Parastomal hernia repair according to Modified Stapled Mesh Stoma Reinforcement Technique (mSMART): which are the results ?

INTRODUCTION: Parastomal hernia repair is a real surgical challenge because of the high rate of recurrence. The Stapled Mesh Stoma Reinforcement Technique (SMART) is a keyhole-like technique in which the mesh is stapled to the fascia using a circular mechanical stapler. METHODS: A prospective study from January 2021 to February 2023 was conducted including all patients operated with the SMART technique. Primary endpoint was the recurrence rate during the follow-up. Secondary endpoints were reoperation, Surgical site Occurrence (SSO) and deep (mesh) surgical site infection (SSI) within 30 days postoperatively. RESULTS: Sixteen patients operated on SMART procedures were included. The mean follow-up was 11.3 ± 9.2 months. The SSO rate was 18.7% (n = 3). A seroma was drained radiologically (IIIa), one haematoma was evacuated surgically (IIIb) and one patient presented a postoperative lesion of a ureter after a parastomal Bricker's hernia repair. In addition, there was one death due to multiple organ failure (V). There was no SSI. The recurrence rate was 57.1% during the follow-up. CONCLUSION: This study shows disappointing results for this SMART technique, with a high recurrence rate.

Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study.

BACKGROUND: In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level. METHODS: All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD. RESULTS: In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma. CONCLUSIONS: This series provides a real-life picture of elective sigmoidectomy for SDD at a national level. TRIAL REGISTRATION: Comité National Information et Liberté (CNIL) (n°920361).

How I do it: using a hammock mesh in the reconstruction of inguinal ligament during a wide en-bloc resection of a groin mesenchymal tumor.

PURPOSE: In case of soft tissue sarcomas (STS), an en-bloc resection with safe margins is recommended. To ensure safe removal without tumor rupture, STS of the groin area, retroperitoneal or pelvic mesenchymal tumors may require incision or resection of the inguinal ligament. Solid reconstruction is mandatory to prevent early and late postoperative femoral hernias. We present here a new technique of inguinal ligament reconstruction. METHODS: Between September 2020 and September 2022, patients undergoing incision and/or resection of inguinal ligaments during a wide en-bloc resection of STS of the groin area in the Department of General Surgery in Strasbourg were included. All patients had an inguinal ligament reconstruction with biosynthetic slowly resorbable mesh shaped as a hammock, pre- or intraperitoneally, associated or not with loco-regional pedicled muscular flaps. RESULTS: A total of 7 hammock mesh reconstructions were performed. One or several flaps were necessary in 57% of cases (4 patients): either for inguinal ligament reconstruction only (n = 1), for recovering of femoral vessels (n = 1), and for both ligament reconstruction and defect covering (n = 2). The major morbidity rate was 14.3% (n = 1), related to a thigh surgical site infection due to sartorius flap infarction. After a median follow-up of 17.8 months (range 7-31), there was neither early nor late occurrence of post-operative femoral hernia. CONCLUSIONS: This is a new surgical tool for inguinal ligament reconstruction with the implementation of a biosynthetic slowly resorbable mesh shaped as a hammock, which should be compared to other techniques.

Do surgical drains reduce surgical site occurrence and infection after incisional hernia repair with sublay mesh? A non-randomised pilot study.

INTRODUCTION: Surgical site occurrence (SSO) and surgical site infection (SSI) are common concerns with incisional hernia repair. Intraoperative drain placement is a common practice aiming to reduce SSO and SSI rates. However, literature on the matter is very poor. The aim of this study is to investigate the role of subcutaneous and periprosthetic drain placement on postoperative outcomes and SSO and SSI rates with incisional hernia repair. METHODS: A non-randomised pilot study was performed between January 2018 and December 2020 and included patients with elective midline or lateral incisional hernia repair with sublay mesh placement. Patients were prospectively included, followed for 1 month and divided into three groups: group 1 without drainage, group 2 with subcutaneous drainage, and group 3 with subcutaneous and periprosthetic drains. Drains were placed at surgeon's discretion. All patients were included in the enhanced recovery program. RESULTS: One hundred and four patients were included. Twenty-four patients (23.1%) did not have drains (group 1), 60 patients (57.7%) had a subcutaneous drain (group 2) and 20 patients (19.2%) had both a subcutaneous and a periprosthetic drains (group 3). SSO rates were significantly different between the 3 groups: 20.8% in group 1, 20.7% in group 2 and 50% in group 3 (p = 0.03). There was no significant difference in deep and superficial SSI rates between the 3 groups. Subgroup analysis revealed that adding a drain in direct contact with the mesh significantly increased SSO rate but did not influence SSI rate. Length of stay was also significantly increased by the presence of a drain, 3.1 ± 1.9 days for group 1; 5.9 ± 4.8 for group 2 and 5.9 ± 2.5 days for group 3 (p < 0.005). CONCLUSION: Drain placement in direct contact with the mesh might increase SSO rate. More studies are necessary to evaluate the actual benefits of drainage after incisional hernia repair.

Incisional hernia repair with a slowly absorbable P4HB mesh: what happens after the mesh disappears? A retrospective longitudinal clinical study.

PURPOSE: To analyze the incisional hernia recurrence rate at a long-term follow-up using a biosynthetic long-term absorbable mesh in patients with a higher risk of surgical infection in a contaminated surgical field. METHODS: This was a retrospective multicentric study. All patients undergoing incisional hernia repair between 2016 and 2018 at 6 participating university centers were included. Patients were classified according to the Ventral Hernia Working Group (VHWG). All consecutive patients who underwent abdominal wall repair using biosynthetic long-term absorbable mesh (Phasix®) in contaminated fields (grade 3 and 4 of the VHWG classification) were included. Patients were followed-up until September 2021. Preoperative, operative, and postoperative data were collected. All patients' surgical site infections (SSIs) and surgical site occurrences (SSOs) were recorded. The primary outcome of interest was the clinical incisional hernia recurrence rate. RESULTS: One hundred and eight patients were included: 77 with VHWG grade 3 (71.3%) and 31 with VHWG grade 4 (28.7%). Median time follow-up was 41 months [24; 63]. Twenty-four patients had clinical recurrence during the follow-up (22.2%). The SSI and SSO rates were 24.1% and 36.1%, respectively. On multivariate analysis, risk factors for incisional hernia recurrence were previous recurrence, mesh location, and postoperative enterocutaneous fistula. CONCLUSIONS: At the 3 year follow-up, the recurrence rate with a biosynthetic absorbable mesh (Phasix®) for incisional hernia repair in high-risk patients (VHWG grade 3 and 4) seemed to be suitable (22.2%). Most complications occurred in the first year, and SSI and SSO rates were low despite high-risk VHWG grading.

Morpho-functional analysis of patient-derived xenografts reveals differential impact of gastric cancer and chemotherapy on the tumor ecosystem, affecting immune check point, metabolism, and sarcopenia.

OBJECTIVES: Gastric cancer (GC) is an aggressive disease due to late diagnosis resulting from the lack of easy diagnostic tools, resistances toward immunotherapy (due to low PD-L1 expression), or chemotherapies (due to p53 mutations), and comorbidity factors, notably muscle atrophy. To improve our understanding of this complex pathology, we established patient-derived xenograft (PDX) models and characterized the tumor ecosystem using a morpho-functional approach combining high-resolution imaging with molecular analyses, regarding the expression of relevant therapeutic biomarkers and the presence of muscle atrophy. MATERIALS AND METHODS: GC tissues samples were implanted in nude mice. Established PDX, treated with cisplatin or not, were imaged by magnetic resonance imaging (MRI) and analyzed for the expression of relevant biomarkers (p53, PD-L1, PD-1, HER-2, CDX2, CAIX, CD31, a-SAM) and by transcriptomics. RESULTS: Three well-differentiated, one moderately and one poorly differentiated adenocarcinomas were established. All retained the architectural and histological features of their primary tumors. MRI allowed in-real-time evaluation of differences between PDX, in terms of substructure, post-therapeutic changes, and muscle atrophy. Immunohistochemistry showed differential expression of p53, HER-2, CDX2, a-SAM, PD-L1, PD-1, CAIX, and CD31 between models and upon cisplatin treatment. Transcriptomics revealed treatment-induced hypoxia and metabolic reprograming in the tumor microenvironment. CONCLUSION: Our PDX models are representative for the heterogeneity and complexity of human tumors, with differences in structure, histology, muscle atrophy, and the different biomarkers making them valuable for the analyses of the impact of platinum drugs or new therapies on the tumor and its microenvironment.

Why and how to implement an electronic resident's surgical logbook to improve operating-room training? First 5-year feedback from a French center.

INTRODUCTION: The evaluation of general surgery residents' operating room (OR)-training and technical skills progression may be difficult in the absence of a standardized evaluation tool. The aim of this study was to evaluate the impact of the implementation of an electronic "surgical logbook" for general surgery residents. METHODS: A prospective single center study was conducted between May 2015 and October 2020. An electronic logbook was filled by all residents immediately after each surgical procedure and data were prospectively collected and analyzed. RESULTS: Fifty-five students (34 men/21 women) reported their participation to 6917 surgical procedures, which corresponded to 55.5% of all procedures performed in our department. Residents performed the entire procedure as the operating surgeon in 28.5% of cases (n=1963), parts of the procedure as operating surgeon in 32.5% of cases (n=2230) and as operating-assistant in 38.5% (n=2672). Residents were more likely an operating surgeon for the entire procedure when they were assisted by a fellow or a practicing physician than an associate professor or a clinical professor (P<0.001). There was no significant difference in the major morbidity rate between different resident's contribution to the procedure (P=0.14). CONCLUSION: We present here a simple, useful and cost efficient tool which offers easy data collection and reporting that could help improve OR-training, OR-supervision and certification at a local or national level.

Cost-effectiveness analysis of resorbable biosynthetic mesh in contaminated ventral hernia repair.

BACKGROUND: The aim of this study was to compare, in terms of cost and serious complications, the use of biosynthetic resorbable parietal mesh with biologic mesh in patients undergoing contaminated ventral hernia repair (modified Ventral Hernia Working Group grade 3). Poly-4-hydroxy-butyrate (P4HB) biosynthetic mesh has rarely been the subject of comparative studies in the context of contamination. Data are required to confirm the effects of a transition from biological mesh to biosynthetic resorbable mesh. PATIENTS AND METHODS: A cost-effectiveness analysis was conducted. It was based on a decision analysis model built with clinical and economic data issued from a before-after study that included 94 patients hospitalized for ventral hernia repair at the University Hospital of Strasbourg (France) from June 2011 to February 2018. The effectiveness endpoint was the number of patients presenting with a serious specific complication or a general complication at 6 months. Data for surgical hospitalization stays, home hospitalizations and ambulatory care costs were included. RESULTS: We found fewer serious complications with biosynthetic mesh: 21% versus 33% with biologic mesh. A cost savings of US $5146 was determined. Deterministic sensitivity analyses and a probabilistic analysis confirmed our findings and the robustness of the model. CONCLUSION: P4HB biosynthetic resorbable mesh appeared to be the most effective and the least costly option. Additional data will be needed to confirm the superiority of biosynthetic mesh in terms of the recurrence risk reduction over a longer period.

Longitudinal cohort study on preoperative pain as a risk factor for chronic postoperative inguinal pain after groin hernia repair at 2-year follow-up.

PURPOSE: To assess the rate of late chronic postoperative inguinal pain (CPIP) after groin hernia repair in patients with different categories of preoperative VRS (Verbal Rating Scale) pain and to make a pragmatic evaluation of the rates of potentially surgery-related CPIP vs. postoperative continuation of preexisting preoperative pain. METHODS: Groin pain of patients operated from 01/11/2011 to 01/04/2014 was assessed preoperatively, postoperatively and at 2-year follow-up using a VRS-4 in 5670 consecutive groin hernia repairs. A PROM (Patient Related Outcomes Measurement) questionnaire studied the impact of CPIP on the patients' daily life. RESULTS: Relevant (moderate or severe VRS) pain was registered preoperatively in 1639 of 5670 (29%) cases vs. 197 of 4704 (4.2%) cases at the 2-year follow-up. Among the latter, 125 (3.7%) cases were found in 3353 cases with no-relevant preoperative pain and 72 (5.3%) in 1351 cases with relevant preoperative pain. Relevant CPIP consisted of 179 (3.8%) cases of moderate pain and 18 (0.4%) cases of severe pain. The rate of severe CPIP was independent of the preoperative VRS-pain category while the rate of moderate CPIP (3.1%, 3.4%, 4.1%, 6.8%) increased in line with the preoperative (none, mild, moderate, and severe) VRS-pain categories. The VRS probably overestimated pain since 71.6% of the relevant CPIP patients assessed their pain as less bothersome than the hernia. CONCLUSION: At the 2-year follow-up, relevant CPIP was registered in 4.2% cases, of which 63.5% were potentially surgery-related (no-relevant preoperative pain) and 36.5% possibly due to the postoperative persistence of preoperative pain. The rate of severe CPIP was constant around 0.4%.