Peritoneal bridging versus fascial closure in laparoscopic intraperitoneal onlay ventral hernia mesh repair: a randomized clinical trial.

BACKGROUND: Many patients develop seroma after laparoscopic ventral hernia repair. It was hypothesized that leaving the hernial sac in situ may cause this complication. METHODS: In this patient- and outcome assessor-blinded, parallel-design single-centre trial, patients undergoing laparoscopic intraperitoneal onlay mesh ventral hernia repair were randomized (1 : 1) to either conventional fascial closure or peritoneal bridging. The primary endpoint was the incidence of seroma 12 months after index surgery detected by CT, evaluated in an intention-to-treat analysis. RESULTS: Between September 2017 and May 2018, 62 patients were assessed for eligibility, of whom 25 were randomized to conventional closure and 25 to peritoneal bridging. At 3 months, one patient was lost to follow-up in the conventional and peritoneal bridging groups respectively. No seroma was detected at 6 or 12 months in either group. The prevalence of clinical seroma was four of 25 (16 (95 per cent c.i. 2 to 30) per cent) versus none of 25 patients in the conventional fascial closure and peritoneal bridging groups respectively at 1 month after surgery (P = 0·110), and two of 24 (8 (0 to 19) per cent) versus none of 25 at 3 months (P = 0·235). There were no significant differences between the groups in other postoperative complications (one of 25 versus 0 of 25), rate of recurrent hernia within 1 year (none in either group) or postoperative pain. CONCLUSION: Conventional fascial closure and peritoneal bridging did not differ with regard to seroma formation after laparoscopic ventral hernia repair. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03344575).

ANTECEDENTES: Tras la reparación laparoscópica de una eventración muchos pacientes desarrollan seromas. Se planteó la hipótesis de que dejar el saco herniario in situ puede ser causa de esta complicación. MÉTODOS: En este ensayo clínico unicéntrico, de grupos paralelos y ciego para el evaluador, se aleatorizaron (1:1) los pacientes en los que se realizó una reparación laparoscópica de una eventración mediante la colocación de una malla intraperitoneal (intraperitoneal onlay mesh, IPOM) con cierre convencional de la fascia o dejando el saco herniario. La variable principal fue la incidencia de seroma 12 meses después de la cirugía, detectada por tomografía computarizada. Se realizó el análisis por intención de tratamiento. RESULTADOS: Entre septiembre de 2017 y mayo de 2018, de 62 pacientes posibles, 25 se asignaron al grupo de cierre convencional y 25 al grupo en el que se dejaba el saco herniario. A los 6 y 12 meses de seguimiento, se perdieron un paciente de cada grupo. No se detectaron seromas en ninguno de los grupos a los 6 ó 12 meses. La prevalencia de seroma clínico a los 1 y 3 meses fue de 4/25 (16%, i.c. del 95% 2-30%) versus 0/25 pacientes (P = 0,110) y 2/24 (8%, i.c. del 95% 0-19%) versus 0/25 pacientes (P = 0,235) en el grupo de cierre fascial convencional versus el grupo en el que se dejó el saco peritoneal, respectivamente. No hubo diferencias significativas entre los grupos en otras complicaciones postoperatorias (1/25 versus 0/25), tasa de recidiva de la hernia al año (ninguna en ambos grupos), dolor postoperatorio o calidad de vida. CONCLUSIÓN: No hubo diferencias entre el cierre convencional de la fascia o dejando el saco herniario en la formación de un seroma tras la reparación laparoscópica de una eventración.

Effects of aging and cytokine blockade on inflammatory cachexia.

OBJECTIVE: To evaluate the role of aging and specific cytokine blockade in the etiology of cachexia caused by adjuvant arthritis (AA), a model of cytokine-associated cachexia. METHODS: AA was induced in Lewis rats using CFA. In Experiment 1, severity of AA and inflammatory cachexia was assessed in young (Y, age 2-6 months, n = 132) and old rats (O, age 18-22 months, n = 40). In Experiment 2, young rats were divided into 5 different intervention groups: Saline-injected (n = 66); CFA-injected (n = 78); CFA-injected and treated with IL-1 receptor antagonist (IL-1Ra, n = 18); CFA-injected and treated with soluble TNF receptor type I (sTNFrI, n = 27); and CFA-injected and treated with both IL-1Ra and sTNFrI (both treatments, n = 8). RESULTS: In Experiment 1, young Lewis rats developed more severe arthritis (mean joint score on day 21 = 5.1 +/- 0.3) compared to the old group (0.6 +/- 0.6, p < 0.0001). The young group with AA lost 2.1% of baseline total body weight loss compared to 13.8% total body weight gain in controls (p < 0.0001). In contrast, old rats injected with CFA lost as much weight (-11%) as age-matched saline injected controls (-13%, p > 0.05, n = 18, age 18-22 months). In Experiment 2, mean joint scores in rats treated with IL-1Ra, sTNFrI or both were higher then untreated rats injected with CFA (p < 0.0001). Despite this, rats given both IL-1Ra and sTNFrI lost less weight on day 16 (p < 0.01) and 21 (p < 0.002) than untreated rats or those rats treated with either IL-1Ra or sTNFrI. CONCLUSION: Lewis rats aged 2-6 months are more susceptible to developing AA than older rats (age range 18-22 months). Inhibition of both IL-1 and TNF is needed to mitigate AA-associated weight loss, and this effect is dissociated from the effect of such inhibition on joint inflammation.