCI is an alarming problem in Qatar, with a bimodal mortality curve. The highest mortality peak occurred in children, followed by old age. However, young males are the most exposed population. Regulatory efforts and strict enforcement of traffic laws would likely reduce morbidity and mortality.

Percutaneous dilatational tracheostomies in a newly established trauma center: a report from Qatar.

BACKGROUND: Percutaneous dilatational tracheostomy (PDT) is a routine surgical procedure for critically ill patients who require prolonged ventilatory support. METHODS: We conducted a retrospective cohort study of all PDTs performed at the adult Trauma Intensive Care Unit (TICU) of Hamad Medical Corporation in Doha, Qatar, from January 2009 through September 2012. For all adult patients, we analyzed the demographic characteristics, mean ventilator time before the procedure, injury severity score (ISS), complications, and outcomes. RESULTS: Of the 1,442 trauma patients admitted to the adult TICU during our study period, 124 (8.5 %) underwent PDT using the Ciaglia Blue Rhino technique. The vast majority were male (94.3 %). The mean age was 35 ± 15.6 years; mean ventilator time before the procedure, 12 ± 3 days; and mean ISS, 24.2 ± 9.3. More than half of patients had head injury (56 %), followed by chest and abdomen (26 %) and cervical spine injuries (18 %). Early complications included difficult tube placement (0.8 %), hypoxemia (0.8 %), minor bleeding (1.6 %), and hypotension (0.8 %), but the vast majority (93 %) of patients had no complications. The procedure-related mortality rate was 0 %. CONCLUSION: PDT is safe and can be performed with minimal complications even in a newly established trauma center.

Clinical outcomes of multiple rib fractures: does age matter?

PURPOSE: To evaluate the clinical outcomes of multiple rib fracture due to blunt trauma in young patients, a 3-year retrospective study was conducted. Patients with ≥3 rib fractures were divided into two groups (group I: <45 years old and group II: ≥45 years old). Mortality, hospital stay, ventilatory support, chest tubes insertion and associated injuries were studied. RESULTS: Of the 902 patients admitted with blunt chest trauma, 240 (27 %) met the inclusion criteria and 72.5 % patients were <45 years old. The most common causes of injury were motor vehicle crash (59 %) and fall (29 %). The Injury Severity Score (ISS) was higher in group I (16 ± 9 vs. 13 ± 6; p = 0.04). Hospital mortality was higher in group II (6 vs. 2 %; p = 0.18). Pneumothorax, haemothorax and ventilatory support were comparable. Patients in group II were more likely to undergo chest tubes insertion (26 vs. 14 %; p = 0.04), while group I had a significantly higher incidence of associated abdominal injuries (25 vs. 12 %; p = 0.03). CONCLUSION: Old age presenting with rib fractures is associated with higher mortality in comparison to young age; however, this difference becomes statistically insignificant in the presence of multiple rib fracture.

Enterocutaneous fistulas and a hostile abdomen: reoperative surgical approaches.

Damage-control surgery and open-abdomen is an acceptable­and often lifesaving­approach to the treatment of patients with severe trauma, abdominal compartment syndrome, necrotizing soft tissue catastrophes, and other abdominal disasters, when closing the abdomen is not possible, ill advised, or will have serious sequelae. However, common consequences of open-abdomen management include large abdominal wall defects, enterocutaneous fistulas (ECFs), and enteroatmospheric fistulas (EAFs). Furthermore, in such patients, a frozen and hostile abdomen (alone or combined with ECFs) is not uncommon. Adding biologic mesh to our surgical armamentarium has revolutionized hernia surgery.