Delphi consensus statement for understanding and managing the subcostal hernia: subcostal hernias collaborative report (scholar study).

INTRODUCTION: Subcostal hernias are categorized as L1 based on the European Hernia Society (EHS) classification and frequently involve M1, M2, and L2 sites. These are common after hepatopancreatic and biliary surgeries. The literature on subcostal hernias mostly comprises of retrospective reviews of small heterogenous cohorts, unsurprisingly leading to no consensus or guidelines. Given the limited literature and lack of consensus or guidelines for dealing with these hernias, we planned for a Delphi consensus to aid in decision making to repair subcostal hernias. METHODS: We adopted a modified Delphi technique to establish consensus regarding the definition, characteristics, and surgical aspects of managing subcostal hernias (SCH). It was a four-phase Delphi study reflecting the widely accepted model, consisting of: 1. Creating a query. 2. Building an expert panel. 3. Executing the Delphi rounds. 4. Analysing, presenting, and reporting the Delphi results. More than 70% of agreement was defined as a consensus statement. RESULTS: The 22 experts who agreed to participate in this Delphi process for Subcostal Hernias (SCH) comprised 7 UK surgeons, 6 mainland European surgeons, 4 Indians, 3 from the USA, and 2 from Southeast Asia. This Delphi study on subcostal hernias achieved consensus on the following areas-use of mesh in elective cases; the retromuscular position with strong discouragement for onlay mesh; use of macroporous medium-weight polypropylene mesh; use of the subcostal incision over midline incision if there is no previous midline incision; TAR over ACST; defect closure where MAS is used; transverse suturing over vertical suturing for closure of circular defects; and use of peritoneal flap when necessary. CONCLUSION: This Delphi consensus defines subcostal hernias and gives insight into the consensus for incision, dissection plane, mesh placement, mesh type, and mesh fixation for these hernias.

Recurrent intestinal fistulation after porcine acellular dermal matrix reinforcement in enteric fistula takedown and simultaneous abdominal wall reconstruction.

PURPOSE: Porcine acellular dermal matrix (PADM) has been promoted as a suitable material for the reinforcement of the abdominal wall in Ventral Hernia Working Group (VHWG) Grade 3/4 wounds by Ventral Hernia Working Group et al. (Surgery 148(3):544-548). We describe our experience of, and assess the mechanisms for the failure of PADM (PermacolTM) in intestinal and abdominal wall reconstruction (AWR) for enterocutaneous fistulation (ECF). METHODS: All patients referred to our unit who had PADM used for AWR and ECF were studied from a prospectively maintained database. Follow-up data until 31/12/2018 were analysed. PADM was explanted at further surgery and examined histologically. RESULTS: 13 patients, (median age-58.5 years) underwent AWR with PADM reinforcement. Twelve of these (92%) patients had developed abdominal wall defects (AWD) and ECF following complications of previous surgery. Six patients underwent fistula takedown and AWR with PADM, of which 5(83%) refistulated. Seven patients referred to us had already undergone similar procedures in their referring hospitals and had also refistulated. Median (range) time to fistulation after AWR with PADM was 17 (7-240) days. In all cases, PADM had been used to bridge the defect and placed in direct contact with bowel. At reconstructive surgery for refistulation, PADM was inseparable from multiple segments of small intestine, necessitating extensive bowel resection. Histological examination confirmed that the PADM almost completely integrated with the seromuscular layer of the small intestine. CONCLUSION: PADM may become inseparable from serosa of the human small intestinal serosa when it is left in the abdomen during reconstructive surgery. This technique is associated with recurrent intestinal fistulation and intestinal failure and should be avoided if at all possible.

Preoperative mechanical and oral antibiotic bowel preparation to reduce infectious complications of colorectal surgery - the need for updated guidelines.

BACKGROUND: Increasing evidence indicates that combined mechanical and oral antibiotic bowel preparation reduces the infectious complications of colorectal surgery. Anecdotal evidence suggests the combination is rarely used in the UK and Europe. AIM: To establish colorectal surgeons' current use and awareness of the benefits of such bowel preparation, and to identify decision-making influences surrounding preoperative bowel preparation. METHOD: An electronic survey was emailed to all members of the Association of Coloproctology of Great Britain and Ireland, and promoted via Twitter. FINDINGS: A total of 495 respondents completed the survey: 413 (83.2%) UK, 39 (7.9%) other European, 43 (8.7%) non-European. Respondents used oral antibiotics for 12-20% of cases. Mechanical bowel preparation (MBP), phosphate enema, and no preparation, respectively, ranged between 9 and 80%. Combined MBP and oral antibiotic bowel preparation ranged between 5.5 and 18.6%. Fifty-three percent (260/495) agreed that combined mechanical and oral antibiotic bowel preparation reduces surgical site infection; 32% (157/495) agreed that the combination reduces risk of anastomotic leak. Kappa statistics between 0.06 and 0.27 indicate considerable incongruity between surgeons' awareness of the literature, and day-to-day practice. Twenty-four percent (96/495) believed MBP to be incompatible with enhanced recovery after surgery (ERAS); 41% (204/495) believed that MBP delays return to normal intestinal function. CONCLUSIONS: Few UK and European colorectal surgeons use mechanical and oral antibiotic bowel preparation, despite evidence of its efficacy in reducing infectious complications. The influence of ERAS pathways and UK and European guidelines may explain this. In contradiction to the UK and Europe, North American guidelines recommend incorporating combined mechanical and oral antibiotic bowel preparation into ERAS programmes. This study suggests that future UK and European guidelines incorporate combined mechanical and oral antibiotic bowel preparation into the ERAS pathway.

Autologous reconstruction of massive enteroatmospheric fistulation with a pedicled subtotal lateral thigh flap.

BACKGROUND: Reconstruction of massive contaminated abdominal wall defects associated with enteroatmospheric fistulation represents a technical challenge. An effective technique that allows closure of intestinal fistulas and reconstruction of the abdominal wall, with a good functional and cosmetic result, has yet to be described. The present study is a retrospective review of simultaneous reconstruction of extensive gastrointestinal tract fistulation and large full-thickness abdominal wall defects, using a novel pedicled subtotal thigh flap. METHODS: The flap, based on branches of the lateral circumflex femoral artery, was used to reconstruct the abdominal wall in six patients who were dependent on artificial nutritional support, with a median (range) of 4·5 (3-23) separate intestinal fistulas, within open abdominal wounds with a surface area of 564·5 (204-792) cm2. Intestinal reconstruction was staged, with delayed closure of a loop jejunostomy. Median follow-up was 93·5 (10-174) weeks. RESULTS: Successful healing occurred in all patients, with no flap loss or gastrointestinal complications. One patient died from complications of sepsis unrelated to the surgical treatment. All surviving patients gained complete nutritional autonomy following closure of the loop jejunostomy. CONCLUSION: Replacement of almost the entire native abdominal wall in patients with massive contaminated abdominal wall defects is possible, without the need for prosthetic material or microvascular free flaps. The subtotal pedicled thigh flap is a safe and effective method of providing definitive treatment for patients with massive enteroatmospheric fistulation.