Prosthetic mesh placement for the prevention of parastomal herniation.

BACKGROUND: Parastomal herniation is a common problem following formation of a stoma after both elective and emergency abdominal surgery. Symptomatic hernias give rise to a significant amount of patient morbidity, and in some cases mortality, and therefore may necessitate surgical treatment to repair the hernial defect and/or re-site the stoma. In an effort to reduce this complication, recent research has focused on the application of a synthetic or biological mesh, inserted during stoma formation to help strengthen the abdominal wall. OBJECTIVES: The primary objective was to evaluate whether mesh reinforcement during stoma formation reduces the incidence of parastomal herniation. Secondary objectives included the safety or potential harms or both of mesh placement in terms of stoma-related infections, mesh-related infections, patient-reported symptoms/postoperative quality of life, and re-hospitalisation/ambulatory visits. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2018, Issue 1), Ovid MEDLINE (1970 to 11 January 2018), Ovid Embase (1974 to 11 January 2018), and Science Citation Index Expanded (1970 to 11 January 2018). To identify ongoing studies, we also searched the metaRegister of Controlled Trials (mRCT) on 11 January 2018. SELECTION CRITERIA: We considered for inclusion all randomised controlled trials (RCTs) of prosthetic mesh (including biological/composite mesh) placement versus a control group (no mesh) for the prevention of parastomal hernia. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies identified by the literature search for potential eligibility. We obtained the full articles for all studies that potentially met the inclusion criteria and included all those that met the criteria. Any differences in opinion between review authors were resolved by consensus. We pooled study data into a meta-analysis. We assessed heterogeneity by calculation of I2 and expressed results for each variable as a risk ratio (RR) with corresponding 95% confidence intervals (CI). We expressed continous outcomes as mean difference (MD) with corresponding 95% CIs. MAIN RESULTS: We included 10 RCTs involving a total of 844 participants. The primary outcome was overall incidence of parastomal herniation. Secondary outcomes were rate of reoperation at 12 months, operative time, postoperative length of hospital stay, stoma-related infections, mesh-related infections, quality of life, and rehospitalisation rate. We judged the risk of bias across all domains to be low in six trials. We judged four trials to have an overall high risk of bias.The overall incidence of parastomal hernia was less in participants receiving a prophylactic mesh compared to those who had a standard ostomy formation (RR 0.53, 95% CI 0.43 to 0.66; 10 studies, 771 participants; I2 = 69%; low-quality evidence). In absolute numbers, the incidence of parastomal hernia was 22 per 100 participants (18 to 27) receiving prophylactic mesh compared to 41 per 100 participants having a standard ostomy formation.There were no differences in the need for reoperation (RR 0.90, 95% CI 0.50 to 1.64; 9 studies, 757 participants; I2 = 0%; low-quality evidence); operative time (MD -6.50 (min), 95% CI -18.24 to 5.24; 6 studies, 671 participants; low-quality evidence); postoperative length of hospital stay (MD -0.95 (days), 95% CI -2.03 to 0.70; 4 studies, 500 participants; moderate-quality evidence); or stoma-related infections (RR 0.89, 95% CI 0.32 to 2.50; 6 studies, 472 participants; I2 = 0%; low-quality evidence) between the two groups.We were unable to analyse mesh-related infections, quality of life, and rehospitalisation rate due to sparse data or because the outcome was not reported in the included studies. AUTHORS' CONCLUSIONS: This Cochrane Review included 10 RCTs with a total of 844 participants. The review demonstrated a reduction in the incidence of parastomal hernia in people who had a prophylactic synthetic mesh placed at the time of the index operation compared to a standard ostomy formation. However, our confidence in this estimate is low due to the presence of a large degree of clinical heterogeneity, as well as high variability in follow-up duration and technique of parastomal herniation detection. We found the rate of stoma-related infection to be similar in both the intervention and control groups.

DNA hypermethylation as a predictor of extramural vascular invasion (EMVI) in rectal cancer.

PURPOSE: DNA hypermethylation in gene promoter regions (CpG islands) is emerging as an important pathway in colorectal cancer tumourigenesis. Whilst genetic mutations have been associated with extramural vascular invasion (EMVI) in rectal cancer, no such association has yet been made with epigenetic factors. METHODS: 100 consecutive neoadjuvant-naïve patients undergoing curative surgery for rectal were classified according to the presence or absence of EMVI on histopathological examination. DNA was extracted from tumours and subjected to bisulfite conversion and methylation-specific PCR to determine CIMP status (high, intermediate, or low; according to a validated panel of 8 genes). CIMP status was correlated with EMVI status, histopathological, clinical, and demographic variables, in addition to overall (OS) and disease free (DFS) survival. RESULTS: 51 patients were characterised as CIMP-low, 48 CIMP-intermediate, and one patient CIMP-high. EMVI-positivity was associated with CIMP-intermediate epigenotype (p < 0.001). Patients with EMVI-positive tumours were found to have significantly more advanced disease by pT, pN, and pAJCC categorisation (p = 0.002, p < 0.001, and = p < 0.001, respectively). EMVI-positivity was significantly associated with the requirement for adjuvant chemotherapy (p < 0.001), and worse DFS but not OS (p = 0.012 and p = 0.052). CONCLUSIONS: Given the association between CIMP-intermediate epigenotype and EMVI-positivity, and the subsequent disadvantage in pathological stage, requirement for adjuvant therapy and worse survival, tumour epigenotyping could potentially play an important role in personalising patients' cancer care. Further work is required to understand the mechanisms that underlie the observed effect, with the hope that they may provide novel opportunities for intervention and inform treatment decisions in rectal cancer.

Clinicopathological characteristics of colorectal cancer presenting under the age of 50.

OBJECTIVE: Previous studies suggest that colorectal cancer (CRC) presenting at a young age tends to be advanced, proximally located and associated with a poor outcome. The aim of this study was to analyse characteristics of CRC in a cohort under the age of 50. METHOD: A single centre retrospective cohort study of consecutive patients under the age of 50 receiving potentially curative resection was performed. Clinical and pathological data was collected from a prospectively maintained cancer registry database. Of 2799 patients having CRC resections between 2002 and 2013, 103 patients (3.6%) were under 50, with full survival data available on 98 (3.5%). An additional 7 patients under 50 had inoperable disease. The proportion of patients under 50 was constant throughout the study period. A group of 98 consecutive patients over the age of 50 undergoing surgery for colorectal cancer in the same centre was used for comparison. Just 7 patients (7%) had pathologically verified FAP or Lynch syndrome, although there was a high suspicion of Lynch syndrome in further 3 patients. CONCLUSION: There was a higher proportion of rectal cancer in the under 50s (p < 0.0001), although there was no significant difference in the staging of the disease or lymph node positivity. There was a greater incidence of poor differentiation in the younger patients, but there was no effect on 5-year overall survival (71.4%) which is much higher than in the reported literature. The majority of colorectal cancers presenting under the age of 50 were sporadic, and a higher proportion of rectal cancer was observed compared with the older patients, and as compared to the published literature on younger CRC patients. This paper adds to the literature by demonstrating that despite advanced stage at presentation of colorectal cancer requiring extended surgery and multimodal treatment, this young age group experienced good overall survival.

Laparoscopic resection of a gastric plasma cell granuloma: a case report.

Plasma cell granuloma, also known as inflammatory myofibroblastic tumour or inflammatory pseudotumour, is a nonneoplastic process characterized by an unregulated growth of inflammatory cells. It most commonly occurs in the lung and upper respiratory tract, and only six other cases of gastric plasma cell granuloma exist. There are no other cases of intragastric laparoscopic resection of this type of lesion. Here, we present a case of a 60-year-old gentleman who had gradual onset epigastric discomfort and was thought to have a gastrointestinal stromal tumour on gastroscopy. Subsequent imaging and laparoscopic transgastric resection of the lesion confirmed the presence of a plasma cell granuloma. We discuss the aetiologies, presentation, investigation, and treatment of this rare disorder and make recommendations on the management.

Patients with non-diagnostic hyperamylasaemia must be investigated and managed as per acute pancreatitis.

OBJECTIVES: The identification of hyperamylasaemia insufficient to confidently diagnose acute pancreatitis in patients with epigastric pain poses a clinical dilemma. The aim of this study was to identify a cohort of such patients and review their presentation, investigation and outcome. DESIGN: Patients admitted through the emergency surgical intake during a 12-month period with serum amylase levels of 100-400 IU/L were identified and case notes reviewed to confirm those presenting with upper abdominal pain. Subsequent radiological and biochemical investigations were recorded. PARTICIPANTS: A total of 25 patients with non-diagnostic hyperamylasaemia. SETTING: Ward patients in a University Hospital. MAIN OUTCOME MEASURES: Amylase level, eventual diagnosis, drug history. RESULTS: Twenty-five patients were identified with a mean age of 46.7 years. The median serum amylase level was 230 IU/L (range 102-358 IU/L). Twenty-two patients underwent transabdominal ultrasound at presentation, with gallstones identified in nine cases. The remaining three had documented gallstones and were awaiting elective cholecystectomy. Of the 13 patients with no evidence of cholelithiasis, six were taking medications known to cause pancreatitis, seven patients underwent computed tomography (CT) scans that identified chronic pancreatitis in three, and were non-diagnostic in four cases. These four patients underwent endoscopic ultrasound (EUS) evaluation of the biliary tree identifying microlithiasis in one but no pathology in the remaining three cases. CONCLUSIONS: Patients with hyperamylasaemia not diagnostic of pancreatitis should be carefully investigated, as gallstones will be identified in at least 50%. An accurate drug history is also invaluable.

Long-stem revision prosthesis for salvage of failed fixation of extracapsular proximal femoral fractures.

A retrospective review was made of radiographs and case notes of patients with failed fixation of extracapsular proximal femoral fractures subsequently managed with long-stem revision arthroplasty. Follow-up radiographs, objective scoring, mobility, and complications were assessed. Twenty five hips were managed with long-stem hip arthroplasty in 24 patients with a mean age of 73 years. The mean follow-up was 24 months. Patients received uncemented acetabular components and long-stem uncemented femoral implants. Complications included two intraoperative femoral fractures which were strut-grafted, three wound infections (one required washout), and one recurrent dislocation managed conservatively. Average postoperative Oxford Hip score was 29. We report a low complication rate and no specific implant related problems, with good functional outcome as evidenced by the outcome scores and mobility status following salvage arthroplasty.