Losartan modifies mesh integration after abdominal wall repair: an experimental study.

PURPOSE: Angiotensin II (AT II) receptor blockers have previously shown to reduce inflammatory response in many settings. We aimed to assess the effects of ATII receptor blocker (Losartan) on mesh integration after abdominal wall repair in a rat model. METHODS: A total of 16 Wistar-Kyoto (WKY) and 16 previously hypertensive (SHRSP) rats were isolated. An acute ventral hernia followed by a bridged repair with heavyweight polypropylene mesh was performed. Subjects received either normal saline (WKY-C n = 8 and SHRPS-C n = 8) or 40 mg/kg losartan (WKY-L n = 8) and SHRPS-L n = 8) in the postoperative period. Blood pressure was recorded preoperatively and weekly after surgery. Necropsy with en-bloc resection of the abdominal wall was performed at postoperative day 30. Macroscopic and microscopic evaluations of the specimens were conducted. H&E and Masson's trichrome were used for histologic evaluation. RESULTS: Both groups receiving Losartan showed a significant reduction of blood pressure after surgery (WKY-L: 130/85 vs 116/81 mmHg, SHRPS-L: 176/137 vs 122/101 mmHg, p < 0.01). A significant reduction in mesh incorporation and adherence scores were also observed on macroscopic analysis in Losartan groups (p < 0.01 and p = 0.02, respectively). Microscopically, higher immature fibroplasia was observed after Losartan, with a significant reduction in scar plate formation and inflammatory response on the prosthetic surface (p = 0.04 and p = 0.02, respectively). CONCLUSION: Losartan modifies the interaction between the host tissue and the prosthesis. An impairment in mesh integration and immature fibroplasia in both normotensive and hypertensive rats detected in our model warrants further research.

Long-term outcomes and quality of life assessment after posterior component separation with transversus abdominis muscle release (TAR).

BACKGROUND: Although transversus abdominis release (TAR) to treat large incisional hernias has shown favorable postoperative outcomes, devastating complications may occur when it is used in suboptimal conditions. We aimed to evaluate postoperative outcomes and long-term follow-up after TAR for large incisional hernias. METHODS: A consecutive series of patients undergoing TAR for complex incisional hernias between 2014 and 2019 with a minimum of 6 month follow-up was included. Demographics, operative and postoperative variables were analyzed. Postoperative imaging (CT-scan) was also evaluated to detect occult recurrences. The HerQLes survey for quality of life (QoL) assessment was performed preoperatively and 6 months after the surgery. RESULTS: A total of 50 TAR repairs were performed. Mean age was 65 (35-83) years, BMI was 28.5 ± 3.4 kg/m2, and 8 (16%) patients had diabetes. Mean Tanaka index was 14.2 ± 8.5. Mean defect area was 420 (100-720) cm2, average defect width was 19 ± 6.2 cm, and mesh area was 900 (500-1050) cm2; 78% were clean procedures, and in 60% a panniculectomy was associated. Operative time was 252 (162-438) minutes, and hospital stay was 4.5 (2-16) days. Thirty-day morbidity was 24% (12 patients), and 16% (8 patients) had surgical site infections. Overall recurrence rate was 4% (2 patients) after 28.2 ± 20.1 months of follow-up. QoL showed a significant improvement after surgery (p = 0.001). CONCLUSIONS: The TAR technique is an effective treatment modality for large incisional hernias, showing an acceptable postoperative morbidity, a significant improvement in QoL, and low recurrence rates at long-term follow-up.

Emergent laparoscopic sigmoid resection for perforated diverticulitis: can it be safely performed by residents?

AIM: Outcomes after resident involvement in emergent colectomies have rarely been studied. The aim of this study was to analyse the outcomes of laparoscopic sigmoidectomy for Hinchey III diverticulitis performed by residents. METHOD: This study was a retrospective analysis of patients undergoing laparoscopic sigmoidectomy for diverticulitis. The sample was divided into two groups: patients operated on by a supervised resident (SR) or a senior surgeon (SS). Supervising surgeons and SSs could be general surgeons (GSs) or colorectal surgeons (CSs). A SR was considered the first surgeon if he/she completed at least three of five defined steps of the procedure. The primary end-points included length of hospital stay (LOS), morbidity and 30-day mortality. A sub-analysis of patients operated on by a SR assisted by either a CS or GS was performed. RESULTS: Supervised residents and SSs operated on 59 and 42 patients, respectively. The presence of a CS was more frequent in the SS group (SR 41% vs SS 81%, P < 0.001). LOS (SR 9.4 days vs SS 6.4 days, P = 0.04) was higher in the SR group. Overall morbidity (SR 39% vs SS 43%, P = 0.69) and 30-day mortality (SR 5% vs SS 5%, P = 0.94) were also comparable among the groups. Procedures performed by SRs and supervised by a CS were associated with lower morbidity (GS 48% vs CS 25%, P = 0.06) and mortality (GS 8% vs CS 0%, P = 0.26). CONCLUSION: Laparoscopic sigmoidectomy for Hinchey III diverticulitis has comparable outcomes when performed by a supervised SR or a SS. Procedures performed by residents assisted by a CS seem to have better outcomes than those assisted by a GS.

Could long-term follow-up modify the outcomes after laparoscopic TAPP? A 5-year retrospective cohort study.

PURPOSE: Laparoscopic inguinal hernia repair (LIHR) has demonstrated multiple benefits. However, long-term results regarding recurrence and quality of life (QoL) are still on debate. We aimed to analyze postoperative outcomes with long-term follow-up after LIHR. METHODS: A consecutive series from December 2012 to May 2017 of laparoscopic TAPP was included. A minimum of 6 months of follow-up was required for inclusion. The sample was divided into two groups, G1: patients with recurrence and G2: patients without recurrence. Patient's characteristics, operative variables and postoperative outcomes were analyzed. A QoL survey (Eura-HS QoL) was performed in the pre- and postoperative period. RESULTS: A total of 717 laparoscopic TAPP were performed in 443 patients. On univariate analysis, smoking, previous recurrence, mesh size smaller than 12 × 15 cm and surgical teams with less than 30 cases/year showed an increased recurrence rate (p < 0.05). But only smoking and less experienced teams were statistically significant on multivariate analysis (p < 0.01). After a 2-year follow-up, recurrence rate was 1.5%, while it increased to 2.6% (n = 19) at 5-year follow-up. Sixty percent of patients answered QoL survey. Average preoperative scores of pain, activities restriction and aesthetic dissatisfaction improved significantly after 6 months of follow-up in patients without recurrence. CONCLUSIONS: After LIHR, quality of life shows a significant improvement in all parameters. Extending follow-up beyond 2 years after laparoscopic TAPP allows a more accurate assessment of recurrence rate. Smoking and inexperienced teams were significant risk factors for its development.

Does DeMeester score still define GERD?

Gastroesophageal reflux disease (GERD) clinical presentation may encompass a myriad of symptoms that may mimic other esophageal and extra-esophageal diseases. Thus, GERD diagnosis by symptoms only may be inaccurate. Upper digestive endoscopy and barium esophagram may also be misleading. pH monitoring must be added often for a definitive diagnosis. The DeMeester score (DMS) is a composite score of the acid exposure during a prolonged ambulatory pH monitoring that has been used since 1970s to categorize patients as GERD+ or GERD-. We showed in this review that DMS has some limitations and strengths. Although there is not a single instrument to precisely diagnose GERD in all of its variances, pH monitoring analyzed at the light of DMS is still a reliable method for scientific purposes as well as for clinical decision making. There are no data that show that acid exposure time is superior-or for that matter inferior-as compared to DMS.

Small Bowel Obstruction Secondary to Interstitial Hernia: Laparoscopic Approach.

Interstitial hernias are a rare entity. Most of them are detected incidentally on imaging studies. We present a case of abdominal bowel obstruction secondary to interstitial hernia on the fifth postoperative day of an open incisional hernia repair. Laparoscopy confirmed the diagnosis and led to an accurate treatment avoiding a new laparotomy. In this case, prompt surgical decision based on clinical and CT scan findings allowed a mini-invasive approach with satisfactory outcome.

Algorithm for early discharge after total thyroidectomy using PTH to predict hypocalcemia: prospective study.

PURPOSE: Hypocalcemia is the most common complication after total thyroidectomy. The aim of this study was to determine whether postoperative parathyroid hormone (PTH) levels predict hypocalcemia in order to design an algorithm for early discharge. METHODS: We present a prospective study including patients who underwent total thyroidectomy. Hypocalcemia was defined as serum ionized calcium < 1.09 mmol/L or clinical evidence of hypocalcemia. PTH measurement was performed preoperatively and at 1, 3, and 6 h postoperatively. The percent decline of preoperative values was calculated for each time point. RESULTS: One hundred and six patients were included. Thirty-six (33.9%) patients presented hypocalcemia. A 50% decline in PTH levels at 3 h postoperatively showed the highest sensitivity and specificity to predict hypocalcemia (91 and 73%, respectively). No patients with a decrease <35% developed hypocalcemia (100% sensitivity), and all patients with a decrease >80% had hypocalcemia (100% specificity). CONCLUSIONS: PTH determination at 3 h postoperatively is a reliable predictor of hypocalcemia. According to the proposed algorithm, patients with less than 80% drop in PTH levels can be safely discharged the day of the surgery.