The effects of physical prehabilitation in elderly patients undergoing colorectal surgery: a systematic review.

AIM: Prehabilitation, defined as enhancement of the preoperative condition of a patient, is a possible strategy for improving postoperative outcome. Lack of muscle strength and poor physical condition, increasingly prevalent in older patients, are risk factors for postoperative complications. Eighty-five per cent of patients with colorectal cancer are aged over 60 years. Since surgery is the cornerstone of their treatment, this review systemically examined the literature on the effect of physical prehabilitation in older patients undergoing colorectal surgery. METHOD: Trials and case-control studies investigating the effect of physical prehabilitation in patients over 60 years undergoing colorectal surgery were retrieved from MEDLINE, EMBASE, CINAHL and the Cochrane library. Patient characteristics, the type of intervention and outcome measurements were recorded. The risk of bias and heterogeneity was assessed. RESULTS: Five studies including 353 patients were identified. They were small, containing an average of 77 patients and were of moderate methodological quality. Compliance rates of the prehabilitation programme varied from 16 to 97%. None of the studies could identify a significant reduction of postoperative complications or length of hospital stay. Four studies showed physical improvement (walking distance, respiratory endurance) in the prehabilitation group. Clinical heterogeneity precluded a meta-analysis. CONCLUSION: Prehabilitation is a possible means of enhancing the physical condition of patients preoperatively. The quality of studies in older patients undergoing colorectal surgery is poor, despite the increase in elderly people with colorectal cancer. Defining specific patient groups at risk and standardizing the outcome are essential for improving the results of treatment.

Subsequent abdominal surgery after laparoscopic ventral and incisional hernia repair with an expanded polytetrafluoroethylene mesh: a single institution experience with 72 reoperations.

PURPOSE: Laparoscopic ventral and incisional hernia repair (LVIHR) carries a risk of adhesion formation and can influence subsequent abdominal operations (SAOs). We performed a retrospective study of findings during reoperations of patients who had previously had an LVIHR by using an expanded polytetrafluoroethylene mesh (DualMesh; WL Gore, Flagstaff, AZ, USA). METHODS: The medical records of all 695 patients who had LVIHR at our hospital were reviewed. Patients who underwent SAO for various indications were identified (n = 72) and analyzed. RESULTS: Seven LVIHR patients (1%) had early SAO (within a few days). In six patients (86%), removal of the mesh was required. Intra-operatively, in all six of these patients with peritonitis, there were no adhesions against the implant identified. Late SAOs (after more than 1 month) were performed in 65 patients (9.4%). Only one patient required acute surgical intervention due to an LVIHR-related adhesion (0.15%). Laparoscopy was performed in 83% and laparotomy in 17% of patients. Adhesions against the implant were present in 83% of patients; in 65%, the adhesions involved omentum only, and in 18%, they involved the bowel. Adhesiolysis was always easy and caused no inadvertent enterotomies. SAOs were devoid of postoperative complications. CONCLUSIONS: In this largest series of reoperations after LVIHR, the majority of patients had mild or moderate adhesions against the implant. The specific observations that: (1) no relaparoscopies had to be converted, (2) no inadvertent enterotomies were made during adhesiolysis, and (3) SAOs have practically been devoid of peri- and postoperative complications indicate that SAOs can be safely performed after previous LVIHR with DualMesh.

Impact of the mesh fixation technique on operation time in laparoscopic repair of ventral hernias.

BACKGROUND: Fixation of the prosthesis is one of the critical components of laparoscopic repair of ventral and incisional hernia (LRVIH). The impact of the fixation technique used on operative time has never been analyzed. We compared the duration of the operation according to the fixation technique used in a series of 138 patients with primary umbilical hernia. METHODS: All patients underwent a straightforward repair by using completely standardized techniques. One hundred and seven patients had mesh fixation with a single crown of tackers (ProTack), TycoUSS, Norwalk, CT) and eight transabdominal sutures (TAS). Thirty-one patients had mesh fixation with a double crown of tackers (DC) without TAS. RESULTS: There were no significant differences in age, sex, hospital stay, and morbidity between the two groups. Mean operating time for the technique with TAS was 50.6 min compared to 41.4 min for the DC technique. The mean difference in operating time was 9.2 min. This difference was significant (P=0.002). During a mean follow-up of 26.4 months, there were no recurrences in the entire series. CONCLUSIONS: The difference in operative times between the two operative techniques can be entirely accounted to the difference in the time needed for insertion of eight TAS as compared to the time needed for application of an inner crown of tackers. This strongly indicates that insertion of every single TAS prolongs LRVIH for approximately 1 min. As long as no significant differences between the two fixation techniques are demonstrated on issues of recurrence, complications, and postoperative pain, the time difference we have measured might be an argument in favor of the DC technique, especially when mesh fixation would require a large number of TAS.

Fatal intestinal ischemia after laparoscopic correction of incisional hernia.

BACKGROUND AND OBJECTIVES: Intestinal ischemia is a very rare complication of laparoscopic procedures. In this report, we describe the first case of fatal large bowel ischemia in the aftermath of laparoscopic incisional hernia repair. METHODS: A literature search using PubMed was performed to identify all published cases of intestinal ischemia following laparoscopic procedures. RESULTS: Our search revealed 13 cases of intestinal ischemia following various laparoscopic procedures. Including this one, 10 of 14 cases reported on so far had impaired cardiovascular, hepatic or renal function or atherosclerosis. None of these patients-at-risk survived. In this series, no indications of faulty operative technique could be identified. CONCLUSION: Patient-related risk factors seem to play the most important role in the development of this rare but devastating complication. Preventive measures and methods to identify patients at risk for developing intestinal ischemia during and after laparoscopy are not completely clear. Patient selection, an optimal hydration status, an optimized technique with lowest insufflation pressure possible, and intermittent decompressions of the abdomen when the procedure is lengthy are the measures that have a potential to prevent this complication. Whatever laparoscopic procedure has been performed, intestinal ischemia should be considered in any patient with nonspecific abdominal symptoms.

Reliability of near-infrared spectroscopy in people with dark skin pigmentation.

OBJECTIVE: Near-infrared spectroscopy (NIRS) is a promising non-invasive technique for the continuous monitoring of tissue oxygen delivery. NIRS detects light absorbance of haemoglobin chromophores to determine tissue oxygen saturation (StO2). As skin colour is also determined by the presence of chromophores, it is plausible that NIRS signal quality may be affected by dark skin pigmentation. METHODS: Tissue saturation in the anterior compartment of the lower leg during isometric contraction was measured using NIRS in 17 volunteers with dark skin pigmentation. Measurements were continued until StO2 was zero percent or until the signal disappeared. RESULTS: The NIRS device failed to register tissue saturation values at some point in nine of seventeen volunteers. This occurred more often in individuals with darker skin. CONCLUSIONS: In patients with a dark pigmented skin, NIRS StO2 measurements should be interpreted with caution, as melanin clearly interferes with the quality of the reflected NIRS signal.

Relationship between the mechanism of gastro-oesophageal reflux and oesophageal acid exposure in patients with reflux disease.

This study investigated the relationship between the oesophageal acid exposure time and the underlying manometric motor events in patients with gastro-oesophageal reflux disease (GORD). In 31 patients, 3-hour oesophageal motility and pH were measured after a test meal. Ten patients underwent 24-hour ambulatory manometry and pH recording. In the 3-hour postprandial study, of 367 reflux episodes 79% was associated with a transient lower oesophageal sphincter relaxation (TLOSR), 14% with absent basal lower oesophageal sphincter (LOS) pressure and the remaining 7% with other mechanisms, representing 62, 28 and 10% of the acid exposure time, respectively. Acid reflux duration per motor mechanism was longer for absent basal LOS pressure than for TLOSR (189 +/- 23 s and 41 +/- 5 s, respectively, P < 0.001). In the 24-hour ambulatory study, the contribution of TLOSRs to reflux frequency vs acid exposure time were 65 vs 54% interprandially and 74 vs 53% after the meal. During the night, absence of basal LOS pressure accounted for 36% of reflux events representing 71% of acid exposure time. In conclusion, the duration of oesophageal acid exposure following a TLOSR is shorter than reflux during absent basal LOS pressure. TLOSRs are, the major contributor to oesophageal acid exposure during the day. At night, however, reflux during absent basal LOS pressure is the major contributor to acid exposure.

Relationship between partial gastric volumes and dyspeptic symptoms in fundoplication patients: a 3D ultrasonographic study.

OBJECTIVES: Impaired gastric accommodation may induce dyspeptic symptoms in postfundoplication patients. Our aim was to assess the effect of a meal on total and partial gastric volumes in relation to dyspeptic symptoms in both dyspeptic and nondyspeptic fundoplication patients using three-dimensional (3D) ultrasonography. METHODS: Eighteen postfundoplication patients of whom eight with and ten without dyspeptic symptoms and eighteen controls were studied. Three-dimensional ultrasonographic images of the stomach were acquired and symptoms were scored while fasting and at 5, 15, 30, 45, and 60 min after ingesting of a 500-ml liquid meal. From the 3D ultrasonographic images of the stomach the total, proximal, and distal gastric volumes were computed. RESULTS: Dyspeptic and nondyspeptic fundoplication patients exhibited similar total gastric volumes at 5 min postprandially compared to controls, whereas smaller total gastric volumes were observed from 15 to 60 min postprandially (p = 0.007 and p < 0.001, respectively). Postprandial proximal/total gastric volume ratios were markedly reduced in both dyspeptic (0.39 +/- 0.016; p < 0.05) and nondyspeptic (0.38 +/- 0.016; p < 0.01) fundoplication patients compared to controls (0.47 +/- 0.008). In contrast, distal/total gastric volume ratios were larger in dyspeptic fundoplication patients (0.14 +/- 0.008) compared to both nondyspeptic fundoplication patients (0.11 +/- 0.007); p < 0.05) and controls (0.07 +/- 0.003); p < 0.001). Dyspeptic fundoplication patients had a higher postprandial score for fullness, nausea, and pain than nondyspeptic patients (p < 0.05) and controls (p < 0.05). Meal-induced distal gastric volume increase correlated significantly with the increase in fullness (r = 0.68; p < 0.01). CONCLUSIONS: After a liquid meal, fundoplication patients exhibit a larger volume of the distal stomach compared with controls. Distal stomach volume was more pronounced in dyspeptic fundoplication patients and related with the increase in postprandial fullness sensations.