Eva B. Deerenberg

Small bites versus large bites for closure of abdominal midline incisions (STITCH): A double-blind, multicentre, randomised controlled trial

BACKGROUND Incisional hernia is a frequent complication of midline laparotomy and is associated with high morbidity, decreased quality of life, and high costs. We aimed to compare the large bites suture technique with the small bites technique for fascial closure of midline laparotomy incisions. METHODS We did this prospective, multicentre, double-blind, randomised controlled trial at surgical and gynaecological departments in ten hospitals in the Netherlands. Patients aged 18 years or older who were scheduled to undergo elective abdominal surgery with midline laparotomy were randomly assigned (1:1), via a computer-generated randomisation sequence, to receive small tissue bites of 5 mm every 5 mm or large bites of 1 cm every 1 cm. Randomisation was stratified by centre and between surgeons and residents with a minimisation procedure to ensure balanced allocation. Patients and study investigators were masked to group allocation. The primary outcome was the occurrence of incisional hernia; we postulated a reduced incidence in the small bites group. We analysed patients by intention to treat. This trial is registered at Clinicaltrials.gov, number NCT01132209 and with the Nederlands Trial Register, number NTR2052. FINDINGS Between Oct 20, 2009, and March 12, 2012, we randomly assigned 560 patients to the large bites group (n=284) or the small bites group (n=276). Follow-up ended on Aug 30, 2013; 545 (97%) patients completed follow-up and were included in the primary outcome analysis. Patients in the small bites group had fascial closures sutured with more stitches than those in the large bites group (mean number of stitches 45 [SD 12] vs 25 [10]; p<0·0001), a higher ratio of suture length to wound length (5·0 [1·5] vs 4·3 [1·4]; p<0·0001) and a longer closure time (14 [6] vs 10 [4] min; p<0·0001). At 1 year follow-up, 57 (21%) of 277 patients in the large bites group and 35 (13%) of 268 patients in the small bites group had incisional hernia (p=0·0220, covariate adjusted odds ratio 0·52, 95% CI 0·31-0·87; p=0·0131). Rates of adverse events did not differ significantly between groups. INTERPRETATION Our findings show that the small bites suture technique is more effective than the traditional large bites technique for prevention of incisional hernia in midline incisions and is not associated with a higher rate of adverse events. The small bites technique should become the standard closure technique for midline incisions. FUNDING Erasmus University Medical Center and Ethicon.

A multicenter randomized controlled trial evaluating the effect of small stitches on the incidence of incisional hernia in midline incisions

BackgroundThe median laparotomy is frequently used by abdominal surgeons to gain rapid and wide access to the abdominal cavity with minimal damage to nerves, vascular structures and muscles of the abdominal wall. However, incisional hernia remains the most common complication after median laparotomy, with reported incidences varying between 2-20%. Recent clinical and experimental data showed a continuous suture technique with many small tissue bites in the aponeurosis only, is possibly more effective in the prevention of incisional hernia when compared to the common used large bite technique or mass closure.Methods/DesignThe STITCH trial is a double-blinded multicenter randomized controlled trial designed to compare a standardized large bite technique with a standardized small bites technique. The main objective is to compare both suture techniques for incidence of incisional hernia after one year. Secondary outcomes will include postoperative complications, direct costs, indirect costs and quality of life.A total of 576 patients will be randomized between a standardized small bites or large bites technique. At least 10 departments of general surgery and two departments of oncological gynaecology will participate in this trial. Both techniques have a standardized amount of stitches per cm wound length and suture length wound length ratios are calculated in each patient. Follow up will be at 1 month for wound infection and 1 year for incisional hernia. Ultrasound examinations will be performed at both time points to measure the distance between the rectus muscles (at 3 points) and to objectify presence or absence of incisional hernia. Patients, investigators and radiologists will be blinded during follow up, although the surgeon can not be blinded during the surgical procedure.ConclusionThe STITCH trial will provide level 1b evidence to support the preference for either a continuous suture technique with many small tissue bites in the aponeurosis only or for the commonly used large bites technique.Trial registrationClinicaltrials.gov NCT01132209

Polyvinyl Alcohol Hydrogel Decreases Formation of Adhesions in a Rat Model of Peritonitis

BACKGROUND Adhesion formation after surgery for peritonitis-related conditions, with such associated complications as intestinal obstruction, pain, and infertility, remains an important problem. Applying a liquid barrier intra-peritoneally might reduce initial adhesion formation. METHODS A combination of the cecal ligation and puncture model of peritonitis with the side-wall defect (SWD) model of adhesion formation was performed. Forty rats were assigned randomly to receive no barrier or 1 mL or 2 mL of the cross-linked polyvinyl alcohol and carboxymethylcellulose (PVA/CMC) hydrogel A-Part(®) Gel (B. Braun Aesculap AG, Tuttlingen, Germany). After 14 days, the animals were sacrificed, and adhesion formation and abscess formation were scored. RESULTS Thirty animals survived, distributed equally among the groups. There were significantly fewer adhesions to the SWD in the PVA/CMC groups (median 0) than in the control group (median 26%-50%) (p<0.05). The median tenacity of the adhesions was significantly higher in the control group (Zühlke score 2) than in the PVA/CMC groups (Zühlke score 0) (p<0.05). The amount and size of intra-abdominal abscesses were not significantly different in the three groups. CONCLUSION In this experiment, PVA/CMC hydrogel reduced the amount of adhesions to the SWD and between viscera significantly with equal risk of abscess formation.

Postoperative adhesion prevention with a new barrier: an experimental study.

Introduction: Postoperative adhesion formation remains a major clinical problem. The aim of this study was to test the effect of a new hydrogel on adhesion formation in a rat model. Materials and Methods: A reproducible rat model was used to induce standardized adhesion formation in three experiments. In experiment 1, a cross-linked polyvinyl alcohol (PVA) and carboxymethylcellulose (CMC) hydrogel (PVA/CMC, A-Part®; B. Braun Aesculap, Germany) was tested in different dosages. In experiment 2, PVA/CMC gel was compared to icodextrin 4% (Adept®; Baxter USA). In both groups, animals were sacrificed after 2 weeks. In experiment 3, histological examination after 4 and 6 weeks was performed. The percentage of adhesions to the defect was measured and the density was determined according to the Zühlke scale. During histological examination of the abdominal wall, the formation of neoperitoneum and potential residues of the agents were assessed. Results: In experiment 1, a significant reduction in amount as well as density of the adhesions was visible with all dosages of PVA/CMC gel. In experiment 2, again quantity and density of the adhesions were diminished by PVA/CMC hydrogel compared to the control group. Icodextrin 4% showed no significant reduction in adhesion formation. In experiment 3, no residues of PVA/CMC gel or icodextrin 4% were found during histological examination after 4 and 6 weeks and neoperitoneum was present in all cases. Conclusion: PVA/CMC hydrogel appears to be a novel effective adhesion prevention agent. Together with an upcoming safety study, these data encourage to start clinical efficacy studies.

Parastomal hernia is an independent risk factor for incisional hernia in patients with end colostomy

BACKGROUND Incisional hernia (IH) is the most frequent complication after abdominal operation, with an incidence of 11-20% and up to 35% in risk groups. Known risk groups for IH are abdominal aortic aneurysm and obesity. Our hypothesis is that parastomal hernia (PH) might also represent a risk factor for developing IH. Identifying risk factors can help determine the need for preventive measures such as primary mesh augmentation. METHODS In a multicenter cross-sectional study, all patients who were operated between 2002 and 2010 by means of a Hartmann procedure or abdominoperineal resection were invited for a follow-up visit to our outpatient clinic. Primary outcome measures were the prevalence of IH and PH. All possible risk factors for IH were scored. A physical examination was performed and, when available, computed tomography was scored for IH and PH. RESULTS A total of 150 patients were seen in the outpatient clinic. The median follow-up was 49 months (range, 30-75). IH had a prevalence of 37.1%, and PH had a prevalence of 52.3% during physical examination. On CT the prevalence was even greater, ie, 48.3% and 52.9%. IH and PH were both present in the same patient in 30% of all examined and in 35.6% after CT examination. PH was found to be a risk factor for IH on univariate and multivariate logistic regression analyses of variance, with an odds ratio of 7.2 (95% confidence interval 3.3-15.7). In addition, an emergency operation was found to be a risk factor for IH with an odds ratio of 5.8 in the multivariate analyses. CONCLUSION Patients with a PH have a 7 times greater chance of developing an IH compared to patients without PH.

Role of endoscopic ultrasonography in patients suspected of pancreatic cancer with negative helical MDCT scan.

Background: In some patients suspected of pancreatic cancer, no mass can be detected by multidetector computed tomography (MDCT) scan as the cause of biliary obstruction. Methods: All patients suspected of pancreatic cancer between January 2007 and 2009 with a negative MDCT were identified from a database. Results: MDCT was performed for suspected pancreatic cancer in 290 patients, and in 258 a pancreatic mass was found. MDCT failed to establish a diagnosis in 32 patients (11%). In 23 patients (74%) with complete endoscopic ultrasonography (EUS), the cause of the obstruction was correctly diagnosed. A mass in the pancreatic head was found in 15 patients; 13 patients had a malignant tumor, and 2 patients a benign cause of obstruction. Further, EUS diagnosed 3 patients with a superficial adenoma of the papilla and 8 patients with a benign cause of the obstruction. In 5 patients EUS could not detect the cause of obstruction but finally a pancreatic malignancy was diagnosed. The positive predictive value of EUS was 86% and the negative predictive value 63%. Accuracy of MDCT and EUS decreased in the presence of pancreatitis or a biliary endoprosthesis. Conclusion: In patients suspected of pancreatic cancer in whom MDCT fails to demonstrate the cause of obstructive jaundice, EUS identifies 74% of the underlying diseases correctly.

Abdominal rectus muscle atrophy and midline shift after colostomy creation

INTRODUCTION Incisional hernia (IH) can be attributed to multiple factors. The presence of a parastomal hernia has shown to be a risk factor for IH after midline laparotomy. Our hypothesis is that this increased risk of IH may be caused by changes in biomechanical forces, such as midline shift to the contralateral side of the colostomy owing to decreased restraining forces at the site of the colostomy, and left abdominal rectus muscle (ARM) atrophy owing to intercostal nerve damage. METHODS Patients were selected if they underwent end-colostomy via open operation between 2004 and 2011. Patients were eligible if computed tomography (CT) had been performed postoperatively. If available, preoperative CTs were collected for case-control analyses. Midline shift was measured using V-scope application in the I-space, a CAVE-like virtual reality system. For the ARM atrophy hypothesis, measurements of ARM were performed at the level of colostomy, and 3 and 8 cm cranial and caudal of the colostomy. RESULTS Postoperative CT were available for 77 patients; of these patients, 30 also had a preoperative CT. Median follow-up was 19 months. A mean shift to the right side was identified after preoperative and postoperative comparison; from -1.3 ± 4.6 to 2.1 ± 9.3 (P = .043). Furthermore, during rectus muscle measurements, a thinner left ARM was observed below the level of colostomy. DISCUSSION Creation of a colostomy alters the abdominal wall. Atrophy of the left ARM was seen caudal to the level of the colostomy, and a midline shift to the right side was evident on CT. These changes may explain the increased rate of IH after colostomy creation.

Effects of New Anti-Adhesion Polyvinyl Alcohol Gel on Healing of Colon Anastomoses in Rats

BACKGROUND Adhesions follow abdominal surgery with an incidence as high as 95%, resulting in invalidating complications such as bowel obstruction, female infertility, and chronic pain. Searches have been performed for a safe and effective adhesion barrier; however, such barriers have impaired anastomotic site healing. The primary aim of this study was to investigate the effect of a new adhesion barrier, polyvinyl alcohol gel, on healing of colonic anastomoses using a rat model. METHODS Thirty-two Wistar rats were divided in two groups. In all animals, an anastomosis was constructed in the ascending colon. The first group received no adhesion barrier, whereas in the second group, 2 mL of polyvinyl alcohol gel (A-Part Gel(®); Aesculap AG, Tuttlingen, Germany) was applied circularly around the anastomosis. All animals were sacrificed on the seventh post-operative day, and the abdomen was inspected for signs of anastomotic leakage. The anastomotic bursting pressure, the adhesions around the anastomosis, and the collagen content of the excised anastomosis were measured. RESULTS No significant differences were observed between the two groups in the incidence of anastomotic leakage, the anastomotic bursting pressure (p=0.08), or the collagen concentration (p=0.91). No significant reduction in amount of adhesions was observed in the rats receiving polyvinyl alcohol gel. CONCLUSIONS This experimental study showed no significant differences in anastomotic leakage, anastomotic bursting pressure, or collagen content of the anastomosis when using the adhesion barrier polyvinyl alcohol around colonic anastomoses. The barrier did not prevent adhesion formation.

Mesh expansion as the cause of bulging after abdominal wall hernia repair

Highlights • Swelling of the abdominal wall after abdominal wall reconstruction can be caused by a recurrence or bulging of the mesh.• CT-scan can be useful to distinguish between a true recurrence or bulging of the mesh.• Bulging of a mesh can be caused by pore enlargement and expansion of the mesh.• The distinction between a recurrence and bulging of the mesh is therapeutically irrelevant in symptomatic patients.• Mesh characteristics should be considered when choosing a feasible and suitable mesh for abdominal wall reconstruction.

Herniation of the colon through the foramen of Winslow—A case report

Highlights • Herniation is rare and diagnostic delay increases mortality and morbidity.• Patients present with nonspecific acute abdominal pain.• Computed tomography helps early diagnosis and could thereby prevent bowel ischemia.• Herniation can be reversed laparoscopically without bowel resection in case of early diagnosis.