Transcutaneous Electric Nerve Stimulation Reduces Pathological Sensation of Mesh One Week after Open Inguinal Hernia Surgery: Follow-Up Results from a Randomized, Double Blind and Placebo-Controlled Trial.

Background and Objectives: Quality of life (QoL) and chronic pain are important outcomes following hernia surgery. The long-term effects of Transcutaneous Electric Nerve Stimulation (TENS) on postoperative recovery are not well known. In this trial we investigated the role of TENS on QoL and on the incidence of chronic pain following inguinal hernia repair with mesh. Materials and Methods: A total of 80 male patients with elective primary unilateral hernia Lichtenstein repair were randomly allocated to receive TENS or a placebo-TENS procedure. The TENS group received conventional TENS twice a day on the first and second postoperative days. The intensity was set at 0-0.5 mA in the placebo-TENS group. General and hernia-specific QoL, as well as the incidence of chronic pain were assessed using SF-36v2 and the Carolinas comfort scale. Results: Less sensation of mesh was reported by the TENS group patients one week after surgery. At this time point, the mean sensation score was 6.07 ± 8.88 in the TENS group and 14.08 ± 16.67 in the placebo-TENS group (p = 0.029). Although at two days and one week postoperatively, TENS group patients tended to have less pain, less movement restrictions and better overall hernia-specific QoL, the differences were not statistically significant. At 6 months postoperatively, no incidence of chronic pain was found in either the placebo-TENS or TENS group. Conclusions: Conventional TENS applied in the early postoperative period following inguinal hernia repair with mesh was found to reduce mesh-related foreign body sensation one week after surgery. Promising results were also found for other QoL domains.

Evaluation of Mobility Status after Inguinal Hernia Surgery.

BACKGROUND: Many different studies have compared open and laparoscopic-endoscopic inguinal hernia repair techniques according to intraoperative and postoperative complications, recurrence rates, postoperative inguinal chronic pain, quality of life, and costs. Most of the researchers have compared these different inguinal hernia repair techniques using a visual analog scale, a short-form survey instrument, or patients' return-to-normal-activity time, but there is a lack of objective data concerning pelvic function recovery after these procedures. AIM: To evaluate and compare real hip and leg function recovery times after the application of different inguinal hernia repair techniques using hip and leg mobility, strength, and stability testing for the first time. PATIENTS AND METHODS: This prospective nonrandomized clinical study included 33 male patients aged 18-75 years hospitalized for primary inguinal hernia repair surgery. The patients were divided into two groups: group 1 (Lichtenstein hernia repair) and group 2 (laparoscopic-endoscopic transabdominal preperitoneal/totally extraperitoneal hernia repair). The two groups were compared in terms of intraoperative and postoperative complications, postoperative recovery time, and hip and leg mobility, strength, and stability functional analysis on the first postoperative day as well as 1, 2, and 4 weeks after surgery. RESULTS: A total of 33 patients were included in the study: 13 in the open hernia repair group and 20 in the minimally invasive hernia repair group. There was no significant difference in early and late postoperative complications and recurrence rates. The surgery time and hospital stay were significantly shorter in the laparoscopic-endoscopic hernia repair group. All pelvic functions in the patients who underwent laparoscopic-endoscopic hernia repair recovered 2 or 3 weeks faster than after Lichtenstein repair. CONCLUSIONS: Hip and leg mobility, strength, and stability tests are useful to evaluate the recovery time after inguinal hernia repair and could be used as objective tools for estimating recovery after the application of other inguinal hernia repair techniques. Hip and leg mobility, strength, and stability recover faster after minimally invasive inguinal hernia repair. There is no significant difference between the groups in early and late postoperative complications or recurrence rates.

Comparison of the Different Treatment Strategies for Patients with Rectus Sheath Haematoma.

Background and objective: Rectus sheath haematoma (RSH) is an uncommon condition that may vary from contained haematoma to life-threatening bleeding. Timely diagnosis and treatment is crucial in this patient population. The aim of the current study was to investigate the results of the different RSH treatment strategies among patients admitted to a surgery department. Materials and methods: A retrospective analysis of 29 patients treated for RSH in surgery departments of two medical centres from 1 January 2007 to 30 September 2017 was conducted. The patient's age, sex, ASA (American Society of Anesthesiologists; physical status classification system), use of anticoagulants, cause of haematoma, radiological data, vital signs, blood investigations, and type of treatment were extracted. The results were analysed according to the type of treatment. Results: The patients' mean age was 67.6 ± 14.3 years, and the mean duration of in-hospital stay was 10.7 ± 6.7 days. All patients were on anticoagulant treatment, and 82.8% of them had spontaneous haematoma. Nine patients (31%) needed transfusion of packed red blood cells with an average of 2.6 units (range: 1⁻4). Five patients (17.2%) presented with symptoms and signs of hypovolemic shock, and four of them underwent embolisation. Embolisation was successful in all cases. Open surgery was performed in 6 patients, 8 patients underwent percutaneous drainage, and 10 patients were treated conservatively. Two patients (6.7%) died in our series. Both of these patients had type III RSH. Patients in the conservatively treated group had the shortest hospital stay. There were no readmissions due to repeated haematoma or infection. Conclusions: Embolisation of epigastric arteries is a useful tool to stop bleeding into RSH in patients with unstable haemodynamics. Conservative treatment is comparable to ultrasound (US) drainage of RSH but results in a shorter hospital stay. Type III RSH is associated with a higher death rate.

European guidelines on perioperative venous thromboembolism prophylaxis: Day surgery and fast-track surgery.

: In recent years, day surgery and fast-track surgery have experienced a continuous increase in volume. Many procedures are now performed on an outpatient protocol, including general, orthopaedic, oncological, reconstructive or vascular surgery. The management of these patients is safe, but the incidence of venous thromboembolism in this population remains unknown. Several risk factors can be identified and stratified derived from studies of inpatient surgical management (e.g. Caprini score). Recommendations for thromboprophylaxis should be tailored from the assessment of both personal and procedure-related risk factors, although with a lack of evidence for application in outpatient management. For patients undergoing a low-risk procedure without additional risk factors, we recommend only general measures of thromboprophylaxis (early ambulation, optimal hydration) (Grade 1B). For patients undergoing a low-risk procedure with additional risk factors, or a high-risk procedure without additional risk factors, we recommend general measures of thromboprophylaxis (Grade 1B) and we suggest the administration of pharmacological prophylaxis with low molecular weight heparins (Grade 2B). For patients undergoing a high-risk procedure with additional risk factors we recommend general measures of thromboprophylaxis (Grade 1B) and pharmacological prophylaxis with low molecular weight heparins over other drugs (Grade 1B), or suggest specific mechanical measures in case of increased bleeding risk (Grade 2C). Pharmacological prophylaxis should last a minimum of 7 days (Grade 1B), although in selected cases of fast-track surgery, thromboprophylaxis could be limited to hospitalisation only (Grade 2C) and in specific cases of high-risk procedures, thromboprophylaxis could be extended for up to 4 weeks (Grade 2B).

European guidelines on perioperative venous thromboembolism prophylaxis: Surgery in the obese patient.

: A systematic literature search was performed and patients were selected as obese patients undergoing bariatric surgery or obese patients undergoing nonbariatric surgical procedures. In addition, patients were stratified according to low risk of venous thromboembolism and high risk of venous thromboembolism (age >55 years, BMI >55 kg m, history of venous thromboembolism, venous disease, sleep apnoea, hypercoagulability or pulmonary hypertension). Prophylaxis of venous thromboembolism was analysed depending on the type of modality: compression devices of the lower extremities (including intermittent pneumatic compression and graduated compression stockings), pharmacological prophylaxis or inferior vena cava filters. Two prospective studies compared mechanical devices and pharmacological prophylaxis vs. a mechanical device alone without significant differences. A few randomised controlled studies and most of the prospective nonrandomised studies showed that low-dose low molecular weight heparin (3000 to 4000 anti-Xa IU 12 h subcutaneously) was acceptable for obese patients with a lower risk of venous thromboembolism, but a higher dose of low molecular weight heparin (4000 to 6000 anti-Xa IU 12 h subcutaneously) should be proposed for obese patients with a higher risk of venous thromboembolism. Extended prophylaxis for 10 to 15 days was well tolerated for obese patients with a high risk of venous thromboembolism in the postdischarge period. The safety and efficacy of inferior vena cava filters in bariatric surgical patients is highly heterogeneous. There were no randomised trials that analysed prophylaxis of venous thromboembolism in obese patients undergoing nonbariatric surgery. Higher doses of anticoagulants could be proposed for obese patients with a BMI more than 40 kg m. The lack of good quality randomised trials with a low risk of bias did not allow us to propose strong recommendations.

Long-term follow-up results of umbilical hernia repair.

INTRODUCTION: Multiple suture techniques and various mesh repairs are used in open or laparoscopic umbilical hernia (UH) surgery. AIM: To compare long-term follow-up results of UH repair in different hernia surgery groups and to identify risk factors for UH recurrence. MATERIAL AND METHODS: A retrospective analysis of 216 patients who underwent elective surgery for UH during a 10-year period was performed. The patients were divided into three groups according to surgery technique (suture, mesh and laparoscopic repair). Early and long-term follow-up results including hospital stay, postoperative general and wound complications, recurrence rate and postoperative patient complaints were reviewed. Risk factors for recurrence were also analyzed. RESULTS: One hundred and forty-six patients were operated on using suture repair, 52 using open mesh and 18 using laparoscopic repair technique. 77.8% of patients underwent long-term follow-up. The postoperative wound complication rate and long-term postoperative complaints were significantly higher in the open mesh repair group. The overall hernia recurrence rate was 13.1%. Only 2 (1.7%) patients with small hernias (< 2 cm) had a recurrence in the suture repair group. Logistic regression analysis showed that body mass index (BMI) > 30 kg/m2, diabetes and wound infection were independent risk factors for umbilical hernia recurrence. CONCLUSIONS: The overall umbilical hernia recurrence rate was 13.1%. Body mass index > 30 kg/m2, diabetes and wound infection were independent risk factors for UH recurrence. According to our study results, laparoscopic medium and large umbilical hernia repair has slight advantages over open mesh repair concerning early postoperative complications, long-term postoperative pain and recurrence.

Weight regain after gastric bypass: etiology and treatment options.

Roux-en-Y gastric bypass (RYGB) is one of the most common operations performed for the patients with morbid obesity. Weight regain (WR) is a complication that may decrease efficiency of the surgical treatment and demand further interventions. Different factors including lifestyle, mental health, hormonal/metabolic and surgical plays role in WR after RYGB. Various treatment options have been proposed for WR. Conservative treatment is less effective than surgery. Endoscopic refashioning of gastric pouch/stoma fails to achieve sustainable weight loss. Surgical reduction of pouch has acceptable short-term results, but WR after 3 years is substantial. Banded gastric bypass achieves good short-term results, but long-term follow-up data are needed. Distalization of RYGB has a high risk of protein calorie malnutrition (PCM) and conversion to BP diversion (BPD)/duodenal switch (DS) is a technically demanding procedure. Both procedures achieve sustainable long-term weight loss. More studies are needed to explore long-term results of various surgical interventions for WR after RYGB.

Epigenetic silencing of miR-137 is a frequent event in gastric carcinogenesis.

MicroRNAs (miRNA) are involved in posttranscriptional regulation of gene expression and are dysregulated during carcinogenesis. CpG island methylation of miR-137 is a common event in different cancers; however, the role of miR-137 in gastric cancer (GC) remains largely unexplored. In this study we aimed to characterize the epigenetic alterations of miR-137 in gastric carcinogenesis. We analyzed total 295 tissues including paired primary gastric cancer (T-GC) with corresponding adjacent gastric mucosa (N-GC), paired primary colorectal cancer (CRC) tissues with corresponding non-tumorous mucosa, gastric tissues from controls (N), and patients with chronic/atrophic gastritis (CG) with and without Helicobacter pylori infection. Bisulfite pyrosequencing and TaqMan RT-PCR were used to analyze miR-137 methylation and expression, respectively. Survival differences were evaluated using Kaplan-Meier analyses. miR-137 CpG island methylation was more frequent in tumorous compared to non-tumorous conditions and higher in CRC than in GC. In comparison to N-GC, miR 137 methylation level was lower in N and CG tissues, which correlates with Correas cascade. MiR-137 methylation inversely correlates with global LINE-1 methylation and miR-137 expression. miR-137 methylation was higher in intestinal type GC compared to diffuse one, and higher in antrum compared to cardia and corpus, however, miR-137 methylation was associated with worse prognosis in diffuse, but not in intestinal type of GC. The expression in colon was significantly higher compared to any gastric tissues suggesting functional difference. In summary, miR-137 methylation is a frequent event in gastrointestinal cancers which occurs early in stepwise manner during gastric carcinogenesis and inversely correlates with global methylation. © 2015 Wiley Periodicals, Inc.

Effects of Cyanidin-3-O-glucoside on Synthetic and Metabolic Activity of Ethanol Stimulated Human Pancreatic Stellate Cells.

Activated pancreatic stellate cells (PSC) play a major role in the development of chronic pancreatitis. Flavonoids (C-3-O-G) theoretically may have potential to suppress activated PSC. The aim of our study was to determine the ability of C-3-O-G to invert synthetic and metabolic activity of alcohol stimulated human pancreatic stellate cells (hPSC). In the present study we demonstrate that treatment with C-3-O-G decreased proliferation rate of ethanol activated hPSC by 51%. Synthesis of extracellular matrix proteins in activated hPSC was markedly inhibited, as shown by reduced levels of collagen I and fibronectin expression. The decrease of secretion of fibronectin by 33% and in collagen I-25% in ethanol activated and C-3-O-G treated hPSC was observed. Moreover, treatment of ethanol activated hPSC with C-3-O-G resulted in the decrease of oxygen consumption rate by 44% and reduced levels of ATP synthesis (i.e. energy production) by 41%. Hence, the effects of C-3-O-G on ethanol activated hPSC may provide new insights for the use of anthocyanins as anti-fibrogenic agents in treatment and/or prevention of pancreatic fibrosis.

Is transcatheter arterial embolization a safer alternative than surgery when endoscopic therapy fails in bleeding duodenal ulcer?

OBJECTIVE: Emergency surgery after unsuccessful endoscopic therapy for bleeding duodenal ulcer has been reported to have a high mortality. Transcatheter arterial embolization (TAE) of the gastroduodenal artery is an alternative strategy when endoscopic therapy fails. This study is a retrospective analysis comparing these two treatment strategies. MATERIAL AND METHODS: Patients who underwent TAE (n = 24) or open surgery (n = 50) after unsuccessful endoscopic therapy for bleeding duodenal ulcers at two university hospitals between 2000 and 2007 were compared. Mortality, morbidity, length of hospital stay, age, number of endoscopic interventions and acute physiology and chronic health evaluation (APACHE) II score were evaluated. RESULTS: The groups were comparable concerning gender and length of hospital stay. The mean age (69.6 +/- 16.1 versus 61.9 +/- 14.1 years; P = 0.043), APACHE II score (17.0 +/- 5.1 versus 12.8 +/- 5.7; P = 0.004) and number of gastroscopies (P = 0.009) were significantly higher in the embolization group. Five patients (20.8%) died in the embolization group compared to 11 (22%) in the surgery group. However, mortality in high-risk patients (APACHE II score >or= 16.5) was lower in the TAE group (23.1% versus 50.0%; P = 0.236). Method-related as well as other complications were not significantly different between the two groups. There was, however, a higher re-bleeding rate in the TAE group. CONCLUSIONS: TAE of the gastroduodenal artery appears to be a safe alternative when endoscopic therapy for bleeding duodenal ulcer fails, at least in high-risk patients. The role of TAE in low-risk patients with bleeding from duodenal ulcer needs to be defined by means of a prospective controlled trial.

Mucinous adenocarcinoma arising in an anorectal fistula.

UNLABELLED: Mucinous adenocarcinoma in association with chronic anal fistula is a rare case in clinical practice. The aim of this article was to report a rare case of anal gland mucinous adenocarcinoma in a patient who was treated in the Hospital of Kaunas University of Medicine. CASE REPORT: A 70-year-old male was treated for anorectal fistula in the surgical department. Four operations were performed for perineal abscess during the period of 15 years. During the period of 15 years, the patient complained of purulent secretion from the perineal abscess. After the last operation, anorectal fistula developed. Multiple biopsies and scrapings of the fistulous track were taken for histological examination. Histological examination revealed mucinous adenocarcinoma, G2. Subsequently, the patient underwent endoanal ultrasound, computed tomography scan, and colonoscopy. The computed tomography scan did not show pathology in the abdomen, but showed soft tissue induration at the site of anorectal fistula. Colonoscopy investigation did not show any pathology in the rectum and bowels. Endoanal ultrasound findings showed soft tissue induration at the site of anorectal fistula, no tumor in the rectum wall. The patient underwent abdominoperineal resection. Histological examination after abdominoperineal resection revealed anal duct mucinous adenocarcinoma pT2 N0 L0 V0 R0, G2. Metastases to the mesenteric lymph nodes were not detected. On the eighth day after abdominoperineal resection, the patient was discharged from the hospital for follow-up. SUMMARY: Mucinous adenocarcinoma in anorectal fistula is a rare condition. If surgical treatment for perineal abscess or anorectal fistula is not successful for a long time, mucinous adenocarcinoma should be suspected.

Umbilical hernia: factors indicative of recurrence.

UNLABELLED: Umbilical hernia has gained little attention from surgeons in comparison with other types of abdominal wall hernias (inguinal, postoperative); however, the primary suture for umbilical hernia is associated with a recurrence rate of 19-54%. The aim of this study was to analyze the results of the umbilical hernia repair and to assess the independent risk factors influencing umbilical hernia recurrence. MATERIALS AND METHODS: A retrospective analysis of patients who underwent surgery for umbilical hernia in the Hospital of Kaunas University of Medicine in 2001-2006 was performed. Age, sex, hospital stay, hernia size, patient's body mass index, and postoperative complications were analyzed. Postoperative evaluation included pain and discomfort in the abdomen and hernia recurrence rate. The questionnaire, which involved all these previously mentioned topics, was sent to all patients by mail. Hernia recurrence was diagnosed during the patients' visit to a surgeon. Two surgical methods were used to repair umbilical hernia: open suture repair technique (keel technique) and open mesh repair technique (onlay technique). Every operation was chosen individually by a surgeon. RESULTS: Ninety-seven patients (31 males and 66 females) with umbilical hernia were examined. The mean age of the patients was 57.1+/-15.4 years, hernia anamnesis - 7.6+/-8.6 years, hospital stay - 5.38+/-3.8 days. Ninety-two patients (94.8%) were operated on using open suture repair technique and 5 (5.2%) patients - open mesh repair technique. Only 7% of patients whose BMI was >30 kg/m(2) and hernia size >2 cm and 4.3% of patients whose BMI was < 30 kg/m(2) and hernia size < 2 cm were operated on using onlay technique (P>0.05). The rate of postoperative complications was 5.2%. Sixty-seven patients (69%) answered the questionnaire. The complete patient's recovery time after surgery was 2.4+/-3.4 months. Fourteen patients (20.9%) complained of pain or discomfort in the abdomen, and 7 patients (10.4%) had ligature fistula after the surgery. Forty-five patients (67.2%) did not have any complaints after surgery. The recurrence rate after umbilical hernia repair was 8.9%. The recurrence rate was higher when hernia size was >2 cm (9% for <2 cm vs 10.5% for >2 cm) and patient's BMI was >30 kg/m(2) (8.6% for < 30 vs 10.7% for >30). There were 5 recurrence cases after open suture repair and one case after onlay technique. Fifty-six patients (83.6%) assessed their general condition after surgery as good, 9 patients (13.4%) as satisfactory, and only 2 patients (3%) as poor. CONCLUSIONS: We did not find any significant independent risk factors for umbilical hernia recurrence. However, based on reviewed literature, higher patient's body mass index and hernia size of >2 cm could be the risk factors for umbilical hernia recurrence.

Long-term results of incisional hernia treatment.

UNLABELLED: Ventral hernia is a common problem in general surgery practice. Incisional hernia can develop in 15-25% of patients after abdominal surgery. The aim of this study was to compare two different methods of incisional hernia surgery. MATERIALS AND METHODS: A retrospective analysis of database of surgery department from 1997 to 2000 was performed. All patients were divided into two groups. The first group patients were operated using open suture repair (keel technique); the second group patients--using open mesh repair (onlay technique). Long-term follow-up was done by a mail questionnaire. A special questionnaire was sent to all patients. Postoperative evaluation included pain and discomfort in the abdomen, physical activity, and recurrence rate after operation. Statistical evaluation was conduced using descriptive analysis: the unpaired Student t test to compare parametric criterions between two study groups, Mann-Whitney U test to compare the unpaired nonparametric criterions between two study groups, and chi2 test to investigate nonparametric criterions between these groups. RESULTS: A total of 202 patients (51 males, 151 females) with incisional hernia were operated during 1997-2000. One hundred seventy-one patients were in the keel technique group, and 31 patients in the onlay technique group. There were no significantly differences in age and sex between these groups. The hospitalization time was significantly longer in the open mesh repair group. The postoperative complication (wound seroma and suppuration) rate was significantly higher in the onlay technique group. One hundred sixty-one patients (79.7%) answered the questionnaire (133 in the keel technique group, 28 the in onlay technique group). The patients' return to physical activity after surgery was significantly longer in the keel technique group. Forty-one patients (31%) had hernia recurrence in the keel technique group and 3 patients (11%) in the onlay technique group (P<0.05). There were no postoperative deaths in both groups. CONCLUSIONS: The rates of postoperative therapeutic complications and hernia recurrence are significantly lower after open mesh repair surgery. Return to normal physical activity after surgery is significantly longer after open suture repair surgery.