Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair.

BACKGROUND: Inguinal or femoral hernia is a tissue protrusion in the groin region and has a cumulative incidence of 27% in adult men and of 3% in adult women. As most hernias become symptomatic over time, groin hernia repair is one of the most frequently performed surgical procedures worldwide. This type of surgery is considered 'clean' surgery with wound infection rates expected to be lower than 5%. For clean surgical procedures, antibiotic prophylaxis is not generally recommended. However after the introduction of mesh-based hernia repair and the publication of studies that have high wound infection rates the debate as to whether antibiotic prophylaxis is required to prevent postoperative wound infections started again. OBJECTIVES: To determine the effectiveness of antibiotic prophylaxis in reducing postoperative (superficial and deep) wound infections in elective open inguinal and femoral hernia repair. SEARCH METHODS: We searched several electronic databases: Cochrane Registry of Studies Online, MEDLINE Ovid, Embase Ovid, Scopus and Science Citation Index (search performed on 12 November 2019). We also searched two trial registers and the reference list of included studies. SELECTION CRITERIA: We included randomised controlled trials comparing any type of antibiotic prophylaxis versus placebo or no treatment for preventing postoperative wound infections in adults undergoing inguinal or femoral open hernia repair surgery (tissue repair and mesh repair). DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data and assessed risk of bias. We separately analysed results for two different surgical methods (herniorrhaphy and hernioplasty). Several studies revealed infection rates that were higher than the expected 5% for clean surgery and we therefore divided studies into two subgroups: high infection risk environments (≥ 5% infection rate); and low infection risk environments (< 5% infection rate). We performed meta-analyses with random-effects models. We analysed three outcomes: superficial surgical site infections (SSSI); deep surgical site infections (DSSI); and all postoperative wound infections (SSSI + DSSI). MAIN RESULTS: In this review update we identified and included 10 new studies. In total, we included 27 studies with 8308 participants in this review. It is uncertain whether antibiotic prophylaxis as compared to placebo (or no treatment) prevents all types of postoperative wound infections after herniorrhaphy surgery (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.56 to 1.33; 5 studies, 1865 participants; very low quality evidence). Subgroup analysis did not change these results. We could not perform meta-analyses for SSSI or DSSI as these outcomes were not reported separately. Twenty-two studies related to hernioplasty surgery (total of 6443 participants) and we analysed three outcomes: SSSI; DSSI; SSSI + DSSI. Within the low infection risk environment subgroup, antibiotic prophylaxis as compared to placebo probably makes little or no difference for the outcomes 'prevention of all wound infections' (RR 0.71, 95% CI 0.44 to 1.14; moderate-quality evidence) and 'prevention of SSSI' (RR 0.71, 95% CI 0.44 to 1.17, moderate-quality evidence). Within the high infection risk environment subgroup it is uncertain whether antibiotic prophylaxis reduces all types of wound infections (RR 0.58, 95% CI 0.43 to 0.77, very low quality evidence) or SSSI (RR 0.56, 95% CI 0.41 to 0.77, very low quality evidence). When combining participants from both subgroups, antibiotic prophylaxis as compared to placebo probably reduces the risk of all types of wound infections (RR 0.61, 95% CI 0.48 to 0.78) and SSSI (RR 0.60, 95% CI 0.46 to 0.78; moderate-quality evidence). Antibiotic prophylaxis as compared to placebo probably makes little or no difference in reducing the risk of postoperative DSSI (RR 0.65, 95% CI 0.26 to 1.65; moderate-quality evidence), both in a low infection risk environment (RR 0.67, 95% CI 0.11 to 4.13; moderate-quality evidence) and in the high infection risk environment (RR 0.64, 95% CI 0.22 to 1.89; low-quality evidence). AUTHORS' CONCLUSIONS: Evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces the risk of postoperative wound infections after herniorrhaphy surgery. Evidence of moderate quality shows that antibiotic prophylaxis probably makes little or no difference in preventing wound infections (i.e. all wound infections, SSSI or DSSI) after hernioplasty surgery in a low infection risk environment. Evidence of low quality shows that antibiotic prophylaxis in a high-risk environment may reduce the risk of all wound infections and SSSI, while evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces DSSI after hernioplasty surgery.

Proctalgia y atrapamiento del nervio pudendo: una asociación por descubrir / Proctalgia and pudendal nerve entrapment: an association to know

Introducción: El síndrome de atrapamiento del nervio pudendo (SANP) es una entidad clínica, poco conocida en el ámbito de la Cirugía General, que comprende un amplio abanico de síntomas urinarios, sexuales y proctológicos. El interés para el cirujano general radica en toda la clínica que pueden presentar estos pacientes en la esfera proctológica. De diagnóstico complejo, exige un tratamiento secuencial que incluye distintas herramientas. El objetivo del presente estudio es exponer el SANP desde el punto de vista de la cirugía general, exponiendo un estudio realizado en pacientes afectos de proctalgia para valorar los resultados en el seguimiento a partir de los seis meses. Métodos: Presentamos un estudio observacional que evalúa 53 pacientes afectos de proctalgia en el contexto de un SANP que han sido sometidos a tratamiento con punción-hidrodistensión corticoideo-anestésica del nervio pudendo y sus ramas terminales, observando su respuesta inmediata en términos clínicos de dolor y en seguimiento a partir de los seis meses. Resultados: De los datos obtenidos de nuestra muestra, se observa que el tratamiento con dichas punciones mejora al 79,25 % de los pacientes en el periodo inmediato tras la punción, y el 39,62 % de los pacientes mantienen dicha mejoría a partir de los seis meses. Conclusiones: Concluimos que ante la presencia de proctalgia, el cirujano debe descartar la existencia de un SANP y que, según nuestro estudio, el tratamiento con punción corticoideoanestésica es una opción eficaz de tratamiento que logra mejorar a un importante porcentaje de pacientes

Introduction: Pudendal nerve entrapment (PNE) is a clinical syndrome, little known in the field of General Surgery, which includes a wide range of urinary, sexual and proctological symptoms. The interest for general surgeons lies in the whole clinical study that these patients may present as regards proctology. Complex diagnosis requires a sequential treatment that includes different tools. The aim of this study is to present PNE from the point of view of general surgery by showing a study carried out in patients with proctalgia to assess the results at follow-up after 6 months. Methods: We present an observational study evaluating 53 proctalgia patients in a PNE context who have undergone hydrocortisone puncture of the pudendal nerve, for anesthetic reasons, and its terminal branches, observing its immediate response in clinical terms of pain and in follow-up as from six months. Results: Based on the data obtained from our sample, it may be seen that the treatment with these punctures improves 79.25% of patients in the period immediately after puncture and 39.62% of patients maintain this improvement after the six months. Conclusions: We conclude that in the presence of proctalgia, surgeons should ignore the presence of PNE and that, according to our study, corticosteroid puncture treatment for anesthesia is an effective treatment option that provides relief to a significant percentage of patients

Pancreatitis aguda necroticohemorrágica en malaria falciparum / Acute hemorrhagic necrotizing pancreatitis in falciparum malaria

La malaria o paludismo es una patología causada por un parásito denominado Plasmodium, propia de países tropicales. Entre la sintomatología más frecuente destaca la malaria cerebral, ictericia, crisis convulsivas, anemia, hipoglucemia, fallo renal y acidosis metabólica, entre otras. Presentamos el caso de un paciente diagnosticado de paludismo, que presentó un cuadro de pancreatitis aguda necroticohemorrágica con mala evolución, como ejemplo inusual de dicha asociación descrita en nuestro país (AU)

Malaria is a pathology caused by a parasite called Plasmodium, characteristic of tropical countries. The most frequent symptomatology includes cerebral malaria, jaundice, convulsive crisis, anemia, hypoglycemia, kidney failure and metabolic asidosis, among others. We are presenting the case of a patient diagnosed with malaria who suffered from acute necrotizing hemorrhagic pancreatitis and evolved poorly, as an example of this combination of symptoms, rarely found in our country (AU)

Acute hemorrhagic necrotizing pancreatitis in falciparum malaria.

Malaria is a pathology caused by a parasite called Plasmodium, characteristic of tropical countries. The most frequent symptomatology includes cerebral malaria, jaundice, convulsive crisis, anemia, hypoglycemia, kidney failure and metabolic asidosis, among others. We are presenting the case of a patient diagnosed with malaria who suffered from acute necrotizing hemorrhagic pancreatitis and evolved poorly, as an example of this combination of symptoms, rarely found in our country.

Evolución en cirugía bariátrica: del abordaje abierto al bypass biliopancreático con preservación gástrica por vía laparoscópica. Doce años de experiencia / Advances in bariatric surgery: from the open approach to the biliopancreatic bypass with laparoscopic gastric preservation. Twelve years of experience

Introducción: Análisis de los resultados en el tratamiento de la obesidad mórbida tras 12 años de experiencia. Material y métodos Estudio restrospectivo de los pacientes intervenidos por obesidad mórbida desde julio de 1998 hasta abril de 2010. Inicialmente realizamos técnicas abiertas y desde enero de 2005 bypass biliopancreático con preservación gástrica por vía laparoscópica. Resultados Se ha intervenido a 165 pacientes: 65 con abordaje abierto (bypass gástrico y Scopinaro) y 100 laparoscópico. Edad media: 40 años, mujeres: 74%, IMC medio: 48,6±6kg/m2. Superobesos 35%. Estancia media: 7 días. Morbilidad 43 (26%) pacientes. Reintervenciones en postoperatorio inmediato: 7 pacientes. Mortalidad 2 pacientes. Seguimiento del 99,4% durante un periodo mediano de 46 meses (de 1 a 141). En 17 pacientes hubo complicaciones de la gastroyeyunostomía. Siete pacientes se reintervinieron por hernias transmesentéricas. La tasa de sobrepeso perdido fue del 67% (IC95%: 65-72%), 68% (IC95%: 65-72%) y 68% (IC95%: 63-73%) a 12, 36 y 60 meses, respectivamente. La tasa de exceso de IMC perdido fue del 73% (IC95%: 70-76%), 74% (IC95%: 70-79%) y 74% (IC95%: 68-69%) a los 12, 36 y 60 meses, respectivamente. Comparando ambos abordajes, hubo más complicaciones postoperatorias, mayores estancias hospitalarias y más eventraciones en el abordaje abierto y no se han encontrado diferencias significativas en el resto de parámetros analizados. Conclusión Nuestros resultados a largo plazo están dentro de los clasificados como excelentes, con una morbilidad y una mortalidad aceptables. Hemos observado que el abordaje laparoscópico ha supuesto un gran avance debido a una menor agresión quirúrgica, manteniendo una pérdida de peso excelente (AU)

Introduction: An analysis is presented of the results in the treatment of morbid obesity after12 years experience. Material and methods: A retrospective study of patients subjected to surgery for morbidobesity from July 1998 to April 2010. Open techniques were initially used, and from January2005 using biliopancreatic bypass with gastric diversion by a laparoscopic approach. Results: A total of 165 patients have been subjected to surgery, 65 with open surgery (gastricbypass and Scopinaro), and 100 laparoscopic. The mean age was 40 years, with 74% females. The mean BMI was 48.6 6 kg/m2, with 35% super-obese. The mean hospital stay was7 days, with a morbidity of 26% (43 patients). Seven patients required further surgery, and2 patients died. There was 99.4% follow-up during a median period of 46 months (1 to 141).There were complications of the gastro-jejunostomy in 17 patients. Seven patients required further surgery due to transmesenteric hernias. The rate of overweight lost was 67% (95% CI:65-72%), 68% (95% CI: 65-72%) and 68% (95% CI: 63-73%) at 12, 36 and 60 months, respectively. The rate of excess BMI lost was 73% (95% CI: 70-76%), 74% (95% CI: 70-79%) and 74% (95% CI:68-69%) at 12, 36 and 60 months, respectively. Comparing both approaches, there were more post-operative complications, longer hospital stays, and more incisional hernias in the open approach, with no significant differences found in the rest of the parameters analysed. Conclusion: Our long-term results are within those classified as excellent, with acceptable morbidity and mortality. A great advance has been observed in the laparoscopic approach due to the less aggressive surgery, and maintaining an excellent weight loss (AU)

[Advances in bariatric surgery: from the open approach to the biliopancreatic bypass with laparoscopic gastric preservation. Twelve years of experience]. / Evolución en cirugía bariátrica: del abordaje abierto al bypass biliopancreático con preservación gástrica por vía laparoscópica. Doce años de experiencia.

INTRODUCTION: An analysis is presented of the results in the treatment of morbid obesity after 12 years experience. MATERIAL AND METHODS: A retrospective study of patients subjected to surgery for morbid obesity from July 1998 to April 2010. Open techniques were initially used, and from January 2005 using biliopancreatic bypass with gastric diversion by a laparoscopic approach. RESULTS: A total of 165 patients have been subjected to surgery, 65 with open surgery (gastric bypass and Scopinaro), and 100 laparoscopic. The mean age was 40 years, with 74% females. The mean BMI was 48.6±6 kg/m(2), with 35% super-obese. The mean hospital stay was 7 days, with a morbidity of 26% (43 patients). Seven patients required further surgery, and 2 patients died. There was 99.4% follow-up during a median period of 46 months (1 to 141). There were complications of the gastro-jejunostomy in 17 patients. Seven patients required further surgery due to transmesenteric hernias. The rate of overweight lost was 67% (95% CI: 65-72%), 68% (95% CI: 65-72%) and 68% (95% CI: 63-73%) at 12, 36 and 60 months, respectively. The rate of excess BMI lost was 73% (95% CI: 70-76%), 74% (95% CI: 70-79%) and 74% (95% CI: 68-69%) at 12, 36 and 60 months, respectively. Comparing both approaches, there were more post-operative complications, longer hospital stays, and more incisional hernias in the open approach, with no significant differences found in the rest of the parameters analysed. CONCLUSION: Our long-term results are within those classified as excellent, with acceptable morbidity and mortality. A great advance has been observed in the laparoscopic approach due to the less aggressive surgery, and maintaining an excellent weight loss.

Antibiotic prophylaxis for hernia repair.

BACKGROUND: The use of antibiotic prophylaxis for hernia repair is currently a controversial issue given the disparity among study results in this area. OBJECTIVES: The objective of this systematic review was to clarify the effectiveness of antibiotic prophylaxis in reducing postoperative wound infection rates in elective open inguinal hernia repair. SEARCH METHODS: We searched the Cochrane Colorectal Cancer Group specialized register, by crossing the terms herni* and inguinal or groin and the terms antimicr* or antibiot* , as free text and MeSH terms. A similar search were performed in Medline using the following terms: #1 antibiotic* OR antimicrob* OR anti infecti* OR antiinfecti*; #2 prophyla* OR prevent*; #3 #1 AND #2; #4 clean AND (surgery OR tech* OR proced*); #5 herni*; #6 (wound infection) AND #4; #7 #3 AND (#4 or #5 or #6). National Research Register, ISI-Web, DARE, Scirus, TRIPDATABASE, NHS EED, reference list of the included studies and web of clinical trials register (www.controlled-trials.com and clinicaltrials.gov) were checked to identify further studies. SELECTION CRITERIA: Only randomised clinical trials were included. DATA COLLECTION AND ANALYSIS: In the present review, we searched for eligible trials in October 2011. This revealed four new included trials, so seventeen trials are included in the meta-analysis. Eleven of them used prosthetic material for hernia repair (hernioplasty) whereas the remaining studies did not (herniorrhaphy). Pooled and subgroup analysis were conducted depending on whether prosthetic material was or not used. A fixed effects model was used in the analysis. MAIN RESULTS: The total number of patients included was 7843 (prophylaxis group: 4703, control group: 3140). Overall infection rates were 3.1% and 4.5% in the prophylaxis and control groups, respectively (OR 0.64, 95% CI 0.50 - 0.82). The subgroup of patients with herniorrhaphy had infection rates of 3.5% and 4.9% in the prophylaxis and control groups, respectively (OR 0.71, 95% CI 0.51 - 1.00). The subgroup of patients with hernioplasty had infection rates of 2.4% and 4.2% in the prophylaxis and control groups, respectively (OR 0.56, 95% CI 0.38 - 0.81). AUTHORS' CONCLUSIONS: Based on the results of this systematic review the administration of antibiotic prophylaxis for elective inguinal hernia repair cannot be universally recommended. Neither can the administration be recommended against when high rates of wound infection are observed.

Profilaxis antibiótica y reparación herniaria. Resultado de una revisión sistemática cuantitativa / Antibiotic prophylaxis and hernia repair. Systematic quantitative review results

FUNDAMENTOS. La utilidad de la profilaxis antibiótica en la reparación herniaria se encuentra actualmente en controversia. Los estudios comparativos han mostrado resultados dispares, por lo que es difícil tener una idea clara de su utilidad. El objetivo del presente estudio es hacer una revisión sistemática cuantitativa o metaanálisis de los estudios controlados publicados sobre profilaxis antibiótica en la reparación herniaria, para mostrar la mejor evidencia posible sobre la utilidad de dicha profilaxis. MÉTODOS: Se han seguido los pasos descritos para la realización de una revisión sistemática cuantitativa, basados en la práctica de la medicina basada en la evidencia: formulación de una pregunta relevante (¿es útil la profilaxis antibiótica en la reparación herniaria inguinal electiva por vía abierta en la prevención de la infección postoperatoria de la herida quirúrgica?), búsqueda de las mejores evidencias disponibles, criterios de selección de los ensayos hallados, análisis de cada uno de ellos, combinación de resultados (método de Yusuf y Peto) y conclusiones. RESULTADOS. Se han hallado 12 estudios, de los cuales 8 han cumplido los criterios de inclusión en el metaanálisis. Nuestros resultados muestran que la profilaxis antibiótica en la reparación herniaria, se utilice o no material protésico, disminuye la tasa de infecciones en el 42 por ciento, 61 por ciento y 48 por ciento en herniorrafias, hernioplastias y en conjunto, respectivamente. El número de pacientes necesario a administrar profilaxis para evitar una infección postoperatoria es de 42 en herniorrafias, 37 en hernioplastias y 40 en la reparación herniaria de forma global. CONCLUSIONES. La profilaxis antibiótica en la reparación herniaria es útil en la prevención de la infección de herida. Sin embargo, esto no implica su administración indiscriminada, sino que hay que basarla en la tasa local de infección de herida y en el análisis de los factores de riesgo de los pacientes, para evitar su administración cuando se estime que el beneficio es escaso (AU)

No disponible