Risk of infection and hernia recurrence for patients undergoing ventral hernia repair with non-absorbable or biological mesh during open bowel procedures.

BACKGROUND: Ventral hernia repair (VHR) with mesh performed concurrently with colorectal surgery is presumably associated with significant risks of infection and recurrence. The purpose of this study is to evaluate the outcomes of patients undergoing VHR with non-absorbable mesh (NAM) or biological mesh (BM) at the same time as open colorectal surgery. METHODS: A retrospective review of short- and long-term outcomes for 25 patients undergoing repair of VHR with NAM or BM at the same time as an open colorectal procedure from 1991 to 2007 was performed. RESULTS: The mean age of the patients was 50.8 ± 12.7 years. Fifteen patients (60 %) underwent VHR with NAM versus 10 (40 %) with BM at the time of colorectal surgery. Mean follow-up after surgery was 32.9 ± 38.2 months. Overall wound infection, mesh infection and hernia recurrence rates were 44, 36 and 36 %, respectively. There was no difference between the NAM and BM mesh repair groups in terms of operative indications (p = 0.23) and operations performed (p = 0.47). Both groups had similar gender, ASA score, age, BMI, operating time, hernia recurrence rate, wound infection and follow-up. CONCLUSIONS: Although a proportion of patients who undergo concomitant use of mesh for VHR during colorectal resection has reasonable outcomes, there is a high associated risk of wound and mesh infection. Thus, a judicious decision regarding the use of mesh for hernia repair needs to be made on a case-by-case basis for patients undergoing open bowel surgery at the same time.

Overlapping sphincter repair: does age matter?

BACKGROUND: The predictors of the outcomes following anal sphincteroplasty have not been well documented. OBJECTIVE: The aim was to evaluate age as a predictor of functional outcome and quality of life after overlapping sphincter repair. DESIGN: This study is a retrospective review of chart review followed by a prospective evaluation by the use of validated questionnaires. SETTINGS: Patients were assigned to group A (≤ 60 years old) or group B (>60 years). PATIENTS: Included were patients with obstetric sphincter injuries who underwent overlapping sphincteroplasty between 1996 and 2007. MAIN OUTCOME MEASURES: The Fecal Incontinence Quality of Life Scale, Fecal Incontinence Severity Index, the Cleveland Global Quality of Life scale, and a patient satisfaction questionnaire were used to assess outcome. RESULTS: Three hundred twenty-one women underwent sphincteroplasty and 197 responded to this study, 146 (74.1%) patients in group A and 51 (25.9%) patients in group B. Median follow-up was 7.7 years (range, 4.7-10.0). The mean overall Fecal Incontinence Quality of Life Scale was 11.0 ± 3.5. Median Fecal Incontinence Severity Index score was 29.8 ± 15.9. Mean Cleveland Global Quality of Life scale was 0.7 ± 0.2. The 2 groups were comparable for BMI (p = 1.0), ethnic background (p = 0.8), smoking (p = 0.8), and follow-up duration (p = 0.9). Intergroup comparison showed no significant difference in the Fecal Incontinence Quality of Life Scale scores (p = 0.5) in all subscales: lifestyle (p = 0.8), coping behavior (p = 0.5), depression and self-perception (p = 0.2), and embarrassment (p = 0.1). No significant differences were noted in Fecal Incontinence Severity Index (p = 0.2), Cleveland Global Quality of Life scale (p =1.0), or postoperative satisfaction (p = 0.6). LIMITATIONS: The study was limited by its retrospective nature. CONCLUSIONS: Comparable long-term Fecal Incontinence Severity Index score and Fecal Incontinence Quality of Life Scale scores following overlapping sphincter repair suggest that age is not a predictor of outcome for overlapping sphincter repair. This procedure can be offered to both young and older patients.

Biological immunomodulators improve the healing rate in surgically treated perianal Crohn's fistulas.

AIM: The role of biological therapy in perianal fistulas associated with Crohn's disease (CD) is uncertain as available data are confused and conflicting. In order to provide some clarity to the issue we have examined a large cohort of patients with perianal fistulas and CD and stratified them according to use of biological agents. METHOD: Patients with perianal Crohn's fistulas treated between June 1999 and June 2009 were stratified according to use of biological agents and outcome was examined. Healing was defined as absence of fistula or drainage. Prior to surgery perianal sepsis was eradicated with drains or setons. Endpoints were defined as either complete healing, improvement (minimal symptoms and drainage) or unhealed, as noted at subsequent outpatient follow-up. Variables assessed were age, body mass index, smoking, perineal involvement with Crohn's granuloma and type of procedure. Fisher's exact test and χ(2) test were used for analysis. RESULTS: Two hundred and eighteen patients had anal fistulas and CD. Mean follow-up was 3.2±3 years with mean age 38.8±12.2years and body mass index of 25.3±6. One hundred and seventeen patients (53.7%) underwent surgery alone (Group A) and 101 patients (46.3%) underwent surgery and biological immunomodulator treatments (Group B). Demographic data and CD history were similar between groups. Surgeries included seton drainge (n=90), fistulotomy (n=22), rectal advancement flap (n=39), fistulotomy plus seton (n=47) and others (n=20). Overall improvement in Group A was in 42 patients (35.9%) vs 72 patients (71.3%) in Group B (P=0.001). There was no significant difference in other studied variables between both groups. CONCLUSIONS: There is a definite role for biological therapy as an adjuvant to surgery in patients with perianal fistulas and CD.

Serum vascular endothelial growth factor level in patients with hepatocellular carcinoma undergoing liver transplantation: experience of a single Western center.

BACKGROUND: The strongest predictor of tumor relapse after liver transplantation for hepatocellular carcinoma (HCC) is vascular invasion, appreciated only on explant analysis. High serum level of vascular endothelial growth factor (VEGF) is associated with worse outcomes after resection or locoregional therapies but its role in liver transplantation remains undefined. OBJECTIVE: We report the first western prospective study exploring serum VEGF in HCC liver transplant patients, correlating pre-operative serum VEGF with poor prognostic histologic features during explant analysis. METHODS: Between May 2008, and June 2010, 75 HCC patients underwent liver transplantation at our institution. Serum VEGF was measured every 3 months until liver transplantation and correlated with histopathologic findings on explant. RESULTS: There was no significant correlation between pre-transplant serum VEGF levels and tumor burden (median 31.0 pg/mL vs. 42.5 pg/mL, p=0.33, for tumors within and beyond the Milan criteria, respectively). Pre-transplant VEGF levels were higher in poorly differentiated tumors compared to well to moderately differentiated tumors, but not statistically significant (median 49.0 pg/mL vs. 31.0 pg/mL, p=0.26). Pre-transplant VEGF did not correlate with vascular invasion (median 37.0 pg/mL vs. 31.0 pg/mL, p=0.35, in the presence and absence of vascular invasion, respectively). CONCLUSION: Pre-operative serum VEGF fails to predict unfavorable histologic HCC features in patients undergoing liver transplantation. Role of serum VEGF in liver transplant HCC patients remains unclear.

Influence of age at ileoanal pouch creation on long-term changes in functional outcomes.

AIM: We reviewed the functional results and quality of life (QOL) of patients who had had an ileoanal pouch (IPAA) for at least 15 years. METHOD: Retrospective analysis was undertaken of data accrued prospectively into a pouch database since 1983. Patients who had retained an IPAA for at least 15 years were identified. Trends in IPAA function and QOL of the patients were determined over a time-period of 15 years after formation of the IPAA. Data were compared for patients who were < 35, 35-55 and > 55 years of age when the IPAA was formed. RESULTS: Three hundred and ninety-six of a total of 3276 patients in the database (53% men, median age 36 years and median follow-up 17.1 years) underwent IPAA with at least 15 years of follow-up. The final pathology was ulcerative colitis in 78%; 66.4% of patients had a restorative proctocolectomy, 91.4% underwent temporary diversion, 59% had a J-pouch configuration and 63.1% a stapled anastomosis. The frequency of bowel movements remained the same over the follow-up period. There was an increase in the incidence of incontinence and urgency after 15 years with no significant change in dietary, social, work and sexual restrictions during follow-up. Patients in all three age groups experienced deterioration in pouch function at 15 years of follow up compared with the function at 5 years. The QOL of the patients remained high and stable. CONCLUSION: There is a deterioration of pouch function after 15 years, irrespective of the age of the patient when the IPAA was formed. Despite this, QOL appears to be high for all patients who retain their pouch.

A retrospective review of chronic anal fistulae treated by anal fistulae plug.

OBJECTIVE: The aim of this study was to analyse the efficacy of the anal fistulae plug (Cook Surgisis AFP) for the management of complex anal fistulae. METHOD: A review of patients with anal fistulae treated using Cook Surgisis AFP between October 2005 and 2007 was undertaken. Patient's demographics, fistulae aetiology and success rates were recorded. RESULTS: Thirty-three patients underwent 49 plug insertions. The median age was 44.4 years; 18 females. The fistulae aetiology was cryptoglandular in 61% and Crohn's disease in 39%. The median follow up 221.5 days (range 44-684). Twenty-one patients had previous failed surgery. Twenty-eight patients had draining setons in situ at time of plug placement. The overall success rate was 8/32 patients (25%). Two of the 22 Crohn's fistulae healed (9.1%) and 9/26(34.6%) cryptoglandular fistulae healed. The reasons for failure were sepsis in 87% and plug dislodgement in 13%. Significant predictor factors for improved outcome were African-Americans patients (P = 0.009), and presence of seton (P = 0.05). CONCLUSIONS: Anal fistulae plug was associated with a lower success rate than previously reported. Septic complications were the main reason for failure.

Outcomes for case-matched laparoscopically assisted versus open restorative proctocolectomy.

BACKGROUND: The aim of this study was to compare safety, early and late outcomes, quality of life and functional results of laparoscopically assisted versus open ileal pouch-anal anastomosis (IPAA). METHODS: Patients who had laparoscopically assisted IPAA between 1992 and 2007 were identified from a database and retrospectively matched for age, sex, body mass index (BMI) and operation date to patients who had open IPAA at a ratio of 1:2. Intraoperative, postoperative and long-term functional outcomes were compared. Quality of life was determined by the Cleveland Global Quality of Life scale at 1 and 5 years. RESULTS: A total of 119 patients (59 men, 60 women; mean(s.d) age 35.5(14.2) years, BMI 24.7(5.0) kg/m(2)) had laparoscopically assisted IPAA, with conversion in nine patients (7.6 per cent); these were compared with 238 patients who had open IPAA. The 30-day and long-term results were similar, as well as quality of life at 1 and 5 years, except that patients in the laparoscopic group had shorter median time to stoma action (2 versus 3 days; P = 0.001) and marginally shorter hospital stay. Median operating times were longer in the laparoscopic group (272 versus 163 min; P = 0.040). CONCLUSION: Laparoscopically assisted IPAA had similar outcomes to open IPAA, but with some short-term advantages.

Outcomes following Turnbull-Cutait abdominoperineal pull-through compared with coloanal anastomosis.

BACKGROUND: The Turnbull-Cutait abdominoperineal pull-through procedure (T-C) is used as a last resort to avoid permanent diversion in patients with complex anorectal conditions. The aim was to evaluate short- and long-term outcomes after T-C. METHODS: Patients undergoing T-C from 1996 to 2007 were reviewed retrospectively in terms of demographics, diagnosis, indications and postoperative complications. Patients were contacted to obtain functional outcomes using a standardized questionnaire. Functional outcomes were compared with those in a matched group of patients undergoing handsewn coloanal anastomosis (CAA) for rectal cancer. RESULTS: Sixty-seven patients (40 men) underwent T-C. Postoperative complications included stricture in 11 patients (16 per cent), fistula in five (7 per cent), prolapse of the colon in five (7 per cent) and leak in two (3 per cent). Mean follow-up was 5.6 (s.d. 3.2) years. The operation failed in 17 patients (25 per cent). Among 44 patients (66 per cent) who completed questionnaires, faecal (P = 0.121) and urinary (P = 0.073) incontinence, and sexual function (P = 0.063) were comparable to those in patients who had CAA. CONCLUSION: T-C is an option for patients with complex anorectal conditions that might otherwise require permanent diversion. Functional outcomes are comparable to those of CAA.

Hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the sixth most common cancer of men and eleventh most common cancer of women world-wide. However, because almost every individual who develops liver cancer dies of the disease, HCC is the third most common cause of the cancer deaths in men and seventh most common in women. The treatment of choice for hepatocellular carcinoma remains surgical resection or liver transplantation, in carefully selected cases. In patients with hepatocellular carcinoma not amenable to surgical intervention a variety of different therapeutic interventions have been investigated. These include direct ablation of the tumour using agents such as ethanol or acetic acid, transcatheter arterial chemoembolization, or systemic chemotherapy. The evaluation of their efficacy is compromised by the paucity of adequately powered randomised clinical trials. The main challenge facing the research community over the next decade is to prioritise the most promising treatments and take these forward into multicentre controlled trials. Even if these fail to improve results, they will help reduce the variation in clinical practice by eliminating anecdotal treatment.

Outcome of liver resection and transplantation for fibrolamellar hepatocellular carcinoma.

Fibrolamellar hepatocellular carcinoma (FL HCC) is an uncommon variant of hepatocellular carcinoma occurring usually in non-cirrhotic livers. Hepatic resection or transplantation offers the only chance of cure. We reviewed our experience of surgery for FL HCC from 1985-1998. Twenty patients with FL HCC (13 females and 7 males) median age 27 years (range 12-69) were treated either by hepatic resection [n = 11; extended right hepatectomy (5), extended left hepatectomy (1), right hemihepatectomy (2), left hemihepatectomy (2), left lateral segmentectomy (1)] or, if the disease was non-resectable, by transplantation (n = 9). The median follow up was 25 months (1-63). The prognostic factors analysed included size [less than 5 cm (3 patients), more than 5 cm (17 patients)], number [solitary (16 patients), multiple (4 patients)], capsular invasion (6 patients), vascular invasion (11 patients) and lymph node invasion (6 patients). The overall survival at 1, 3 and 5 years was 89.5, 75 and 50%, respectively. The liver resection survival was better than liver transplantation survival at 3 years 100 vs 76%, respectively (P < 0.025). Although all prognostic factors analysed did not show a significant difference, there is tendency that tumour stage was the most significant for prognosis. Most of the patients in this study are young and presented without specific symptoms, with normal liver function range and had no tumour marker to help in diagnosis. As a result most of our patients were diagnosed late. However the outcome of surgical intervention was favourable.

Hepatocellular cancer: resection or transplantation.

Surgery remains the treatment of choice for hepatocellular carcinoma (HCC). For HCC without underlying cirrhosis resection remains the mainstay treatment option. Prognosis depends on the stage of the tumor. Survival appears to be better for small (less than 5 cm) solitary tumors with negative resection margins and absence of vascular invasion. At present, liver transplantation does not have an established role in the treatment of HCC in a non-cirrhotic liver. Because of the high recurrence rate, it should not be considered for more advanced disease which is not amenable to resection. The surgical approach in cirrhotics depends not only on the stage of the tumor but also on the liver functional reserve. Tumor size, presence of multifocal disease, and vascular invasion determine the risk of HCC recurrence after resection, and the functional stability of the liver determines both resectability and outcome. In societies in which transplantation is not available, small tumors will be treated with liver resection. The outcome in patients with well preserved liver function is relatively good, at least in the medium term. However, recurrent tumor and progressive hepatic decompensation have significant adverse effects on long-term survival. Poor functional reserve may be associated with significant perioperative mortality and lower survival due to progressive liver failure. In our opinion, for small cirrhosis-related HCCs, liver transplantation offers better long-term prospects than resection. Therefore, if liver transplantation is available as an option it should be considered as the treatment of choice, particularly for younger patients with otherwise good life expectancy.