META Score: An International Consensus Scoring System on Mesh-Tissue Adhesions.

BACKGROUND: Currently, the lack of consensus on postoperative mesh-tissue adhesion scoring leads to incomparable scientific results. The aim of this study was to develop an adhesion score recognized by experts in the field of hernia surgery. METHODS: Authors of three or more previously published articles on both mesh-tissue adhesion scores and postoperative adhesions were marked as experts. They were queried on seven items using a modified Delphi method. The items concerned the utility of adhesion scoring models, the appropriateness of macroscopic and microscopic variables, the range and use of composite scores or subscores, adhesion-related complications and follow-up length. This study comprised two questionnaire-based rounds and one consensus meeting. RESULTS: The first round was completed by 23 experts (82%), the second round by 18 experts (64%). Of those 18 experts, ten were able to participate in the final consensus meeting and all approved the final proposal. From a total of 158 items, consensus was reached on 90 items. The amount of mesh surface covered with adhesions, tenacity and thickness of adhesions and organ involvement was concluded to be a minimal set of variables to be communicated separately in each future study on mesh adhesions. CONCLUSION: The MEsh Tissue Adhesion scoring system is the first consensus-based scoring system with a wide backing of renowned experts and can be used to assess mesh-related adhesions. By including this minimal set of variables in future research interstudy comparability and objectivity can be increased and eventually linked to clinically relevant outcomes.

Intraperitoneal mesh devices for small midline hernias: mesh behavior in a porcine model.

PURPOSE: Although clinical data on long-term efficacy are lacking, the use of self-expanding devices for intraperitoneal placement in the management of small midline hernias has been popularized. In the present experimental study, two different devices were investigated regarding tissue ingrowth, adhesion formation and solid mesh placement. METHODS: Two devices of 4.3 cm diameter, one ePTFE-containing small pore polypropylene mesh (PP/ePTFE) and a multi-layered large-pore polypropylene patch with an oxidized cellulose anti-adhesive barrier (PP/ORC), both containing a self-deployment system, were placed intraperitoneally at the linea alba of 24 female pigs. A first laparoscopy was performed to evaluate mesh positioning against the abdominal wall. 1 (n = 6), 2 (n = 6), 4 (n = 6) and 12 weeks (n = 6) later, mesh appearance was inspected and adhesion formation was assessed. All meshes were excised for histological evaluation. RESULTS: Folding of the patch was more frequently observed at PP/ePTFE, yet no excessive cupping was noticed. Adhesions predominantly presented at short-term evaluation. Overall adhesion formation at all samples was significantly more extensive for PP/ORC (p = 0.048). Massive shrinkage was observed for PP/ORC: after a 12-week period 22% residual surface was preserved, compared to 83% for PP/ePTFE (p < 0.001). While at short-term inflammatory reaction was comparable, at long-term PP/ORC induced a significant more pronounced inflammatory and foreign body reaction. CONCLUSIONS: Although a strong deployment system provides adequate initial placement, shrinkage and excessive adhesion formation are much more prominent in the large-pore multi-layered restorbable devices compared to the ePTFE patch. This might influence long-term clinical outcome and caution seems warranted.

The use of cyanoacrylate sealant as simple mesh fixation in laparoscopic ventral hernia repair: a large animal evaluation.

PURPOSE: The use of glue as mesh fixation in laparoscopic ventral hernia repair (LVHR) significantly reduces fixation associated morbidity. This experiment evaluates the intraperitoneal use of synthetic glue as single mesh fixation. METHODS: A total of 21 sheep were operated using a hernia model with two fascial defects of 2 cm(2) at the linea alba. One week later two polypropylene meshes (Dynamesh®) were implanted laparoscopically, using cyanoacrylate glue (Ifabond®) or conventional fixation (Securestrap®). In half of the animals the fascial defect was closed before mesh placement. After 1 day (n = 6), 2 weeks (n = 8) and 6 months (n = 6), a second laparoscopy was performed at which hernia recurrence, mesh integration and adhesion formation were evaluated. After euthanasia, burst strength testing and histopathology were evaluated. RESULTS: One animal died due to intestinal incarceration. In 20 surviving animals, no hernias were diagnosed and mesh placement was satisfying. Adhesions could hardly be observed after 1 day but were omnipresent in both groups at 2 weeks and 6 months. Burst strength testing exceeded 100 N in all samples, independent of the fixation device used. Not after 1 day, but after 2 weeks the inflammatory cell response was significantly higher in the glue group. At 6 months minor inflammation was seen, as was foreign body reaction (FBR). CONCLUSIONS: Using a standardized biomechanical testing system, synthetic glue can be considered an effective fixation tool in LVHR. The possible tissue toxicity of cyanoacrylates does not lead to an increased FBR. No difference in burst strength was observed for closing or not closing the defect.

Severe infection, sepsis and acute kidney injury.

Both severe infection and acute kidney injury (AKI) have a high, and rising incidence in critically ill patients admitted to the intensive care unit (ICU), and are associated with increased in-hospital mortality. Septic AKI patients are more severely ill compared to non-septic AKI patients and have worse outcome. Severe infection is a major cause of AKI in ICU patients, while conversely, AKI patients are at increased risk for infection. The dogma from the past relates the development of AKI in sepsis patients to decreased renal blood flow. However, current data suggest that there is no impairment of renal blood flow in patients with sepsis. The pathogenesis of AKI in sepsis is probably related to cytotoxic effects of inflammation, and impaired microcirculation. In addition, hyperglycaemia, and antimicrobial agent-induced drug nephrotoxicity may contribute to the development of AKI. On the other hand, AKI patients are at greater risk for infection as a result of volume overload, dialysis catheter insertion and secondary manipulation, inflammation of the kidneys leading to'organ cross talk', and impaired host immunity.