Comparison of open and endoscopic posterior component separation with transversus abdominis release: a propensity score-matched study.

BACKGROUND: Posterior component separation with transversus abdominis release (TAR) is considered to be the optimal technique for large incisional ventral hernia repair. Endoscopic TAR (eTAR) that gets all the benefits of minimally invasive surgery (MIS) gives a possibility to enhance results of the treatment. The aim of our study was to make the comparison between open and endoscopic TAR procedures with an emphasis on frequency and severity of postoperative complications in comparable groups. MATERIALS AND METHODS: All patients had midline incisional hernia and underwent either open (open TAR group) or endoscopic (eTAR group) Rives-Stoppa repair in combination with bilateral transversus abdominis release in Moscow City Hospital №1 from January 2018 to December 2022. A propensity score matching (PSM) was used to make groups comparable. Postoperative complications were classified according to Clavien-Dindo Classification, and Comprehensive complication index was calculated. RESULTS: We performed 133 open and endoscopic TAR separation for midline incisional hernia. After PSM analysis 51 patients were matched to each group. Overall surgical morbidity in the open TAR group (56.9%) was statistically significantly higher than in the eTAR group (29.4%) (p = 0.009). There were more severe complications (Clavien IIIa-V) in the open TAR group (11.8% vs. 0%, p = 0.027). Length of hospital stay after surgery was shorter in eTAR group (p < 0.001). The Comprehensive complication index in the open TAR group was significantly higher than in eTAR group, 8.7 (0-20.9) vs. 0 (0-8.7) (p = 0.011). CONCLUSION: Based on the data from our study, the entire MIS procedure including endoscopic TAR is a safe and optimal technique for surgery of midline incisional ventral hernia, requiring TAR separation in terms of reducing the rate of postoperative complications, their severity and hospital length of stay, compared to open TAR procedure.

Risk factors of venous thromboembolism after incisional ventral hernia repair.

BACKGROUND: The problem of venous thromboembolic events (VTE) after incisional hernia repair remains relevant. According to the literature the frequency of VTE ranges from 0.2 to 4.2%. The data on risk factors of VTE in this cohort of patients are scarce. Aim of our study is to find frequency and risk factors for VTE development in patients who underwent surgery for incisional ventral hernia. MATERIALS AND METHODS: There were 240 patients enrolled in our retrospective study. We included patients, who were operated for incisional hernia in Saveljev University Surgery Clinic from January 2018 to December 2019. Compression duplex ultrasound of lower extremity veins was performed within median 3 days (min 1 day, max 7 days) after surgery for all participants. The primary endpoint was the occurrence of the VTE event, including deep venous thrombosis (DVT) and pulmonary embolism (PE). RESULTS: VTE was detected in 19 patients, which accounted for 7.9% in analyzed cohort. All patients received standard pharmacological prophylaxis. There were 3 (1.3%) proximal, 16 (6.7%) distal DVT, in one patient (0.4%) distal thrombosis was complicated by symptomatic pulmonary embolism. In multivariate Cox proportional hazard model was found that component separation (HR 3.99, 95% CI 1.14-14.0, p = 0.03), duration of operation in hours (HR 1.67. 95% CI 1.13-2.5, p = 0.011) and body mass index (HR 1.13, 95% CI 1.02-1.2, p = 0.02) were statistically significant risk factors. CONCLUSION: The incidence of postoperative VTE in patients after incisional hernia repair is high with a predominant distal DVT as a thrombotic event. Component separation, duration of operation and body mass index are statistically significant factors of VTE in patients undergoing surgery for incisional hernia.

[Biomarkers of system inflammation in local and diffuse peritonitis]. / Markery sistemnogo vospaleniia pri mestnom i rasprostranennom peritonite.

In cases of any acute surgical abdominal disease the progression of purulent inflammation can lead to local or diffuse peritonitis. The indicators of the degree and specificity of the inflammatory response in blood such as cytokine concentration, neutrophil activity, plasma antioxidant capacity (thiols concentration) could be considered as potential predictors of complications. The luminol-dependent chemiluminescence (CL) response of blood activated by the phorbol ester (PMA), and the concentration of cytokines IL-6, IL-8, IL-10, myeloperoxidase (MPO) and thiols in plasma were measured in patients with uncomplicated condition (group 1, n=8), local peritonitis (group 2, n=9) or diffuse peritonitis (group 3, n=9) at admission to surgery (before surgical operation, b/o), immediately after surgical operation (a/o) and a day after surgery (1 day) as well as in healthy volunteers (norm, n=12). In all time-points the cytokines and MPO concentrations measured by ELISA, in group 3 were higher than in healthy volunteers and in patients in groups 1 and 2. Blood CL demonstrated a more than 5-fold increase above the normal values in all patients, and was also higher in group 2 as compared to group 1 (b/o and a/o). Patients in group 3 had shown both maximum and minimum of CL values, which could be a consequence of neutrophil priming or exhaustion ("immune paralysis"), respectively. The same patients' plasma exhibited low thiol concentration (≤30% vs normal values). In patients with fatal outcomes (group 3, n=2) within a day after surgery, either a decrease of the CL to zero values concurrently with elevated IL-8 and IL-6 concentrations and low thiol levels was observed, or CL exceeded normal values more than 20 times with concurrent complete exhaustion of the plasma thiol pool. No clear dependency between the plasma parameters and neutrophil activity was found. Hence a parameter set for prognosis and/or early diagnosis of infectious complications in acute abdominal pathology should include different biomarkers of the inflammatory response: cytokine profile (IL-6, IL-8, IL-10), MPO and neutrophil activity, antioxidant plasma capacity (e.g., total thiols concentration).

[Diagnostic and treatment approaches for acute appendicitis in the Russian Federation. Results of the all-Russian survey]. / Diagnosticheskie i lechebnye podkhody pri ostrom appenditsite v praktike khirurgov Rossiiskoi Federatsii. Rezul'taty obshcherossiiskogo oprosa.

OBJECTIVE: To improve treatment outcomes in patients with acute appendicitis (AA). MATERIAL AND METHODS: An internet survey was performed. Questionnaire consisted of 15 questions concerning diagnosis and treatment of AA: application of prognostic scales, incidence and technical aspects of laparoscopic appendectomy (LA), antibiotic prophylaxis, postoperative management, compliance with international and national clinical guidelines. A total of 690 questionnaires were received and analyzed (3.67% of all surgeons in the Russian Federation). RESULTS: Eighteen percent of respondents use at least one prognostic scale. The vast majority of surgeons (92%) use antibiotic prophylaxis. Almost half of respondents place trocars in the triangulation position (44%), one third of surgeons ligate the mesentery of the appendix (35%), most respondents perform mesoappendectomy (60%) with monopolar and bipolar cautery. Forty-five percent of all respondents do not invert the appendix stump. Significant number of respondents use abdominal drainage routinely. Only 3.5% of surgeons use multimodal postoperative analgesia. Less than 22% of patients are operated under low-pressure pneumoperitoneum. Standardization of surgical technique and perioperative approaches including those specified in the guidelines is absent. We also found insufficient awareness of surgeons about international and national clinical guidelines. CONCLUSION: This study may be useful for standardizing treatment approaches, choosing the best practice, popularizing and improving of current clinical guidelines.

[Laparoscopic surgery for advanced appendicular peritonitis]. / Laparoskopicheskaya khirurgiya rasprostranennogo appendikulyarnogo peritonita.

OBJECTIVE: To evaluate the results of laparoscopic treatment of patients with advanced appendicular peritonitis. MATERIAL AND METHODS: There were 271 patients with acute appendicitis complicated by peritonitis. The main group consisted of patients who underwent laparoscopic appendectomy after diagnostic laparoscopy (n=231), the control group - diagnostic laparoscopy followed by conversion to median laparotomy (n=36). Four extremely ill patients were operated through laparotomy and excluded from the further analysis. RESULTS: Diagnostic laparoscopy was performed in 267 patients with advanced appendicular peritonitis. Laparoscopic appendectomy, debridement and abdominal drainage were performed in 231 (85.2%) patients. Mean age of patients was 44±18.5 years, duration of disease - 36.2±20.3 hours. Diffuse peritonitis was diagnosed in 219 (82%) patients, advanced peritonitis - in 48 (16.5%) cases. Incidence of conversion was 13.5%. Mortality was absent in both groups. Postoperative morbidity was significantly higher in the conversion group (72.2% vs. 29.4%, p<0.0001). CONCLUSION: Laparoscopic interventions for common appendicular peritonitis are feasible, effective and reduce postoperative morbidity.

[Comparison of laparoscopic and open suturing of perforated peptic ulcer complicated by advanced peritonitis]. / Sravnitel'naia otsenka rezul'tatov laparoskopicheskogo i otkrytogo ushivaniia perforativnykh gastroduodenal'nykh iazv, oslozhnennykh rasprostranennym peritonitom.

AIM: To compare the results of open and laparoscopic interventions for PGDU complicated by advanced peritonitis. MATERIAL AND METHODS: A retrospective analysis enrolled 172 patients with PGDU who underwent surgery for the period 2014-2016. The research was performed at the bases of the Department of Faculty-Based Surgery No. 1 of the Medical Faculty of the Pirogov Russian National Research Medical University. Further analysis enrolled 138 patients in accordance with inclusion and exclusion criteria (laparoscopic intervention - 116 patients, open surgery - 22). Propensity score matching (pseudorandomization) was applied after comparative analysis of patients' characteristics and treatment outcomes in order to ensure maximum comparability of both groups. RESULTS: Length of hospital-stay (7.1 vs. 9.8 days), incidence of extra-abdominal complications (6.3%. vs. 41.2%) and adverse events Clavien-Dindo grade II (6.3% vs. 35.3%) were significantly lower after minimally invasive surgery (p<0.05). CONCLUSION: Analysis of comparable groups of patients with PGDU complicated by peritonitis revealed that laparoscopic surgery is accompanied by significantly lower incidence of extra-abdominal postoperative complications and shorter hospital-stay compared with open surgery. Mortality and incidence of intra-abdominal postoperative complications were similar in both groups.

[Complicated appendicitis during pregnancy]. / Oslozhnennye formy ostrogo appenditsita u beremennykh.

AIM: To analyze incidence, diagnosis and treatment of complicated appendicitis in pregnant women and to determine the optimal surgical approach. MATERIAL AND METHODS: Retrospective cohort analysis included 338 pregnant women who underwent appendectomy in 2012-2016. Complicated appendicitis (abscess, local or common peritonitis and their combinations) was diagnosed in 22 cases. The main perioperative variables (duration of the disease, time of surgery, length of hospital-stay, incidence of wound complications, etc.), clinical and laboratory symptoms, results of ultrasound diagnosis and pregnancy outcomes were analyzed. Statistical analysis was carried out in Stata 14.2. Fisher's exact test, Mann-Whitney-Wilcoxon's U-test and multivariate regression analysis were used to compare data. RESULTS: The incidence of complicated appendicitis in pregnant women was 6.51%. There are no clinical symptoms which would be significantly more common in complicated appendicitis during pregnancy. Complicated course prolongs surgery and hospital-stay, however duration of postoperative analgesia depends on surgical technique as a rule. There were 27% of laparoscopic interventions that is lower compared with women with uncomplicated appendicitis. The percentage of conversions was higher too. CONCLUSION: Clinical diagnosis of complicated appendicitis during pregnancy even by using of ultrasound is not satisfactory and requires the involvement of other objective methods, such as MRI. Laparoscopic intervention is not contraindicated in pregnant women with complicated appendicitis and determine better treatment outcomes than open surgery.

[Fast-track rehabilitation for acute cholecystitis: intermediate outcomes of prospective randomized trial]. / Uskorennoe vyzdorovlenie pri ostrom kholetsistite: promezhutochnye rezul'taty prospektivnogo randomizirovannogo issledovaniia.

AIM: To analyze an efficacy of FT-protocol in patients with acute cholecystitis. MATERIAL AND METHODS: Prospective randomized study included 102 patients (45 of main group (FT) and 57 of control groups). Patients did not differ by TG13 severity index. The protocol included information, antibiotic prophylaxis, restriction of drainage, intraperitoneal anesthesia with long-term anesthetics, low pressure pneumoperitoneum, antiemetics in the presence of risk factors, early activation and feeding of the patient. Pain was assessed by VAS immediately after surgery, and 2, 6 and 12-24 hours postoperatively. RESULTS: Surgery time was similar in both groups. Need for anesthesia and pain severity were significantly lower in the FT group. A total absence of pain (VAS 0-1) on the 1st postoperative day was noted in 8 (17.7%) of the FT group and 2 (3.5%) patients of the control group (p=0.038). Shoulder pain developed in 4 (8.9%) cases of the main and 22 (38.6%) cases of the control group (p=0.001). Postoperative nausea developed in 13% of the FT group vs 40.5% in the control group (p=0.05). Hospital-stay was 1.29±0.7 days and 2.7±1.6 (p<0.0001), respectively. The time of the first stool was similar. Twenty-four (53.5%) patients of the FT group and 8,9% of the control group were discharged on 1st postoperative day. There were 2 (IIIA) complications in the main group and 3 - in the control group (IIIA, IIIB and IV). There were no mortality and readmissions. CONCLUSION: FT protocol in AC reduce postoperative pain, dyspepsia, shoulder pain and in-hospital stay with equal number of postoperative complications.

[Comparison of standard and fast track rehabilitation in patients with acute appendicitis. Intermediate results of multicenter prospective randomized trial]. / Sravnitel'naia otsenka metodov standartnoi i uskorennoi reabilitatsii bol'nykh s ostrym appenditsitom. Promezhutochnye rezul'taty mnogotsentrovogo prospektivnogo randomizirovannogo issledovaniia.

AIM: To analyze outcomes of fast track rehabilitation in patients with acute appendicitis. MATERIAL AND METHODS: Prospective, randomized multi-center trial including 86 patients was conducted. There were 38 patients in the main group and 48 in the control group. All patients underwent laparoscopic appendectomy under endotracheal anesthesia. Protocol included informing, no premedication, glucose infusion prior to surgery, antibiotics administration, mesoappendix excision, limited deployment of drainage tubes, intraabdominal prolonged anesthesia, minimal pneumoperitoneum, limited irrigation, minimum power monopolar electrocautery, antiemetics, early activation and eating (2 and 6 hours after surgery). Pain was evaluated by visual-analogue scale. Auscultative peristalsis was considered every 2 hours after surgery. Cortisol level was assessed preoperatively, in 6 and 12-24 hours after surgery in 11 (29%) and 15 (31%) patients of the main and control groups respectively. Discharge criteria: no leukocytosis, fever and pain syndrome requiring anesthesia, no signs of complications and patient's consent. RESULTS: Terms of disease, gender, age and comorbidities were similar in all patients. Duration of surgery under minimal pneumoperitoneum and standard pressure was also similar: 69.2±3.98 and 70.9±3.89 min (p=0.762). Pain syndrome grade and need for analgesics were significantly lower in the main group within entire follow-up. Pain syndrome was absent at the 1st postoperative day in 16 (42%) and 2 (4.1%) patients of both groups, respectively (score 0-1). Phrenic nerve syndrome was observed in 36.8% of the main group and 60.4% of the control group (p=0.05). Incidence of dyspepsia and terms of peristalsis onset were similar. Length of hospital-stay was 1.45 days in the main group and 3.15 days in the control group (p=0.002). In the main group 18 (47%) patients were discharged on the first day after surgery. There were only 4 (8.3%) patients with similar hospital-stay in the control group (p<0.001). There were no repeated hospitalizations. Postoperative cortisol concentration was similar in both groups as well as in complicated and uneventful postoperative period. In the main group postoperative intestinal paresis (Clavien-Dindo grade 2) occurred in 1 patient. In the control group 7 patients had postoperative infiltrate and 1 patient - intestinal paresis (Clavien-Dindo grade 2). Postoperative drainage tube was deployed in 3 out of 7 patients with postoperative infiltrates and 6 of them received antibiotic therapy. Medication was successfully applied in all patients with complications. CONCLUSION: There are some advantages of FTR for AA including reduced pain syndrome, morbidity and less length of hospital-stay. Issue of cortisol concentration requires further trials.

[Endoscopic retro-muscular alloplasty for primary and postoperative ventral hernias: our initial experience]. / Éndoskopicheskaia retromuskuliarnaia alloplastika pri pervichnykh i posleoperatsionnykh ventral'nykh gryzhakh: nash pervyi opyt.

AIM: To define optimal surgical approach for middle primary and postoperative ventral hernias. MATERIAL AND METHODS: We have presented the first results of endoscopic retro-muscular alloplasty in 8 patients with umbilical hernia and postoperative ventral hernia combined with rectus abdominis muscles diastase. RESULTS: One patient had seroma above mesh implant that was evacuated under ultrasonic control. Absent hernial protrusion and reduced diastase were noted in all patients. There were no symptoms of recurrence, purulent-septic complications and venous thromboembolic complications. Mortality was absent. CONCLUSION: Further experience and analysis of long-term results are necessary to determine the role of this technique in anterior abdominal wall hernias management.

[Optimal time of surgery for acute adhesive small bowel obstruction]. / Vybor sroka operativnogo lecheniia pri ostroi spaechnoi tonkokishechnoi neprokhodimosti (mul'titsentrovoe prospektivnoe randomizirovannoe issledovanie).

AIM: To define optimal terms of surgery for acute adhesive non-strangulatory small bowel obstruction. MATERIAL AND METHODS: The analysis included 703 publications from e-LIBRARI.RU (342 works) and NCBI (361 works) databases for acute adhesive intestinal obstruction. The vast majority of articles presented retrospective analysis of single-center experience. RESULTS: It has been established that short course of medication is predominantly used for acute adhesive intestinal obstruction in the Russian Federation. International studies point 2-5 days for conservative treatment. The advantages and disadvantages of short and long courses of medication were analyzed. Therefore, multicenter, prospective, randomized trial 'Comparison of early operative treatment (12-hour medication) and long-term conservative treatment (48 hours) for acute adhesive small bowel obstruction' (COTACSO) was planned and registered (Unique Protocol ID: 14121729). The study protocol involves clinical, laboratory and instrumental exclusion of strangulation, randomization and conservative treatment of 2 groups of patients for 12 and 48 hours. Patients will undergo surgical interventions if obstruction will be present by that date. The main endpoint is mortality rate in both groups. The end of the study is December 2020.