Feasibility and potential significance of prophylactic ablation of the major ascending tributaries in endovenous laser ablation (EVLA) of the great saphenous vein: A case series.

BACKGROUND: Recurrent varicosities after endovascular laser ablation (EVLA) of the great saphenous vein (GSV) are frequently due to varicose transformed, initially unsealed major ascending tributaries of the saphenofemoral junction (SFJ). Preventive ablation of these veins, especially the anterior accessory saphenous vein, is discussed as an option, along with flush occlusion of the GSV. However, few related data exist to date. METHODS: A consecutive case series of 278 EVLA procedures of the GSV for primary varicosis in 213 patients between May and December 2019 was retrospectively reviewed. The ablations were performed with a 1470 nm dual-ring radial laser and always included flush occlusion of the GSV, and concomitant ablation of its highest ascending tributaries by additional cannulation and ablation when this seemed anatomically appropriate. The initial technical success, comprising occlusion of the GSV and its major tributaries, was set as the primary endpoint. Possible determinants were explored using downstream multiple logistic regression analysis. RESULTS: The early technical success was 92.8%, with the GSV occluded in 99.6% and the highest ascending SFJ tributary, if present, in 92.4%. Additional ablations of ascending tributaries were performed in 171 cases (61.5%), the latter being associated with success (OR 10.39; 95% CI [3.420-36.15]; p < 0.0001). Presence of anterior as opposed to posterior accessory saphenous vein was another positive predictor (OR 3.959; 95% CI [1.142-13,73]; p = 0.027), while a confluence of the tributary in the immediate proximity to the SFJ had a negative impact (OR 0.2253; 95% CI [0.05456-0.7681]; p = 0.0253). An endothermal heat-induced thrombosis (EHIT) ≥ grade 2 was observed in three cases (1.1%). CONCLUSIONS: A co-treatment of the tributaries is feasible and could improve the technical success of EVLA if a prophylactic closure of these veins is desired, especially if their distance to the SFJ is short. Its effect on the recurrence rate needs further research.

Prevention of parastomal hernia using mesh in patients undergoing rectum extirpation.

INTRODUCTION: Developing a parastomal hernia can lead to emergency surgery and cause discomfort. Placing a pro-phylactic mesh around the ostomy may potentially prevent hernias from developing. Randomised clinical trials and reviews have reported contradictory results from this prophylactic procedure with different rates of hernias and success. This descriptive cohort study aimed to investigate the rate of parastomal hernia after applying prophylactic mesh in patients undergoing surgery for rectal cancer. METHODS: In the period from 2010 to 2016, we included 133 patients who had a permanent colostomy with prophylactic mesh placement due to rectal cancer. The patients were seen in the ostomy ambulatory at least three times annually, and bulges and hernias were registered by a trained nurse. Computed tomography was used for verification of parastomal hernia. Data were registered retrospectively from patient files. RESULTS: After a median follow-up of 22 months, 24% of patients developed a parastomal hernia. Development of parastomal bulge without a subsequent hernia diagnosis was seen in 21%. The one-year rate of parastomal hernia was 9.7%. CONCLUSIONS: This cohort study supports the thesis of a low short-time rate of parastomal hernia in patients who had a prophylactic mesh placed during the ostomy formation and indicates that the rate of hernia increases over time after the first post-operative year. FUNDING: none. TRIAL REGISTRATION: not relevant.

The use of a composite synthetic mesh in the vicinity of bowel - For repair and prophylaxis of parastomal hernias. Does it increase the risk of short term infective complications?

AIMS: The use of synthetic meshes in potentially infected operative fields such as in the vicinity of large bowel, is controversial. This study describes our experience with the use of a synthetic composite mesh for prophylaxis and repair of parastomal hernias. METHODS: Data were collected retrospectively over a 7-year period from 2008 to 2015. An IPOM (DynaMesh™) was used either during the formation of the stoma to reinforce the abdominal wall around the stoma or during the surgical repair of existing parastomal hernias, using keyhole or sandwich technique. Majority of meshes were placed laparoscopically. Clinical data and outcomes any stoma wound complications were collected. RESULTS: Forty seven patients were included with a male to female ratio of 34:13. Median age was 66 years (38-91 years) with median follow-up of 17 months (3-73 months). Twenty seven patients had a prophylactic mesh placement (PMP) around colostomy after resection of colorectal cancer. None of these patients had any wound complications. Twenty patients had repair of parastomal hernias (RPH). One patient (1/20) in this group had a superficial wound infection around the stoma site and underwent an incision and drainage. One patient developed seroma and one had parastomal wound haematoma. CONCLUSIONS: The use of a composite synthetic mesh using a laparoscopic IPOM technique for the prophylaxis and treatment of parastomal hernias, even in a clean contaminated surgical field, is safe and feasible.

Prophylactic pinning for slipped capital femoral epiphysis: does it affect proximal femoral morphology?

This study was designed to determine whether prophylactic pinning of the unaffected hip in unilateral slipped capital femoral epiphysis affects the proximal femoral morphology. Twenty-four hips prophylactically pinned were compared with 26 cases observed. The articulotrochanteric distance (ATD) and the trochanteric-trochanteric distance (TTD) were measured. Postoperative radiographs were compared with final follow-up radiographs. The final TTD : ATD ratio was higher (P=0.048) in the pinned group, suggesting relative coxa vara/breva. There was a smaller difference between the two hips in the prophylactically pinned group (0.7) as opposed to those observed (1.47). Prophylactic pinning does not cause growth to stop immediately but alters the proximal femoral morphology.

Preventing Postendoscopic Retrograde Cholangiopancreatography Pancreatitis.

Postendoscopic retrograde cholangiopancreatography pancreatitis is a common and potentially devastating complication of endoscopic retrograde cholangiopancreatography. Advances in risk-stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the ability to prevent this complication. This article presents the evidence-based approaches to preventing postendoscopic retrograde cholangiopancreatography pancreatitis and discusses timely research questions in this important area.

Prospective, Randomized Study on the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia of Permanent Colostomy.

BACKGROUND: Prophylactic placement of a mesh has been suggested to prevent parastomal hernia, but evidence to support this approach is scarce. OBJECTIVE: The aim of this study was to evaluate whether laparoscopic placement of a prophylactic, dual-component, intraperitoneal onlay mesh around a colostomy is safe and prevents parastomal hernia formation after laparoscopic abdominoperineal resection. DESIGN: This is a prospective, multicenter, randomized controlled clinical trial. SETTINGS: This study was conducted at 2 university and 3 central Finnish hospitals. PATIENTS: From 2010 to 2013, 83 patients undergoing laparoscopic abdominoperineal resection for rectal cancer were recruited. After withdrawals and exclusions, the outcome of 70 patients, 35 patients in each study group, could be examined. INTERVENTIONS: In the intervention group, an end colostomy was created with placement of a intraperitoneal, dual-component onlay mesh and compared with a group with a traditional stoma. MAIN OUTCOME MEASURES: The main outcome measures were the incidence of clinically and radiologically detected parastomal hernias and their extent 12 months after surgery. Stoma-related morbidity and the need for surgical repair of parastomal hernia were secondary outcome measures. RESULTS: Parastomal hernia was observed by clinical inspection in 5 intervention patients (14.3%) and in 12 control patients (32.3%; p = 0.049). Surgical repair of parastomal hernia was performed in 1 control patient (3.2%) and in none of the patients in the intervention group. CT detected parastomal hernia in 18 intervention patients (51.4%) and in 17 control patients (53.1%; p = 1.00). The extent of hernias was similar according to European Hernia Society classification (p = 0.41). Colostomy-related morbidity (32.3% vs 14.3%; p = 0.140) did not differ between the study groups. LIMITATIONS: The study was limited by its small size and short follow-up time. CONCLUSIONS: Prophylactic laparoscopic placement of intraperitoneal onlay mesh does not significantly reduce the overall risk of radiologically detected parastomal hernia after laparoscopic abdominoperineal resection. However, prophylactic mesh repair was associated with significantly lower risk of clinically detected parastomal hernia.