Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients.

PURPOSE: In 2009, the European Hernia Society published the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. The guidelines expired January 1, 2012. To keep them updated, a revision of the guidelines was planned including new level 1 evidence. METHODS: The original Oxford Centre for Evidence-Based Medicine ranking was used. All relevant level 1A and level 1B literature from May 2008 to June 2010 was searched (Medline and Cochrane) by the Working Group members. All chapters were attributed to the two responsible authors in the initial guidelines document. One new chapter on fixation techniques was added. The quality was assessed by the Working Group members during a 2-day meeting and the data were analysed, especially with respect to any change in the level and/or text of any of the conclusions or recommendations of the initial guidelines. In the end, all relevant references published until January 1, 2013 were included. The final text was approved by all Working Group members. RESULTS: For the following topics, the conclusions and/or recommendations have been changed: indications for treatment, treatment of inguinal hernia, day surgery, antibiotic prophylaxis, training, postoperative pain control and chronic pain. The addendum contains all current level 1 conclusions, Grade A recommendations and new Grade B recommendations based on new level 1 evidence (with the changes in bold). CONCLUSIONS: Despite the fact that the Working Group responsible for it tried to represent most kinds of surgeons treating inguinal hernias, such general guidelines inevitably must be fitted to the daily practice of every individual surgeon treating his/her patients. There is no doubt that the future of guideline implementation will strongly depend on the development of easy to use decision support algorithms tailored to the individual patient and on evaluating the effect of guideline implementation on surgical outcome. At the 35th International Congress of the EHS in Gdansk, Poland (May 12-15, 2013), it was decided that the EHS, IEHS and EAES will collaborate from now on with the final goal to publish new joint guidelines, most likely in 2015.

Recommendations for reporting outcome results in abdominal wall repair: results of a Consensus meeting in Palermo, Italy, 28-30 June 2012.

BACKGROUND: The literature dealing with abdominal wall surgery is often flawed due to lack of adherence to accepted reporting standards and statistical methodology. MATERIALS AND METHODS: The EuraHS Working Group (European Registry of Abdominal Wall Hernias) organised a consensus meeting of surgical experts and researchers with an interest in abdominal wall surgery, including a statistician, the editors of the journal Hernia and scientists experienced in meta-analysis. Detailed discussions took place to identify the basic ground rules necessary to improve the quality of research reports related to abdominal wall reconstruction. RESULTS: A list of recommendations was formulated including more general issues on the scientific methodology and statistical approach. Standards and statements are available, each depending on the type of study that is being reported: the CONSORT statement for the Randomised Controlled Trials, the TREND statement for non randomised interventional studies, the STROBE statement for observational studies, the STARLITE statement for literature searches, the MOOSE statement for metaanalyses of observational studies and the PRISMA statement for systematic reviews and meta-analyses. A number of recommendations were made, including the use of previously published standard definitions and classifications relating to hernia variables and treatment; the use of the validated Clavien-Dindo classification to report complications in hernia surgery; the use of "time-to-event analysis" to report data on "freedom-of-recurrence" rather than the use of recurrence rates, because it is more sensitive and accounts for the patients that are lost to follow-up compared with other reporting methods. CONCLUSION: A set of recommendations for reporting outcome results of abdominal wall surgery was formulated as guidance for researchers. It is anticipated that the use of these recommendations will increase the quality and meaning of abdominal wall surgery research.

Comet-tail-like inflammatory infiltrate to polymer filaments develops in tension-free conditions.

BACKGROUND: Mesh reinforcement in hiatal hernia repair becomes more frequent but is charged by complications such as erosion or stenosis of the oesophagus. These complications are accompanied by an intense inflammatory infiltrate around the polymer fibres. To characterize this effect, the response to polypropylene fibres in the absence of tension was examined. METHODS: In rats, polypropylene sutures (USP size 1, 3-0 and 7-0) were placed in the subcutis of the abdominal wall without knot or tension. On postoperative days 3, 7 and 21, specimens were excised. The expressions of c-myc, ß-catenin, Notch3, COX-2, CD68 and Ki-67 were measured by immunohistochemistry. RESULTS: In the absence of tension, sutures were surrounded by a foreign body granuloma with an inflammatory infiltrate not encircling the fibre but forming almost symmetric comet-tail-like infiltrates on opposite sides. The expression of c-myc, ß-catenin, Notch3, COX-2, CD68 and Ki-67 was significantly reduced over time in the comet tail, but not in the granuloma. CONCLUSIONS: Even in tension-free conditions, surgical sutures cause a foreign body response with infiltrates of inflammatory cells. This reaction is shaped like a comet tail, and its extension depends on the diameter of the used fibre. Therefore, for reduction of perifilamental infiltrates, not only absence of tension is required, but also a small-sized fibre textile.

Influence of the elasticity module of synthetic and natural polymeric tissue substitutes on the mobility of the diaphragm and healing process in a rabbit model.

Mesh implants are frequently used in congenital diaphragmatic hernia. This experimental study aimed to examine the influence of different materials on the diaphragmatic movement over time as well as their mechanical qualities after 4 months. Ultrapro®, Surgisis®, and Proceed® were implanted onto a diaphragmatic defect in growing rabbits. Diaphragmatic mobility was determined at three time points. At 4 months, defect shrinkage and mechanical properties were measured. The break strength decreased for Ultrapro® and Surgisis®, but did not change relevantly for Proceed®. Ultrapro® (32.46 N/cm) and Proceed® (31.75 N/cm) showed a four-fold higher resistance to tearing than Surgisis® (8.31 N/cm). The elasticity of Ultrapro® showed no significant difference compared to Surgisis® (p = 0.75). Proceed®, on the other hand, was more than twice as elastic as Ultrapro® or Surgisis® (p = 0.015). Ultrapro® had a higher spring rate (6.48 N/mm) compared to Surgisis® (3.82 N/mm) or Proceed® (5.23 N/mm). Observing the standardized movement rates of the diaphragm for each mesh group over time the only statistical differences were seen for the Proceed® group. On account of its material qualities Ultrapro® was found to be the most suitable mesh material for demanding locations in our model.

Is biocompatibility affected by constant shear stress?--comparison of three commercially available meshes in a rabbit model.

Mesh implants as standard treatment for tissue defects can be adapted to patient's needs by specific bioactive coatings. The biophysical interaction with the surrounding tissue must be understood to describe the influence of coatings qualitatively and quantitatively. This study investigates the use of meshes to repair diaphragmatic defects. The physical stress in this tissue is high in comparison to other applications. Therefore, knowledge gained from this experimental model can be applied to other locations. Meshes were implanted on surgically created diaphragmatic defects in growing rabbits. A standardized load model was used to investigate 33 rabbits. The commercial products Ultrapro®, Surgisis®, and Proceed® were implanted. The adhesive properties of the meshes as well as the defect size were determined macroscopically at explantation after 4 months. Sections of the explanted meshes and diaphragms were examined histologically and immunohistochemically. The median defect size for all mesh groups decreased from the initial size of 10 mm down to 4.5 mm at explantation. No statistically significant differences were seen between the three mesh groups. Surgisis® was found to be completely disintegrated after 4 months. Ultrapro® and Proceed® showed no macroscopic differences compared to their original appearance. Both sealed the original diaphragmatic defect as tightly as at time of implantation. Histological and immunohistochemical analyses showed significant differences between the three mesh groups. Proceed® caused stronger inflammatory reaction in the surrounding tissue and inferior connective tissue formation. Regarding the composition of the newly generated tissue within the defect area, Ultrapro® and Surgisis® were found superior. This can sufficiently be explained by the different gradient of inflammatory reaction in the surrounding tissue. Because Surgisis® offers no sufficiently lasting support for the diaphragmatic defect, our future main focus for mesh modification is laid on Ultrapro®.

Treatment algorithm for postoperative upper gastrointestinal fistulas and leaks using combined vicryl plug and fibrin glue.

The incidence of clinically significant anastomotic leaks after upper gastrointestinal surgery is approximately 4 % - 20 %, and the associated mortality can be as high as 80 %. Depending on the clinical presentation, the treatment options are surgery, conservative treatment with external drainage, or endoscopic treatment. This report presents 39 cases of clinically apparent anastomotic leaks or fistulas after surgery for upper gastrointestinal cancers that were treated by endoscopy with insertion of fibrin glue alone (n = 24) or with a combination of Vicryl plug and fibrin glue (n = 15). Thirteen of the 15 patients who underwent Vicryl/fibrin treatments showed complete healing of the anastomotic leak or fistula after one to four sessions. Long-term follow-up results are presented. Postoperative upper gastrointestinal fistulas or anastomotic leaks can be managed successfully with low morbidity by means of endoscopic insertion of Vicryl mesh with fibrin glue, thereby avoiding repeated major surgery and its associated risks.

Harrahill's technique: a simple screening test for intra-abdominal pressure measurement.

BACKGROUND: Repair of giant incisional hernias may lead to an increase in intra-abdominal pressure (IAP) and, sometimes, to abdominal compartment syndrome. Measurement of IAP using Kron's technique (Kron et al. in Ann Surg 199:28-30, 1984) is currently accepted as the gold standard, whereas Harrahill has described a simple measurement setup using urinary drainage manometry (Harrahill in J Emerg Nurs 24:465-466, 1998). The aim of this clinical trail was to evaluate the correlation, reproducibility and effectiveness of this device. METHODS: A prospective cohort study was performed in 43 patients undergoing elective standard abdominal intervention with laparotomy. These patients remain under surveillance in the intensive care unit and require a urinary catheter because of the operation. We performed comparative measurements of IAP using both Korn's (IVM) and Harrahill's (UDM) technique. RESULTS: Evaluating the correlation between the IVM and UDM techniques, we measured median IAPs of 9.8 +/- 4.1 mmHg (2.9-19.9 mmHg) and 10.0 +/- 4.1 mmHg (min-max: 1.5-19.9 mmHg), respectively. Pearson's coefficient of correlation was r = 0.97. The average of difference between UDM and IVM was -0.2 +/- 0.9 mmHg with limits of agreement of -1.7 to 2.0 mmHg. Evaluating the reproducibility of Harrahill's technique, we found median IAPs of 10.4 +/- 2.1 mmHg (min-max: 2.9-19.1 mmHg) and 10.4 +/- 2.7 mmHg (3.7-19.9 mmHg), respectively, in 43 comparative measurements (Pearson's coefficient of correlation, r = 0.97. The average difference between both measurements was -0.1 +/- 1.1 mmHg with limits of agreement of -2.3 to 2.2 mmHg. CONCLUSIONS: We were able to demonstrate good correlation and high reproducibility of IAP measurement using Harrahill's technique compared to the gold standard Korn method. We consider this technique as a suitable method for quick and simple screening test for intra-abdominal hypertension, especially after repair of giant incisional hernias.

[Eosinophilic oesophagitis. Significance of routine oesophageal biopsies for dysphagia of unknown aetiology]. / Eosinophile Ösophagitis. Signifikanz von Routinebiopsien des Ösophagus bei unklarer Dysphagie.

Eosinophilic oesophagitis (EO), primarily a gastro-enterological disease, should be known to the surgeon and endoscopist as a differential diagnosis of dysphagia. We present a chronic and recurrent case of EO. As frequently seen, macroscopic findings are indicative of the causal illness. The diagnosis is finally made by the histological findings of a macroscopically inconspicuous mucosa of the esophagus, which is found in 10% of cases with EO. Random biopsies are necessary for the diagnosis. A short overview of therapy and course and a review of the literature are given.

Evaluation of tissue components in the peripheral nervous system using Sirius red staining and immunohistochemistry: a comparative study (human, pig, rat).

Little is known about species differences in the peripheral nerve system and quantitative evaluation of main tissue components has rarely been done. Nevertheless, animal models are used for example in pain research without exact knowledge of degree of fibrosis in pathological states which would determine possible treatment options. It would therefore be of crucial interest to describe the degree of fibrosis and the remaining functional nerve tissue as exact as possible. In the present study we evaluated collagen (stroma) and nerve fiber (parenchyma) composition of peripheral nerves in three species (human, rat, pig) and used digital colour-separation and analysis for collagen type differentiation and quantification of immuno-positive-stained area. We found similar ratios of collagen types I and III in epineurium and similar immuno-positive area for staining of neurofilament and S-100beta. In contrast, we measured significantly different ratios of collagen type I to type III in the endoneurium. This combined analysis of the main tissue components of peripheral nerves could be an easy-to-use tool in evaluating changes during damage caused by scaring, systemic disease or compression syndromes. The calculated collagen type I/III ratio may serve as an objective diagnostic value for the description or as prognostic marker for therapeutic approaches in peripheral nerve pathology. However, in particular studies of collagen accumulation in nerves, species dependant differences have to be considered.

[German general and visceral surgery: positioning within the international scientific community]. / Deutsche Allgemein- und Viszeralchirurgie: Positionierung im internationalen wissenschaftlichen Vergleich

BACKGROUND: Assessment of scientific performance is critical for selection committees and research funding. The present work evaluated the standing of German surgical research within the international community. METHODS: A database analysis was performed in December 2009 using the ISI Web of Science. RESULTS: The highest impact factor of surgical journals is currently 8.460 with a median impact of all journals of 1.369. Leading academic surgeons have an h-index of more than 60. German surgeons are within the top five leading researchers in the fields of surgery for esophageal and pancreatic cancer, thyroid, hernia, and liver/kidney transplantation. Among the 50 institutions with most publications on a particular topic, 4-5 German centers are mostly represented. The top positions are in total decisively occupied by leading universities in the USA. CONCLUSION: On the basis of scientific parameters German surgical research can compete with leading international centers in certain fields, but should aim to increase the overall impact of research by publishing more in journals with above average impact factors.

[Incisional hernia - how do I do it? Standard surgical approach]. / Narbenhernie - Wie ist zu verfahren? Chirurgische Standardversorgung.

Various techniques for repair of an incisional hernia are available for the surgeon. Conventional suture techniques are quick and easy to perform but they are associated with an unacceptable rate of recurrence and therefore should only be used in exceptional cases. An underlying systemic disturbance of collagen metabolism is assumed to exist in patients with an incisional hernia. In such patients the mechanisms of wound healing and remodeling of the abdominal wall following laparotomy are insufficient, which necessitates reinforcement of the abdominal wall with a non-resorbable alloplastic mesh prosthesis to enable a long-term cure. The implantation of such meshes can be carried out laparoscopically or by an open approach. The gold standard of open repair techniques is the retromuscular placement of a mesh prosthesis. The retromuscular mesh placement as a reinforcement of the abdominal wall (augmentation) must be categorically differentiated into the abdominal wall replacement by mesh bridging. In this technique the mesh is likewise placed in the retromuscular space, however a complete closure of the ventral fascia is not necessary. Retromuscular augmentation enables an extra-peritoneal placement of the prosthesis, an optimization of tissue integration by plane coverage of the prosthesis by well vascularized muscular tissue and a sufficient overlap in cranio-caudal and lateral directions. Mesh fixation is best made with absorbable suture material but is better suited for technical simplification. The use of a prophylactic drainage should be decided depending on the individual patient's risk factors, because sufficient evidence-based data are currently not available. If augmentation is not possible bridging is necessary and then the mesh has to be fixed without underlying support. Current data reveal that the recurrence rate following incisional hernia repair by retromuscular mesh augmentation has decreased promisingly in comparison to simple suture techniques. In total the recurrence rate following retromuscular mesh placement ranges between 2 and 12%. Current results of prospective randomized multicentre trials are not available. However, it is to be expected that further development of mesh materials as well as improvement of surgical techniques with avoidance of typical pitfalls will lead to further reduction of the recurrence rate with an improvement in patient satisfaction.

[Realistic surgical training. The Aachen model]. / Praxisnahe Weiterbildung: Das Aachener Modell.

The Aachen model is a practical mode in teaching and advanced training, which is closely geared to the areas of academic acquisition and training. During medical education optional student courses with constitutive curricula offer practical points of contact to the surgical department at all times. Besides improvement of manual training the aims are enhancing interests and acquisition of talents. This guided structure will be intensified with progression into advanced education. Next to the formal guidelines of the curriculum, education logbook and progression conversations, quality, transparency and reliability are particularly emphasized. An evaluation of both the reforms and the surgical trainers is still to be made. In addition procurement of an affirmative occupational image is essential.

[Quality criteria for treatment of colorectal cancer. From a surgeon's viewpoint]. / Qualitätsanforderungen zur Behandlung des Kolon- und Rektumkarzinoms. Aus chirurgischer Sicht.

The surgeon is the key "prognosis factor" for colorectal cancer. For this reason quality criteria were recently established (including minimum numbers) in order to treat patients who are entitled to the best quality of care and to improve the prognosis. The aim of this study was to critically discuss the existing demands on the surgeon based on the current literature and our own results and to formulate evidence-based quality criteria for surgical clinics. After reviewing the current literature criteria were compiled, discussed and finally presented in a summarized form. These are based on current developments on the diagnostic and therapy of large intestine and colorectal carcinoma. New developments of the German Cancer Society for planning of organ centers are incorporated. The quintessence of our study is that the number of cases alone is not decisive for the success of therapy. Important are the application of the correct surgical-oncology operation procedure, adherence to standards and the training of surgeons. Following the S3 guidelines stage-oriented therapy should additionally be carried out in a structured sequence. This includes an interdisciplinary decision making on the diagnostic and therapy strategy (tumor board). The organization structure of the hospital (teams, tumor board, emergency care with intensive care unit, emergency diagnostic and options for interventional measures) can be more important than the hospital case numbers alone. These demands which have been evaluated from published data and own results are designed to raise the therapy of colorectal cancer to the best possible level of quality and to effect a further improvement in the prognosis.

Haemorrhoids - a collagen disease?

OBJECTIVE: The cause of haemorrhoidal disease is unknown, epidemiological data and histopathological findings support the hypothesis that reduced connective tissue stability is associated with the incidence of haemorrhoids. Therefore the aim of this study was to analyse the quantity and quality of collagen formation in the corpus cavernosum recti in patients with III°/IV° haemorrhoids in comparison with persons without haemorrhoids. METHOD: Haemorrhoidectomy specimens of 31 patients with III°/IV° haemorrhoids were examined. The specimens of 20 persons who died a natural death and who had no haemorrhoidal disease served as the controls. The amount of collagen was estimated photometrically by calculating the collagen/protein ratio. The collagen I/III ratio served as parameter for the quality of collagen formation and was calculated using cross polarization spectroscopy. RESULTS: Patients with haemorrhoids had a significantly reduced collagen/protein ratio (42.2 ± 16.2µg/mg vs 72.5±31.0µg/mg; P= 0.02) and a significantly reduced collagen I/III ratio (2.0±0.1 vs 4.6±0.3; P<0.001) compared with persons without haemorrhoidal disease. There was no correlation with patients' age or gender. CONCLUSIONS: There is a fundamental disorder of collagen metabolism in patients with haemorrhoidal disease. It remains unclear whether this is due to exogenous or endogenous influences.