Conservative treatment versus elective repair of umbilical hernia in patients with liver cirrhosis and ascites: results of a randomized controlled trial (CRUCIAL trial).

PURPOSE: To establish optimal management of patients with an umbilical hernia complicated by liver cirrhosis and ascites. METHODS: Patients with an umbilical hernia and liver cirrhosis and ascites were randomly assigned to receive either elective repair or conservative treatment. The primary endpoint was overall morbidity related to the umbilical hernia or its treatment after 24 months of follow-up. Secondary endpoints included the severity of these hernia-related complications, quality of life, and cumulative hernia recurrence rate. RESULTS: Thirty-four patients were included in the study. Sixteen patients were randomly assigned to elective repair and 18 to conservative treatment. After 24 months, 8 patients (50%) assigned to elective repair compared to 14 patients (77.8%) assigned to conservative treatment had a complication related to the umbilical hernia or its repair. A recurrent hernia was reported in 16.7% of patients who underwent repair. For the secondary endpoint, quality of life through the physical (PCS) and mental component score (MCS) showed no significant differences between groups at 12 months of follow-up (mean difference PCS 11.95, 95% CI - 0.87 to 24.77; MCS 10.04, 95% CI - 2.78 to 22.86). CONCLUSION: This trial could not show a relevant difference in overall morbidity after 24 months of follow-up in favor of elective umbilical hernia repair, because of the limited number of patients included. However, elective repair of umbilical hernia in patients with liver cirrhosis and ascites appears feasible, nudging its implementation into daily practice further, particularly for patients experiencing complaints. TRIAL REGISTRATION: Clinicaltrials.gov , NCT01421550, on 23 August 2011.

Emergency repair of inguinal hernia in the premature infant is associated with high direct medical costs.

PURPOSE: Inguinal hernia repair is frequently performed in premature infants. Evidence on optimal management and timing of repair, as well as related medical costs is still lacking. The objective of this study was to determine the direct medical costs of inguinal hernia, distinguishing between premature infants who had to undergo an emergency procedure and those who underwent elective inguinal hernia repair. METHODS: This cohort study based on medical records concerned premature infants with inguinal hernia who underwent surgical repair within 3 months after birth in a tertiary academic children's hospital between January 2010 and December 2013. Two groups were distinguished: patients with incarcerated inguinal hernia requiring emergency repair and patients who underwent elective repair. Real medical costs were calculated by multiplying the volumes of healthcare use with corresponding unit prices. Nonparametric bootstrap techniques were used to derive a 95 % confidence interval (CI) for the difference in mean costs. RESULTS: A total of 132 premature infants were included in the analysis. Emergency surgery was performed in 29 %. Costs of hospitalization comprised 65 % of all costs. The total direct medical costs amounted to €7418 per premature infant in the emergency repair group versus €4693 in the elective repair group. Multivariate analysis showed a difference in costs of €1183 (95 % CI -1196; 3044) in favor of elective repair after correction for potential risk factors. CONCLUSION: Emergency repair of inguinal hernia in premature infants is more expensive than elective repair, even after correction for multiple confounders. This deserves to be taken into account in the debate on timing of inguinal hernia repair in premature infants.

Open incisional hernia repair with a self-gripping retromuscular Parietex mesh: a retrospective cohort study.

INTRODUCTION: The Rives-Stoppa and component separation technique are considered to be favourable techniques in the treatment of complex incisional hernias. However, mesh-related complications like chronic pain are still a common problem after mesh repair. As a result, a new self-gripping mesh to omit suture fixation has been developed. This study aimed to evaluate the safety and feasibility of the Parietex™ Progrip self-gripping mesh in retromuscular position for the treatment of incisional hernias. METHODS: Patients with incisional hernia who underwent repair between June 2012 and June 2014, using a self-gripping mesh in retromuscular position, were included in the study. All patients visited the outpatient clinic to identify postoperative complications and early recurrence. RESULTS: A total of 28 consecutive patients with a median age of 48 years were included in the study. Twenty-two patients (79%) were diagnosed with an incisional hernia, of whom nine (32%) had a recurrence. Six patients (21%) had an incisional hernia combined with another abdominal wall hernia. The median follow-up was 12 weeks (IQR: 8-20 weeks). Twenty-three patients (82%) did not report any pain at their final outpatient clinic visit; two patients (7%) reported mild abdominal pain, and three patients (11%) had moderate abdominal pain. None of the 28 patients developed a recurrence during follow-up. CONCLUSION: This is the first study concerning the use of a Parietex™ Progrip mesh placed in retromuscular position. The study shows that it is a safe and feasible prosthesis in incisional hernias repair, as short-term recurrence did not occur and adverse events were limited.

Umbilical hernia management during liver transplantation.

PURPOSE: Patients with liver cirrhosis scheduled for liver transplantation often present with a concurrent umbilical hernia. Optimal management of these patients is not clear. The objective of this study was to compare the outcomes of patients who underwent umbilical hernia correction during liver transplantation through a separate infra-umbilical incision with those who underwent correction through the same incision used to perform the liver transplantation. METHODS: In the period between 1990 and 2011, all 27 patients with umbilical hernia and liver cirrhosis who underwent hernia correction during liver transplantation were identified in our hospital database. In 17 cases, umbilical hernia repair was performed through a separate infra-umbilical incision (separate incision group) and 10 were corrected from within the abdominal cavity without a separate incision (same incision group). Six patients died during follow-up; no deaths were attributable to intraoperative umbilical hernia repair. All 21 patients who were alive visited the outpatient clinic to detect recurrent umbilical hernia. RESULTS: One recurrent umbilical hernia was diagnosed in the separate incision group (6 %) and four (40 %) in the same incision group (p = 0.047). Two patients in the same incision group required repair of the recurrent umbilical hernia; one of whom underwent emergency surgery for bowel incarceration. The one recurrent hernia in the separate incision group was corrected electively. CONCLUSION: In the event of liver transplantation, umbilical hernia repair through a separate infra-umbilical incision is preferred over correction through the same incision used to perform the transplantation.

Meta-analysis of glue versus sutured mesh fixation for Lichtenstein inguinal hernia repair.

BACKGROUND: Chronic pain remains a frequent complication after Lichtenstein inguinal hernia repair. As a consequence, mesh fixation using glue instead of sutures has become popular. This meta-analysis aimed to clarify which fixation technique is to be preferred for elective Lichtenstein inguinal hernia repair. METHODS: A meta-analysis was conducted according to the PRISMA guidelines. Articles published between January 1990 and April 2012 were searched for in MEDLINE, Embase and the Cochrane Library. Randomized controlled trials (RCTs) comparing glue and sutured mesh fixation in elective Lichtenstein repair for unilateral inguinal hernia were included. The quality of the RCTs and the potential risk of bias were assessed using the Cochrane risk of bias tool. RESULTS: Of 254 papers found in the initial search, a meta-analysis was conducted of seven RCTs comprising 1185 patients. With the use of glue mesh fixation, the duration of operation was shorter (mean difference -2·57 (95 per cent confidence interval (c.i.) -4·88 to -0·26) min; P = 0·03), patients had lower visual analogue scores for postoperative pain (mean difference -0·75 (-1·18 to -0·33); P = 0·001), early chronic pain occurred less often (risk ratio 0·52, 95 per cent c.i. 0·31 to 0·87; P = 0·01), and time to return to daily activities was shorter (mean difference -1·17 (-2·30 to -0·03) days; P = 0·04). The hernia recurrence rate did not differ significantly. CONCLUSION: Elective Lichtenstein repair for inguinal hernia using glue mesh fixation compared with sutures is faster and less painful, with comparable hernia recurrence rates.

Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication.

BACKGROUND: Complications after thoracic surgery have well been established, pain being the most prominent. Intercostal nerves are mixed type nerves combining motor and sensory functions. This notion is not consistent with the incidence of PTPS compared to the incidence of muscle paresis or paralysis. We would hypothesize that abdominal wall paresis or paralysis is underdiagnosed. METHODS: In our hospital, three patients developed abdominal wall paralysis after thoracic surgery and consequent nerve damage. Their cases are discussed, and a review of the literature was conducted concerning (intercostal) nerve damage on a cellular level, the anatomy of the intercostal nerve, prevention of intercostal nerve damage and surgical techniques. RESULTS: A cellular cascade known as Wallerian degeneration and regeneration determine whether a damaged nerve can function again. The recovery of the nerve is highly dependent on the correct function of activated Schwann cells and macrophages and is related to the amount of damage that has taken place. The anatomy of the intercostal nerve makes it susceptible to injury. Retractor placement during open thoracic surgery has shown to effect compression injury and induced mechanical deformation and damage. Given the known factors of pathophysiology and anatomy, a number of preventive measures have been tested to reduce intercostal nerve damage. Several techniques have been proposed, but the most used technique, the video-assisted thoracic surgery, has been the most effective in reducing nerve damage. CONCLUSION: Abdominal wall paralysis is an underdiagnosed complication after thoracic surgery. The amount of stress on the intercostal nerves could be reduced with less invasive techniques such as the VATS technique.

Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis.

BACKGROUND: Open cholecystectomy (OC) is often preferred over laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and portal hypertension, but evidence is lacking to support this practice. This meta-analysis aimed to clarify which surgical technique is preferable for symptomatic cholecystolithiasis in patients with liver cirrhosis. METHODS: A meta-analysis was conducted according to the PRISMA guidelines. Articles published between January 1990 and October 2011 were identified from MEDLINE, Embase and the Cochrane Library. Randomized clinical trials (RCTs) comparing outcomes of OC versus LC for cholecystolithiasis in patients with liver cirrhosis were included. The quality of the RCTs was assessed using the Jadad criteria. RESULTS: Following review of 1422 papers by title and abstract, a meta-analysis was conducted of four RCTs comprising 234 surgical patients. They provided evidence of at least level 2b on the Oxford Level of Evidence Scale, but scored poorly according to the Jadad criteria. Some 97·0 per cent of the patients had Child-Turcotte-Pugh (CTP) grade A or B liver cirrhosis. In all, 96·6 per cent underwent elective surgery. No postoperative deaths were reported. LC was associated with fewer postoperative complications (risk ratio 0·52, 95 per cent confidence interval (c.i.) 0·29 to 0·92; P = 0·03), a shorter hospital stay (mean difference -3·05 (95 per cent c.i. -4·09 to -2·01) days; P < 0·001) and quicker resumption of a normal diet (mean difference -27·48 (-30·96 to -23·99) h; P < 0·001). CONCLUSION: Patients with CTP grade A or B liver cirrhosis who undergo LC for symptomatic cholecystolithiasis have fewer overall postoperative complications, a shorter hospital stay and resume a normal diet more quickly than those who undergo OC.

Morbidity and mortality related to non-hepatic surgery in patients with liver cirrhosis: a systematic review.

BACKGROUND: The aim of this study is to review systematically morbidity and mortality after non-hepatic surgery in patients with liver cirrhosis. METHODS: Comprehensive searches were conducted in PubMed, Embase and the Cochrane Library for articles using the words: liver failure, hepatic insufficiency, liver cirrhosis, cirrhosis, cirrhotic, surgical procedures, operative complications, operative mortality, postoperative complications, surgical complication, surgical risk, hernia. RESULTS: Forty-six articles were selected from 5247 included after the initial search. Level of evidence provided in the articles varied greatly. Non-hepatic surgery of patients with cirrhosis resulted in increased postoperative morbidity and mortality compared to similar surgery for non-cirrhotic patients. Cholecystectomy and umbilical and inguinal hernia correction were associated with the lowest increased morbidity and mortality while pancreatic surgery, cardiovascular, and trauma surgery correlated with the highest. The preoperative model for end stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) scores appeared to be predictive of postoperative risks. Portal hypertension and surgery in the emergency setting were associated with extra increased mortality and morbidity rates. CONCLUSION: This systematic review of the literature showed that in patients with liver cirrhosis who undergo non-hepatic surgery, postoperative morbidity and mortality rates varied greatly depending on severity of the cirrhosis and the surgical procedure. However, the majority of procedures can be safely performed in patients with low MELD scores or CTP A cirrhosis without portal hypertension.

A prospective study on elective umbilical hernia repair in patients with liver cirrhosis and ascites.

BACKGROUND: Patients with both cirrhosis and ascites have a 20% risk of developing umbilical hernia. A retrospective study from our center comparing conservative management of umbilical hernia with elective repair in these patients showed a significant risk of mortality as a result of hernia incarceration in conservatively treated patients. The goal of this study was to assess the safety and efficacy of elective umbilical hernia repair in these patients prospectively. METHODS: Patients with liver cirrhosis and ascites presenting with an umbilical hernia were included in this study. For all patients, the expected time to liver transplantation was more than 3 months, and they did not have a patent umbilical vein in the hernia sac. The following data were collected prospectively for all patients: Child-Pugh-Turcotte (CPT) classification, model for end-stage liver disease (MELD) score, kidney failure, cardiovascular comorbidity, operation-related complications, and duration of hospital stay. Mortality rates were registered in hospital records and verified in government records during follow-up. Mortality rates were registered in hospital records and verified in government records during follow-up. On completion of the study, a retrospective survey was performed to search for any patients who met the study inclusion criteria but were left out of the study cohort. RESULTS: In total, 30 patients (25 males) underwent operation at a mean age of 58 years (standard deviation [SD] ± 9 years). Of these 30 patients, 6 were classified as CPT grade A (20%), 19 (63%) as grade B, and 5 (17%) as grade C. The patients' median MELD score was 12 (interquartile range [IQR], 8-16). In 10 (33%) of the 30 patients hernia repair was performed with mesh. The median duration of hospital stay was 3 days (IQR, 2-4). None of the patients were admitted to the intensive care unit. Postoperative complications included pneumonia and decompensation of cirrhosis (1 case each,) resulting in prolonged hospital stay for those 2 patients. After a median follow-up period of 25 months (IQR, 14-34), 2 (7%) of the 30 patients died; neither of the deaths were attributable to the umbilical hernia repair. A total of 2 patients suffered recurrence. CONCLUSION: Elective umbilical hernia repair is safe and the preferred approach in cirrhotic patients with ascites.