Safety and efficacy of absorbable and non-absorbable fixation systems for intraperitoneal mesh fixation: an experimental study in swine.

PURPOSE: Choice of the best possible fixation system in terms of safety and effectiveness for intraperitoneal mesh placement in hernia surgery remains controversial. The aim of the present study was to compare the performance of four fixation systems in a swine model of intraperitoneal mesh fixation. METHODS: Fourteen Landrace swine were utilized in the study. The experiment included two stages. Initially, four pieces of mesh (Ventralight ™ ST) sizing 10 × 5 cm were placed and fixed intraperitoneally to reinforce 4 small full thickness abdominal wall defects created with diathermy. These defects were repaired primarily with absorbable suture before mesh implantation. Each mesh was anchored with a different tack device between Absorbatack™, Protack™, Capsure™, or Optifix™. The second stage took place after 60 days and included euthanasia, laparoscopy, and laparotomy via U-shaped incision to obtain the measurements for the outcome parameters. The primary endpoint of the study was to compare the peel strength of the compound tack/mesh from the abdominal wall. Secondary parameters were the extent and quality of visceral adhesions to the mesh, the degree of mesh shrinkage and the histological response around the tacks. RESULTS: Thirteen out of 14 animals survived the experiment and 10 were included in the final analysis. Capsure™ tacks had higher peel strength when compared to Absorbatack™ (p = 0.028); Protack™ (p = 0.043); and Optifix™ (p = 0.009). No significant differences were noted regarding the extent of visceral adhesions (Friedman's test p value 0.854), the adhesion quality (Friedman's test p value 0.506), or the mesh shrinkage (Friedman's test p value = 0.827). Four out of the ten animals developed no adhesions at all 2 months after implantation. CONCLUSION: Capsure™ fixation system provided higher peel strength that the other tested devices in our swine model of intraperitoneal mesh fixation. Our findings generate the hypothesis that this type of fixation may be superior in a clinical setting. Clinical trials with long-term follow-up are required to assess the safety and efficacy of mesh fixation systems in hernia surgery.

Outcomes of posterior component separation with transversus abdominis release (TAR) in large and other complex ventral hernias: a single-surgeon experience.

PURPOSE: Over the last years, great advances in the repair of abdominal wall hernias have dramatically improved patients' outcomes. Especially for large and other complex ventral hernias, the application of component separation techniques has been a landmark in their successful management. The aim of this study is to present our experience with the posterior component separation with transversus abdominis release (TAR) in patients with these demanding ventral hernias. METHODS: A retrospective analysis of prospectively collected data of all patients who underwent elective ventral hernia repair with TAR between January 2016 and December 2019 was performed. Preoperative, intraoperative, and postoperative data were analyzed. RESULTS: A total of 125 patients with large and other complex ventral hernias were included in the final analysis. More than 80% of patients had one or more comorbidities. Of all patients, 116 (92.8%) had a history of previous abdominal surgery, 27 (21.6%) had a history of SSI and nine (7.2%) had active fistulas. Postoperatively, SSOs were presented in 11 patients (8.8%), including three cases of SSI. Neither mesh infection occurred, nor mesh excision required. With a mean follow-up of 2.5 years, only one recurrence was observed. CONCLUSIONS: With a wound complication rate of less than 9% and a recurrence rate of less than 1%, our results show that TAR is a reliable, safe and effective technique for the repair of massive and other complex ventral hernias. The combination of knowledge of the abdominal wall anatomy at a proficient level, proper training, and adoption of a strict prehabilitation program are considered prerequisites for the successful management of such demanding hernias.

Trocar site hernia following laparoscopic cholecystectomy: a 10-year single center experience.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is the gold standard of treatment for patients with symptomatic cholelithiasis. Compared to open cholecystectomy, LC is associated with significantly lower postoperative complications. Trocar site hernia (TSH) is an uncommon, but potentially dangerous, complication of LC. The aim of this study was to evaluate the incidence of TSH following LC. METHODS: The records of all patients who underwent elective LC between January 2004 and December 2013 were retrospectively reviewed. The open technique with a vertical incision infraumbilically was used to establish pneumoperitoneum. Two or three other skin incisions were made and trocars were inserted. In all cases, only the fascia at the site of infra-umbilical incision was closed. Following hospital discharge, all patients were regularly re-examined 1, 4 and 52 weeks postoperatively and were contacted by phone during November-December 2015. Based on the findings from clinical and telephone follow-ups, the incidence of TSH was recorded. Using univariate/multivariate analysis, we investigated several variables to identify risk factors for TSH development. RESULTS: During the study period, 1172 patients were eligible and included in the final analysis. Seven patients (0.6%) presented TSH at 1-year follow-up. At the end of the study and with a mean follow-up of 65.86 ± 25.19 months, 11 patients (0.94%) presented TSH. Interestingly, all TSHs were developed at the infra-umbilical site. Multivariate analysis identified obesity as an independent risk factor for TSH. CONCLUSION: The incidence of TSH following LC is considerably low. Obesity is an independent risk factor for TSH development, while closure of fascial incision of 10 mm below the xiphoid is not justified.

Abdominoperineal resection for rectal cancer: is the pelvic drain externalization site an independent risk factor for perineal wound healing?

Aim. The aim of this paper is to investigate if the insertion of the pelvic drainage tube via the perineal wound could be considered as an independent risk factor for perineal healing disorders, after abdominoperineal resection for rectal malignancy. Patients and Methods. The last two decades, 75 patients underwent elective abdominoperineal resection for malignancy. In 42 patients (56%), the pelvic drain catheter was inserted through the perineal wound (PW group), while in the remaining 33 (44%) through a puncture skin wound of the perineum (SW group). Patients' data with respect to age (P = 0.136), stage (P > 0.05), sex (P = 0.188) and comorbidity (P = 0.128) were similar in both groups. 25 patients (PW versus SW: 8 versus 17, P = 0.0026) underwent neoadjuvant radio/chemotherapy. Results. The overall morbidity rate was 36%, but a significant increase was revealed in PW group (52.4% versus 9%, P = 0.0007). In 33.3% of the patients in the PW group, perineal healing was delayed, while in the SW group, no delay was noted. Perineal healing disorders were revealed as the main source of increased morbidity in this group. Conclusion. The insertion of the pelvic drain tube through the perineal wound should be considered as an independent risk factor predisposing to perineal healing disorders.

The handsewn anastomosis after colon resection due to colonic cancer.

AIM: The purpose of our study is to present the results of the handsewn single-layer interrupted extramucosal anastomosis following colon cancer. PATIENTS AND METHODS: In the period between 1989 and 2009, 276 intestinal anastomoses were fashioned following colon resection using single-layer interrupted extramucosal 3/0 Vicryl. RESULTS: The mean hospital stay was 8.2 days. Twenty-three patients had postoperative complications, and the total morbidity was 8.3%. Seven anastomotic leakages occurred (2.5%). The mortality rate was 2.5%. CONCLUSION: The single-layer anastomosis with interrupted extramucosal sutures after colon resection is safe and effective.

Submucosal lipoma of the ascending colon as a source of massive lower gastro-intestinal bleeding: a case report.

Colonic lipomas are relatively uncommon lesions. They have been documented as the source of massive low gastro-intestinal bleeding in only five previous reports in the English language literature. We report an extremely rare case of massive haemorrhage caused by an ascending colon submucosal lipoma and review the pathophysiology, diagnosis and management.

The healing of colon anastomosis covered with fibrin glue after early postoperative intraperitoneal chemotherapy.

BACKGROUND: After colon resection for colonic cancer, the administration of antineoplastic agents may prolong survival by killing residual cancer calls and preventing metastasis, but may also slow anastomotic healing. This study was designed to determine the effects of 5-fluorouracil (5-FU) and leucovorin (LEV), injected intraperitoneally, on the healing of colonic anastomoses with or without fibrin glue (FG) covering. METHODS: Sixty rats were randomized to one of four groups. After resection of a transverse colon segment, an end-to-end sutured anastomosis was performed. Rats in the 5-FU+LEV and the 5- FU+LEV+FG groups received 5-FU+LEV intraperitoneally. The colonic anastomoses of the rats in the FG group and in the 5-FU+LEV+FG group were covered with fibrin glue. All rats were killed on postoperative day 8. Bursting pressure measurements were recorded and the anastomoses were examined macroscopically and histologically. RESULTS: The leakage rate of the anastomoses was significantly different among groups. Specifically, the leakage rate was significantly higher in the 5-FU+LEV group (40%) than in the FG and in the 5-FU+LEV+FG groups where there were no leakages (p=0.017). The mean adhesion formation score was significantly higher in rats of the 5-FU+LEV group, compared to the control (p=0.023), the FG (p=0.006) and the 5-FU+LEV+FG (p=0.006) groups. Bursting pressures were significantly lower in the 5-FU+LEV group than in the other groups (p<0.001). Also, bursting pressures were significantly lower in the control group compared to the FG and 5-FU+LEV+FG groups (p<0.001). Rats in the 5-FU+LEV+FG group had significantly greater neoangiogenesis and fibroblast activity than those in the 5-FU+LEV group (p=0.025). CONCLUSION: The early intraperitoneal postoperative administration of 5-fluorouracil plus leucovorin impaired colonic wound healing. However, the application of fibrin glue prevented the deleterious effect of chemotherapy.

Thoracic splenosis twenty-nine years after traumatic splenectomy mimicking intrathoracic neoplasm.

Thoracic splenosis refers to a condition of ectopic splenic tissue in the thoracic cavity. It is usually a consequence of splenic tissue seeding in the pleural cavity after thoracoabdominal trauma. A rare case of thoracic splenosis, in a 62-year-old man who had had a traumatic splenectomy due to thoracoabdominal trauma 29 years earlier, is reported. The patient, a heavy smoker, was admitted for evaluation of a left-side thoracic lesion discovered on a plain chest film. Bronchoscopy, CT scan and needle biopsy proved inconclusive for the diagnosis. Exploratory thoracotomy was necessary to establish the diagnosis. During the operation, a thoracic splenosis was confirmed. To date, only 28 cases of thoracic splenosis have been reported in the literature. The purpose of this report is to present a new case of splenosis of the thoracic cavity simulating intrathoracic neoplasm.

Endoscopic management of retained bile stones with an indwelling T-tube.

BACKGROUND: Endoscopic sphincterotomy (ES) is widely used for the treatment of residual bile duct stones in patients who had common bile duct (CBD) exploration and T-tube insertion. METHODS: In a 4-year period 45 patients were referred for endoscopic removal of residual bile duct stones. All patients had been operated 7-15 days earlier for choledocholithiasis and had a T-tube in the common bile duct (CBD). RESULTS: Four patients were excluded. Three patients had a periampullary carcinoma and the fourth patient had no residual stone seen at cholangiography. All patients had a successful ES, conventional in 34, precut-knife in 3, and with the rendezvous technique in 4 patients. In 24 patients, all having stones distal to the T-tube, complete clearance of the CBD was achieved during one session and the T-tube was removed after 48 h. In the remaining 17 patients (15 having stones proximal to the T-tube), the T-tube had to be removed first and following stone extraction, a plastic stent was inserted in the CBD. Complete bile duct clearance and stent removal was achieved in a second session 3-4 weeks later. There were no serious complications or biliary related symptoms after the procedures and after a mean follow-up period of 18 months. CONCLUSION: The endoscopic technique is safe and efficient for the treatment of residual stones after CBD exploration with a T-tube insertion, offering immediate cure compared to the percutaneous techniques. It is also an ideal method for the diagnosis of periampullary carcinomas.

Abdominal wall metastasis following treatment of rectal cancer.

We present a 60-year-old man with a metastatic subcutaneous lump in the left lower quadrant of the abdomen, from rectal cancer, which was treated three years earlier with low anterior resection of the rectum. Excision of the abdominal wall metastasis was accomplished with negative histological margins, but six months later a new abdominal wall mass was detected. The patient underwent surgery again, in which the abdominal wall metastasis was resected en bloc with adherent portion of small bowel, along with inguinal lymph node dissection. The patient's condition deteriorated 10 months after the initial diagnosis, presenting again with abdominal wall cancer and dying from disseminated peritoneal disease.

Locally recurrent rectal cancer after curative resection.

BACKGROUND: To determine the incidence of local recurrence, after curative resection for rectal cancer, with the application of total mesorectal excision (TME). PATIENTS AND METHODS: During the last ten years, 120 patients underwent curative resection for rectal cancer. As a rule, except for the cases that underwent high anterior resection, TME was applied. In terms of local relapse, routine TME, preoperative radiotherapy, tumour's stage, differentiation grade and number of positive nodes were taken into account. RESULTS: Eight patients (6.7%) presented with local relapse. At 5 years, 91.9% of patients were free of local recurrence and the actuarial disease-free survival was 81%. A significant association between routine TME, tumour's stage, differentiation grade, lymph node invasion and local recurrence was observed. Conversely, preoperative radiotherapy appeared to play no protective role. CONCLUSIONS: The curative resection of rectal cancer, with the application of TME, has led to a very low incidence of local relapse during the last few years.

Current treatment of colorectal liver metastases.

BACKGROUND: The aim of our study is to present our experience in the treatment of liver metastases in patients with colorectal cancer. PATIENTS AND METHODS: Between 1997 and 2003 a total of 12 patients with liver metastases from a primary colorectal cancer were treated in our department. They were 8 males and 4 females with a median age of 64 years (range 56-70 years). RESULTS: Ten patients underwent liver resection. The surgical procedures were 4 major hepatectomies (3 right hepatectomies, 1 left lobectomy) and 9 wedge liver resections. In total, 16 metastatic lesions were resected. Already at the time of the primary tumour, 5 patients presented with a synchronous liver metastasis. In 3 of them, liver metastasis was resected together with the primary tumour, and in the rest, resection was performed 1 month after the initial operation. In 5 patients liver metastases were metachronous and were diagnosed 3-14 months after the initial operation. The median survival of the patients was 39 months. Two patients (one with 2 metastatic lesions) underwent radiofrequency ablation (RFA) of the metachronous metastatic lesions and remain well 3-6 months postoperatively. CONCLUSIONS: Hepatectomy is the treatment of choice for hepatic metastasis of colorectal cancer, whenever feasible. Recent promising treatments such as RFA can further improve the outcome of these patients.

Effects of steroid on the healing of colonic anastomoses in the rat.

BACKGROUND: The aim of this experimental study was to evaluate the effects of steroid on colonic anastomosis in a rat model. METHODS: Forty female Wistar rats were randomised into two groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. In the rats of the control group 2 ml of solution 0.9% NaCl was injected once daily intraperitoneally perioperatively. Rats of the steroid group received intraperitoneally once daily, and on the same perioperative days, hydrocortisone (5 mg/kg body weight in 2 ml solution NaCl). All the rats were sacrificed on the 8th postoperative day and the anastomoses were examined macroscopically. The bursting pressure measurements were recorded and anastomoses were graded histologically. RESULTS: Dehiscence rate was significantly higher in the steroid group than in the control group (p<0.001). Mean bursting pressure was significantly lower in the steroid group compared to the control group (p<0.001). Colonic healing process assessed as inflammatory cell infiltration and collagen deposition was significantly lower in the steroid group than in the control group (p<0.001, p=0.03 respectively). CONCLUSIONS: Perioperative steroid treatment adversely affects healing of colonic anastomoses in the rat.

Is TNM classification related to early postoperative morbidity and mortality after colorectal cancer resections?

BACKGROUND: To examine the role of TNM staging system as a predictive factor for postoperative morbidity and mortality, after colorectal cancer resections. PATIENTS AND METHODS: During the last ten years, 368 patients with colorectal cancer were referred to our institution. All patients, who underwent primary treatment elsewhere or defunctioning colostomy only, or who did not undergo surgical therapy were excluded from the analysis. The early postoperative outcomes registration of the remaining 351 patients (197 men, median age 66.2 years) was retrospectively linked to TNM stage. RESULTS: TNM stage had a poor prognostic value for the early postoperative morbidity rate. In addition, according to the statistical analysis, the proportion of early postoperative mortality proved to be higher in patients with TNM stage III or IV colorectal cancer. CONCLUSIONS: TNM classification could be considered as a reliable predictor of early postoperative mortality, but has no role in the prediction of early postoperative morbidity after colorectal resections.

A comparison of the simultaneous application of sclerotherapy and rubber band ligation, with sclerotherapy and rubber band ligation applied separately, for the treatment of haemorrhoids: a prospective randomized trial.

OBJECTIVE: To compare simultaneous application of sclerotherapy and rubber band ligation, with sclerotherapy and rubber band ligation applied separately for the treatment of 2nd degree haemorrhoids. PATIENTS AND METHODS: Between 1993 and 1996, 255 patients that suffered from 2nd degree haemorrhoids were divided into 3 groups of 85 patients, each to receive either simultaneous sclerotherapy for smaller and rubber band ligation for larger piles (SCL/RBL) in one session, or sclerotherapy (SCL), or rubber band ligation (RBL), respectively. After a period of 4 years all patients were examined and their symptoms were recorded. RESULTS: The patients of the SCL group developed significantly fewer complications after treatment compared to the other two methods (P < 0.001), which did not differ from each other. After the SCL/RBL treatment, significantly more patients were symptom free (46%) than after SCL (8%), P < 0.001. There was no significant difference between the SCL/RBL (46%) and the RBL (31%) groups (P = 0.217), although the combined treatment seemed to be more effective than rubber band ligation. Only 10% of the patients of the SCL/RBL group needed additional sessions 6-24 months after the initial treatment compared to 30% of the patients of the SCL group (P = 0.001). However, there was no significant difference between SCL/RBL and RBL (17%) groups (P = 0.151). CONCLUSION: The combination of sclerotherapy and rubber band ligation for treatment of 2nd degree haemorrhoids is significantly more efficient than sclerotherapy on its own.

Management of bile duct injury during and after laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury (BDI) is perhaps the most feared complication of laparoscopic cholecystectomy (LC). Proper management of iatrogenic BDI is mandatory to avoid immediate or later life-threatening sequelae. The results of surgery depend mainly on the type of injury, prompt detection of the injury, and timing of the surgery. METHODS: Twelve patients with BDI after LC were treated. Eight of them were referred to our institution for further treatment. The follow-up evaluation was focused on clinical outcome and biochemical analysis. RESULTS: Five of the patients had minor BDI with leakage. In all of them, the BDI was recognized postoperatively. Two of these patients were managed by endoscopic retrograde cholongio pancreatographic sphincterotomy and stent placement. The other three patients underwent open laparotomy and bile duct ligation. Seven of the patients had major BDI. In two patients, biliary injuries were identified at the time of LC, and the procedure was converted to laparotomy. At the time of conversion, primary suture repair with T-tube drainage of the injured bile duct was performed. Strictures developed in these patients after 2 and 6 months, respectively, and they were treated with a Roux-en-Y hepaticojejunostomy. In five additional patients, BDI was recognized postoperatively. One of these patients died because of delayed detection of biliary peritonitis. At this writing, during a median follow-up period of 52 months, neither clinical nor biochemical evidence of biliary disease has been found in the remaining patients. CONCLUSIONS: Laparoscopic BDI has a high morbidity and mortality rate. Late recognition of the BDI remains a problem.

The endoscopic management of persistent bile leakage after laparoscopic cholecystectomy.

BACKGROUND: Bile leakage after laparoscopic biliary surgery is a surgical challenge in which endoscopy can play an important role. METHODS: A total of 26 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) in our department. Patients with evidence of major ductal injury were treated surgically. In all other cases, endoscopic sphincterotomy was performed, any retained bile duct stones were removed, and a biliary endoprosthesis or a nasobiliary catheter was inserted on a selective basis. RESULTS: ERCP was successful in 24 patients. Seven patients were treated surgically after cholangiography revealed major ductal injury. Two more patients were eventually operated on due to bile peritonitis. Of the other 15 patients, 11 had leakage from the cystic duct and four had leakage from the gallbladder bed. Bile duct stones were removed from eight patients, an endoprosthesis were inserted in five patients, and a nasobiliary catheter was inserted in two patients. Bile leakage was treated successfully in all 15 patients with no further complications. CONCLUSION: ERCP is a means of safe diagnosing the cause of a bile leakage and offers a definitive treatment in most cases.

Post-ERCP pancreatitis and hyperamylasemia: patient-related and operative risk factors.

BACKGROUND AND STUDY AIMS: Previous studies on the development of post-endoscopic retrograde cholangiopancreatography (post-ERCP) hyperamylasemia and pancreatitis have focused on different risk factors, either procedure- or patient-related, and also prognostic factors, such as amylase levels together with the occurrence of pancreatic-type pain, which might be implicated. The aim of this study is to identify possible predictive risk factors and also prognostic factors in order to better organize the treatment strategy. PATIENTS AND METHODS: During a 5-year period, 556 ERCP procedures were performed by the same operator. Of these, 43 procedures were excluded from the study. Data recorded from the procedures included both patient characteristics and procedure details. Patients were evaluated for pancreatic-type pain at 4 and 24 h after the procedure, and serum amylase levels were determined at 2 and 24 h after the procedure. Pancreatitis was diagnosed on the basis of both clinical and laboratory examination, while patients with hyperamylasemia were in a normal clinical condition but had high serum amylase levels. RESULTS: Post-ERCP pancreatitis occurred after 17 procedures (3.3%) and hyperamylasemia after 85 procedures (16.5%). Patients who developed pancreatitis all had pancreatic-type pain together with amylase levels higher than 4-5 times the upper normal limit at 24 h after ERCP. There was a significant association between serum amylase levels and post-procedure pancreatic-type pain both at 4 h and 24 h after ERCP (P = 0.006). Age less than 50 years, history of relapsing pancreatitis, pancreatic duct opacification, and difficulty in obtaining bile duct cannulation all proved to be significant predictive risk factors for the development of either hyperamylasemia or pancreatitis. In contrast, additional procedures and sphincterotomy seemed to reduce the likelihood of both complications. CONCLUSIONS: Serum amylase levels higher than 4 - 5 times the normal upper limit together with the existence of pancreatic-type pain, at 24 h after ERCP, strongly suggest the occurrence of pancreatitis. When any of the predictive risk factors coexist during a procedure it would be better either to abandon the procedure and try again later or, if the situation is urgent, to have earlier recourse to an alternative, such as precut or needle-knife papillotomy.

Stapled haemorrhoidectomy compared with Milligan-Morgan excision for the treatment of prolapsing haemorrhoids: a prospective study.

OBJECTIVE: To compare stapled haemorrhoidectomy with Milligan-Morgan haemorrhoidectomy. DESIGN: Prospective open study. SETTING: Teaching hospital, Greece. PATIENTS: 85 patients with prolapsing haemorrhoids were invited to choose between stapled and Milligan-Morgan haemorrhoidectomy. 48 chose the former and 37 the latter. INTERVENTIONS: Operation. Postoperatively, the patients were given analgesics on demand, and were discharged as soon as their condition and particularly their pain had improved. MAIN OUTCOME MEASURES: Patients' symptoms and their opinion about the procedures, which were recorded during their follow-up which lasted for 6 months. RESULTS: Stapling resulted in a significantly shorter operating time, and less postoperative pain and other symptoms, than Milligan-Morgan excision (p < 0.001). Postoperative complications, and mean time in hospital did not differ significantly between the two groups. During the follow-up period there was no significant difference in the incidence of recurrences between the two groups. Six months after the operation, significantly more patients in the stapled group had residual skin tags-external haemorrhoids than in the Milligan-Morgan group, and all these patients had fourth degree haemorrhoids. CONCLUSIONS: Stapled haemorrhoidectomy is a promising method of treatment for prolapsing third degree haemorrhoids. Its effectiveness is questionable for fourth degree ones. Initially, the results are as good as after Milligan-Morgan haemorrhoidectomy, especially for third degree haemorrhoids. However, more patients and longer follow-up periods are required for its long-term efficacy to be confirmed.