Reliability and validity of surface EMG assessments combined with isometric muscle strength testing in patients with abdominal rectus diastasis and asymptomatic controls.

PURPOSE: Patients with abdominal rectus diastasis (ARD) may have muscular functional impairments, but clinics lack appropriate objective assessment tools. The aim was to establish the relative and absolute reliability, and convergent validity, of muscular activity using Surface Electromyography (SEMG) during isometric abdominal muscle strength testing in patients with ARD and controls without ARD. METHODS: Twenty-six patients with ARD were matched for age, sex and BMI with controls without ARD. Participants were tested twice during isometric muscular contractions using SEMG located on six abdominal sites. Mean amplitude, fatigue, and recruitment order were analyzed. Relative reliability was evaluated with Intraclass Correlation Coefficients (ICC), while absolute reliability was estimated by calculating the Standard Error of Measurement and Minimal Detectable Change. Convergent validity was addressed in relation to participant characteristics, functional ability, and symptoms. RESULTS: Mean SEMG amplitude for all abdominal wall muscle contractions showed moderate to excellent relative test-retest reliability, with ICC values ranging from 0.46 to 0.97. In contrast, fatigue and recruitment order displayed poor to moderate relative reliability in both groups. Absolute reliability measures were generally high. A moderate to high convergent validity (ARD: rho-value 0.41-0.70; Controls: rho-value 0.41-0.75) was observed for mean amplitude in relation to a functional sit-to-stand test, abdominal circumference, BMI, back pain, and quality-of-life. CONCLUSIONS: The results of applying SEMG during isometric abdominal muscle support practicing the method in clinics, although additional development is needed with further standardization and more functional testing. Furthermore, the method demonstrates construct validity in patients with ARD and in age- and sex-matched controls.

Similar collagen distribution in full-thickness skin grafts in intraperitoneal and onlay positions, an experimental mice-study.

PURPOSE: Autologous full-thickness skin grafting (FTSG) has the potential to become an option in abdominal wall repair. An understanding of tissue remodelling in the extracellular matrix (ECM) is crucial as this interplay determines such parameters as tissue strength and flexibility. This cross-sectional preclinical laboratory study in mice provides information on the distribution of collagen types and matrix metalloproteinases (MMPs) in the ECM of FTSGs in the intraperitoneal and onlay positions compared with internal controls. The aim was to evaluate morphologic changes after tissue remodelling and repair in FTSGs applied in the two positions and to detect any adverse host response. METHODS: ECM components were evaluated as follows: qualitative examination of collagen bundle thickness using Picrosirius Red staining (collagen types I, III and IV); and evaluation of collagen types IV and V, as well as MMPs 1, 8 and 9 using immunohistochemical staining. Full-thickness grafts transplanted between female twin mice were examined as this best mimics autologous transplantation. RESULTS: At 8 weeks, FTSGs in the intraperitoneal position did not show any noticeable differences in morphologic appearance to those in the onlay position. Both intraperitoneal and onlay FTSGs showed increases in the amount of thick collagen bundles compared to internal controls. No correlation was seen between distribution of MMPs 1, 8 or 9 and distribution of collagen types I, III, IV or V. CONCLUSION: This preclinical study shows that FTSGs in both intraperitoneal and onlay positions are possible application site options and, by extension, promising application site options for abdominal wall reinforcement in hernia surgery. Clinical studies in humans are required to confirm these findings.

Antibiotic treatment for appendicitis in Norway and Sweden: a nationwide survey on treatment practices.

BACKGROUND: Appendicitis is one of the most common causes of acute abdomen. Uncomplicated appendicitis is as an inflamed appendix without perforation, gangrene or abscess formation. Recent trials show that one can safely treat uncomplicated appendicitis with antibiotics, given patient approval and appropriate follow-up. A recent study has also indicated no difference between antibiotic treatment and placebo. Our aim was to investigate if Norwegian and Swedish surgical departments treat uncomplicated appendicitis with antibiotics and to explore their opinions on this treatment practice. METHODS: A questionnaire was distributed to all heads of department in hospitals that treat appendicitis in Norway and Sweden. Answers were collected using a REDCap survey. Answers were compared between centers and nations and the results were presented anonymously. RESULTS: We sent the questionnaire to 94 eligible recipients and received 61 (65%) answers. In total, 8/61 (13%) departments stated that they have established antibiotic treatment as sole treatment for uncomplicated appendicitis. Almost half of the responders stated that they have used antibiotics sporadically to treat uncomplicated appendicitis. Lack of evidence and guidelines were noted as reasons why antibiotic treatment has not been implemented as sole treatment. CONCLUSIONS: Most Norwegian and Swedish departments have not implemented antibiotic treatment as the sole treatment for uncomplicated appendicitis. Despite several recent large trials on this subject, lack of evidence and guidelines was the most frequently reported reason in our survey.

Long-term follow-up of full-thickness skin grafting in giant incisional hernia repair: a randomised controlled trial.

PURPOSE: Conventional repair of a giant incisional hernia often requires implantation of a synthetic mesh (SM). However, this surgical procedure can lead to discomfort, pain, and potentially serious complications. Full-thickness skin grafting (FTSG) could offer an alternative to SM, less prone to complications related to implantation of a foreign body in the abdominal wall. The aim of this study was to compare the use of FTSG to conventional SM in the repair of giant incisional hernia. METHODS: Patients with a giant incisional hernia (> 10 cm width) were randomised to repair with either FTSG or SM. 3-month and 1-year follow-ups have already been reported. A clinical follow-up was performed 3 years after repair, assessing potential complications and recurrence. SF-36, EQ-5D and VHPQ questionnaires were answered at 3 years and an average of 9 years (long-term follow-up) after surgery to assess the impact of the intervention on quality-of-life (QoL). RESULTS: Fifty-two patients were included. Five recurrences in the FTSG group and three in the SM group were noted at the clinical follow-up 3 years after surgery, but the difference was not significant (p = 0.313). No new procedure-related complication had occurred since the one-year follow-up. There were no relevant differences in QoL between the groups. However, there were significant improvemnts in both physical, emotional, and mental domains of the SF-36 questionnaire in both groups. CONCLUSION: The results of this long-term follow-up together with the results from previous follow-ups indicate that autologous FTSG as reinforcement in giant incisional hernia repair is an alternative to conventional repair with SM. TRIAL REGISTRATION: The study was registered August 10, 2011 at ClinicalTrials.gov (ID NCT01413412), retrospectively registered.

Autologous full-thickness skin graft as reinforcement in parastomal hernia repair: a feasibility study.

BACKGROUND: Parastomal hernia is a common complication of stoma formation and the methods of repair available today are unsatisfactory with high recurrence and complication rates. To improve outcome after surgical repair of parastomal hernia, a surgical method using autologous full-thickness skin grafts as intraperitoneal reinforcement has been developed. The purpose of this study was to evaluate the feasibility of this novel surgical technique in the repair of parastomal hernia. METHODS: A pilot study was conducted between January 2018 and June 2019 on four patients with symptomatic parastomal hernia. They had a laparotomy with suture reduction of the hernia and reinforcement of the abdominal wall with autologous full-thickness skin. They were then monitored for at least 1 year postoperatively for technique-related complications and recurrence. RESULTS: No major technique-related complications were noted during the follow-up Two patients developed a recurrent parastomal hernia at the long term follow-up. The other two had no recurrence. CONCLUSIONS: Autologous full-thickness skin graft as reinforcement in parastomal hernia repair is feasible and should be evaluated in a larger clinical trial.

Parastomal Hernia Repair; Seldom Performed and Seldom Reported: Results From a Nationwide Survey.

BACKGROUND: Parastomal hernia is common, but there are few population-based studies showing the frequency and outcome of parastomal hernia repair in routine surgical practice. The aim of this study was to identify patients undergoing surgery for parastomal hernia in Sweden and to define risk factors for complication and recurrence. METHODS: A broad search of the Swedish National Patient Register 1998-2007 for all possible parastomal hernia repairs using surgical procedure codes. Records of all patients identified were reviewed and those with a definite parastomal hernia procedure were included and analyzed. RESULTS: A total of 71 patients were identified after review of the records. The most common reason for surgery was cosmetic and the most frequent method was relocation of the stoma. Parastomal hernia recurrence rate was 18% during follow-up of a minimum 2 years. Overall, a surgical complication occurred in 32%. Possible risk factors were analyzed including emergency surgery versus planned, gender, age, indication for surgery, and method of surgery; none of which was significant. CONCLUSION: The frequency of parastomal hernia procedures was much lower than suggested by previous studies. The number of procedures per surgeon was even lower than expected. No specific risk factor could be identified. Parastomal hernia auditing in the form of a nationwide quality register should be mandatory. Centralization should be considered.

Mismatch repair status predicts survival after adjuvant treatment in stage II colon cancer patients.

BACKGROUND AND OBJECTIVES: Stage II colon cancer is primarily a surgical disease. Only a still not well-defined subset of patients may benefit from postoperative adjuvant chemotherapy. The relationship between adjuvant chemotherapy and survival after relapse is furthermore still not definitely explored in this group of patients. A number of reports suggest some association between defective mismatch repair (dMMR) and colorectal cancer stage II prognosis, but due to contradictory results from existing studies, the exact predictive role is still not fully understood. METHODS: Retrospective multicenter study including 451 stage II colon cancer patients. The proficiency or deficiency of mismatch repair was tested using immunohistochemistry and analyzed in relationship to two survival outcomes: overall survival (OS) and postrelapse survival. RESULTS: Patients with dMMR (20.4%) derived no OS benefit from adjuvant chemotherapy (hazard ratio [HR], 1.05; 95% confidence interval [CI], 0.47-2.38; P = .897). Patients with proficient mismatch repair (pMMR) tumors receiving adjuvant chemotherapy had the significantly better OS in comparison to those not receiving chemotherapy (HR, 0.54; 95% CI, 0.35-0.82; P = .004). This relationship remained significant in multivariable analysis (HR, 0.42; 95% CI, 0.22-0.78; P = .007). Patients with pMMR relapsing after adjuvant treatment lived significantly longer than those relapsing without previous adjuvant treatment (HR, 0.55; 95% CI, 0.32-0.96; P = .033) and this result remained significant in the multivariable model (HR, 0.49; 95% CI, 0.26-0.93; P = .030). CONCLUSION: In stage II CC patients, adjuvant chemotherapy improves therapeutic outcomes only in patients with pMMR tumors. Survival after relapse in patients having received adjuvant chemotherapy is significantly longer for patients with pMMR. No survival benefit from adjuvant chemotherapy was seen among patients with dMMR tumors.

One-year outcome after repair of giant incisional hernia using synthetic mesh or full-thickness skin graft: a randomised controlled trial.

PURPOSE: Repair of giant incisional hernia often requires complex surgery and the results of conventional methods using synthetic mesh as reinforcement are unsatisfactory, with high recurrence and complication rates. Our hypothesis was that full-thickness skin graft (FTSG) provides an alternative reinforcement material for giant incisional hernia repair and that outcome is improved. The aim of this study was to compare FTSG with conventional materials currently used as reinforcement in the repair of giant incisional hernia. METHODS: A prospective randomised controlled trial was conducted, comparing FTSG with synthetic mesh as reinforcement in the repair of giant (> 10 cm minimum width) incisional hernia. One-year follow-up included a blinded clinical examination by a surgeon and objective measurements of abdominal muscle strength using the Biodex-4 system. RESULTS: 52 patients were enrolled in the study: 24 received FTSG and 28 synthetic mesh. Four recurrences (7.7%) were found at 1-year follow-up, two in each group. There were no significant differences regarding pain, patient satisfaction or aesthetic outcome between the groups. Strength in the abdominal wall was not generally improved in the study population and there was no significant difference between the groups. CONCLUSION: The outcome of repair of giant incisional hernia using FTSG as reinforcement is comparable with repair using synthetic mesh. This suggests that FTSG may have a future place in giant incisional hernia repair.

Patient Reported Injuries After Ventral Hernia Repair.

BACKGROUND AND AIMS:: The Swedish National Patient Insurance Company (LÖF) can compensate patients who believe they have been exposed to an avoidable injury or malpractice in healthcare. Its register covers 95% of Swedish healthcare providers. MATERIAL AND METHODS:: Data on patients operated for primary or incisional ventral hernia in Sweden between 2010 and 2015 and who had filed a claim, were retrieved from LÖF. A total of 290 cases were identified and included. Files include a copy of records, relevant imaging, and an expert advisor's opinion. RESULTS:: Inadvertent enterotomy occurred during 25 repairs and in these cases, laparoscopic repair was clearly overrepresented ( p < 0.001). Complications related to the surgical site (infection and ugly scar) were predominantly related to open repairs ( p < 0.001). Twenty percentage (57/290) of the claims were directly related to an anesthetic mishap. Univariate ordinal regression showed that the odds of receiving a high reimbursement was significantly increased if laparoscopic repair was performed p < 0.001 (odds ratio: 0.37; 95% confidence interval: 0.21-0.65). Sixty-three percentage of claims were filed by women. CONCLUSION:: Inadvertent enterotomy is overrepresented, and the probability that a claim filed for an avoidable injury leads to high reimbursement is greater if laparoscopic repair is performed rather than open ventral hernia repair. The high amount of injuries related to general anesthesia during umbilical hernia repair may be reduced with an increased proportion executed in local anesthesia.

Full-thickness skin graft vs. synthetic mesh in the repair of giant incisional hernia: a randomized controlled multicenter study.

PURPOSE: Repair of large incisional hernias includes the implantation of a synthetic mesh, but this may lead to pain, stiffness, infection and enterocutaneous fistulae. Autologous full-thickness skin graft as on-lay reinforcement has been tested in eight high-risk patients in a proof-of-concept study, with satisfactory results. In this multicenter randomized study, the use of skin graft was compared to synthetic mesh in giant ventral hernia repair. METHODS: Non-smoking patients with a ventral hernia > 10 cm wide were randomized to repair using an on-lay autologous full-thickness skin graft or a synthetic mesh. The primary endpoint was surgical site complications during the first 3 months. A secondary endpoint was patient comfort. Fifty-three patients were included. Clinical evaluation was performed at a 3-month follow-up appointment. RESULTS: There were fewer patients in the skin graft group reporting discomfort: 3 (13%) vs. 12 (43%) (p = 0.016). Skin graft patients had less pain and a better general improvement. No difference was seen regarding seroma; 13 (54%) vs. 13 (46%), or subcutaneous wound infection; 5 (20%) vs. 7 (25%). One recurrence appeared in each group. Three patients in the skin graft group and two in the synthetic mesh group were admitted to the intensive care unit. CONCLUSION: No difference was seen for the primary endpoint short-term surgical complication. Full-thickness skin graft appears to be a reliable material for ventral hernia repair producing no more complications than when using synthetic mesh. Patients repaired with a skin graft have less subjective abdominal wall symptoms.

Giant ventral hernia-relationship between abdominal wall muscle strength and hernia area.

BACKGROUND: Symptoms arising from giant ventral hernia have been considered to be related to weakening of the abdominal muscles. The aim of this study was to investigate the relationship between the area of the abdominal wall defect and abdominal wall muscle strength measured by the validated BioDex system together with a back/abdominal unit. METHODS: Fifty-two patients with giant ventral hernia (>10 cm wide) underwent CT scan, clinical measurement of hernia size and BioDex measurement of muscle strength prior to surgery. The areas of the hernia derived from CT scan and from clinical measurement were compared with BioDex forces in the modalities extension, flexion and isometric contraction. The Spearman rank test was used to calculate correlations between area, BMI, gender, age, and muscle strength. RESULT: The hernia area calculated from clinical measurements correlated to abdominal muscle strength measured with the Biodex for all modalities (p-values 0.015-0.036), whereas no correlation was seen with the area calculated by CT scan. No relationship was seen between BMI, gender, age and the area of the hernia. DISCUSSION: The inverse correlation between BioDex abdominal muscle strength and clinically assessed hernia area, seen in all modalities, was so robust that it seems safe to conclude that the area of the hernia is an important determinant of the degree of loss of abdominal muscle strength. Results using hernia area calculated from the CT scan showed no such correlation and this would seem to concur with the results from a previous study by our group on patients with abdominal rectus diastasis. In that study, defect size assessed clinically, but not that measured by CT scan, was in agreement with the size of the diastasis measured intra-operatively. The point at which the area of a hernia begins to correlate with loss of abdominal wall muscle strength remains unknown since this study only included giant ventral hernias.

Surgical outcome of mesh and suture repair in primary umbilical hernia: postoperative complications and recurrence.

PURPOSE: To compare recurrence and surgical complications following two dominating techniques: the use of suture and mesh in umbilical hernia repair. METHODS: 379 consecutive umbilical hernia repair procedures performed between 1 January 2005 and 14 March 2014 in a university setting were included. Gathering was made using International Classification of Diseases codes for both procedure and diagnosis. Each patient record was scrutinized with respect to 45 variables, and the results entered in a database. RESULTS: Exclusion <18 years-of-age (32), non-primary umbilical hernia (25), wrong diagnosis (7), concomitant major abdominal surgery (5), double registration (3) and pregnancy (1) left 306 patients eligible for analysis. Gender distribution was 97 women and 209 men. There was no difference between mesh and suture with regard to the primary outcome variable, cumulative recurrence rate, 8.4 %. Recurrence was both self-reported and found on clinical revisit and defined as recurrence when verified by a clinician and/or radiologist. Results presented as odds ratio (OR) with 95 % confidence interval (CI) show a significantly higher risk for recurrence in patients with a coexisting hernia OR 2.84, 95 % CI 1.24-6.48. Secondary outcome, postoperative surgical complication (n = 51 occurrences), included an array of postoperative surgical events commencing within 30 days after surgery. Complication rate was significantly higher in patients receiving mesh repair OR 6.63, 95 % CI 2.29-20.38. CONCLUSIONS: Suture repair decreases the risk for surgical complications, especially infection without an increase in recurrence rate. The risk for recurrence is increased in patients with a history of another hernia.

A comparison between intrastomal 3D ultrasonography, CT scanning and findings at surgery in patients with stomal complaints.

PURPOSE: Since there are no reliable investigative tools for imaging parastomal hernia, new techniques are needed. The aim of this study was to assess the validity of intrastomal three-dimensional ultrasonography (3D) as an alternative to CT scanning for the assessment of stomal complaints. METHOD: Twenty patients with stomal complaints, indicating surgery, were examined preoperatively with a CT scan in the supine position and 3D intrastomal ultrasonography in the supine and erect positions. Comparison with findings at surgery, considered to be the true state, was made. RESULTS: Both imaging methods, 3D ultrasonography and CT scanning, showed high sensitivity (ultrasound 15/18, CT scan 15/18) and specificity (ultrasound 2/2, CT scan 1/2) when judged by a dedicated radiologist. Corresponding values for interpretation of CT scans in routine clinical practice was for sensitivity 17/18 and for specificity 1/2. CONCLUSION: 3D ultrasonography has a high validity and is a promising alternative to CT scanning in the supine position to distinguish a bulge from a parastomal hernia.

Early complications, pain, and quality of life after reconstructive surgery for abdominal rectus muscle diastasis: a 3-month follow-up.

AIM: The aim of this study was to evaluate early complications following retromuscular mesh repair with those after dual layer suture of the anterior rectus sheath in a randomised controlled clinical trial for abdominal rectus muscle diastasis (ARD). METHODS: Patients with an ARD wider than 3 cm and clinical symptoms related to the ARD were included in a prospective randomised study. They were assigned to either retromuscular inset of a lightweight polypropylene mesh or to dual closure of the anterior rectus fascia using Quill self-locking technology. All patients completed a validated questionnaire for pain assessment (Ventral Hernia Pain Questionnaire, VHPQ) and for quality of life (SF36) prior to and 3 months after surgery. RESULTS: The most frequently seen adverse event was minor wound infection. Of the patients, 14/57 had a superficial wound infection; five related to Quill and nine to mesh repair. No deep wound infections were reported. Patient rating for subjective muscular improvement postoperatively was better in the mesh technique group with a mean of 6.9 (range 0-10) compared to a mean of 4.8 (range 0-10) in the Quill group (p=0.01). The pre- and post-operative SF36 scores improved in both groups. CONCLUSIONS: There was no significant difference between the two surgical techniques in terms of early complications and perceived pain at the 3-month follow-up. Both techniques may be considered equally reliable for ARD repair in terms of adverse outcomes during the early postoperative phase, even though patients operated with a mesh experienced better improvement in muscular strength. ClinicalTrial.gov: 2009/227-31/3/PE/96.

Analysis of the abdominal musculo-aponeurotic anatomy in rectus diastasis: comparison of CT scanning and preoperative clinical assessment with direct measurement intraoperatively.

PURPOSE: To evaluate and compare the consistency of agreement of two methods for measuring abdominal rectus diastasis (ARD), preoperative computed tomography (CT) scanning and preoperative clinical assessment were compared with direct measurement intraoperatively. METHODS: Fifty-five consecutive patients were retrieved from an ongoing prospective randomised trial comparing two operative techniques for the repair of ARD. All patients underwent a preoperative clinical assessment and CT scan, and the results were compared with intraoperative measurement of the ARD width. Agreement between methods was described with Bland-Altman plots (BA plots) and calculated using Lin's Concordance Correlation Coefficient (CCC). RESULTS: The median width of the diastasis was 4.0 cm in the upper midline and 3.0 cm in the lower midline for the intraoperative measurement. BA plots showed that measurements on CT and intraoperatively are not in agreement in the lower midline, whereas the agreement was stronger between the clinical and the intraoperative method. The CCC was higher for clinical vs. intraoperative measurement (0.479) than for CT vs. intraoperative measurement (-0.002) in the lower midline, although the agreement was over all low. CT scanning underestimated the width of the ARD when compared to 87 % of preoperative clinical assessments, and 83 % of intraoperative measurements. Preoperative clinical assessment overestimated ARD in 35 % when compared with intraoperative measurements. CONCLUSION: Clinical assessment prior to surgery provides more accurate information than CT scanning in the assessment of ARD width. CT scanning underestimates ARD width when compared with intraoperative measurement.

Effect of an elastic girdle on lung function, intra-abdominal pressure, and pain after midline laparotomy: a randomized controlled trial.

PURPOSE: Girdles and abdominal binders may reduce pain and stabilize the abdominal wall after laparotomy, but a risk for increased intra-abdominal pressure and decreased lung function is also hypothesized. The aim of this study was to investigate the effect of an abdominal girdle after midline laparotomy in a randomized controlled trial. METHODS: Twenty-three patients undergoing laparotomy were randomized to wear an elastic girdle postoperatively and 25 were randomized to no girdle. Pulmonary function was evaluated with; forced vital capacity (FVC), forced expiratory volume during one second (FEV1), peak expiratory flow (PEF), and cough PEF. Pain was recorded using a visual analog scale (VAS). All patients completed the ventral hernia pain questionnaire (VHPQ) before surgery and at the end of the study. Intra-abdominal pressure was measured via an indwelling urinary catheter. Wound healing was assessed from photographs. RESULTS: FVC, FEV1, PEF, and cough PEF were reduced by about 30 % after surgery, but there were no differences between patients with or without a girdle (ANOVA). Intra-abdominal pressure and wound healing were the same in both groups. Pain was significantly lower on day 5 in the girdle group (p = 0.004). CONCLUSIONS: An individually fitted elastic girdle used after midline laparotomy was found to be safe, as this did not affect lung function, coughing, intra-abdominal pressure, or wound healing. The immediate decline in lung function after surgery is restrictive and due to anesthesia and the surgical procedure. Pain was significantly decreased in the girdle group. The study is registered at ClinicalTrials.gov, number NCT01517217.