Leonard F. Kroese

Reducing colorectal anastomotic leakage with tissue adhesive in experimental inflammatory bowel disease.

Background:Anastomotic leakage after gastrointestinal surgery remains a challenging clinical problem. This study aimed to investigate the effectiveness of TissuCol (fibrin glue), Histoacryl Flex (n-butyl-2-cyanoacrylate), and Duraseal (polyethylene glycol) on colorectal anastomotic healing during experimental colitis. Methods:We first performed colectomy 7 days after 10 mg trinitrobenzene sulfonic acid (TNBS)-induced colitis to validate a rat TNBS-colitis-colectomy model. Subsequently, this TNBS-colitis-colectomy model was used in 73 Wistar rats that were stratified into a colitis group (CG, no adhesive), a TissuCol group (TG), a Histoacryl group (HG), and a Duraseal group (DG). Anastomotic sealant was applied with one adhesive after constructing an end-to-end hand-sewn anastomosis. Clinical manifestations, anastomotic bursting pressure, and immunohistochemistry of macrophage type-one (M1) and type-two (M2) was performed on postoperative day (POD)3 or POD7. Results:TNBS-caused mucosal and submucosal colon damage and compromised anastomotic healing (i.e., abscess formation and low anastomotic bursting pressure). On POD3, higher severity of abscesses was seen in CG. Average anastomotic bursting pressure was 53.2 ± 35.5 mm Hg in CG, which was significantly lower than HG (134.4 ± 27.5 mm Hg) and DG (95.1 ± 54.3 mm Hg) but not TG (83.4 ± 46.7 mm Hg). Furthermore, a significantly higher M2/M1 index was found in HG. On POD7, abscesses were only seen in CG (6/9) but not in other groups; HG had the lowest severity of adhesion. Conclusions:We describe the first surgical IBD model by performing colectomy in rats with TNBS-induced colitis, which causes intra-abdominal abscess formation and compromises anastomotic healing. Anastomotic sealing with Histoacryl Flex prevents these complications in this model. Alternative activation of macrophages seems to be involved in its influence on anastomotic healing.

European Hernia Society guidelines on prevention and treatment of parastomal hernias

BackgroundInternational guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project.MethodsThe guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants.ResultsEnd colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed.ConclusionAn evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

Clinical, mechanical, and immunohistopathological effects of tissue adhesives on the colon: An in‐vivo study

BACKGROUND Tissue adhesives may be useful for sealing bowel anastomoses by preventing anastomotic leakage. Prior to clinical implementation, an in-depth analysis of the clinical and immunohistopathological effects of tissue adhesives on the target tissue and of the mechanical strength of the adhesive bond in an in vivo model is needed. MATERIALS AND METHODS In 84 rats, two bowel segments were glued using one of the following tissue adhesive: Bioglue, Gelatin-resorcinol-formaldehyde (GRF), Glubran 2, Histoacryl Flex, Omnex, Duraseal Xact, or Tissucol. Rats were followed for 7 or 28 days. Endpoints were clinical complication rate, mechanical strength, and immunohistopathological reactions. RESULTS Of the seven tissue adhesives, GRF and Bioglue showed the highest rates of bowel wall destruction and ileus and the most severe immunohistopathological tissue reactions at 7 and 28 days. Cyanoacrylates (Histoacryl Flex, Omnex, Glubran 2) showed high mechanical strength and mild immunohistopathological reactions at 7 and 28 days. Duraseal Xact and Tissucol were the most inert tissue adhesives, but exhibited low mechanical strength. At 28 days, mechanical strength was significantly correlated to CD8, CD68, and Ki67 cell counts. CONCLUSION Based on the clinical and immunohistopathological outcomes, GRF and Bioglue were found to be the least suitable tissue adhesives for colonic use. Duraseal Xact and Tissucol were inert but also showed low mechanical strength. Cyanoacrylates exhibited mild clinical and immunohistopathological effects while maintaining high strength, which makes them promising as colonic sealants.

Incidence, risk factors and prevention of stoma site incisional hernias: a systematic review and meta-analysis

Stoma reversal might lead to a stoma site incisional hernia. Recently, prophylactic mesh reinforcement of the stoma site has gained increased attention, supporting the need for accurate data on the incidence of and risk factors for stoma site incisional hernia and to identify high‐risk patients. The aim of this study was to assess incidence, risk factors and prevention of stoma site incisional hernias.

Oxygen therapies and their effects on wound healing

Oxygen is an important factor for wound healing. Although several different therapies investigated the use of oxygen to aid wound healing, the results of these studies are not unequivocal. This systematic review summarizes the clinical and experimental studies regarding different oxygen therapies for promoting wound healing, and evaluates the outcomes according the methodological details. A systematic literature search was conducted using Embase, Medline, Web of Science, Cochrane, PubMed publisher, and Google Scholar libraries. Clinical and experimental studies investigating oxygen for wound healing were selected. Included articles were categorized according to the kind of therapy, study design, and wound type. The methodological details were extracted and analyzed. Sixty‐five articles were identified and divided in three different oxygen therapies: Local oxygen therapy, hyperbaric oxygen therapy, and supplemental inspired oxygen therapy. More than half of the included local oxygen and hyperbaric oxygen studies had one or more significant positive outcomes, 77 and 63%, respectively. Supplemental inspired oxygen therapy during gastrointestinal and vascular surgery was more likely to have a positive result than during other surgical interventions reducing surgical site infections. These many positive outcomes promote the use of oxygen treatment in the stimulation of wound healing. However, the lack of clinical studies and vast methodological diversity made it impossible to perform a proper comparison within and between the different therapies. Further randomized clinical studies are warranted to examine the value of these therapies, especially studies that investigate the more patient‐friendly oxygen dressings and topical wound oxygen therapies. Also, to achieve more solid and consistent data, studies should use more standardized methods and subjects.

Primary and incisional ventral hernias are different in terms of patient characteristics and postoperative complications - A prospective cohort study of 4,565 patients

BACKGROUND Primary and incisional hernias are often pooled in publications studying hernia symptoms, treatment, or surgical outcomes. The question rises whether this is justified or if primary and incisional hernia should be considered as two separate entities. The aim of this prospective cohort study is to compare primary and incisional ventral hernias regarding patient characteristics, hernia characteristics, surgical characteristics, and postoperative complications. MATERIALS AND METHODS A registry-based, prospective cohort study was performed. All patients undergoing primary or incisional hernia repair surgery between September 1st, 2011 and February 29th, 2016 were included. Patient baseline characteristics, hernia characteristics, surgical characteristics, and postoperative outcomes were collected and analyzed. RESULTS A total of 4565 patients were included, of whom 2374 had a primary hernia and 2191 had an incisional hernia. All patient, hernia, and surgical characteristics were statistically significantly different between primary and incisional hernias except for corticosteroid use, history of inguinal hernia, incarceration, and emergency surgery. Overall complication rates (wound, surgical, and medical) were significantly different (105/2374 (4.4%) for primary hernia versus 323/2191 (15%) for incisional hernia, p < 0.001). CONCLUSION Primary and incisional hernia are statistically significantly different for almost all patient, hernia, surgical, and postoperative characteristics analyzed. Given these differences, data on primary hernias and incisional hernias should not be pooled in studies reporting on hernia repair.

External Validation of the European Hernia Society Classification for Postoperative Complications after Incisional Hernia Repair: A Cohort Study of 2,191 Patients

BACKGROUND Incisional hernia is a frequent complication after midline laparotomy. Surgical hernia repair is associated with complications, but no clear predictive risk factors have been identified. The European Hernia Society (EHS) classification offers a structured framework to describe hernias and to analyze postoperative complications. Because of its structured nature, it might prove to be useful for preoperative patient or treatment classification. The objective of this study was to investigate the EHS classification as a predictor for postoperative complications after incisional hernia surgery. STUDY DESIGN An analysis was performed using a registry-based, large-scale, prospective cohort study, including all patients undergoing incisional hernia surgery between September 1, 2011 and February 29, 2016. Univariate analyses and multivariable logistic regression analysis were performed to identify risk factors for postoperative complications. RESULTS A total of 2,191 patients were included, of whom 323 (15%) had 1 or more complications. Factors associated with complications in univariate analyses (p < 0.20) and clinically relevant factors were included in the multivariable analysis. In the multivariable analysis, EHS width class, incarceration, open surgery, duration of surgery, Altemeier wound class, and therapeutic antibiotic treatment were independent risk factors for postoperative complications. Third recurrence and emergency surgery were associated with fewer complications. CONCLUSIONS Incisional hernia repair is associated with a 15% complication rate. The EHS width classification is associated with postoperative complications. To identify patients at risk for complications, the EHS classification is useful.

Long term results of open complex abdominal wall hernia repair with self-gripping mesh: A retrospective cohort study

BACKGROUND In case of complex ventral hernias, Rives-Stoppa and component separation technique are considered as favourable treatment techniques. However, mesh-related complications like recurrence, infection and chronic pain are still a common problem after mesh repair. Previous studies have reported promising results of the use of a self-gripping mesh (ProGrip™) in incisional hernia repair. This study aimed to evaluate the long term results of this mesh for complex ventral hernia treatment. MATERIALS AND METHODS Patients with complex ventral hernia undergoing repair between June 2012 and June 2015, using the ProGrip™-mesh in retromuscular position, were included. All patients visited the outpatient clinic to evaluate short term complications and recurrence. After at least one year, telephone interviews were conducted to evaluate long term results. RESULTS A total of 46 patients (median age 59 years) were included. 40 patients (87%) were diagnosed with incisional hernia. Seven patients (18%) had incisional hernia combined with another hernia. Four patients (8.7%) had an umbilical hernia, one patient (2.2%) had an epigastric hernia and one patient (2.2%) had rectus diastasis. 39 patients completed follow-up. Median follow-up was 25 months (IQR: 19-35 months). 28 patients (72%) did not report any complaints. Nine patients reported pain (average VAS of 1.7). Two patients developed a recurrence requiring reoperation. One patient developed mesh infection requiring reoperation. CONCLUSION Long term results of the use of a self-gripping mesh for complex abdominal wall hernias show a low recurrence rate, even in complex hernia cases. This makes the mesh a good choice in this difficult patient group.

Identification of risk factors for 30-day postoperative complications in patients undergoing primary ventral hernia repair: a prospective cohort study of 2,374 patients

Background: Primary ventral hernia is a common condition. Surgical repair is associated with complications, but no clear predictive risk factors have been identified. The European Hernia Society classification offers a structured framework to describe hernias and to analyze postoperative complications. Given this structured nature, the European Hernia Society classification might prove useful for preoperative patient or treatment classification. The objective of this study was to investigate the European Hernia Society classification as a predictor for complications within 30 days after primary ventral hernia surgery. Methods: A registry‐based, prospective cohort study was performed, including all patients undergoing primary ventral hernia surgery between September 1, 2011 and February 29, 2016. Univariate analyses and multivariable logistic regression analysis were performed to identify risk factors for postoperative complications. Results: A total of 2,374 patients were included, of whom 105 (4.4%) patients had ≥1 complications, either a wound, surgical, or medical complication. Factors associated with complications in univariate analyses (P < .10) and clinically relevant factors were included into the multivariable analyses. In the multivariable analyses, age, body mass index, and the duration of the operation were independent risk factors. The diameter of the hernia was not an independent risk factor. Conclusion: Primary ventral hernia repair is associated with a 4.4% rate of complications. No correlation was found between the European Hernia Society classification and postoperative complications. Age, body mass index, and duration of the operation were correlated with postoperative complications. Therefore, age and body mass index should be used in the preoperative risk assessment.

Definitive Closure, Long-Term Results, and Management of Ventral Hernia

After treatment of open abdomen, large defects remain, often with loss of domain and without the possibility of tension-free closure. Loss of domain, in combination with other factors, increases the risk of complications after closure surgery.