Chronic pain following totally extra-peritoneal inguinal hernia repair: a randomized clinical trial comparing glue and absorbable tackers.

PURPOSE: Chronic pain following inguinal hernia repair occurs in up to 20% of patients. The underlying mechanism probably involves sensory nerve damage and abnormal healing that might be influenced by the materials chosen for mesh fixation. The main objective of this study was to compare glue and absorbable tackers on the rate of chronic pain after surgery in patients undergoing totally extraperitoneal inguinal hernia repair (TEP). METHODS: Patients undergoing (TEP) inguinal hernia repair were enrolled in a single-blind randomized clinical trial and were randomized for mesh fixation with glue (LIQUIBAND FIX 8 Neopharm) or absorbable tackers (SECURE STRAP Johnson & Johnson). Pain was assessed using a validated 4-point verbal-rank scale (none, mild, moderate, and severe) at 1 week, 1 month, 6 months, and 1 year postoperatively. Chronic pain was defined as pain persisting beyond 3 months. RESULTS: Two hundred and eight patients were analyzed. The groups were similar in age, gender, and hernia side. Chronic pain of any intensity was reported in 31.7% (66/208) after 6 months and in 13% (29/208) after 12 months. No differences in postoperative pain were observed between the two forms of mesh fixation. Still, when only those with severe pain were considered, mesh fixation with glue resulted in less pain compared to fixation by tackers (log-rank p = 0.025). At 1 year, 4 symptomatic recurrent hernias were identified in patients whose mesh was fixated with absorbable tackers. CONCLUSIONS: Patients who underwent TEP inguinal hernia repair with mesh fixated by glue suffered from less pain.

Marginal ulcer causing delayed anastomotic perforation following one anastomosis gastric bypass (OAGB).

BACKGROUND: One anastomosis gastric bypass (OAGB) is gaining favor. Anastomotic perforation is a dreaded complication. OBJECTIVES: To describe a series of patients presenting with delayed (> 90 days) perforation of a marginal ulcer (MU) following OAGB. SETTING: Two university hospitals, Israel. METHODS: A retrospective query identifying patients after OAGB admitted with delayed MU perforation. Demographic characteristics, time between OAGB to presentation, clinical, laboratory and imaging at presentation and management data were collected. RESULTS: Between 1/2017-1/2020, 7 patients were identified. Mean body mass index (BMI) and time difference between OAGB and perforation were 14 kg/m2 (range 7-23) and 13 months (range 4-23), respectively. All presented with upper abdominal pain, 4 had concomitant nausea and vomiting. One patient displayed tachycardia, none had fever and 3 exhibited leukocyte abnormalities. C-reactive protein ranged widely (2-311 mg/L). Mean albumin level was 2.9 g/dL (range 1.9-4). Pneumoperitoneum was demonstrated in half of plain abdominal films and all computed tomography (CT) scans. Management was tailored to clinical status. Four patients underwent laparoscopic primary repair with omentopexy. Two patients were initially managed nonoperatively, one eventually requiring conversion to Roux-en-Y gastric bypass (RYGB) while the other recovered without further intervention. One patient underwent exploratory laparotomy and "damage control" management with pouch gastrostomy and double-barrel jejunostomy. Risk factors for MU were present in 4 cases. Mean length of hospital stay was 18 days (range 3-79 days). CONCLUSIONS: Perforation of MU may occur months to years after OAGB even without risk factors. Laboratory results are unreliable. The CT scan is diagnostic. A tailored approach can achieve good outcomes.

Clinical Outcome of Novel Reconstruction of Double Shouldering Technique after Proximal Gastrectomy.

Purpose: Various reconstruction methods have been proposed to reduce reflux after proximal gastrectomy, and we report here a double shouldering technique. The purpose of this study is to compare the novel double shouldering technique with conventional esophagogastrostomy in terms of short term and 3-year clinical outcome. Methods: A retrospective observational case control study was performed on 63 patients for cT1N0 upper third gastric cancer who underwent proximal gastrectomy from January 2012 to November 2016 at the National Cancer Center, Korea. There were 26 patients with conventional esophagogastrostomy, and 37 patients with novel double shouldering technique. The primary outcome was endoscopic reflux esophagitis findings one and three year after surgery according to Los Angeles classification. Secondary outcomes were short term surgical outcome and reflux symptom. Results: There was no significant difference in reflux esophagitis on endoscopic findings at 1 and 3 years after surgery between the two group. The double shouldering (DS) technique group showed significantly better postoperative outcomes with bile reflux at one and three years via endoscopic findings versus conventional esophagogastrostomy (CEG). Operative time and hospital stay were significantly shorter in the CEG group than the DS group. There was no significant difference in terms of reflux symptoms and complications. Conclusion: This novel DS technique is a reconstruction method for use after proximal gastrectomy. It did not show a significant clinical benefit. Development of surgical techniques and further study is needed to identify the optimal reconstruction method after proximal gastrectomy.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery.

BACKGROUND: Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges. METHODS: An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria. RESULTS: In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies. CONCLUSIONS: Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

A comparative study of totally laparoscopic distal gastrectomy versus laparoscopic-assisted distal gastrectomy in gastric cancer patients: Short-term operative outcomes at a high-volume center.

OBJECTIVE: Laparoscopic gastrectomy has been established as a standard treatment for early gastric cancer, and its use is increasing recently. Compared with the conventional laparoscopy-assisted distal gastrectomy (LADG), totally laparoscopic distal gastrectomy (TLDG) involves intracorporeal reconstruction, which can avoid the additional incision, resulting in pain reduction and early recovery. This study aimed to compare the short-term postoperative outcomes of TLDG vs. LADG in gastric cancer in a high-volume center. METHODS: A retrospective cohort study was conducted on 1,322 patients who underwent laparoscopic distal gastrectomy from June 2012 to June 2017 at the National Cancer Center, Korea. LADG was performed in the early period before July 2015, and TLDG was applied in the later period. Postoperative short-term outcomes were compared in terms of complication and clinical course between the two groups. Pain score was measured by rating the pain intensity from 0 to 10 points on postoperative day (POD) 1 and 3. RESULTS: A total of 667 patients underwent LADG and 655 patients underwent TLDG. Clinicopathologic characteristics were not different in both groups. Intraoperative estimated blood loss (EBL) was significantly lower in the TLDG group (P<0.001). Postoperative pain scores were significantly lower in the TLDG group than in the LADG group on POD 1 (5.1±1.5vs. 4.8±1.4, P=0.015). First flatus passage after operation was significantly earlier in the TLDG group (3.4±0.8 d vs. 3.2±0.6 d, P<0.001). There were no differences in postoperative complications and hospital stay between the two groups. CONCLUSIONS: Based on the reported short-term postoperative outcomes, TLDG is safe and feasible as well as LADG. Moreover, compared with LADG, TLDG can reduce intraoperative EBL and postoperative pain and enhance the bowel motility in gastric cancer surgery.