Treatment of incisional and parastomal hernias in Denmark.

Incisional and parastomal hernias are frequent complications after abdominal surgery. Patients with relevant symptoms should be referred to the local surgical department for diagnosis and indication for surgery. Patients with giant and parastomal hernias are referred to one of the five Danish regional hernia centres. Patients with parastomal hernias often benefit from being referred to a stoma nurse. The most frequent complications after hernia repair are wound complications and recurrence. In case of severe wound infection, incarceration, or strangulation the patient must always be referred acutely, as argued in this review.

Effect of fixation devices on postoperative pain after laparoscopic ventral hernia repair: a randomized clinical trial of permanent tacks, absorbable tacks, and synthetic glue.

PURPOSE: The method of anchoring the mesh in laparoscopic ventral hernia repair is claimed to cause postoperative pain, affecting the quality of life of the patients. The aim of this randomized study was to compare the effect of three types of fixation devices on postoperative pain, patient quality of life, and hernia recurrence. METHODS: Patients with ventral hernias between 2 and 7 cm were randomized into one of three mesh fixation groups: permanent tacks (Protack™), absorbable tacks (Securestrap™), and absorbable synthetic glue (Glubran™). The primary endpoint was pain on the second postoperative day, measured on a visual analogue scale. Quality of life and recurrence rate were secondary endpoints and investigated through questionnaires and clinical examination at follow-up visits 1, 6, and 12 months after surgery. RESULTS: Seventy-five non-consecutive patients were included in the study, with 25 patients in each group. There was no significant difference between groups for unspecified pain on the second postoperative day (p = 0.250). The DoloTest™ values were 55.3 ± 28.9 mm, 43.5 ± 28.5 mm, and 55.9 ± 26.3 mm for permanent tacks, absorbable tacks, and synthetic glue, respectively. No differences were observed between groups with respect to quality of life of the patients and hernia recurrence rate. CONCLUSIONS: In patients with small- and medium-sized ventral hernias, the type of fixation device did not affect the immediate or long-term postoperative pain, quality of life, or recurrence rate when comparing permanent tacks, absorbable tacks, and synthetic glue for mesh fixation. TRIAL REGISTRATION: NCT01534780.

Leakage Rate After Laparoscopic Ileocolic Intracorporeal Anastomosis.

BACKGROUND AND AIMS: The prevailing technique in laparoscopic resection of the right colon has been laparoscopic-assisted procedure with externalization of the bowel for extracorporeal creation of the ileocolic anastomosis. The total laparoscopic technique performing all steps intracorporeally, however, has gained increasing interest. The purpose of this study was to describe our experience with creation of an ileocolic intracorporeal anastomosis (IIA) and to determine anastomotic leakage (AL) rate and short-term outcome of performing IIA. MATERIALS AND METHODS: In the period 2011-2017, 2 surgeons in two centers performed 96 laparoscopic resections of malignant and premalignant diseases in the right colon. A linear stapler was used to construct an isoperistaltic side-to-side anastomosis, closing the residual defect with a running suture. Data regarding the surgical procedure and the postoperative course were recorded prospectively. Complications were defined as postoperative until the 30th postoperative day. Readmission was defined as any readmission related to the surgical procedure within 90 days postoperative. RESULTS: AL rate was observed in 4 patients (4.2%, 95% CI = 1.15-10.33). Postoperative complications occurred in a total of 20 patients (20.83%, 95% CI = 13.22-30.33), none of them fatal. Patients with AL had increased risk of other postoperative complications with OR = 14.25 (95% CI = 1.03-757.36, P = .0236) and complications of Clavien-Dindo Grade ≥IIIb (OR = 10.8, P = .012). Smoking was the only factor predisposing to AL. Patients without AL stayed in hospital a median of 3 days, compared with 32 days for patients with AL. CONCLUSION: IIA was found to be a feasible and safe technique in laparoscopic resections of the right colon with an AL rate of 4.2%.

Perioperative lipid-enriched enteral nutrition versus standard care in patients undergoing elective colorectal surgery (SANICS II): a multicentre, double-blind, randomised controlled trial.

BACKGROUND: Postoperative ileus and anastomotic leakage severely impair recovery after colorectal resection. We investigated the effect of perioperative lipid-enriched enteral nutrition versus standard care on the risk of postoperative ileus, anastomotic leakage, and other clinical outcomes. METHODS: We did an international, multicentre, double-blind, randomised, controlled trial of patients (≥18 years) undergoing elective colorectal surgery with primary anastomosis at six clinical centres in the Netherlands and Denmark. Patients were randomly assigned (1:1), stratified by location (colonic and rectal) and type of surgery (laparoscopic and open), via online randomisation software, with block sizes of six, to receive either continuous lipid-enriched enteral tube feeding from 3 h before until 6 h after surgery (intervention) or no perioperative nutrition (control). Surgeons, patients, and researchers were masked to treatment allocation for the entire study period. The primary outcome was postoperative ileus. Secondary outcomes included anastomotic leakage, pneumonia, preoperative gastric volumes, time to functional recovery, length of hospital stay, the need for additional interventions, intensive care unit admission, postoperative inflammatory response, and surgical complications. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT02175979, and trialregister.nl, number NTR4670. FINDINGS: Between July 28, 2014, and February 20, 2017, 280 patients were randomly assigned, 15 of whom were excluded after random allocation because they fulfilled one or more exclusion criteria. 265 patients received perioperative nutrition (n=132) or standard care (n=133) and were included in the analyses. A postoperative ileus occurred in 37 (28%) patients in the intervention group versus 29 (22%) in the control group (risk ratio [RR] 1·09, 95% CI 0·95-1·25; p=0·24). Anastomotic leakage occurred in 12 (9%) patients in the intervention group versus 11 (8%) in the control group (RR 1·01, 95% CI 0·94-1·09; p=0·81). Pneumonia occurred in ten (8%) patients in the intervention group versus three (2%) in the control group (RR 1·06, 95% CI 1·00-1·12; p=0·051). All other secondary outcomes were similar between groups (all p>0·05). INTERPRETATION: Perioperative lipid-enriched enteral nutrition in patients undergoing elective colorectal surgery has no advantage over standard care in terms of postoperative complications. FUNDING: Netherlands Organisation for Health Research and Development (ZonMW), Fonds NutsOhra, and Danone Research.

Quality of endoscopic surveillance of Barrett's esophagus.

OBJECTIVES: The aim of this study was to evaluate adherence to Barrett's esophagus (BE) surveillance guidelines in Denmark. METHODS: The Danish Pathology Registry was used to identify 3692 patients. A total of 300 patients were included by drawing a simple random sample. Description of the BE segment, biopsy protocol, communication with the pathologist and planned follow-up endoscopy, was evaluated. RESULTS: Thirty-one patients were excluded due to missing reports and 83 patients (28%) due to no endoscopic evidence of BE. Endoscopists suspected BE in 186 patients (62%) and these patients were included. Prague C&M classification was used in 34% of the endoscopy reports. The median number of biopsies was 4 (interquartile range (IQR), 3-6). The BE segment was stratified by lengths of 1-5, 6-10 and 11-15 cm and endoscopists obtained a sufficient number of biopsies in 12, 8 and 0% of cases, respectively. 28% of endoscopists described the exact location of the biopsy site in the pathology requisition. Patients with nondysplastic BE had endoscopic surveillance performed after a median of 24 months (IQR, 6-24). CONCLUSIONS: Adherence to the Danish guidelines was poor. This may be associated with insufficient quality of BE surveillance. Lack of endoscopic evidence of BE in the Danish Pathology Registry may have underestimated the incidence of adenocarcinoma in BE patients in previous studies.

Difficult Tracheal Intubation in Obese Gastric Bypass patients.

BACKGROUND: Endotracheal intubation is commonly perceived to be more difficult in obese patients than in lean patients. Primarily, we investigated the association between difficult tracheal intubation (DTI) and obesity, and secondarily, the association between DTI and validated scoring systems used to assess the airways, the association between DTI and quantities of anesthetics used to induce general anesthesia, and the association between DTI and difficulties with venous and arterial cannulation. METHODS: This is a monocentric prospective observational clinical study of a consecutive series of 539 obese patients undergoing gastric bypass. Tracheal intubation was done preoperatively together with scoring of Intubation Score (IS), Mallampati (MLP), and Cormack-Lehane classification (CLC) and registration of the quantities of anesthetics and total attempts on cannulation. RESULTS: The overall proportion of patients with DTI was 3.5 % and the patients with DTI were more frequently males, had higher CLC, higher American Society of Anesthesiologists physical status classification (ASA), and noticeably, a lower BMI compared to the patients with easy tracheal intubation. After adjustment with multivariable analyses body mass index (BMI) <40, CLC >2, ASA scores >2, and male gender were risk factors of DTI. Males generally had higher CLC, MLP, and ASA scores compared to females, but no difference in BMI. There was no difference in quantities of anesthetics used between the two groups with or without DTI. Intra-venous and intra-arterial cannulation was succeeded in first attempt in 85 and 86 % of the patients, respectively, and there were no association between BMI and difficult vascular access. CONCLUSIONS: We found no association between increasing BMI and DTI.

[Congenital trans-mesenteric hernia with incarceration in a five-year-old boy].

This is a case report of a five-year-old boy, presenting with abdominal pain and signs of gastrointestinal emergency imitating appendicitis. Diagnostic laparoscopy revealed an incarcerated internal hernia involving 50 cm of ischaemic small bowel. Bowel resection and primary anastomosis was performed. The post-operative outcome was uneventful. We wish to shed light on a seldom but important differential diagnosis to appendicitis in children, and raise attention to internal hernias in patients presenting with acute abdomen, whether it is due to congenital defects or a post-operative complication.

[Conservative treatment of oesophageal perforation in a child caused by a toothbrush].

Traumatic perforation of the oesophagus is a condition with high morbidity and mortality. We report a case of a one-year-old girl with traumatic oesophageal perforation caused by a fall with a toothbrush. She underwent a conservative regimen consisting of drainage of the mediastinum by a naso-cavitary drain, antibiotics and a feeding tube. No sign of mediastinitis was found on a follow-up computed tomography 19 days later, and she was discharged in good condition.

[Cat Scratch Disease as a differential diagnosis in a patient with swelling in the groin]. / Cat-scratch disease som differentialdiagnose til lyskebrok.

at Scratch Disease is caused by the bacteria Bartonella henselae and presents in patients exposed to a scratch/bite from cats. We present a case with a 12-year-old boy with an enlarged inguinal lymph node, initially suspected to be a femoral hernia by ultrasonography. Histologic examination of an inguinal lymph node showed necrosis and B. henselae infection. It is important with a thorough anamnesis including any history of animal bites/scratch and it should be kept in mind as a differential diagnosis in patients with swelling in the groin, despite the rare diagnosis of this disease.

Leakage and internal herniation are the most common complications after gastric bypass.

INTRODUCTION: The aim is to report the diagnostic strategy, clinical findings and treatment in patients admitted on suspicion of early or late complications associated with a previous laparoscopic Roux-en-Y gastric bypass (LRYGB). MATERIAL AND METHODS: Patients admitted in 2011-2012 to our department with the International Classification of Diseases 10 code DZ980C (condition with a gastric bypass) were identified using the Hospital register system. Patient data included co-morbidity, time between LRYGB and the actual admission, body mass index development, diagnostic strategy, clinical findings and treatment of complications. Early and late complications were defined as 30 days post-operatively. RESULTS: Among 186 patients, the primary early complication was leakage or unexplained abdominal pain. Internal hernia or unexplained abdominal pain was observed most frequently as a late complication. The majority of patients had a computed tomography performed as their first diagnostic procedure. 19% of patients who were operated for internal hernia underwent a re-operation. Among patients undergoing laparoscopy, 72% had internal hernia and 20% had a leak. The length of stay was 18 days for patients with leakage compared to three days for patients with internal hernia. CONCLUSION: In conclusion, the primary early complication of LRYGB patients was leakage, and internal hernia was the most frequent late complication. A substantial number of the patients who are readmitted after LRYGB suffer from unexplained abdominal pain that should be managed by specialised centres. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Changes in fatigue and physical function following laparoscopic colonic surgery.

UNLABELLED: The aim of the study was to describe changes in postoperative fatigue, quality of life, physical performance, and body composition in patients undergoing laparoscopic colonic cancer surgery. MATERIAL AND METHODS: In a follow-up study from 2009-2011 at two regional hospitals in Denmark we examined 62 patients having a right hemicolectomy ora sigmoid resection performed. The main outcome measures were fatigue level subjectively scored from 1 ("fit") to 10 ("fatigued") on a modified visual analogue scale and by objective measurements of hand grip and knee extension strength, work capacity, weight, and lean body mass. Quality of life was assessed using the SF-36 questionnaire and pain using an ordinal scale. Patients were examined preoperatively, 1-2 and 4 weeks postoperatively. RESULTS: Eight patients (13%) were converted to open surgery and the median bleeding (95% confidence interval of the median) was 75 (50-100) ml. One to two weeks after surgery the fatigue level and pain when moving had increased significantly (p=0.0011 and p=0.0002 respectively) and the SF-36 physical component quality of life score decreased (p<0.0001) when compared to preoperatively. However, at 4 weeks postoperatively fatigue level, pain, and quality of life scores were at the preoperative level. There were no significant changes from preoperatively to postoperatively in any of the measures of physical performance, whereas there was a slight reduction in weight and lean body mass after the operation. CONCLUSIONS. Laparoscopic colonic cancer surgery was associated with a short lasting increased fatigue and pain and reduced quality of life, but no significant reduction in physical performance after surgery.

Laparoscopic minimally invasive total gastrectomy with linear stapled oesophagojejunostomy--experience from the first thirty procedures.

BACKGROUND: There are only few reports on total gastrectomy by a laparoscopic surgical approach. One explanation is the fear of complications due to anastomotic dehiscence in oesophagojejunal anastomosis known to carry high morbidity and mortality. The introduction of staplers have contributed to making anastomosis safer and easier to perform and has facilitated more advanced laparoscopic surgery. In open surgery, most surgeons use a circular stapler for oesophagojejunal anastomosis or a hand sutured technique. Both techniques are difficult to use in laparoscopic surgery, especially if the oesophagus is narrow. To facilitate the creation of oesophagojejunal anastomoses, we have adopted a technique with a linear stapled anastomosis. Our method is based on a stapling technique where the oesophagus is divided above the gastric cardia followed by a oesophagojejunostomy performed with Covidien's new Endo GIA-60™ Ultra Universal stapler. The residual opening is closed with a 3-0 re-absorbable suture. PATIENTS AND METHODS: From June 2009 to May 2012, 14 men and 16 women (median age=66 years, range=39-84 years) underwent laparoscopic total gastrectomy due to gastric cancer. RESULTS: One patient died during hospital stay; corresponding to a postoperative mortality of 3,3%. Leakage in the oesophagojejunal anastomosis occurred in three patients (10%). Two of the patients with leakage in the oesophagojejunal anastomosis had an additional duodenal bulb leakage, which might have caused anastomotic dehiscence. The patients had a median postoperative hospital stay of six days (range=3-156 days). Six patients had a re-operation due to complications, including one endoscopic stent application in the anastomosis. CONCLUSION: Even though a leakage rate of 10% can be considered high, this study describes a simple method for performing oesophagojejunostomy after gastrectomy by a laparoscopic approach independently of the width of the oesophagus. This study also shows that laparoscopic gastrectomy can be performed in more advanced stages of gastric cancer.

[Internal hernia as a complication to laparoscopic gastric bypass]. / Internt hernie som komplikation efter laparoskopisk gastrisk bypass.

Internal hernia is a well-known complication after gastric bypass surgery. However, the diagnosis relies on a high degree of clinical suspicion and a low threshold for diagnostic laparoscopy as the results from clinical and radiological examination may be non-specific. We present two cases of internal herniation 24 months postoperatively with very different outcomes.

Eliminating learning curve-related morbidity in fast track laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is associated with a significant learning curve. We report the results of a systematic training program from a high-volume bariatric center measuring the outcome by comparing the results with data from a consecutive series of 1000 fast-track LRYGB. METHODS: Using a stepwise training program, the Roux-en-Y gastric bypass operation was divided into an upper and lower procedure and subdivided into 11 well-defined steps. A laparoscopic surgeon without experience in upper-gastrointestinal surgery was mentored by an experienced bariatric surgeon. During 6-month full-time fellowship, 300 operations were performed. RESULTS: The trainee surgeon performed 61 upper procedures and 121 lower procedures in which the mentor surgeon did the other part of the operation. In 110 patients, the trainee performed both procedures. Two percent had perioperative complications compared with 1% of 1000 patients. All were repaired and had an uneventful recovery. Two percent had postoperative complications <30 days compared with 2.8% in the clinic. In the trainees series, there were no leaks compared with 1% in 1000 patients. Operative time was 56/55/70 minutes for operation 0-100/100-200/200-300 compared with an average of 47 minutes registered in the clinic. Concerning time to discharge, there was no difference between patients operated by the trainee and the standard of the clinic. CONCLUSION: Using a systematic training program in LRYGB surgery eliminates morbidity of the learning curve without affecting the volume.

[Toothpick perforation of the intestine causing abdominal wall abscess]. / Hudabsces forårsaget af tyndtarmsperforerende tandstik.

An 81-year-old woman was hospitalized after two weeks of abdominal pain and a mass in the lower right abdominal wall. Ultrasonography showed what was interpreted as a malignant tumour. However, a computer tomography displayed an abscess in the abdominal wall and inflammation in nearby small intestinal loops. Subsequently, a laparoscopy was performed and an 8-cm-long toothpick penetrating from the small intestine into the abdominal wall causing the abscess was found. The patient did not recall ingesting the toothpick.

[Chest pain caused by pancreatic pseudocyst located in the mediastinum]. / Brystsmerter forårsaget af mediastinal beliggende pancreaspseudocyste.

Mediastinal pancreatic pseudocyst is a rare condition, causing pulmonary, cardiac or oesophageal symptoms. We present a case of a mediastinal pancreatic pseudocyst in a 31-year-old male patient who was admitted on suspicion of having an acute myocardial infarction because of retrosternal pain. Diagnosis was achieved by CT scan, and the pseudocyst was treated by percutanous drainage. The patient recovered well with no further need of intervention.