Non-Cross-Linked Collagen Mesh Performs Best in a Physiologic, Noncontaminated Rat Model.

BACKGROUND: In laparoscopic incisional hernia repair, direct contact between the prosthesis and abdominal viscera is inevitable and may lead to adhesions. Despite the large variety of mesh prosthesis, little is known about their in vivo behavior. Biological meshes are considered to have many advantages, but due to their price they are rarely used. A rat model was used to assess biological and conventional synthetic meshes on their in vivo characteristics. DESIGN: One-hundred twenty male Wistar rats were randomized into five groups of 24 rats. A mesh was implanted intraperitoneally and fixated with nonresorbable sutures. The following five meshes were implanted: Parietene (polypropylene), Permacol (cross-linked porcine acellular dermal matrix), Strattice (non-cross-linked porcine acellular dermal matrix), XCM Biologic (non-cross-linked porcine acellular dermal matrix), and Omyra Mesh (condensed polytetrafluoroethylene). The rats were sacrificed after 30, 90, or 180 days. Incorporation, shrinkage, adhesions, abscess formation, and histology were assessed for all meshes. RESULTS: All animals thrived postoperatively. After 180 days, Permacol, Parietene, and Omyra Mesh had a significantly better incorporation than Strattice ( P = .001, P = .019, and P = .037 respectively). After 180 days, Strattice had significantly fewer adhesions on the surface of the mesh than Parietene ( P < .001), Omyra Mesh ( P = .011), and Permacol ( P = .027). After 30 days, Permacol had significantly stronger adhesions than Strattice ( P = .030). However, this difference was not significant anymore after 180 days. After 180 days, there was significantly less shrinkage in Permacol than in Strattice ( P = .001) and Omyra Mesh ( P = .050). CONCLUSION: Based on incorporation, adhesions, mesh shrinkage, and histologic parameters, Strattice performed best in this experimental rat model.

Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): study protocol for a randomized controlled trial.

BACKGROUND: Acute appendicitis is one of the most common indications for emergency surgery. In patients with a complex appendicitis, prolonged antibiotic prophylaxis is recommended after appendectomy. There is no consensus regarding the optimum duration of antibiotics. Guidelines propose 3 to 7 days of treatment, but shorter courses may be as effective in the prevention of infectious complications. At the same time, the global issue of increasing antimicrobial resistance urges for optimization of antibiotic strategies. The aim of this study is to determine whether a short course (48 h) of postoperative antibiotics is non-inferior to current standard practice of 5 days. METHODS: Patients of 8 years and older undergoing appendectomy for acute complex appendicitis - defined as a gangrenous and/or perforated appendicitis or appendicitis in presence of an abscess - are eligible for inclusion. Immunocompromised or pregnant patients are excluded, as well as patients with a contraindication to the study antibiotics. In total, 1066 patients will be randomly allocated in a 1:1 ratio to the experimental treatment arm (48 h of postoperative intravenously administered (IV) antibiotics) or the control arm (5 days of postoperative IV antibiotics). After discharge from the hospital, patients participate in a productivity-cost-questionnaire at 4 weeks and a standardized telephone follow-up at 90 days after appendectomy. The primary outcome is a composite endpoint of infectious complications, including intra-abdominal abscess (IAA) and surgical site infection (SSI), and mortality within 90 days after appendectomy. Secondary outcomes include IAA, SSI, restart of antibiotics, length of hospital stay (LOS), reoperation, percutaneous drainage, readmission rate, and cost-effectiveness. The non-inferiority margin for the difference in the primary endpoint rate is set at 7.5% (one-sided test at ɑ 0.025). Both per-protocol and intention-to-treat analyses will be performed. DISCUSSION: This trial will provide evidence on whether 48 h of postoperative antibiotics is non-inferior to a standard course of 5 days of antibiotics. If non-inferiority is established, longer intravenous administration following appendectomy for complex appendicitis can be abandoned, and guidelines need to be adjusted accordingly. TRIAL REGISTRATION: Dutch Trial Register, NTR6128 . Registered on 20 December 2016.

Long term results of open complex abdominal wall hernia repair with self-gripping mesh: A retrospective cohort study.

BACKGROUND: In case of complex ventral hernias, Rives-Stoppa and component separation technique are considered as favourable treatment techniques. However, mesh-related complications like recurrence, infection and chronic pain are still a common problem after mesh repair. Previous studies have reported promising results of the use of a self-gripping mesh (ProGrip™) in incisional hernia repair. This study aimed to evaluate the long term results of this mesh for complex ventral hernia treatment. MATERIALS AND METHODS: Patients with complex ventral hernia undergoing repair between June 2012 and June 2015, using the ProGrip™-mesh in retromuscular position, were included. All patients visited the outpatient clinic to evaluate short term complications and recurrence. After at least one year, telephone interviews were conducted to evaluate long term results. RESULTS: A total of 46 patients (median age 59 years) were included. 40 patients (87%) were diagnosed with incisional hernia. Seven patients (18%) had incisional hernia combined with another hernia. Four patients (8.7%) had an umbilical hernia, one patient (2.2%) had an epigastric hernia and one patient (2.2%) had rectus diastasis. 39 patients completed follow-up. Median follow-up was 25 months (IQR: 19-35 months). 28 patients (72%) did not report any complaints. Nine patients reported pain (average VAS of 1.7). Two patients developed a recurrence requiring reoperation. One patient developed mesh infection requiring reoperation. CONCLUSION: Long term results of the use of a self-gripping mesh for complex abdominal wall hernias show a low recurrence rate, even in complex hernia cases. This makes the mesh a good choice in this difficult patient group.

Incidence, risk factors, and treatment of incisional hernia after kidney transplantation: An analysis of 1,564 consecutive patients.

BACKGROUND: The objective was to evaluate the incidence and treatment of incisional hernia after kidney transplantation and to identify potential risk factors. METHODS: A retrospective cohort study was performed. All kidney transplant recipients between 2002 and 2012 were included. Two groups were identified: patients with and without incisional hernia. An analysis of risk factors for the development of incisional hernia was performed. RESULTS: A total of 1,564 kidney recipients were included. Fifty patients (3.2%) developed incisional hernia. On univariate analysis, female sex (54 vs 35%), body mass index (BMI) >30 kg/m(2) (38 vs 17%), concurrent abdominal wall hernia (30 vs 16%), multiple explorations of the ipsilateral iliac fossa (38 vs 19%), left iliac fossa implantation (36 vs 24%), history of smoking (72 vs 57%), and duration of the kidney transplantation procedure (210 vs 188 minutes) were associated with the development of incisional hernia (P < .05 each). In multivariate analyses, female sex (hazard ratio [HR] 2.6), history of smoking (HR 2.2), obesity (BMI >30; HR 2.9), multiple explorations of the ipsilateral iliac fossa (HR 2.0), duration of operation (HR 1.007), and concurrent abdominal wall hernia (HR 2.3) were independent risk factors. Twenty-six of 50 patients (52%) underwent operative repair, of whom 9 (35%) required emergency repair. CONCLUSION: The incidence of incisional hernia after kidney transplantation with a median follow-up of 59 months is 3.2%. Obesity (BMI >30), female sex, concurrent abdominal wall hernias, history of smoking, duration of surgery, and multiple explorations were independent risk factors for the development of incisional hernia after kidney transplantation. Attempts at preventing incisional hernias based on these risk factors should be explored.

Watchful waiting in incisional hernia: is it safe?

BACKGROUND: Incisional hernia (IH) is among the most common postoperative complications after abdominal surgery. Operative treatment (OT) using mesh is the treatment of choice. A strategy of watchful waiting (WW) might be a considered in some patients. This retrospective study compares the outcomes of WW and OT. METHODS: All patients presenting with IH in an academic surgery department between January 2004 and December 2009 were analyzed according to whether they were treated by WW or OT. Crossovers between both groups were also analyzed. Patient characteristics, information about the initial abdominal operative procedure, symptoms at presentation, and characteristics of the hernia were collected retrospectively. In case of OT, postoperative complications were analyzed. RESULT: In total, 255 patients were included; 151 (59%) in the OT group and 104 (41%) in WW group. The median follow-up was 68 months (interquartile range [IQR], 52-93). The reasons for WW were the absence of symptoms in 34 patients (33%), comorbidities in 24 (23%), and obesity in 23 (22%). During follow-up, 34 patients (33%) crossed over from WW to OT. Eight of the crossovers (24%) were emergency repairs owing to incarceration at a median of 1 month (IQR, 1-5) after the start of WW. The incidence of unexpected intraoperative intestinal perforation was greater in the crossover group (13%) compared with the OT group (2%; P = .002). Postoperative fistulas were seen in 7% of patients who crossed over from WW to OT versus 0% in primary OT (P = .002). Postoperatively, 3 patients died, 2 of whom were treated operatively after belonging initially to the WW group. CONCLUSION: WW for IH leads to high crossover rates with significantly greater incidence of intraoperative perforations, fistulas, and mortality, than in the OT group, particularly in patients who require emergency repair of IH owing to incarceration.

Very low birth weight is an independent risk factor for emergency surgery in premature infants with inguinal hernia.

BACKGROUND: Common surgical knowledge is that inguinal hernia repair in premature infants should be postponed until they reach a certain weight or age. Optimal management, however, is still under debate. The objective of this study was to collect evidence for the optimal management of inguinal hernia repair in premature infants. STUDY DESIGN: In the period between 2010 and 2013, data for all premature infants with inguinal hernia who underwent hernia correction within 3 months after birth in the Erasmus MC-Sophia Children's Hospital, Rotterdam were analyzed. Primary outcomes measures were the incidences of incarceration and subsequent emergency surgery. In a multivariate analysis, Cox proportional hazards model served to identify independent risk factors for incarceration requiring an emergency procedure. RESULTS: A total of 142 premature infants were included in the analysis. Median follow-up was 28 months (range 15 to 39 months). Seventy-nine premature infants (55.6%) presented with a symptomatic inguinal hernia; emergency surgery was performed in 55.7%. Complications occurred in 27.3% of emergency operations vs 10.2% after elective repair; recurrences occurred in 13.6% vs 2.0%, respectively. Very low birth weight (≤1,500 g) was an independent risk factor for emergency surgery, with a hazard ratio of 2.7 in the Cox proportional hazards model. CONCLUSIONS: More than half of premature infants with an inguinal hernia have incarceration. Those with very low birth weight have a 3-fold greater risk of requiring an emergency procedure than heavier premature infants. Emergency repair results in higher recurrence rates and more complications. Elective hernia repair is recommended, particularly in very low birth weight premature infants.

Implementing a clinical pathway for hip fractures; effects on hospital length of stay and complication rates in five hundred and twenty six patients.

PURPOSE: Modern management of the elderly with a hip fracture is complex and costly. The aim of this study was to compare the treatment-related hospital length of stay (HLOS) before and after implementing a clinical pathway for patients undergoing hip fracture surgery. METHODS: This was a retrospective, before-and-after study. The first period ranged from June 21, 2008 to November 1, 2009 (N = 212), and the second was from January 7, 2010 to July 7, 2011 (N = 314). The electronic hospital system and patients records were reviewed for demographics, HLOS, mortality, complications and readmissions. RESULTS: In the first period 53 % had a femoral neck fracture, of which 57 % were treated with hemiarthroplasty. In the second period this was 46 % and 71 %. Pertrochanteric fractures were treated with a Gamma nail in 85 % in the first period, and in 92 % in the second period. The median HLOS decreased from nine to six days (p < 0.001). For the hemiarthroplasty group HLOS decreased from nine to seven days (p < 0.001); for internal fixation there was no significant difference (five versus six days, p = 0.557) and after Gamma nailing it decreased from ten to six days (p < 0.001). For mortality no statistically significant difference was found (6 % versus 5 %, p = 0.698). Complications decreased for the Gamma nail group (44 % versus 31 %, p = 0.049). Readmissions for the total group were not different (16 % versus 17 %, p = 0.720). CONCLUSIONS: Implementing a clinical pathway for hip fractures is a safe way to reduce the HLOS and it improves the quality of care.