The use of botulinum toxin in the acute management of symptomatic complex incisional hernia: a case series.

PURPOSE: Complications of incisional hernia are amongst the commonest presentations to the emergency surgical take. Outcomes from emergency hernia repair are poor, particularly for those with complex defects and for the growing population of comorbid, high-risk patients. Attempts to avoid emergency surgery by improving success rates of non-operative management could prove hugely beneficial. Botulinum toxin A (Botox) is already used in the elective management of incisional hernia and this study evaluates if the relaxation produced could be used to augment the outcomes of conservative management of acutely presenting incisional hernia. METHODS: Patients presenting between October 2020 and April 2022 without evidence of visceral ischaemia, who had been selected for a non-operative approach, were given 300 units of Botox under image guidance to the abdominal wall in addition to standard conservative measures. RESULTS: Twelve patients were eligible for Botox administration. Median age was 75 years and median BMI was 36.45 kg/m2. All patients were high risk; minimum ASA score was 3, and median frailty score was 5. In ten patients, symptoms resolved following Botox allowing for discharge without further complication. Seven subsequently referred on to the abdominal wall team. Symptoms did not settle in the two remaining patients; one required emergency laparotomy and the second was palliated. CONCLUSION: Botox may be a useful adjunct to established non-operative measures in patients with acute presentations of incisional hernia. It may improve the acute symptoms, eliminate the need for high-risk emergency surgery, or provide a bridge to abdominal wall reconstruction.

Inguinoscrotal hernias containing stomach: risk of emergency presentation.

INTRODUCTION: Inguinoscrotal hernias are the commonest form of abdominal wall hernia, but for them to contain stomach is extremely rare. The management of these hernias can be very challenging owing to their acute nature of presentation and distortion of anatomy. Our aim was to systematically review the literature for all reported cases of inguinoscrotal hernias containing stomach. In turn we analysed patient demographics, site of hernia, presentation and treatment. Outcomes were reviewed where available. METHOD: We conducted a systematic search of the PUBMED, Embase and Medline databases with a combination of keywords: Hernia AND (inguin* OR scrot*) AND (gastric OR gastro*). An author's own case has also been included. RESULTS: There were 20 case reports included in the review, plus the author's own case. They ranged in publication date from 1942 to 2020. Mean age at presentation was 71 years (range 49 to 87). All cases were male. In total, 62% (n = 13) of cases presented with combined symptoms of abdominal pain and vomiting, 48% (n = 10) presented with gastric outlet obstruction (GOO) and 48% (n = 10) presented with gastric perforation. All successfully treated cases with gastric perforation required a midline laparotomy approach, whereas 56% (n = 5) of patients in the GOO group were successfully treated conservatively. There were three deaths reported in this review, all in the gastric perforation group. CONCLUSION: Stomach as a content of inguinoscrotal hernias is extremely rare. These hernias predominantly present acutely in the form of GOO or gastric perforation. All patients with gastric perforation will require a midline laparotomy. Patients with GOO can be successfully managed either surgically or in selective cases with conservative management.

Analysis of 11 years of clinical negligence claims in esophagogastric cancer in England.

In the National Health Service (NHS), clinical negligence claims and associated compensations are constantly rising. The aim of this study is to identify the size, trends, and causes of litigations claims in relation to esophagogastric (EG) cancer in the NHS. Data requests were submitted to the NHS Litigation Authority (NHSLA) for the period of January 2003 to December 2013. Data were reviewed, categorized clinically, and analyzed in terms of causes and costs behind claims. In this time period, there were 163 claims identified from the NHSLA database. Ninety-five (58.3%) claims were successful with a pay out of £6.25 million. An increasing overall claim frequency and success rate were found over the last few years. Majority of the claims were from gastric cancer 84 (88.4%). The commonest cause of complaint in successful claims was delay or failure in diagnosis (21.1%) and treatment (17.9%). There were only 10.5% successful intraoperative claims, of which 50% were due to unnecessary or additional procedures. The frequency and success rates of malpractice claims in EG cancer are rising. The failure or delay in diagnosing and treatment in EG malignancy are the common cause for successful litigation claims. The findings further reinforce the need to improve early diagnosis.

Meta-analysis of the diagnostic accuracy of laparoscopic ultrasonography and intraoperative cholangiography in detection of common bile duct stones.

Introduction During laparoscopic cholecystectomy, intraoperative cholangiography (IOC) is currently regarded as the gold standard in the detection of choledocholithiasis. Laparoscopic ultrasonography (LUS) is an attractive alternative with several potential advantages. Methods A systematic review was undertaken of the published literature comparing LUS with IOC in the assessment of common bile duct (CBD) stones. Results Twenty-one comparative studies were analysed. There were 4,566 patients in the IOC group and 5,044 in the LUS group. The combined sensitivity and specificity of IOC in the detection of CBD stones were 0.87 (95% confidence interval [CI]: 0.83-0.89) and 0.98 (95% CI: 0.98-0.98) respectively with a pooled area under the curve (AUC) of 0.985 and a diagnostic odds ratio (OR) of 260.65 (95% CI: 160.44-423.45). This compares with a sensitivity and specificity for LUS of 0.90 (95% CI: 0.87-0.92) and 0.99 (95% CI: 0.99-0.99) respectively with a pooled AUC of 0.982 and a diagnostic OR of 765.15 (95% CI: 450.78-1,298.76). LUS appeared to be more successful in terms of coming to a clinical decision regarding CBD stones than IOC (random effects, risk ratio: 0.95, 95% CI: 0.93-0.98, df=20, z=-3.7, p<0.005). Furthermore, LUS took less time (random effects, standardised mean difference: 0.95, 95% CI: 0.93-0.98, df=20, z=-3.7, p<0.005). Conclusions LUS is comparable with IOC in the detection of CBD stones. The main advantages of LUS are that it does not involve ionising radiation, is quicker to perform, has a lower failure rate and can be repeated during the procedure as required.

A novel technique for modified onlay incisional hernia repair with mesh incorporation into the fascial defect: a method for addressing suture line failure.

PURPOSE: Biological mechanisms such as abnormal wound healing and impaired scar formation are important aetiological factors in the development of abdominal wall hernias. Standard onlay repair often involves suture closure of the fascial defect with placement of the mesh over this closed defect. This has the disadvantage that suture line failure may occur early in the healing process and predispose to recurrence. Our technique aims to overcome this by incorporating the mesh into the fascial closure. The aim of this retrospective study was to audit recurrence rate and surgical complications relating to this modified repair. METHODS: This study included all patients undergoing incisional hernia repair over a 5-year period under a single consultant. An initial stitch was taken through the Ultrapro(TM) mesh and fascia on one side of the defect followed by the fascia and mesh on the other side. By repeating this process with a continuous suture, the mesh was incorporated into the fascial defect closure. Telephone survey was performed, and where there was suspicion of a recurrence patients were brought back to the outpatient clinic. RESULTS: The study included 72 patients with a median follow-up of 29 months. There was a 7 % recurrence rate and a 10 % minor complication rate, with no patient requiring readmission or mesh removal. In 70 % of patients the procedure was performed as a day case and 90 % were satisfied with the repair. CONCLUSIONS: This is a promising new technique that aims to address suture line failure and the significant recurrence rate that occurs with incisional hernia repair.

Meta-analysis of randomized controlled trials comparing lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair.

PURPOSE: Lichtenstein inguinal hernia repair is associated with a low incidence of recurrence; however, the use of heavyweight mesh has been linked with chronic pain and foreign body sensation. It is hypothesized that the use of lightweight mesh may reduce these problems. This study aims to use meta-analysis to compare lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair. METHODS: Information was gathered from randomized controlled trials that compared lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair. The Cochrane Library, Medline, EMBASE, trial registries, conference proceedings and reference lists were searched. Primary outcome measures were chronic pain, foreign body sensation and hernia recurrence. Secondary outcome measures were duration of surgery, mean visual analogue scale (VAS) pain scores, surgical-site infection, testicular atrophy and haematoma/seroma. The pooled Peto odds ratio (OR) was calculated for categorical data and weighted mean difference (WMD) for continuous data. RESULTS: Six trials with 1936 hernias were included. Lightweight mesh was associated with reduced chronic pain (OR = 0.67, 95% CI = 0.50-0.90; p < 0.01) and foreign body sensation (OR = 0.43, 95% CI = 0.21-0.93; p < 0.05). Lightweight mesh was also associated with lower VAS pain scores at 3 months after surgery (WMD = -0.35, 95% CI = -0.39 to -0.31; p < 0.0001). There were no differences in hernia recurrence (OR = 1.19, 95% CI = 0.54-2.64; p = 0.66) or other post-operative complications between the two groups. CONCLUSIONS: The use of lightweight mesh in Lichtenstein inguinal hernia repair is associated with less chronic pain, and foreign body sensation compared with heavyweight mesh without any difference in recurrence.

The role of ultrasound scan in the diagnosis of occult inguinal hernias.

AIMS: The aim of this study is to examine the role of ultrasound in conjunction with clinical judgment in diagnosing occult inguinal hernias in patients with groin pain. METHODS: The study involved a retrospective analysis of 297 patients who presented over an 18 month period from January 2007 to August 2008. All the patients presented to outpatient clinic with groin pain but a normal or equivocal clinical examination. Data was obtained from hospital records, radiology system and operation notes. RESULTS: 167 examinations (56%) were positive for a hernia, as a result of which 116 patients underwent surgery. At surgery, a hernia was found in 85 cases and no hernia was found in 31 cases. 130 examinations (44%) were negative for hernia. Six patients proceeded to surgery despite a negative ultrasound due to ongoing pain and a hernia was found in 5 cases. Overall, correlation with surgical findings showed ultrasound to have a sensitivity of 94%. Ultrasound used with clinical judgment has a positive predictive value of 73%. CONCLUSIONS: Ultrasound scan alone in diagnosing groin hernias is not effective when correlated with operative findings. However in conjunction with clinical judgment it is a useful tool in diagnosing occult inguinal groin hernias and aiding in further management.

Meta-analysis of the use of glyceryl trinitrate ointment after haemorrhoidectomy as an analgesic and in promoting wound healing.

INTRODUCTION: Glyceryl Trinitrate (GTN) ointment has been used to treat anal fissure and pain relief in haemorrhoids, but the value of its use post-haemorrhoidectomy as an analgesic and in wound healing is unclear. The side effect of headache has often been an associated problem. Therefore, a meta-analysis of randomised controlled trials was carried out investigating the role of GTN post-haemorrhoidectomy as an analgesic, its role in would healing and the unwanted incidence of headache. METHOD: A structured literature search from 1966 to 2009, both paper and online, with no language barrier was carried out. 760 papers were identified and 5 randomised control trials which met the entry criteria were included in this study. RESULTS: A total of 333 patients were included in the meta-analysis. The results revealed that GTN ointment was statistically significant in reducing pain on Day 3 and 7 compared to the placebo group. Day 3 shows a pain score of - 1.51 (p value of 0.029) and Day 7 by - 1.66 (p value of 0.014) respectively. However, it was not significant in reducing pain on Day 1. The Odds ratio for wound healing after GTN treatment at 3 weeks was 3.57 (P < 0.0001) when compared to the placebo group. Side effect of headache was not statistically significant. CONCLUSION: This meta-analysis has shown that GTN ointment used post-haemorrhoidectomy has a significant analgesic effect in the intermediate time period (ie. Days 3-7). It also significantly improved wound healing at 3 weeks.

Incarcerated lumbar hernia: a rare presentation.

This case illustrates the diagnostic uncertainty seen in lumbar herniation as a rare cause of large bowel obstruction.

Crohn's disease of the vulva.

Crohn's involvement of the Vulva is unfamiliar and difficult to treat. The aim is to review the presentation, clinical course and different treatments of Vulva Crohn's disease (CD). We have reviewed the literature without language barrier from 1966 to 2009 through Pubmed with the following words: vulva and CD, vulvitis and CD, genital CD. We included articles that had Crohn's involvement of the vulva arising from a distant site (metastatic) or arising from a Crohn's fistula from the perineum and/or anorectum. We excluded CD of other gynaecological organs. One hundred thirty six abstracts were identified and related articles reviewed. Fifty-five cases of CD of the vulva were included in the final anlaysis of this review. Vulva involvement is rare and gives long-term discomfort. A combined medical therapy (metronidazole with prednisolone) appears to be the most effective treatment. The surgical approach should be reserved for non-responding cases. CD is often unrecognized cause of vulva pain and difficult to diagnose. However if diagnosed and adequately treated it usually responds to conservative therapies.