Lucas Timmermans

Tissue adhesives in gastrointestinal anastomosis: a systematic review.

BACKGROUND Anastomotic leakage in gastrointestinal (GI) surgery remains a major problem. Although numerous studies have been undertaken on the role of tissue adhesives as GI anastomotic sealants, no clear overview has been presented. This systematic review aims to provide a clear overview of recent experimental and clinical research on the sealing of different levels of GI anastomosis with tissue adhesives. METHODS We searched MEDLINE and Embase databases for clinical and experimental articles published after 2000. We included articles only if these addressed a tissue adhesive applied around a GI anastomosis to prevent anastomotic leakage or decrease leakage-related complications. We categorized results according to level of anastomosis, category of tissue adhesive, and level of evidence. RESULTS We included 48 studies: three on esophageal anastomosis, 13 on gastric anastomosis, four on pancreatic anastomosis, eight on small intestinal anastomosis, and 20 on colorectal anastomosis; 15 of the studies were on humans. CONCLUSIONS Research on ileal and gastric/bariatric anastomosis reveals promising results for fibrin glue sealing for specific clinical indications. Sealing of pancreatico-enteric anastomosis does not seem to be useful for high-risk patients; however, research in this field is limited. Ileal anastomotic sealing was promising in every included study, and calls for clinical evaluation. For colorectal anastomoses, sealing with fibrin glue sealing seems to have more positive results than with cyanoacrylate. Further research should concentrate on the clinical evaluation of promising experimental results as well as on new types of tissue adhesives. This research field would benefit from a systematic experimental approach with comparable methodology.

Meta-analysis of sublay versus onlay mesh repair in incisional hernia surgery

BACKGROUND Incisional hernia (IH) remains a very frequent postoperative complication. The 2 techniques most frequently used are the onlay repair and sublay repair. However, it remains unclear which technique is superior. DATA SOURCES A meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of the nonrandomized studies was assessed using the Newcastle-Ottawa Scale. RESULTS Of 178 articles, 10 articles (2 randomized controlled trials, 1 prospective study, and 7 retrospective studies) comprising a total of 1,948 patients (775 onlay operations and 1173 sublay operations) were selected. Two of the studies scored below 5 points on the Newcastle-Ottawa Scale and were not selected. A trend was observed for IH recurrence in favor of sublay repair (odds ratio = 2.41; 95% confidence interval, .99 to 5.88; I(2) = 70%; P = .05). Surgical site infection occurred significantly less after sublay repair (odds ratio = 2.42; 95% confidence interval, 1.02 to 5.74; I(2) = 16%; P = .05). No difference was observed regarding seroma and hematoma. CONCLUSIONS Although the majority of the included studies were retrospective studies, sublay repair seems the preferred technique for IH repair.

Meta-analysis of glue versus sutured mesh fixation for Lichtenstein inguinal hernia repair

Chronic pain remains a frequent complication after Lichtenstein inguinal hernia repair. As a consequence, mesh fixation using glue instead of sutures has become popular. This meta‐analysis aimed to clarify which fixation technique is to be preferred for elective Lichtenstein inguinal hernia repair.

Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement versus primary suture only in midline laparotomies (PRIMA): 2-year follow-up of a multicentre, double-blind, randomised controlled trial

BACKGROUND Incisional hernia is a frequent long-term complication after abdominal surgery, with a prevalence greater than 30% in high-risk groups. The aim of the PRIMA trial was to evaluate the effectiveness of mesh reinforcement in high-risk patients, to prevent incisional hernia. METHODS We did a multicentre, double-blind, randomised controlled trial at 11 hospitals in Austria, Germany, and the Netherlands. We included patients aged 18 years or older who were undergoing elective midline laparotomy and had either an abdominal aortic aneurysm or a body-mass index (BMI) of 27 kg/m2 or higher. We randomly assigned participants using a computer-generated randomisation sequence to one of three treatment groups: primary suture; onlay mesh reinforcement; or sublay mesh reinforcement. The primary endpoint was incidence of incisional hernia during 2 years of follow-up, analysed by intention to treat. Adjusted odds ratios (ORs) were estimated by logistic regression. This trial is registered at ClinicalTrials.gov, number NCT00761475. FINDINGS Between March, 2009, and December, 2012, 498 patients were enrolled to the study, of whom 18 were excluded before randomisation. Therefore, we included 480 patients in the primary analysis: 107 were assigned primary suture only, 188 were allocated onlay mesh reinforcement, and 185 were assigned sublay mesh reinforcement. 92 patients were identified with an incisional hernia, 33 (30%) who were allocated primary suture only, 25 (13%) who were assigned onlay mesh reinforcement, and 34 (18%) who were assigned sublay mesh reinforcement (onlay mesh reinforcement vs primary suture, OR 0·37, 95% CI 0·20-0·69; p=0·0016; sublay mesh reinforcement vs primary suture, 0·55, 0·30-1·00; p=0·05). Seromas were more frequent in patients allocated onlay mesh reinforcement (34 of 188) than in those assigned primary suture (five of 107; p=0·002) or sublay mesh reinforcement (13 of 185; p=0·002). The incidence of wound infection did not differ between treatment groups (14 of 107 primary suture; 25 of 188 onlay mesh reinforcement; and 19 of 185 sublay mesh reinforcement). INTERPRETATION A significant reduction in incidence of incisional hernia was achieved with onlay mesh reinforcement compared with sublay mesh reinforcement and primary suture only. Onlay mesh reinforcement has the potential to become the standard treatment for high-risk patients undergoing midline laparotomy. FUNDING Baxter; B Braun Surgical SA.

Meta-analysis of primary mesh augmentation as prophylactic measure to prevent incisional hernia.

Background: Incisional hernia (IH) remains one of the most frequent postoperative complications after abdominal surgery. As a consequence, primary mesh augmentation (PMA), a technique to strengthen the abdominal wall, has been gaining popularity. This meta-analysis was conducted to evaluate the prophylactic effect of PMA on the incidence of IH compared to primary suture (PS). Methods: A meta-analysis was conducted according to the PRISMA guidelines. Randomized controlled trials (RCTs) comparing PMA and PS for closing the abdominal wall after surgery were included. Results: Out of 576 papers, 5 RCTs were selected comprising 346 patients. IH occurred significantly less in the PMA group (RR 0.25, 95% CI 0.12-0.52, I20%; p < 0.001). No difference could be observed with regard to wound infection (RR 0.86, 95% CI 0.39-1.91, I2 0%; p = 0.71) or seroma (RR 1.22, 95% CI 0.64-2.33, I2 0%; p = 0.55). A trend was observed for chronic pain in favor of the PS group (RR 5.95, 95% CI 0.74-48.03, I20%; p = 0.09). Conclusion: The use of PMA for abdominal wall closure is associated with significantly lower incidence of IH compared to PS.

Short-term results of a randomized controlled trial comparing primary suture with primary glued mesh augmentation to prevent incisional hernia

BACKGROUND Incisional hernia is one of the most frequent postoperative complications after abdominal surgery. Patients with an abdominal aortic aneurysm and patients with a body mass index of 27 or higher have an increased risk to develop incisional hernia. Primary mesh augmentation is a method in which the abdominal wall is strengthened to reduce incisional hernia incidence. This study focused on the short-term results of the PRImary Mesh Closure of Abdominal Midline Wounds trial, a multicenter double blind randomized controlled trial. METHODS Between 2009 and 2012 patients were included if they were operated via midline laparotomy, and had an abdominal aortic aneurysm or a body mass index of 27 or higher. Patients were randomly assigned to either receive primary suture, onlay mesh augmentation (OMA), or sublay mesh augmentation. RESULTS Outcomes represent results after 1-month follow-up. A total of 480 patients were randomized. During analysis, significantly (P = 0.002) more seromas were detected after OMA (n = 34, 18.1%) compared with primary suture (n = 5, 4.7%) and sublay mesh augmentation (n = 13, 7%). No differences were discovered in any of the other outcomes such as surgical site infection, hematoma, reintervention, or readmission. Multivariable analysis revealed an increase in seroma formation after OMA with an odds ratio of 4.3 (P = 0.004) compared with primary suture and an odds ratio of 2.9 (P = 0.003) compared with sublay mesh augmentation. CONCLUSIONS On the basis of these short-term results, primary mesh augmentation can be considered a safe procedure with only an increase in seroma formation after OMA, but without an increased risk of surgical site infection.

The principles of abdominal wound closure.

Abstract Background : Incisional hernia (IH) is a common complication of abdominal surgery. Its incidence has been reported as high as 39.9%. Many factors influence IH rates. Of these, surgical technique is the only factor directly controlled by the surgeon. There is much evidence in the literature on the optimal midline laparotomy closure technique. Despite the high level of evidence, this optimal closure technique has not met wide acceptance in the surgical community. In preparation of a clinical trial, the PRINCIPLES trial, a literature review was conducted to find the best evidence based technique for abdominal wall closure after midline laparotomy. Methods : An Embase search was performed. Articles describing closure of the fascia after midline laparotomy by different suture techniques and/or suture materials were selected. Results : Fifteen studies were identified, including five meta-analyses. Analysis of the literature showed significant lower IH rates with single layer closure, using a continuous technique with slowly absorbable suture material. No significant difference in IH incidence was found comparing slowly absorbable and non absorbable sutures. Furthermore, a suture length to wound length ratio of four or more and short stitch length significantly decreased IH rates. Conclusions : Careful analysis of the literature indicates that an evidenced based optimal midline laparotomy closure technique can be identified. This technique involves single layer closure with a running suture, using a slowly absorbable suture with a suture length to wound length ratio of four or more and a short stitch length. We adopt this technique as the PRINCIPLES technique.

Watchful waiting in incisional hernia: Is it safe?

BACKGROUND Incisional hernia (IH) is among the most common postoperative complications after abdominal surgery. Operative treatment (OT) using mesh is the treatment of choice. A strategy of watchful waiting (WW) might be a considered in some patients. This retrospective study compares the outcomes of WW and OT. METHODS All patients presenting with IH in an academic surgery department between January 2004 and December 2009 were analyzed according to whether they were treated by WW or OT. Crossovers between both groups were also analyzed. Patient characteristics, information about the initial abdominal operative procedure, symptoms at presentation, and characteristics of the hernia were collected retrospectively. In case of OT, postoperative complications were analyzed. RESULT In total, 255 patients were included; 151 (59%) in the OT group and 104 (41%) in WW group. The median follow-up was 68 months (interquartile range [IQR], 52-93). The reasons for WW were the absence of symptoms in 34 patients (33%), comorbidities in 24 (23%), and obesity in 23 (22%). During follow-up, 34 patients (33%) crossed over from WW to OT. Eight of the crossovers (24%) were emergency repairs owing to incarceration at a median of 1 month (IQR, 1-5) after the start of WW. The incidence of unexpected intraoperative intestinal perforation was greater in the crossover group (13%) compared with the OT group (2%; P = .002). Postoperative fistulas were seen in 7% of patients who crossed over from WW to OT versus 0% in primary OT (P = .002). Postoperatively, 3 patients died, 2 of whom were treated operatively after belonging initially to the WW group. CONCLUSION WW for IH leads to high crossover rates with significantly greater incidence of intraoperative perforations, fistulas, and mortality, than in the OT group, particularly in patients who require emergency repair of IH owing to incarceration.

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.

Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication

BackgroundComplications after thoracic surgery have well been established, pain being the most prominent. Intercostal nerves are mixed type nerves combining motor and sensory functions. This notion is not consistent with the incidence of PTPS compared to the incidence of muscle paresis or paralysis. We would hypothesize that abdominal wall paresis or paralysis is underdiagnosed.MethodsIn our hospital, three patients developed abdominal wall paralysis after thoracic surgery and consequent nerve damage. Their cases are discussed, and a review of the literature was conducted concerning (intercostal) nerve damage on a cellular level, the anatomy of the intercostal nerve, prevention of intercostal nerve damage and surgical techniques.ResultsA cellular cascade known as Wallerian degeneration and regeneration determine whether a damaged nerve can function again. The recovery of the nerve is highly dependent on the correct function of activated Schwann cells and macrophages and is related to the amount of damage that has taken place. The anatomy of the intercostal nerve makes it susceptible to injury. Retractor placement during open thoracic surgery has shown to effect compression injury and induced mechanical deformation and damage. Given the known factors of pathophysiology and anatomy, a number of preventive measures have been tested to reduce intercostal nerve damage. Several techniques have been proposed, but the most used technique, the video-assisted thoracic surgery, has been the most effective in reducing nerve damage.ConclusionAbdominal wall paralysis is an underdiagnosed complication after thoracic surgery. The amount of stress on the intercostal nerves could be reduced with less invasive techniques such as the VATS technique.