Laparoscopic bilateral groin hernia repair with one large self-fixating mesh: prospective observational study with patient-reported outcome of urological symptoms and EuraHS-QoL scores.

BACKGROUND: Laparoscopic bilateral inguinal hernia repair may be completed with one large self-fixating mesh crossing the midline. No studies have investigated in detail whether preperitoneal mesh placement induces temporary or more lasting urinary symptoms. METHODS: Urinary and hernia-related symptoms were evaluated preoperatively and postoperatively at 1, 3 and 12 months using the ICIQ-MLUTS questionnaire and EuraHS-QoL score in patients undergoing bilateral inguinal hernia repair. RESULTS: One hundred patients were included. Voiding symptoms and bother scores were unchanged at 1 or 3 months, but there was significant improvement at 12 months compared with preoperative findings (symptoms P < 0.001; bother score P < 0.01). Incontinence symptoms improved at 1 month (P < 0.05) but not at 3 or 12 months, with a bother score significantly improved at 1 month (P < 0.01) and 12 months (P < 0.01). Diurnal and nocturnal frequency did not change significantly postoperatively, but 12 months nocturnal bother score was decreased (P < 0.05). EuraHS-QoL scores showed statistical significant improvement in all three domains for all measurements at the different follow-up moments compared to previous measurements. Postoperative symptoms were improved at 12 months, compared with preoperative pain scores (- 6.1), restriction of activity (- 10.1) and cosmetic scores (- 4.7) These findings were statistically significant (P < 0.001). At 12 months, there were no patients with severe discomfort (score ≥ 5) for any of the three domains. No recurrences were diagnosed with 95% clinical follow-up at 12 months. CONCLUSION: Laparoscopic bilateral groin hernia repair with one large preperitoneal self-fixating mesh did not cause new urinary symptoms and demonstrated significant improvement in voiding symptoms at 12 months. Incontinence and nocturnal bother score were significantly improved. CLINICAL TRIAL REGISTRY IDENTIFIER: Clinical.Trials.gov: NCT02525666.

Robotic-assisted laparoscopic groin hernia repair: observational case-control study on the operative time during the learning curve.

BACKGROUND: Robotic groin hernia repair (r-TAPP) is demonstrating rapid adoption in the US. Barriers in Europe include: low availability of robotic systems to general surgeons, cost of robotic instruments, and the perception of longer operative time. METHODS: Patients undergoing r-TAPP in our start-up period were prospectively entered in the EuraHS database and compared to laparoscopic TAPP (l-TAPP) performed by the same surgeon within the context of two other prospective studies. Operations were performed with the daVinci Xi robot and the primary endpoint was skin-to-skin operative time. RESULTS: Following proctoring in September 2016 by US surgeons, 50 r-TAPP (34 unilateral and 16 bilateral) procedures have been performed up to January 2017. Mean operative time for unilateral r-TAPP was 54 min, with a decrease from 63 min for the first tertile to 44 min for the third tertile. For unilateral l-TAPP, the mean operative time was 45 min. Mean operative time for bilateral r-TAPP was 78 min, with a decrease from 90 min for the first half to 68 min for the second half. For bilateral l-TAPP, the mean operative time was 61 min. There were no intraoperative complications and no conversions to conventional laparoscopy or open surgery. The operation was performed as an outpatient in 67% of cases. Urinary retention requiring urinary catheterization was the only early postoperative complication noted in 5 patients (10.2%). At 4 week follow-up, 7 patients (14.3%) had an asymptomatic seroma, but no other complications were seen. CONCLUSION: Robotic TAPP was associated with a rapid reduction in operative time during our learning curve and afterwards the operative time to perform a robotic TAPP equals the operative time to perform a laparoscopic TAPP, both for unilateral and for bilateral groin hernia repairs. No complications related to the introduction of robotic-assisted laparoscopic groin hernia repair were observed.

Prospective cohort study on mesh shrinkage measured with MRI after laparoscopic ventral hernia repair with an intraperitoneal iron oxide-loaded PVDF mesh.

BACKGROUND: Current data on shrinkage of intraperitoneal meshes come mainly from animal studies. High-quality human data in prospective studies are scarce. METHODS: We used the ability to visualize intraperitoneal PVDF meshes enhanced with iron particles (DynaMesh IPOM visible) with magnetic resonance imaging (MRI) to determine the amount of shrinkage between 1 and 13 months postoperatively. All measurements of the width, length, and surface area of the mesh were performed with a standardized methodology independently by four radiologists blinded for the timing of the MRI. RESULTS: Of the 15 patients undergoing laparoscopic ventral hernia repair, 13 patients received an MRI both at 1 and at 13 months. Evaluation of inter-rater reliability between the radiologists showed intra-class correlations of 0.95 (95% CI 0.92-0.98) for the width, 0.96 (95% CI 0.93-0.98) for the length, and 0.99 (90% CI 0.99-1.00) for the surface area of the mesh. The change between measurement at implantation and 1-month MRI was - 0.7 cm (P = 0.023; - 3.6%) for the width and - 1.9 cm (P = 0.001; - 7.2%) for the length. The change between 1 and 13 months was - 0.06 cm (P = 0.74; shrinkage = 0.3%) for the width, - 0.12 cm (P = 0.56; shrinkage = 0.5%) for the length, and - 4.0 cm2 (P = 0.20; shrinkage = 1.0%) for the surface area of the mesh. CONCLUSION: There is excellent inter-rater reliability between radiologists when measuring width, length, and surface area of visible intraperitoneal PVDF mesh with MRI. There is no significant shrinkage between 1 and 13 months of intraperitoneal PVDF mesh after laparoscopic ventral hernia repair.

Prevention of Incisional Hernias with Biological Mesh: A Systematic Review of the Literature.

BACKGROUND: Prophylactic mesh-augmented reinforcement during closure of abdominal wall incisions has been proposed in patients with increased risk for development of incisional hernias (IHs). As part of the BioMesh consensus project, a systematic literature review has been performed to detect those studies where MAR was performed with a non-permanent absorbable mesh (biological or biosynthetic). METHODS: A computerized search was performed within 12 databases (Embase, Medline, Web-of-Science, Scopus, Cochrane, CINAHL, Pubmed publisher, Lilacs, Scielo, ScienceDirect, ProQuest, Google Scholar) with appropriate search terms. Qualitative evaluation was performed using the MINORS score for cohort studies and the Jadad score for randomized clinical trials (RCTs). RESULTS: For midline laparotomy incisions and stoma reversal wounds, two RCTs, two case-control studies, and two case series were identified. The studies were very heterogeneous in terms of mesh configuration (cross linked versus non-cross linked), mesh position (intraperitoneal versus retro-muscular versus onlay), surgical indication (gastric bypass versus aortic aneurysm), outcome results (effective versus non-effective). After qualitative assessment, we have to conclude that the level of evidence on the efficacy and safety of biological meshes for prevention of IHs is very low. No comparative studies were found comparing biological mesh with synthetic non-absorbable meshes for the prevention of IHs. CONCLUSION: There is no evidence supporting the use of non-permanent absorbable mesh (biological or biosynthetic) for prevention of IHs when closing a laparotomy in high-risk patients or in stoma reversal wounds. There is no evidence that a non-permanent absorbable mesh should be preferred to synthetic non-absorbable mesh, both in clean or clean-contaminated surgery.

A prospective, multicenter, observational study on quality of life after laparoscopic inguinal hernia repair with ProGrip laparoscopic, self-fixating mesh according to the European Registry for Abdominal Wall Hernias Quality of Life Instrument.

BACKGROUND: There is an increasing interest in patient-reported outcome measurement to evaluate hernia operations. Several hernia-specific quality of life (QoL) scales have been proposed, but none are constructed for preoperative assessment. METHODS: The European Registry for Abdominal Wall Hernias (EuraHS) proposed the short, 9-question EuraHS-QoL instrument for assessment pre- and postoperatively. The EuraHS-QoL was evaluated in a prospective, multicenter validation study alongside the Visual Analogue Scale, Verbal Rating Scale, and Carolina Comfort Scale (https://clinicaltrials.gov; NCT01936584). RESULTS: We included 101 patients undergoing unilateral laparoscopic inguinal hernia repair with ProGrip laparoscopic, self-fixating mesh. Clinical follow-up at 12 months was 87% complete. The EuraHS-QoL score shows good internal consistency (Cronbach's α ≥ .90), good test-retest reliability (Spearman correlation coefficient r ≥ 0.72), and high correlation for pain with the Visual Analogue Scale, the Verbal Rating Scale, the Carolina Comfort Scale pain scale (r between 0.64 and 0.86), and for restriction of activity with the Carolina Comfort Scale movement scale (r between 0.65 and 0.79). Our results show significant improvement in quality of life at 3 weeks compared with preoperative and further significant improvement at 12 months (P < .05). No late complications or recurrences were recorded. An operation was performed in day surgery (>75%) or with a <24-hour admission (>95%) in the majority of the patients. CONCLUSION: The EuraHS-QoL instrument is a short and valid patient-reported outcome measurement following groin hernia repair. Laparoscopic inguinal hernia repair with ProGrip laparoscopic, self-fixating mesh results in a favorable outcome and significant improvement of quality of life compared with the preoperative assessment.

Mesh fixation alternatives in laparoscopic ventral hernia repair.

Since the introduction of laparoscopic ventral hernia repair, there has been an ongoing dispute over the optimal method of fixating the mesh against the abdominal wall. In general, one could say that the more penetrating the fixation used, the stronger the fixation, but at the cost of increased acute postoperative pain. The occurrence of chronic pain in some patients has led to the search for less permanent penetrating fixation, but without risking a less stable mesh fixation and increased recurrences due to shift or shrinkage of the mesh. Avoiding transfascial sutures by using a double crown of staples has been proposed and recently absorbable fixation devices have been developed. Some surgeons have proposed fixation with glue to reduce the number of staples, or even eliminate them entirely. The continuously increasing multitude of marketed meshes and fixating devices leads to unlimited options in mesh fixation combination and geometry. Therefore, we will never be able to get a clear view on the benefits and pitfalls of every specific combination. Clearance of the anterior abdominal wall from peritoneal fatty tissue and correct positioning of the mesh with ample overlap of the hernia defect are possibly as important as the choice of mesh and fixation. Other topics that are involved in successful outcomes but not addressed in this article are adequate training in the procedure, appropriate selection of patients, and careful adhesiolysis to minimize accidental visceral injuries.

Absence of the complement regulatory molecule CD59a leads to exacerbated neuropathology after traumatic brain injury in mice.

BACKGROUND: Complement represents a crucial mediator of neuroinflammation and neurodegeneration after traumatic brain injury. The role of the terminal complement activation pathway, leading to generation of the membrane attack complex (MAC), has not been thoroughly investigated. CD59 is the major regulator of MAC formation and represents an essential protector from homologous cell injury after complement activation in the injured brain. METHODS: Mice deleted in the Cd59a gene (CD59a-/-) and wild-type littermates (n = 60) were subjected to focal closed head injury. Sham-operated (n = 60) and normal untreated mice (n = 14) served as negative controls. The posttraumatic neurological impairment was assessed for up to one week after trauma, using a standardized Neurological Severity Score (NSS). The extent of neuronal cell death was determined by serum levels of neuron-specific enolase (NSE) and by staining of brain tissue sections in TUNEL technique. The expression profiles of pro-apoptotic (Fas, FasL, Bax) and anti-apoptotic (Bcl-2) mediators were determined at the gene and protein level by real-time RT-PCR and Western blot, respectively. RESULTS: Clinically, the brain-injured CD59a-/- mice showed a significantly impaired neurological outcome within 7 days, as determined by a higher NSS, compared to wild-type controls. The NSE serum levels, an indirect marker of neuronal cell death, were significantly elevated in CD59a-/- mice at 4 h and 24 h after trauma, compared to wild-type littermates. At the tissue level, increased neuronal cell death and brain tissue destruction was detected by TUNEL histochemistry in CD59a-/- mice within 24 hours to 7 days after head trauma. The analysis of brain homogenates for potential mediators and regulators of cell death other than the complement MAC (Fas, FasL, Bax, Bcl-2) revealed no difference in gene expression and protein levels between CD59a-/- and wild-type mice. CONCLUSION: These data emphasize an important role of CD59 in mediating protection from secondary neuronal cell death and further underscore the key role of the terminal complement pathway in the pathophysiology of traumatic brain injury. The exact mechanisms of complement MAC-induced secondary neuronal cell death after head injury require further investigation.

Human periosteum-derived progenitor cells express distinct chemokine receptors and migrate upon stimulation with CCL2, CCL25, CXCL8, CXCL12, and CXCL13.

For bone repair, transplantation of periosteal progenitor cells (PCs), which had been amplified within supportive scaffolds, is applied clinically. More innovative bone tissue engineering approaches focus on the in situ recruitment of stem and progenitor cells to defective sites and their subsequent use for guided tissue repair. Chemokines are known to induce the directed migration of bone marrow CD34(-) mesenchymal stem cells (MSCs). The aim of our study was to determine the chemokine receptor expression profile of human CD34(-) PCs and to demonstrate that these cells migrate upon stimulation with selected chemokines. PCs were isolated from periosteum of the mastoid bone and displayed a homogenous cell population presenting an MSC-related cell-surface antigen profile (ALCAM(+), SH2(+), SH3(+), CD14(-), CD34(-), CD44(+), CD45(-), CD90(+)). The expression profile of chemokine receptors was determined by real-time PCR and immunohistochemistry. Both methods consistently demonstrated that PCs express receptors of all four chemokine subfamilies CC, CXC, CX(3)C, and C. Migration of PCs and a dose-dependent migratory effect of the chemokines CCL2 (MCP1), CCL25 (TECK), CXCL8 (IL8), CXCL12 (SDF1alpha), and CXCL13 (BCA1), but not CCL22 (MDC) were demonstrated using a 96-multiwell chemotaxis assay. In conclusion, for the first time, here we report that human PCs express chemokine receptors, present their profile, and demonstrate a dose-dependent migratory effect of distinct chemokines on these cells. These results are promising towards in situ bone repair therapies based on guiding PCs to bone defects, and encourage further in vivo studies.

Tracheal remodeling: comparison of different composite cultures consisting of human respiratory epithelial cells and human chondrocytes.

The reconstruction of extensive tracheal defects is still an unsolved challenge for thoracic surgery. Tissue engineering is a promising possibility to solve this problem through the generation of an autologous tracheal replacement from patients' own tissue. Therefore, this study investigated the potential of three different coculture systems, combining human respiratory epithelial cells and human chondrocytes. The coculture systems were analyzed by histological staining with alcian blue, immunohistochemical staining with the antibodies, 34betaE12 and CD44v6, and scanning electron microscopy. The first composite culture consisted of human respiratory epithelial cells seeded on human high-density chondrocyte pellets. For the second system, we used native articular cartilage chips as base for the respiratory epithelial cells. The third system consisted of a collagen membrane, seeded with respiratory epithelial cells and human chondrocytes onto different sides of the membrane, which achieved the most promising results. In combination with an air-liquid interface system and fibroblast-conditioned medium, an extended epithelial multilayer with differentiated epithelial cells could be generated. Our results suggest that at least three factors are necessary for the development towards a tracheal replacement: (1) a basal lamina equivalent, consisting of collagen fibers for cell-cell interaction and cell polarization, (2) extracellular factors of mesenchymal fibroblasts, and (3) the presence of an air-liquid interface system for proliferation and differentiation of the epithelial cells.

Inhibition of the alternative complement activation pathway in traumatic brain injury by a monoclonal anti-factor B antibody: a randomized placebo-controlled study in mice.

BACKGROUND: The posttraumatic response to traumatic brain injury (TBI) is characterized, in part, by activation of the innate immune response, including the complement system. We have recently shown that mice devoid of a functional alternative pathway of complement activation (factor B-/- mice) are protected from complement-mediated neuroinflammation and neuropathology after TBI. In the present study, we extrapolated this knowledge from studies in genetically engineered mice to a pharmacological approach using a monoclonal anti-factor B antibody. This neutralizing antibody represents a specific and potent inhibitor of the alternative complement pathway in mice. METHODS: A focal trauma was applied to the left hemisphere of C57BL/6 mice (n = 89) using a standardized electric weight-drop model. Animals were randomly assigned to two treatment groups: (1) Systemic injection of 1 mg monoclonal anti-factor B antibody (mAb 1379) in 400 mul phosphate-buffered saline (PBS) at 1 hour and 24 hours after trauma; (2) Systemic injection of vehicle only (400 mul PBS), as placebo control, at identical time-points after trauma. Sham-operated and untreated mice served as additional negative controls. Evaluation of neurological scores and analysis of brain tissue specimens and serum samples was performed at defined time-points for up to 1 week. Complement activation in serum was assessed by zymosan assay and by murine C5a ELISA. Brain samples were analyzed by immunohistochemistry, terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) histochemistry, and real-time RT-PCR. RESULTS: The mAb 1379 leads to a significant inhibition of alternative pathway complement activity and to significantly attenuated C5a levels in serum, as compared to head-injured placebo-treated control mice. TBI induced histomorphological signs of neuroinflammation and neuronal apoptosis in the injured brain hemisphere of placebo-treated control mice for up to 7 days. In contrast, the systemic administration of an inhibitory anti-factor B antibody led to a substantial attenuation of cerebral tissue damage and neuronal cell death. In addition, the posttraumatic administration of the mAb 1379 induced a neuroprotective pattern of intracerebral gene expression. CONCLUSION: Inhibition of the alternative complement pathway by posttraumatic administration of a neutralizing anti-factor B antibody appears to represent a new promising avenue for pharmacological attenuation of the complement-mediated neuroinflammatory response after head injury.

Metabolic changes after polytrauma: an imperative for early nutritional support.

Major trauma induces marked metabolic changes which contribute to the systemic immune suppression in severely injured patients and increase the risk of infection and posttraumatic organ failure. The hypercatabolic state of polytrauma patients must be recognized early and treated by an appropriate nutritional management in order to avoid late complications. Clinical studies in recent years have supported the concept of "immunonutrition" for severely injured patients, which takes into account the supplementation of Omega-3 fatty acids and essential aminoacids, such as glutamine. Yet many aspects of the nutritional strategies for polytrauma patients remain controversial, including the exact timing, caloric and protein amount of nutrition, choice of enteral versus parenteral route, and duration. The present review will provide an outline of the pathophysiological metabolic changes after major trauma that endorse the current basis for early immunonutrition of polytrauma patients.

Reduced neuronal cell death after experimental brain injury in mice lacking a functional alternative pathway of complement activation.

BACKGROUND: Neuroprotective strategies for prevention of the neuropathological sequelae of traumatic brain injury (TBI) have largely failed in translation to clinical treatment. Thus, there is a substantial need for further understanding the molecular mechanisms and pathways which lead to secondary neuronal cell death in the injured brain. The intracerebral activation of the complement cascade was shown to mediate inflammation and tissue destruction after TBI. However, the exact pathways of complement activation involved in the induction of posttraumatic neurodegeneration have not yet been assessed. In the present study, we investigated the role of the alternative complement activation pathway in contributing to neuronal cell death, based on a standardized TBI model in mice with targeted deletion of the factor B gene (fB-/-), a "key" component required for activation of the alternative complement pathway. RESULTS: After experimental TBI in wild-type (fB+/+) mice, there was a massive time-dependent systemic complement activation, as determined by enhanced C5a serum levels for up to 7 days. In contrast, the extent of systemic complement activation was significantly attenuated in fB-/- mice (P < 0.05,fB-/- vs. fB+/+; t = 4 h, 24 h, and 7 days after TBI). TUNEL histochemistry experiments revealed that posttraumatic neuronal cell death was clearly reduced for up to 7 days in the injured brain hemispheres of fB-/- mice, compared to fB+/+ littermates. Furthermore, a strong upregulation of the anti-apoptotic mediator Bcl-2 and downregulation of the pro-apoptotic Fas receptor was detected in brain homogenates of head-injured fB-/- vs. fB+/+ mice by Western blot analysis. CONCLUSION: The alternative pathway of complement activation appears to play a more crucial role in the pathophysiology of TBI than previously appreciated. This notion is based on the findings of (a) the significant attenuation of overall complement activation in head-injured fB-/- mice, as determined by a reduction of serum C5a concentrations to constitutive levels in normal mice, and (b) by a dramatic reduction of TUNEL-positive neurons in conjunction with an upregulation of Bcl-2 and downregulation of the Fas receptor in head-injured fB-/- mice, compared to fB+/+ littermates. Pharmacological targeting of the alternative complement pathway during the "time-window of opportunity" after TBI may represent a promising new strategy to be pursued in future studies.

Pharmacological complement inhibition at the C3 convertase level promotes neuronal survival, neuroprotective intracerebral gene expression, and neurological outcome after traumatic brain injury.

The complement system represents an important mediator of neuroinflammation in traumatic brain injury. We have previously shown that transgenic mice with central nervous system-targeted overexpression of Crry, a potent murine complement inhibitor at the level of C3 convertases, are protected from complement-mediated neuropathological sequelae in brain-injured mice. This knowledge was expanded in the present study to a pharmacological approach by the use of a recombinant Crry molecule (termed Crry-Ig) which was recently made available in a chimeric form fused to the non-complement fixing mouse IgG1 Fc region. In a standardized model of closed head injury in mice, the systemic injection of 1 mg Crry-Ig at 1 h and 24 h after trauma resulted in a significant neurological improvement for up to 7 days, as compared to vehicle-injected control mice (P < 0.05, repeated measures ANOVA). Furthermore, the extensive neuronal destruction seen in the hippocampal CA3/CA4 sublayers in head-injured mice with vehicle injection only was shown to be preserved - to a similar extent as in "sham"-operated mice - by the posttraumatic injection of Crry-Ig. Real-time RT-PCR analysis revealed that the post-treatment with Crry-Ig resulted in a significant up-regulation of candidate neuroprotective genes in the injured hemisphere (Bcl-2, C1-Inh, CD55, CD59), as compared to the vehicle control group (P < 0.01, unpaired Student's t test). Increased intracerebral Bcl-2 expression by Crry-Ig treatment was furthermore confirmed at the protein level by Western blot analysis. These data suggest that pharmacological complement inhibition represents a promising approach for attenuation of neuroinflammation and secondary neurodegeneration after head injury.

Changes in the gene expression pattern of cytokeratins in human respiratory epithelial cells during culture.

The replacement of extensive tracheal defects resulting from intensive care medicine, trauma or large resections is still challenged by the re-epithelialization of an autologous or alloplastic trachea replacement. Therefore, this study was performed to investigate the potential of culture-expanded human respiratory epithelial cells (hREC) to regenerate a functional epithelium for tracheal tissue engineering. hREC from seven male nasal turbinates were freshly isolated, expanded on a collagenous matrix and subsequently cultured in high-density multi-layers to allow epithelial differentiation. The composition of epithelial cells in native respiratory epithelial tissue and culture-expanded hREC was analyzed by histological staining with Alcian blue and by immunohistochemical staining of cytokeratin pairs CK1/10 and CK5/14 with the antibodies 34betaE12 and CD44v6. Differentiation of culture-expanded hREC was further characterized by gene expression analysis of cytokeratins CK5, CK13, CK14 and CK18 using semi-quantitative real-time RT-PCR technique. Histological and immunohistochemical staining of culture-expanded hREC demonstrated basal cells covering the collagenous matrix. These cells formed a cellular multi-layer, which was composed of a basal layer of undifferentiated basal cells and an upper layer of cells differentiating along the squamous metaplasia and ciliated cell lineage. Lineage development of culture-expanded hREC was further documented by the induction of cytokeratins CK13 and CK18. Our results suggest that culture-expanded hREC have the potential to colonize collagen-coated biomaterials and to regenerate epithelial cell types for tracheal tissue engineering.