A systematic review of the surgical treatment of large incisional hernia.

PURPOSE: Incisional hernia (IH) is one of the most frequent postoperative complications. Of all patients undergoing IH repair, a vast amount have a hernia which can be defined as a large incisional hernia (LIH). The aim of this study is to identify the preferred technique for LIH repair. METHODS: A systematic review of the literature was performed and studies describing patients with IH with a diameter of 10 cm or a surface of 100 cm2 or more were included. Recurrence hazards per year were calculated for all techniques using a generalized linear model. RESULTS: Fifty-five articles were included, containing 3,945 LIH repairs. Mesh reinforced techniques displayed better recurrence rates and hazards than techniques without mesh reinforcement. Of all the mesh techniques, sublay repair, sandwich technique with sublay mesh and aponeuroplasty with intraperitoneal mesh displayed the best results (recurrence rates of <3.6%, recurrence hazard <0.5% per year). Wound complications were frequent and most often seen after complex LIH repair. CONCLUSIONS: The use of mesh during LIH repair displayed the best recurrence rates and hazards. If possible mesh in sublay position should be used in cases of LIH repair.

Local ischaemia does not influence anastomotic healing: an experimental study.

The role of local ischaemia in the pathogenesis of colorectal anastomotic leakage (AL) is not known. This study investigates the role of local ischaemia caused by sutures in an experimental colonic anastomosis model. 36 mice were assigned to three types of anastomosis, all using running sutures; in the first group 5 stitches were used, in the second group 12 stitches were used, and in the third group at least 30 stitches were used. After 7 days the mice were re-operated, signs of AL were scored, and coronal sections of the anastomosis were histologically analyzed. The distribution of weight was not significantly different between the three groups. Mortality was 44% and not significantly different between the groups (group 1: 5/12, group 2: 4/12, and group 3: 7/12, p = 0.72). Faecal and purulent AL were observed in 6 animals in group 1, 2 in group 2, and 3 in group 3 (group 1: 50%, group 2: 17%, and group 3: 25%, p = 0.19). The distance between the two colonic edges (group 1: 0.51 µm, group 2: 1.34 µm, and group 3: 0.53 µm, p = 0.18), the diameter of the lumen at the site of the anastomosis (group 1: 2.92 µm, group 2: 4.06 µm, and group 3: 3.2 µm, p = 0.9), and the largest diameter of the lumen proximally to the anastomosis (group 1: 2.05 µm, group 2: 3.1 µm, and group 3: 2.6 µm, p = 0.25) were not different between the groups. Histological parameters of wound healing were not significantly different for the three groups. In this study no macroscopic and microscopic differences were observed between colon anastomosis with 5 stitches versus 12 and >30 stitches. This might indicate that local ischaemia does not negatively influence colonic wound healing.

The influence of mechanical bowel preparation in elective colorectal surgery for diverticulitis.

BACKGROUND: Mechanical bowel preparation (MBP) has been shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in elective surgery in combination with an inflammatory component such as diverticulitis is yet unclear. This study evaluates the effects of MBP on anastomotic leakage and other septic complications in 190 patients who underwent elective surgery for colonic diverticulitis. METHODS: A subgroup analysis was performed in a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP in elective colorectal surgery. Primary endpoint was the occurrence of anastomotic leakage in patients operated on for diverticulitis, and secondary endpoints were septic complications and mortality. RESULTS: Out of a total of 1,354 patients, 190 underwent elective colorectal surgery (resection with primary anastomosis) for (recurrent or stenotic) diverticulitis. One hundred and three patients underwent MBP prior to surgery and 87 did not. Anastomotic leakage occurred in 7.8 % of patients treated with MBP and in 5.7 % of patients not treated with MBP (p = 0.79). There were no significant differences between the groups in septic complications and mortality. CONCLUSION: Mechanical bowel preparation has no influence on the incidence of anastomotic leakage, or other septic complications, and may be safely omitted in case of elective colorectal surgery for diverticulitis.

Treatment of colorectal anastomotic leakage: results of a questionnaire amongst members of the Dutch Society of Gastrointestinal Surgery.

Anastomotic leakage after colorectal surgery is correlated with considerable morbidity and mortality. Although many studies focus on risk factors and detection, studies on the treatment strategy for colorectal anastomotic leakage are scarce. A national questionnaire amongst 350 members of the Dutch Society for Gastrointestinal Surgery was undertaken on the current treatment of colorectal anastomotic leakage. The response was 40% after two anonymous rounds. 27% of the respondents state that a leaking anastomosis above the level of the promontory should be salvaged in ASA 1-2 patients <80 years of age, for ASA 3 and/or >80 years of age this percentage is 7.3%. For an anastomosis under the promontory, 50% of the respondents choose preserving the anastomosis for ASA 1-2 compared to 17% for ASA 3 and/or >80 years of age. In ASA 1-2 patients with a local abscess after a rectum resection without protective ileostomy, 31% of the respondents will create an protective ileostomy, 40% break down the anastomosis to create a definite colostomy, in ASA 3 and/or >80 years of age 14% of the respondents create a protective ileostomy and 63% a definitive colostomy. In ASA 1-2 patients with peritonitis after a rectum resection with deviating ileostomy, 31% prefer a laparotomy for lavage and repair of the anastomosis, 25% for lavage without repair and 36% of the respondents prefer to break down the anastomosis. When the patient is ASA 3 and/or >80 years of age, 13% prefer repair, 9% a lavage and 74% breaking down the anastomosis. This questionnaire shows that in contrast to older people, more surgeons make an effort to preserve the anastomosis in younger people.

The importance of portal venous blood flow in ischemic-type biliary lesions after liver transplantation.

Ischemic-type biliary lesions (ITBL) are the most frequent cause of nonanastomotic biliary strictures after liver transplantation. This complication develops in up to 25% of patients, with a 50% retransplantation rate in affected patients. Traditionally, ischemia-reperfusion injury to the biliary system is considered to be the major risk factor for ITBL. Several other risk factors for ITBL have been identified, including the use of liver grafts donated after cardiac death, prolonged cold and warm ischemic times and use of University of Wisconsin preservation solution. In recent years however, impaired microcirculation of the peribiliary plexus (PBP) has been implicated as a possible risk factor. It is widely accepted that the PBP is exclusively provided by blood from the hepatic artery, and therefore, the role of the portal venous blood supply has not been considered as a possible cause for the development of ITBL. In this short report, we present three patients with segmental portal vein thrombosis and subsequent development of ITBL in the affected segments in the presence of normal arterial blood flow. This suggests that portal blood flow may have an important contribution to the biliary microcirculation and that a compromised portal venous blood supply can predispose to the development of ITBL.