Nasra N. Alam

Systematic review of guidelines for the assessment and management of high-grade anal intraepithelial neoplasia (AIN II/III)

There is ambiguity with regard to the optimal management of anal intraepithelial neoplasia (AIN) III. The aim of this review was to assess and compare international/national society guidelines currently available in the literature on the management, treatment and surveillance of AIN III. We also aimed to assess the quality of the studies used to compile the guidelines and to clarify the terminology used in histological assessment.

A systematic review of new treatments for cryptoglandular fistula in ano

AIM In 2007 the ACPGBI published a position statement on the management of cryptoglandular fistula in ano. Over the last seven years a number of new treatments have been developed and the aim of this systematic review was to assess their effectiveness. METHOD A systematic review of all English language literature relevant to novel treatment strategies for cryptoglandular fistula in ano, published between 1 January 2007 and 31 Dec 2014 was carried out using MEDLINE (PubMed and Ovid), EMBASE (Ovid) and the Cochrane Library of Systematic Reviews/Controlled Trials for relevant literature. Technical notes, commentaries, letters and meeting abstracts were excluded. The different treatments were assessed with regards to fistula closure rate in relation to length of follow up and reported complications. RESULTS Seventy potential articles published between 1 January 2007 and 31 December 2014 were identified from the initial literature search. Twenty-one articles were included for final analysis although only two were randomized controlled trials, the remainder being retrospective or prospective series. CONCLUSION This systematic review has demonstrated that whilst there have been technological advances to treat complex cryptoglandular fistula in ano, these are in an early stage of evolution and although early results were promising they are difficult to reproduce. Longer follow up data is not currently available and these treatments should not be introduced without further evidence.

Delayed absorbable synthetic plug (GORE® BIO-A®) for the treatment of fistula-in-ano: a systematic review.

Recent advances in the treatment of fistula‐in‐ano have focused on surgical techniques that preserve sphincter integrity. Plugs that obliterate the lumen of the fistula track have been proposed as one such method, and may be derived from biological or delayed absorbable synthetic materials. Biological plugs have highly variable results and have not been widely adopted. The aim of this systematic review was to assess the effectiveness and safety of a delayed absorbable synthetic plug (GORE® BIO‐A®) for treatment of anal fistula.

Biological Meshes for Inguinal Hernia Repair - Review of the Literature.

Introduction Biological meshes are a potential alternative to the synthetic meshes to avoid complications and are used in a contaminated field for incarcerated inguinal hernias. The clinical experiences gained with biological meshes for repair of inguinal hernias are presented in this review. Materials and methods In a literature search of the Medline database using the key word “Biological mesh,” 2,277 citations were found. There remained 14 studies in which biological meshes had been used to repair inguinal hernias. Results In prospective randomized trials, the use of polypropylene vs. biological meshes was compared in open inguinal hernia repair. There was no difference in the recurrence rate, but differences were observed in the postsurgical pain incidence in favor of the biological mesh. In the remaining retrospective studies, the recurrence rates were also acceptable. The biological mesh was used successfully in a potentially contaminated setting. Conclusion Inguinal hernias can be repaired with biological meshes with reasonable recurrence rate, also as an alternative in a potentially contaminated field.

Biologic Mesh Reconstruction of the Pelvic Floor after Extralevator Abdominoperineal Excision: A Systematic Review.

Introduction The aim of this review is to provide an overview of the evidence for the use of biologic mesh in the reconstruction of the pelvic floor after extralevator abdominoperineal excision of the rectum (ELAPE). Methods A systematic search of PubMed was conducted using the search terms: “ELAPE,” “extralevator abdominoperineal excision of rectum,” or “extralevator abdominoperineal resection.” The search yielded 17 studies. Results Biologic mesh was used in perineal reconstruction in 463 cases. There were 41 perineal hernias reported but rates were not consistently reported in all studies. The most common complications were perineal wound infection (n = 93), perineal sinus and fistulae (n = 26), and perineal haematoma or seroma (n = 11). There were very few comparative studies, with only one randomized control trial (RCT) identified that compared patients undergoing ELAPE with perineal reconstruction using a biological mesh, with patients undergoing a conventional abdominoperineal excision of the rectum with no mesh. There was no significant difference in perineal hernia rates or perineal wound infections between the groups. Other comparative studies comparing the use of biologic mesh with techniques, such as the use of myocutaneous flaps, were of low quality. Conclusion Biologic mesh-assisted perineal reconstruction is a promising technique to improve wound healing and has comparable complications rates to other techniques. However, there is not enough evidence to support its use in all patients who have undergone ELAPE. Results from high-quality prospective RCTs and national/international collaborative audits are required.

Treatment of fistula-in-ano with fistula plug - a review under special consideration of the technique

Introduction In a recent Cochrane review, the authors concluded that there is an urgent need for well-powered, well-conducted randomized controlled trials comparing various modes of treatment of fistula-in-ano. Ten randomized controlled trials were available for analyses: There were no significant differences in recurrence rates or incontinence rates in any of the studied comparisons. The following article reviews the studies available for treatment of fistula-in-ano with a fistula plug with special attention paid to the technique. Material and Methods PubMed, Medline, Embase, and the Cochrane medical database were searched up to July 2015. Sixty-four articles were relevant for this review. Results Healing rates of 50–60% can be expected for treatment of complex anal fistula with a fistula plug, with a plug-extrusion rate of 10–20%. Such results can be achieved not only with plugs made of porcine intestinal submucosa but also those made of other biological or synthetic bioabsorbable mesh materials. Important technical steps are firm suturing of the head of the plug in the primary opening and wide drainage of the secondary opening. Discussion Treatment of a complex fistula-in-ano with a fistula plug is an option with a success rate of 50–60% with low complication rate. Further improvements in technique and better studies are needed.

Repair of Perineal Hernia Following Abdominoperineal excision with Biological Mesh: A Systematic Review

Introduction Perineal hernia (PerH) following abdominoperineal excision (APE) procedure is a recognized complication. PerH was considered an infrequent complication of APE procedure; however, PerH rates of up to 45% have been reported in recent publications following a laparoscopic APE procedure. Various methods of repair of PerH with the use of synthetic meshes or myocutaneous flap have been described, although there is no general agreement on an optimal strategy. The use of biological meshes for different operations is growing in popularity, and these have been promoted as being superior and safer when compared to synthetic meshes. Although the use of biologics is becoming popular claims of better outcomes are largely unsupported by evidence. The aim of this systematic review is to evaluate the currently available evidence supporting the use of biologic or biosynthetic meshes for the repair of PerH that develop following an APE. Methods A systematic review of all English language literature relevant to repair of PerH following APE with biologic or biosynthetic mesh published between January 1, 2000 and July 31, 2016 was carried out using MEDLINE, EMBASE, and the Cochrane Library of Systematic Reviews for relevant literature. Searches were performed using a combination of Medical Subject Headings (MeSH) terms and text words “PerH,” “APE,” “morbidity,” “biologics,” “biosynthetic,” and “hernia.” Studies in which the use of biological meshes was not reported were excluded from the review. Various outcome measures, including operative technique, complication rates, recurrence rates, type of mesh, management of recurrences, and risk factors, were extracted. Oxford Centre for Evidence-based Medicine – Levels of Evidence (March 2009) was used to assess the quality of evidence. Results The systematic review of the literature identified three case reports, four case series, and one pooled analysis that were included in the final review. Overall, these studies were of poor quality providing level 4 evidence. Various different approaches and techniques of repair of PerH were described; however, it was difficult to extract information with regard to the primary and secondary outcome measures. Conclusion There is no general agreement to the optimal operative strategy to repair PerH following an APE. There is insufficient evidence to recommend any specific operative approach or repair technique for PerH following an APE.

Rectopexy for rectal prolapse

Introduction Ventral mesh rectopexy (VMR) is a recognized treatment for posterior compartment pelvic organ prolapse (POP). The aim of this review is to provide a synopsis of the evidence for biological mesh use in VMR, the most widely recognized surgical technique for posterior compartment POP. Methods A systematic search of PubMed was conducted using the search terms “VMR,” “ventral mesh rectopexy,” or “mesh rectopexy.” Six studies were identified. Results About 268/324 patients underwent ventral rectopexy using biological mesh with a further 6 patients having a combination of synthetic and biological mesh. Recurrence was reported in 20 patients; however, 6 were from studies where data on biological mesh could not be extracted. There are no RCTs in VMR surgery and no studies have directly compared types of biological mesh. Cross-linked porcine dermal collagen is the most commonly used mesh and has not been associated with mesh erosion, infection, or fistulation in this review. The level of evidence available on the use of biological mesh in VMR is of low quality (level 4). Conclusion Ventral mesh rectopexy has become prevalent for posterior compartment POP. The evidence base for its implementation is not strong and the quality of evidence to inform choice of mesh is poor.

Complex Cases in Abdominal Wall Repair and Prophilactic Mesh

Methods: Our method stands for three steps. First, the open abdominal wall is closed by an absorbable mesh and the wound care has been continued until the entire surface is covered with good granulation tissue. It usually takes about four to six weeks. Second, skin grafting is applied to the granulated surface. At this point, the planned ventral hernia is completed. Finally several months after grafting, the planned ventral hernia is repaired using modified component separation method.

PTU-245 Rectopexy for rectal prolapse

Introduction Ventral mesh rectopexy (VMR) is a recognised treatment for posterior compartment pelvic organ prolapse (POP). A variety of synthetic meshes have been used for a wide range of POP surgery but there have been reports of high rates of pelvis sepsis, as well as concerns regarding mesh erosion, dyspareunia, fistulation and stricturing. It has been postulated that biological mesh may cause fewer complications in comparison to synthetic mesh in certain high-risk circumstances. The aim of this review is to provide a synopsis of the evidence for biologic mesh use in VMR, the most widely recognised surgical technique for posterior compartment POP. Method A systematic search of PubMed was conducted using the search terms ‘VMR’, ‘ventral mesh rectopexy’ or ‘mesh rectopexy’. Inclusion criteria were studies that described a ventral rectopexy using a biological mesh in either an open or laparoscopic technique. Studies were excluded if only synthetic mesh was used or if there was no mention of a mesh. Furthermore, studies on patients under the age of 18 were excluded as well as non-English language studies, technical tips or duplicates series from the same research group. Overall, the search yielded 6 studies for analysis after the exclusion of review articles. Results From 6 case series, 268/324 patients underwent ventral rectopexy using biological mesh with a further 6 patients having a combination of synthetic mesh and biological mesh. Overall, 155 patients underwent VMR using additionally cross-linked porcine dermal collagen (PermacolTM or PelvicolTM) and 89 using porcine intestinal submucosa (Surgisis©). Recurrence was reported in 20 patients; however, 6 of these were from studies where data on biological mesh could not be extracted. One study did not report recurrence. There are no randomised controlled trials in VMR surgery generally and no studies have directly compared types of biologic mesh e.g. cross-linked vs.non-cross-linked. Cross-linked porcine dermal collagen is the most commonly used mesh and has not been associated with mesh erosion, infection or fistulation in this current review. The level of evidence available on the use of biologic mesh in VMR is of low quality (level 4). Conclusion VMR has become prevalent for posterior compartment POP. The evidence base for its implementation is not strong and the quality of evidence to inform choice of mesh is poor. Disclosure of interest None Declared.