Abdominal Decompression after Cardiac Surgery: Outcome of 42 Patients with Abdominal Compartment Syndrome.

BACKGROUND: Up to 50% of patients in intensive care units develop intraabdominal hypertension (IAH) in the course of medical treatment. If not detected on time and treated adequately, IAH may develop into an abdominal compartment syndrome (ACS) which is associated with a high mortality rate. Patients undergoing cardiac surgery are especially prone to develop ACS due to several risk factors including intraoperative hypothermia, fluid resuscitation and acidosis. We investigated patients who developed ACS after cardiac surgery and analyzed potential risk factors, treatment and outcome. METHODS: From 2011 to 2016, patients with ACS after cardiac surgery requiring decompressive laparotomy were prospectively recorded. Patient characteristics, details on the cardiac surgery, mortality rate and type of treatment of the open abdomen were analyzed. RESULTS: Incidence of ACS in cardiac surgery patients was 1.0% (n = 42/4128), with a mortality rate of 57%. Ejection fraction, Euroscore2 as well as the perfusion time are independent risk factors for the development of ACS. The outcome of patients with ACS was independent of elective versus emergency surgery, gender, age, BMI or ASA score. In the 18 surviving patients, fascial closure was achieved in 72% after a median of 9 days. CONCLUSION: Abdominal compartment syndrome is a rare but serious complication after cardiac surgery with a high mortality rate. Independent risk factors for ACS were identified. Negative pressure wound therapy seems to promote and allow early fascia closure of the abdomen and represents therefore a likely benefit for the patient.

Dynamic Serosal Perfusion Assessment during Colorectal Resection Using Visible Light Spectroscopy.

INTRODUCTION: Anastomotic leakage (AL) in colorectal surgery occurs with an incidence of up to 20%. Bowel perfusion is deemed to be one of the most important factors for anastomotic healing. However, not much is known about its variability during colorectal surgery and its impact on the outcome. Therefore, this study aims to evaluate serosal oxygen saturation patterns during colorectal resections with visible light spectroscopy (VLS). MATERIALS AND METHODS: Bowel perfusion in patients undergoing left-sided colorectal resections was assessed at different timepoints during surgery using VLS on the colonic serosa. The primary outcome parameter was serosal oxygen saturation (StO2) at the anastomosis during different timepoints of surgery. RESULTS: We included 50 patients who underwent colorectal resection for bowel cancer (58%) and diverticular disease (34%). StO2 at the proximal site of the anastomosis increased significantly throughout the surgery (mean difference 3.61%; 95% CI -6.22 to -1.00; p = 0.008). However, aberrancy from this identified perfusion pattern had no impact on the postoperative outcome. CONCLUSION: During colorectal resections, we could demonstrate an increase of the colonic StO2 throughout surgery. Appearance of AL was not associated with lower StO2, underlining the multifactorial genesis of developing AL.

Smaller Inguinal Hernias are Independent Risk Factors for Developing Chronic Postoperative Inguinal Pain (CPIP): A Registry-based Multivariable Analysis of 57, 999 Patients.

OBJECTIVE: Impact of inguinal hernia defect size as stratified by the European Hernia Society (EHS) classification I to III on the rate of chronic postoperative inguinal pain (CPIP). BACKGROUND: CPIP is the most important complication after inguinal hernia repair. The impact of hernia defect size according to the EHS classification on CPIP is unknown. METHODS: In total, 57,999 male patients from the Herniamed registry undergoing primary unilateral inguinal hernia repair including a 1-year follow-up were selected between September 1, 2009 and November 30, 2016. Using multivariable analysis, the impact of EHS inguinal hernia classification (EHS I vs EHS II vs EHS III and/or scrotal) on developing CPIP was investigated. RESULTS: Multivariable analysis revealed for smaller inguinal hernias a significant higher rate of pain at rest [EHS I vs EHS II: odds ratio, OR = 1.350 (1.180-1.543), P < 0.001; EHS I vs EHS III and/or scrotal: OR = 1.839 (1.504-2.249), P < 0.001; EHS II vs EHS III and/or scrotal: OR = 1.363 (1.125-1.650), P = 0.002], pain on exertion [EHS I vs EHS II: OR = 1.342 (1.223-1.473), P < 0.001; EHS I vs EHS III and/or scrotal: OR = 2.002 (1.727-2.321), P < 0.001; EHS II vs EHS III and/or scrotal: OR = 1.492 (1.296; 1.717), P < 0.001], and pain requiring treatment [EHS I vs EHS II: OR = 1.594 (1.357-1.874), P < 0.001; EHS I vs EHS III and/or scrotal: OR = 2.254 (1.774-2.865), P < 0.001; EHS II vs EHS III and/or scrotal: OR = 1.414 (1.121-1.783), P = 0.003] at 1-year follow-up. Younger patients (<55 y) revealed higher rates of pain at rest, pain on exertion, and pain requiring treatment (each P < 0.001) with a significantly trend toward higher rates of pain in smaller hernias. CONCLUSIONS: Smaller inguinal hernias have been identified as an independent patient-related risk factor for developing CPIP.

Outcome of laparoscopic paraesophageal hernia repair in octogenarians: a registry-based, propensity score-matched comparison of 360 patients.

BACKGROUND: Paraesophageal hernias (PEH) tend to occur in elderly patients and the assumed higher morbidity of PEH repair may dissuade clinicians from seeking a surgical solution. On the other hand, the mortality rate for emergency repairs shows a sevenfold increase compared to elective repairs. This analysis evaluates the complication rates after elective PEH repair in patients 80 years and older in comparison with younger patients. METHODS: In total, 3209 patients with PEH were recorded in the Herniamed Registry between September 1, 2009 and January 5, 2018. Using propensity score matching, 360 matched pairs were formed for comparative analysis of general, intraoperative, and postoperative complication rates in both groups. RESULTS: Our analysis revealed a disadvantage in general complications (6.7% vs. 14.2%; p = 0.002) for patients ≥ 80 years old. No significant differences were found between the two groups for intraoperative (4.7% vs. 5.8%, p = 0.627) and postoperative complications (2.2% vs. 2.8%, p = 0.815) or for complication-related reoperations (1.7% vs. 2.2%, p = 0.791). CONCLUSIONS: Despite a higher risk of general complications, PEH repair in octogenarians is not in itself associated with increased rates of intraoperative and postoperative complications or associated reoperations. Therefore, PEH repair can be safely offered to elderly patients with symptomatic PEH, if general medical risk factors are controlled.

Does coagulopathy, anticoagulant or antithrombotic therapy matter in incisional hernia repair? Data from the Herniamed Registry.

BACKGROUND: A considerable number of patients undergoing incisional hernia repair are on anticoagulant or antiplatelet therapy or have existing coagulopathy which may put them at higher risk for postoperative bleeding complications. Data about the optimal treatment of these patients are sparse. This analysis attempts to determine the rate of postoperative bleeding complications following incisional hernia repair and the consecutive rate of reoperation among patients with coagulopathy or receiving antiplatelet and anticoagulant therapy (higher risk group) compared to patients who do not have a higher risk (normal risk group). METHODS: Out of the 43,101 patients documented in the Herniamed Registry who had an incisional hernia repair, 6668 (15.5%) were on anticoagulant or antithrombotic therapy or had existing coagulopathy. The implication of that higher risk profile for onset of postoperative bleeding was investigated in multivariable analysis. Hence, other influential variables were identified. RESULTS: The rate of postoperative bleeding in the higher risk group was 3.9% (n = 261) and significantly higher compared to the normal risk group at 1.6% (n = 564) (OR 2.001 [1.699; 2.356]; p < 0.001). Additionally, male gender, use of drains, larger defect size, open incisional hernia repair, lower BMI, and higher ASA score significantly increased the risk of postoperative bleeding. The rate of reoperations due to postoperative bleeding was significantly increased in the higher risk group compared to the normal risk group (2.4 vs. 1.0%; OR 1.217 [1.071; 1.382]; p = 0.003). Likewise, the postoperative general complication rate (6.04 vs. 3.66%; p < 0.001) as well as the mortality rate (0.46 vs. 0.17%; p < 0.001) were significantly higher in the higher risk group. CONCLUSIONS: Patients with anticoagulant or antiplatelet therapy or existing coagulopathy who undergo incisional hernia repair have a significantly higher risk for onset of postoperative bleeding. The risk of bleeding complications and complication-related reoperations seems to be lower after laparoscopic intraperitoneal onlay mesh.

Blended Learning Methods for Surgical Education.

The emergence and maturation of the concept of blended learning in public and military education may prove equally valuable in CME surgical education and training. Creating a learner-centric environment in which multiple modes of education are encouraged, available, integrated, and accredited can increase the level of competence achieved in CME courses. This paper defines a framework for blended surgical training using principles developed for the military and it is applied in courses at a major post-graduate surgical education center.

Prevention of Parastomal Hernia.

Parastomal hernia (PSH), defined as an incisional hernia at the abdominal wall defect resulting from stoma formation, is a frequent complication of enterostomy (ileostomy and jejunostomy), colostomy, and urostomy. A growing body of evidence supports the use of prophylactic mesh at the time of stoma creation to prevent the development of PSH. In particular, the use of permanent mesh has been supported in the creation of an end colostomy, and prophylactic mesh has been studied for use in other types of stoma. Permanent mesh materials used for PSH prophylaxis include polypropylene, polyester, polytetrafluoroethylene, and composite prosthetics. Despite the appeal of biologic and bioabsorbable materials in an operative field that poses a potentially higher risk of infection, there is insufficient evidence to support their use in primary PSH prevention. Two-dimensional meshes are usually cut to contain a keyhole through which the bowel passes, and may be placed in the sublay/retrorectus, intraperitoneal, or preperitoneal position. Alternative techniques include placement of a non-keyhole mesh in a position similar to that of a Sugarbaker PSH repair or use of a circular stapler fired through the abdominal wall fascia and mesh simultaneously, fixing both together. Three-dimensional mesh devices, including the Prolene® and Ultrapro® Hernia Systems (PHS/UHS) (Ethicon US, LLC, Somerville, NJ), have been studied for use in PSH prevention. Novel, specialized devices such as the Koring™ (Koring AG, Basel, Switzerland) stoma mesh have been designed specifically for primary PSH prevention. While the benefits of mesh prophylaxis have been established, further evidence is needed to identify the optimal materials and technique for PSH prevention in a variety of patients and settings. The purpose of this report is to provide an overview of the operative techniques and evidence supporting prophylaxis of parastomal hernias.

Colon Perfusion Patterns During Colorectal Resection Using Visible Light Spectroscopy.

BACKGROUND: The impact of blood supply to the anastomosis on development of anastomotic leakage is still a matter of debate. Considering that bowel perfusion may be affected by manipulation during surgery, perfusion assessment of the anastomosis alone may be of limited value. We propose perfusion assessment at different time points during surgery to explore the dynamics of bowel perfusion during colorectal resection and its impact on outcome. METHODS: In this prospective cohort study, patients undergoing elective colorectal resection were eligible. Colon perfusion was evaluated using visible light spectroscopy. Main outcome was the difference in colon perfusion, quantified by measuring tissue oxygen saturation (StO2) in the colonic serosa, before and after anastomosis during surgery. RESULTS: We included 58 patients between July 2013 and November 2015. Colon perfusion increased by an average of 5.9% StO2 during surgery (95% confidence interval 3.1, 8.8; P < 0.001). The number of patients with abnormal perfusion (defined as StO2 < 65%) decreased from 50% at the beginning to 24% by the end of surgery. Six patients (10%) developed anastomotic leaks (AL), of which five patients had abnormal perfusion at the beginning of surgery, whereas four patients had normal StO2 at the anastomosis. CONCLUSION: Colon perfusion significantly increased during colorectal surgery. Considering that one quarter of patients had suboptimal anastomotic perfusion without developing AL, impaired blood flow at the anastomosis alone does not seem to be critical. Further investigations including more patients are necessary to evaluate the impact of perioperative parameters on colon perfusion, anastomotic healing and surgical outcome.

A promising new device for the prevention of parastomal hernia.

Parastomal hernia (PSH) is the most frequent long-term stoma complication with serious negative effects on quality of life. Surgical revision is often required and has a substantial morbidity and recurrence rate. The development of PSH requires revisional surgery with a substantial perioperative morbidity and high failure rate in the long-term follow-up. Prophylactic parastomal mesh insertion during stoma creation has the potential to reduce the rate of PSH, but carries the risk of early and late mesh-related complications such as infection, fibrosis, mesh shrinkage, and/or bowel erosion. We developed a new stomaplasty ring (KORING), which is easy to implant, avoids potential mesh-related complications, and has a high potential of long-term prevention of PSH. Here we describe the technique and the first use.

[Current recommendations for aftercare in patients following hernia repair]. / Nachsorge des Hernienpatienten.

Abdominal wall hernias, in particular inguinal hernias are the most frequently encountered entity in general surgery. Consequently, the socio-economic burden results from the in-hospital phase itself and to a considerable extent from the convalescence period. In addition to the surgical procedure and the occupation of the patient there are two factors of particular significance influencing the aftercare: the post-operative pain and the given recommendations for postoperative strain. Next to patient-factor adapted operative procedures it is therefore essential, to offer a standardized pain management and recommendations for postoperative strain. Currently there is no conclusion, whether the minimally invasive techniques will be established as the "Gold-standard", particularly from an economic point of view and the introduction of the DRG in Switzerland.

Zinc salts provide a novel, prolonged and rapid inhibition of gastric acid secretion.

OBJECTIVES: The overproduction of acid and the associated illnesses linked to hypersecretion have a lifetime prevalence of 25-35% in the United States. Although a variety of pharmaceutical agents have been used to reduce the production of acid, alarming new evidence questions the long-term efficacy and safety of the agents. These issues coupled with the delayed onset of action and the return of symptoms in over 60% of the patients is less than satisfactory. The purpose of this study was to determine whether administration of a zinc salt could lead to a rapid and sustained increase in gastric pH in both animals and in humans and provide a new rapid acid suppression therapy. METHODS: Intracellular pH was measured with 2',7'-bis-(2-carboxyethyl)-5-and-6-carboxy-fluorescein in both human and rat gastric glands following an acid load±a secretagogue. In a separate series of studies, whole stomach acid secretion was monitored in rats. A final study used healthy human volunteers while monitoring with a gastric pH measurement received placebo, zinc salt, or a zinc salt and proton pump inhibitor (PPI). RESULTS: We demonstrate that exposure to ZnCl(2) immediately abolished secretagogue-induced acid secretion in isolated human and rat gastric glands, and in intact rat stomachs. Chronic low-dose zinc exposure effectively inhibited acid secretion in whole stomachs and isolated glands. In a randomized cross-over study in 12 volunteers, exposure to a single dose of ZnCl(2) raised intragastric pH for over 3 h, including a fast onset of effect. CONCLUSIONS: Our findings demonstrate that zinc offers a novel rapid and prolonged therapy to inhibit gastric acid secretion in human and rat models.

Predictive risk factors for intra- and postoperative complications in 526 laparoscopic sigmoid resections due to recurrent diverticulitis: a multivariate analysis.

BACKGROUND: Laparoscopic sigmoid resection is a feasible and frequent operation for patients who suffer from recurrent diverticulitis. There is still an ongoing debate about the optimal timing for surgery in patients who suffer from recurrent diverticulitis episodes. In elective situations the complication rate for this procedure is moderate, but there are patients at high risk for perioperative complications. The few identified risk factors so far refer to open surgery. Data for the elective laparoscopic approach is rare. The objective of this study was to identify potential predictive risk factors for intra- and postoperative complications in patients who underwent laparoscopic sigmoid resection due to diverticular disease. METHODS: Uni- and multivariate analyses of a prospectively gathered database (1993-2006) were performed on a consecutive series of 526 patients who underwent laparoscopic sigmoid resection due to recurrent diverticulitis in a single institution. Patients were assessed for demographic data, operative indications, and intra- and postoperative complications. Altogether, we analyzed 17 potential risk factors to identify significant influence on the intra- and postoperative outcome, including timing of surgery. RESULTS: Statistical analysis of specific medical and surgical complications revealed anemia, previous myocardial infarction, heart failure, experience of the surgeon, and male gender, as independent predictive risk factors for postoperative complications. Patients older than age 75 years was the only independent risk factor for intraoperative complications in a multiple logistic regression model. Early elective surgery led to increased conversion rate but did not influence the postoperative complication rate. CONCLUSIONS: This large, single-center study provides first evidence of the significance of specific predictive risk factors for intra- and postoperative complications in laparoscopic sigmoid resection for diverticular disease.

Perioperative Tablet-Based Telemonitoring After Abdominal Wall Hernia Surgery: Pilot Prospective Observational Cohort Study.

BACKGROUND: Hernia repairs account for millions of general surgical procedures performed each year worldwide, with a notable shift to outpatient settings over the last decades. As technical possibilities such as smartphones, tablets, and different kinds of probes are becoming more and more available, such systems have been evaluated for applications in various clinical settings. However, there have been few studies conducted in the surgical field, especially in general surgery. OBJECTIVE: We aimed to assess the feasibility of a tablet-based follow up to monitor activity levels after repair of abdominal wall hernias and to evaluate a possible reduction of adverse events by their earlier recognition. METHODS: Patients scheduled for elective surgical repair of minor abdominal wall hernias (eg, inguinal, umbilical, or trocar hernias) were equipped with a telemonitoring system, including a tablet, pulse oximeter, and actimeter, for a monitoring phase of 7 days before and 30 days after surgery. Descriptive statistical analyses were performed. RESULTS: We enrolled 16 patients with a mean overall age of 48.75 (SD 16.27) years. Preoperative activity levels were reached on postoperative day 12 with a median of 2242 (IQR 0-4578) steps after plunging on the day of surgery. The median proportion of available activity measurements over the entire study period of 38 days was 69% (IQR 56%-81%). We observed a gradual decrease in the proportion of available data for all parameters during the postoperative course. Six out of ten patients (60%) regained preoperative activity levels within 3 weeks after surgery. Overall, patients rated the usability of the system as relatively easy. CONCLUSIONS: Tablet-based follow up is feasible after surgical repair of minor abdominal wall hernias, with good adherence rates during the first couple of weeks after surgery. Thus, such a system could be a useful tool to supplement or even replace traditional outpatient follow up in selected general surgical patients.

Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study.

OBJECTIVE: To prospectively assess the construct and criterion validity of ClassIntra version 1.0, a newly developed classification for assessing intraoperative adverse events. DESIGN: International, multicentre cohort study. SETTING: 18 secondary and tertiary centres from 12 countries in Europe, Oceania, and North America. PARTICIPANTS: The cohort study included a representative sample of 2520 patients in hospital having any type of surgery, followed up until discharge. A follow-up to assess mortality at 30 days was performed in 2372 patients (94%). A survey was sent to a representative sample of 163 surgeons and anaesthetists from participating centres. MAIN OUTCOME MEASURES: Intraoperative complications were assessed according to ClassIntra. Postoperative complications were assessed daily until discharge from hospital with the Clavien-Dindo classification. The primary endpoint was construct validity by investigating the risk adjusted association between the most severe intraoperative and postoperative complications, measured in a multivariable hierarchical proportional odds model. For criterion validity, inter-rater reliability was evaluated in a survey of 10 fictitious case scenarios describing intraoperative complications. RESULTS: Of 2520 patients enrolled, 610 (24%) experienced at least one intraoperative adverse event and 838 (33%) at least one postoperative complication. Multivariable analysis showed a gradual increase in risk for a more severe postoperative complication with increasing grade of ClassIntra: ClassIntra grade I versus grade 0, odds ratio 0.99 (95% confidence interval 0.69 to 1.42); grade II versus grade 0, 1.39 (0.97 to 2.00); grade III versus grade 0, 2.62 (1.31 to 5.26); and grade IV versus grade 0, 3.81 (1.19 to 12.2). ClassIntra showed high criterion validity with an intraclass correlation coefficient of 0.76 (95% confidence interval 0.59 to 0.91) in the survey (response rate 83%). CONCLUSIONS: ClassIntra is the first prospectively validated classification for assessing intraoperative adverse events in a standardised way, linking them to postoperative complications with the well established Clavien-Dindo classification. ClassIntra can be incorporated into routine practice in perioperative surgical safety checklists, or used as a monitoring and outcome reporting tool for different surgical disciplines. Future studies should investigate whether the tool is useful to stratify patients to the appropriate postoperative care, to enhance the quality of surgical interventions, and to improve long term outcomes of surgical patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT03009929.

AMP-activated protein kinase: a physiological off switch for murine gastric acid secretion.

Adenosine monophosphate (AMP)-activated protein kinase (AMPK) has been shown to be a metabolic energy regulator in various cells. Activation is a direct result of rising AMP concentration coupled with falling adenosine triphosphate (ATP). AMPK activation during metabolic stress consequently reduces cellular ATP consumption. The gastric parietal cell has a large abundance of mitochondria per cell volume due to the numerous energy-dependent transporters and channels responsible for acid secretion. We identified AMPK in the parietal cell as a metabolic energy regulator that can switch acid secretion off as cellular ATP levels fall. AMPK presence in murine gastric glands was evaluated by immunofluorescent localization. We used a digital imaging system to monitor acid secretion as observed by proton efflux from parietal cells in hand-dissected gastric glands loaded with the pH-sensitive dye 2',7'-bis-(2-carboxyethyl)-5-(and 6)-carboxyfluorescein. Individual murine gastric glands were exposed to histamine, pentagastrin, or carbachol. AMPK was pharmacologically activated with 5-aminoimidazole-4-carboxamide-1-beta-D: -riboside (AICAR) monophosphate or inhibited with 6-[4-(2-piperidin-1-yl-ethoxy)-phenyl)]-3-pyridin-4-yl-pyyrazolo[1,5-a] pyrimidine (compound C) or ATP. Acid secretion was evaluated under these conditions as the rate of intracellular pH recovery. In addition, whole-stomach pH measurements were performed. Immunofluorescent localization confirmed the presence of AMPK in gastric mucosa. Exposure to AICAR monophosphate significantly reduced secretagogue-induced acid secretion; addition of compound C or ATP restored acid secretion. Our results indicate that secretagogue-induced acid secretion could be significantly reduced with AMPK activation and restored with its deactivation. We therefore propose the AMPK as a cellular metabolic off switch for gastric acid secretion.

A multivariate analysis of potential risk factors for intra- and postoperative complications in 1316 elective laparoscopic colorectal procedures.

OBJECTIVE: To identify predictive risk factors for intra- and postoperative complications in patients undergoing laparoscopic colorectal surgery. BACKGROUND DATA: In emergency situations or in elective open and laparoscopic colorectal surgery, there are many risk factors that should be recognized by the surgeon to reduce complications and initiate adequate treatment. Most available data, thus far, refer to open colorectal surgery and literature that focuses mainly on a laparoscopic approach is still rare. METHODS: Univariate and multivariate analyses of a prospectively gathered database (1993-2006) were performed on a consecutive series of patients (1316) undergoing laparoscopic colorectal surgery who were operated at a single institution (first referral center). Patients were assessed for demographic data, operative indications, type of resection, and intra- and postoperative complications. Altogether, we analyzed 20 potential risk factors to identify significant influence on the intra- and postoperative outcome. RESULTS: Significant risk factors that led to intraoperative complications consisted of age > or = 75 years and malignant neoplasia. Increased postoperative rate of surgical complications was significantly influenced by male gender, age > or = 75 years, American Society of Anesthesiology class > or = III, malignant neoplasia, and the experience of the surgeon. The analysis of specific medical postoperative complications revealed even more significant predictive risk factors. In addition, our analysis showed that specific risk factors predict specific complications such as postoperative bleeding, anastomotic leakage, and surgical site infections. The type of surgical procedure performed also influenced patient outcome. CONCLUSION: This large single center study provides the first evidence of the significance of predictive risk factors for intra- and postoperative complications in laparoscopic colorectal surgery.

Pneumoscrotum after colorectal surgery: A case report.

Pneumoscrotum is a very rare complication. Currently, very little evidence-based medicine exists on treatment guidelines. We think a prophylactic antibiotic course and a 48 hours in hospital observation are justified in these rare cases.

Is antibiotic prophylaxis mandatory in laparoscopic incisional hernia repair? Data from the herniamed registry.

BACKGROUND: Several meta-analyses showed that laparoscopic incisional hernia repair is associated with lower surgical site infection (SSI) rates compared to open repair. However, the efficiency of antibiotic prophylaxis (AP) in laparoscopic incisional hernia repair alone is unknown and needs evaluation. Due to increasing antimicrobial resistance, a major global health care problem, AP needs to be critically evaluated. The aim of this study was to investigate the impact of AP on the rate of SSI and complication-related reoperations in patients undergoing laparoscopic incisional hernia repair. MATERIALS AND METHODS: Prospectively documented data from the Herniamed Hernia Registry from 2009 to 2017 were retrospectively analysed. Multivariable analyses were used to study the influence of AP as well as further patient and surgery-related risk factors on SSI and complication-related reoperation rates. This was verified in a sensitivity analysis using propensity-score matching. RESULTS: In the analysed time period 13'513 patients undergoing elective laparoscopic incisional hernia repair were recorded, of which 14.4% (n = 1949) did not receive AP. The overall SSI rate showed no significant difference when directly comparing patients with (0.74%) and without AP (0.97%; p = 0.262). In the multivariable analysis the presence of patient related risk factors (p = 0.015) and defect size >10 cm (p = 0.035) significantly increased the rates of SSI and complication-related reoperations. The propensity-score matching analysis verified that SSI rates are not significantly different between the two groups (p = 0.265). CONCLUSIONS: In cases of laparoscopic incisional hernia repair in patients without risk factors and moderate hernia diameter (<10 cm), routine administration of AP in laparoscopic incisional hernia repair does not seem to be justified.

An amino acid transporter involved in gastric acid secretion.

Gastric acid secretion is regulated by a variety of stimuli, in particular histamine and acetyl choline. In addition, dietary factors such as the acute intake of a protein-rich diet and the subsequent increase in serum amino acids can stimulate gastric acid secretion only through partially characterized pathways. Recently, we described in mouse stomach parietal cells the expression of the system L heteromeric amino acid transporter comprised of the LAT2-4F2hc dimer. Here we address the potential role of the system L amino acid transporter in gastric acid secretion by parietal cells in freshly isolated rat gastric glands. RT-PCR, western blotting and immunohistochemistry confirmed the expression of 4F2-LAT2 amino acid transporters in rat parietal cells. In addition, mRNA was detected for the B(0)AT1, ASCT2, and ATB(0+) amino acid transporters. Intracellular pH measurements in parietal cells showed histamine-induced and omeprazole-sensitive H+-extrusion which was enhanced by about 50% in the presence of glutamine or cysteine (1 mM), two substrates of system L amino acid transporters. BCH, a non-metabolizable substrate and a competitive inhibitor of system L amino acid transport, abolished the stimulation of acid secretion by glutamine or cysteine suggesting that this stimulation required the uptake of amino acids by system L. In the absence of histamine glutamine also stimulated H+-extrusion, whereas glutamate did not. Also, phenylalanine was effective in stimulating H+/K+-ATPase activity. Glutamine did not increase intracellular Ca2+ levels indicating that it did not act via the recently described amino acid modulated Ca2+-sensing receptor. These data suggest a novel role for heterodimeric amino acid transporters and may elucidate a pathway by which protein-rich diets stimulate gastric acid secretion.