Comparison of Mesh Fixation Techniques in Elective Laparoscopic Repair of Incisional Hernia-ReliaTack™ v ProTack™ (TACKoMesh) - A double-blind randomised controlled trial.

BACKGROUND: Minimally invasive incisional hernia repair has been established as a safe and efficient surgical option in most centres worldwide. Laparoscopic technique includes the placement of an intraperitoneal onlay mesh with fixation achieved using spiral tacks or sutures. An additional step is the closure of the fascial defect depending upon its size. Key outcomes in the evaluation of ventral abdominal hernia surgery include postoperative pain, the presence of infection, seroma formation and hernia recurrence. TACKoMESH is a randomised controlled trial that will provide important information on the laparoscopic repair of an incisional hernia; 1) with fascial closure, 2) with an IPOM mesh and 3) comparing the use of an articulating mesh-fixation device that deploys absorbable tacks with a straight-arm mesh-fixation device that deploys non-absorbable tacks. METHODS: A prospective, single-centre, double-blinded randomised trial, TACKoMESH, will establish whether the use of absorbable compared to non-absorbable tacks in adult patients undergoing elective incisional hernia repair produces a lower rate of pain both immediately and long-term. Eligible and consenting patients will be randomized to surgery with one of two tack-fixation devices and followed up for a minimum one year. Secondary outcomes to be explored include wound infection, seroma formation, hernia recurrence, length of postoperative hospital stay, reoperation rate, operation time, health related quality of life and time to return to normal daily activity. DISCUSSION: With ongoing debate around the best management of incisional hernia, continued trials that will add substance are both necessary and important. Laparoscopic techniques have become established in reducing hospital stay and rates of infection and report improvement in some patient centered outcomes whilst achieving similarly low rates of recurrence as open surgical techniques. The laparoscopic method with tack fixation has developed a reputation for its tendency to cause post-operative pain. Novel additions to technique, such as intraoperative-sutured closure of a fascial defect, and developments in surgical technology, such as the evolution of composite mesh design and mesh-fixation devices, have brought about new considerations for patient and surgeon. This study will evaluate the efficacy of several new technical considerations in the setting of elective laparoscopic incisional hernia repair. TRIAL REGISTRATION: Name of registry - ClinicalTrials.gov Registration number: NCT03434301 . Retrospectively registered on 15th February 2018.

Efficacy and safety of pharmacological venous thromboembolism prophylaxis following liver resection: a systematic review and meta-analysis.

BACKGROUND: Current guidelines recommend pharmacological prophylaxis for patients undergoing abdominal surgery for malignancy. Liver resection exposes patients to risk factors for venous thromboembolism, but there is a risk of bleeding. The aim of this study is to evaluate the evidence base supporting the use of pharmacological thromboprophylaxis in liver surgery. METHODS: An electronic search was carried out for studies reporting the incidence of VTE following liver resection comparing patients receiving pharmacological prophylaxis with those who did not. The search resulted in 990 unique citations. Following the application of strict eligibility criteria 5 studies comprise the final study population. RESULTS: Included studies report on 3675 patients undergoing liver resection between 1999 and 2013. 2256 patients received chemical thromboprophylaxis, 1412 had mechanical prophylaxis only and 7 received no prophylaxis. Meta-analysis revealed lower VTE rates in patients receiving chemical thromboprophylaxis (2.6%) compared to without prophylaxis (4.6%) (Dichotomous correlation test, odds ratio: 0.631 [95% Cl: 0.416-0.959], Fixed model, p = 0.030). Data regarding bleeding could not be pooled for meta-analysis, but chemical thromboprophylaxis was reported as safe in four studies. CONCLUSION: This systematic review and meta-analysis of retrospective studies indicates that the use of perioperative chemical thromboprophylaxis reduces VTE incidence following liver surgery without an apparent increased risk of bleeding.

Antibiotic use in acute pancreatitis: An audit of current practice in a tertiary centre.

INTRODUCTION: Intravenous antibiotic prophylaxis is not recommended in acute pancreatitis. According to current international guidelines antibiotics together with further intervention should be considered in the setting of infected necrosis. Appropriate antibiotic therapy particularly avoiding over-prescription is important. This study examines antibiotic use in acute pancreatitis in a tertiary centre using the current IAP/APA guidelines for reference. METHODS: Data were collected on a consecutive series of patients admitted with acute pancreatitis over a 12 month period. Data were dichotomized by patients admitted directly to the centre and tertiary transfers. Information was collected on clinical course with specific reference to antibiotic use, episode severity, intervention and outcome. RESULTS: 111 consecutive episodes of acute pancreatitis constitute the reported population. 31 (28%) were tertiary transfers. Overall 65 (58.5%) patients received antibiotics. Significantly more tertiary transfer patients received antibiotics. Mean person-days of antibiotic use was 23.9 (sd 29.7) days in the overall study group but there was significantly more use in the tertiary transfer group as compared to patients having their index admission to the centre (40.9 sd 37.1 vs 10.2 sd 8.9; P < 0.005). Thirty four (44%) of patients with clinically mild acute pancreatitis received antibiotics. CONCLUSIONS: There is substantial use of antibiotics in acute pancreatitis, in particular in patients with severe disease. Over-use is seen in mild acute pancreatitis. Better consideration must be given to identification of prophylaxis or therapy as indication. In relation to repeated courses of antibiotics in severe disease there must be clear indications for use.

Work-Up and Outcome of Hepatic Resection for Peri-Hilar Cholangiocarcinoma (PH-CCA) without Staging Laparoscopy.

Background: This study reports the outcome of a work-up programme for resection of peri-hilar cholangiocarcinoma (PH-CCA) without the use of staging laparoscopy. Methods: This is a clinical case cohort series of patients undergoing surgical resection of PH-CCA without the use of staging laparoscopy in the work-up algorithm. During the 13 years from 1 January 2009 to 1 January 2022, 32 patients underwent laparotomy for planned surgical resection of PH-CCA. Data were collected on demographic profile, admission biochemistry, radiology, pre-operative intervention, operation and outcome, together with post-operative complications and disease-free and overall survival. Results: All patients underwent pre-operative contrast-enhanced CT. Twenty-four (75%) underwent pre-operative MR. Twenty-three (72%) underwent pre-operative biliary drainage. Twenty-nine patients (91%) had either type III or IV peri-hilar cholangiocarcinoma. One patient (3%) in this series underwent a non-resectional laparotomy. Twenty-nine (91%) had a final histopathological diagnosis of PH-CCA. One further patient had a final diagnosis of an intraductal papillary neoplasm of the biliary tree (IPNB) with high-grade dysplasia but no invasive cancer. Eleven patients (36%) received chemotherapy after surgery. The median (95% CI) time to recurrence was 14 (7-31) months. The median survival was 25 (18-upper limit not reached) months. Conclusion: This cohort of 32 patients undergoing attempted resection for PH-CCA without the use of staging laparoscopy in the work-up algorithm indicates that with careful attention to patient fitness and cross-sectional and interventional radiologic/endoscopic imaging, a very low non-therapeutic laparotomy rate of 3% can be achieved and sustained.

The Impact of a Dedicated "Hot List" on the In-Patient Management of Patients With Acute Gallstone-Related Disease.

Background: Index admission laparoscopic cholecystectomy is the standard of care for patients admitted to hospital with symptomatic acute cholecystitis. The same standard applies to patients suffering with mild acute biliary pancreatitis. Operating theatre capacity can be a significant constraint to same admission surgery. This study assesses the impact of dedicated theatre capacity provided by a specialist surgical team on rates of index admission cholecystectomy. Methods: This clinical cohort study compares the management of patients with symptomatic gallstone disease admitted to a tertiary care university teaching hospital over two equal but chronologically separate time periods. The periods were before and after service reconfiguration including a specialist HPB service with dedicated operating theatre time allocation. Results: There was a significant difference in the number of admissions over the two time periods with a greater proportion of patients having index admission surgery in the second time period with correspondingly fewer having more than one admission during this latter time period. In the second time period 43% of patients underwent index admission cholecystectomy compared to 23% in the first (P < 0.001). The duration of surgery was shorter for patients undergoing surgery during the second time period [135 (102-178) min in the first period and in the second period 106 (89-145) min] (P = 0.02). Discussion: This paper shows that the concentration of theatre resources and surgical expertise into regular theatre access for patients undergoing urgent laparoscopic cholecystectomy is an effective and safe model for dealing with acute biliary disease.

Outcome of the "Manchester Groin Repair" (Laparoscopic Totally Extraperitoneal Approach With Fibrin Sealant Mesh Fixation) in 434 Consecutive Inguinal Hernia Repairs.

Introduction: This study looks at the outcome of 352 patients that underwent the "Manchester groin repair" in the period from 2007 to 2016. The effect of laterality on chronic groin pain and the reduction of pain scores post-surgery are evaluated as well as the rate of hernia recurrence for the inguinal hernia repairs. Methods: The "Manchester groin repair" is a modification of a laparoscopic totally extra-peritoneal approach with fibrin sealant mesh fixation. Data were collected prospectively. In addition to demographic data and the European Hernia Society classification grading of each hernia, pain scores were assessed prior to surgery and at 4-6 weeks post-operatively using a ten-point visual analog pain scale. Data were collected on a bespoke database and differences between time-points analyzed by non-parametric Wilcoxon signed rank tests with Kruskal-Wallis rank sum test for three-group comparisons. Significance was at the P < 0.05 level. The study was undertaken as an institutional audit. Results: Three hundred and fifty two patients underwent TEP repair as per the "Manchester Groin Repair" modification during the period of interest with a median follow-up period of 109.5 (IQR 57.0-318.5) weeks. Of these 274 (77.8%) were for the repair of true hernias and 78 (22.2%) were for inguinal disruptions. All inguinal hernia repairs patients were evaluated (254 m, 20 f); median [interquartile range] age 50 (39-65) years. There were 75 right inguinal hernias (27.4%), 39 Left inguinal hernias (14.2%), and 160 bilateral inguinal hernias (58.4%), giving a total of 434 hernia repairs. During follow-up there were 6 recurrences (1.4%).Of the 274 patients evaluated, 145 (52.9%) had both pre and post-operative pain scores available. Median pre-operative pain score was 5 [IQR 4-7]. Median post-operative pain score was 1 [IQR 1-2]. This difference was significant (P < 0.001). Pre-operative pain scores were higher for those with a bilateral hernia (median 6 vs. 5 and 4, respectively; P = 0.005), but there was no difference in post-operative scores (P = 0.347). One patient (0.3%) presented with chronic groin pain (pain after 3 months). Conclusion: This study demonstrates that the "Manchester groin repair" provides an excellent repair with a low rate of recurrence and low incidence of chronic pain. Longer-term evaluation and larger patient series will add to the understanding of the role of this procedure in groin hernia repair.

Bone mineral density and its correlation with clinical and laboratory factors in chronic peritoneal dialysis patients.

The aim of this study was to assess the clinical and laboratory correlations of bone mineral density (BMD) measurements among a large population of patients on chronic peritoneal dialysis (PD). This cross-sectional, multicenter study was carried out in 292 PD patients with a mean age of 56 +/- 16 years and mean duration of PD 3.1 +/- 2.1 years. Altogether, 129 female and 163 male patients from 24 centers in Canada, Greece, and Turkey were included in the study. BMD findings, obtained by dual-energy X-ray absorptiometry (DEXA) and some other major clinical and laboratory indices of bone mineral deposition as well as uremic osteodystrophy were investigated. In the 292 patients included in the study, the mean lumbar spine T-score was -1.04 +/- 1.68, the lumbar spine Z-score was -0.31 +/- 1.68, the femoral neck T-score was -1.38 +/- 1.39, and the femoral neck Z score was -0.66 +/- 1.23. According to the WHO criteria based on lumbar spine T-scores, 19.2% of 292 patients were osteoporotic, 36.3% had osteopenia, and 44.4% had lumbar spine T-scores within the normal range. In the femoral neck area, the prevalence of osteoporosis was slightly higher (26%). The prevalence of osteoporosis was 23.3% in female patients and 16.6% in male patients with no statistically significant difference between the sexes. Agreements of lumbar spine and femoral neck T-scores for the diagnosis of osteoporosis were 66.7% and 27.3% and 83.3% for osteopenia and normal BMD values, respectively. Among the clinical and laboratory parameters we investigated in this study, the body mass index (BMI) (P < 0.001), daily urine output, and urea clearance time x dialysis time/volume (Kt/V) (P < 0.05) were statistically significantly positive and Ca x PO(4) had a negative correlation (P < 0.05) with the lumbar spine T scores. Femoral neck T scores were also positively correlated with BMI, daily urine output, and KT/V; and they were negatively correlated with age. Intact parathyroid hormone levels did not correlate with any of the BMD parameters. Femoral neck Z scores were correlated with BMI (P < 0.001), and ionized calcium (P < 0.05) positively and negatively with age, total alkaline phosphatase (P < 0.05), and Ca x P (P < 0.01). The overall prevalence of fractures since the initiation of PD was 10%. Our results indicated that, considering their DEXA-based BMD values, 55% of chronic PD patients have subnormal bone mass-19% within the osteoporotic range and 36% within the osteopenic range. Our findings also indicate that low body weight is the most important risk factor for osteoporosis in chronic PD patients. An insufficient dialysis dose (expressed as KT/V) and older age may also be important risk factors for osteoporosis of PD patients.