Stanisław Dąbrowiecki

The Glubran 2 glue for mesh fixation in Lichtenstein's hernia repair: a double-blind randomized study

Introduction With an average incidence rate of 11%, chronic pain is considered the most serious complication of inguinal hernioplasty after surgical site infection. One of the proposed solutions to this problem is to use tissue adhesive for mesh fixation, which helps prevent nerve and tissue damage. Aim The goal of this study was to compare mesh fixation with the use of sutures vs. adhesive in Lichtensteins inguinal hernia repair in a randomized, double-blind one-center study. Material and methods The study group consisted of 41 males with primary inguinal hernia undergoing Lichtensteins repair (20 – adhesive; 21 – suture) and remaining in follow-up from July 2008 to November 2010. Randomization took place during the operation. The follow-up was performed by one surgeon (blinded) according to a pre-agreed schedule; the end-of-study unblinding was performed during the last follow-up visit, usually 16 months postoperatively. Results In 1 patient from the “adhesive” group, a recurrence was observed one year after the initial repair. The early postoperative pain was less intense in this group. In later postoperative periods the method of mesh fixation had no influence on the pain experienced by the patient. Other complications were not correlated with the method of mesh fixation. Conclusions In this randomized, one-center double-blind clinical study of males with primary inguinal hernia it has been show during follow-up that the use of Glubran 2 cyanoacrylate adhesive for mesh implant fixation yields similar recurrence and chronic pain rates as the classical suture technique. In the early postoperative period, the pain reported by these patients was relatively weaker; patients undergoing adhesive mesh fixation experienced a quicker return to daily household activities.

Intragastric Balloon (BIB System) in the Treatment of Obesity and Preparation of Patients for Surgery - Own Experience and Literature Review

UNLABELLED Despite the recognition of bariatric surgery as the only effective method of weight reduction, we remain in search of minimally invasive methods, both for the treatment of obesity and preparation of patients for surgical procedures. The aim of the study was to determine intragastric balloon (Allergan) implantation results as the only method of treating obesity, and patient preparation for further stages of abdominal hernia operations, as well as other surgical procedures. MATERIAL AND METHODS The study presented own results considering the use of Bioenteric Intragastric Balloons (BIB system) in the treatment of pathological obesity, and preparation of patients for bariatric surgery and abdominal hernia operations. The study group comprised 18 female and 7 male patients. Average patient age amounted to 50.6 and 54 years, respectively. Indications for intragastric balloon insertion were as follows: preparation for hernia (10 cases) and bariatric (5 patients) operations, and weight reduction management (8 patients). In two cases the implantation of the intragastric balloon served the preparation for gynecological and orthopedic (vertebral column) operations. One female patient was prepared for both bariatric and hernial surgery. The procedure was performed under general anesthesia. Statistical analysis considered 22 patients (one female patient was excluded from analysis, due to death, two other were excluded because of lack of sufficient data).Results. In case of two patients the intragastric balloon system was removed before 6 months had elapsed because of intolerance. One female patient died during the observation period for reasons not related to the procedure. The obtained BMI reduction ranged between 2 and 6 kg/m2, which amounted to a maximum weight loss of 24 kg. In one patient a weight gain of 2 kg was observed. Considering patients prepared for abdominal hernia operations weight reduction was greater and better maintained after the removal of the BIB system. CONCLUSIONS According to the authors of the presented study the intragastric balloon serves its role as a bridge to bariatric procedures and weight reduction, before planned extensive postoperative hernia operations. The use of the intragastric balloon only to reduce weight has no medical and economic justification.

Urgent endoscopy in elderly patients with non-variceal upper gastrointestinal bleeding.

Introduction Age of the patient is an important prognostic factor in patients with non-variceal upper gastrointestinal bleeding (UGIB). Despite that fact, current treatment algorithms do not differentiate UGIB management according to the patients age. Aim To compare treatment outcomes in patients below and above 75 years of age, treated for UGIB with urgent endoscopy. Material and methods Prospective analysis of treatment outcomes in 295 patients with non-variceal UGIB divided into two age groups (group A < 75 years of age, group B > 75 years of age). Urgent endoscopy (up to 3 h since admission) was performed in 292 patients. The groups were compared in regards to the duration of symptoms, previous UGIB, presence of factors predisposing to UGIB (NSAIDs, peptic ulcer disease, liver cirrhosis, and previous gastrointestinal surgery), haemodynamic state and haemoglobin (Hb) levels on admission. We analysed the causes of UGIB, severity of UGIB on the Forrest scale, type of endoscopic bleeding control method, and co-morbidities with use of the Charlson Co-morbidity Index (CCI). Treatment outcomes were assessed in regard of mortality rate, UGIB-recurrence rate, duration of hospital stay, amount of transfused blood products and the requirement of intensive therapy unit (ITU) or other departments’ admissions. Patients were followed until their discharge home. Results Mortality rate was 6.8% (group A vs. B: 3.5% vs. 18.7%; p = 0.001). Upper gastrointestinal bleeding recurrence was noted in 12.2% of patients (group A vs. B: 12.5% vs. 10.9%; p = 0.73). 2.4% of patients required surgery for UGIB (group A vs. B: 1.7% vs. 4.7%; p = 0.16). Patients in group B required ITU admission more frequently (group A vs. B: 1% vs. 4.7%; p < 0.01). The mean hospital stay (4.3 days) and the mean number of transfused packed red blood cells (PRBCs) (2.35 Units) did not differ between the groups. Patients in group B used NSAIDS much more frequently, more often had hypovolaemic shock and had a higher CCI score. Conclusions Urgent endoscopy is an important and broadly accepted method of treatment of UGIB. Despite strict adherence to the modern UGIB-treatment algorithms, mortality remains high in the elderly. Thus, these patients need particular attention. The presented study indicates that the standard management might not be sufficient in elderly patients.

An analysis of the expression of collagen I and III genes in the fascia of obese patients

BACKGROUND The etiology of incisional hernias in the population of morbidly obese patients remains unclear. Most likely, factors other than purely mechanical are at play; it has been ascertained that nonobese patients suffering from inguinal and incisional hernias display alterations in the architecture of the connective tissue. The goal of this study has been to evaluate and compare the relative expression of collagen type I and III genes in the rectus abdominis muscle sheath (RMS) of obese and nonobese individuals to investigate their possible influence on the quality of the connective tissue. MATERIALS AND METHODS RMS specimens were harvested in the early stages of either bariatric or non-bariatric laparotomies; total RNA was isolated and enzymatically purified from the tissue samples. The resulting material was subjected to a quantitative and qualitative analysis; reverse transcription reactions were then performed and the resulting complementary DNA was used in real-time reverse transcription polymerase chain reactions. The biopsy specimens were also examined by scanning electron microscopy. RESULTS The real-time reverse transcription polymerase chain reactions, performed on complementary DNA, provided specific amplicons for individual genes. The efficacy of the reactions was rather low. An almost twofold decrease of the relative expression level for type I and III collagen was observed between the two patient groups; the results did not reach statistical significance. Scanning electron microscope photographs have documented a marked difference in the ultrastructure of the RMS in both groups. CONCLUSIONS The authors have shown that changes in messenger RNA levels for collagen type I and III genes may be related to the pathogenesis of incisional hernia through alterations in the ultrastructure of the RMS fascia. Our report should be considered preliminary; the results should be verified on a larger group of patients.

The experience and awareness of laparoendoscopic procedures among Polish surgeons in everyday clinical practice

Introduction In 2012, a total of 56 647 inguinal hernia repairs were performed in Poland. However, the absence of a uniform hernia repair register obscures the current herniology status in Poland, especially regarding laparoendoscopic procedures. Aim To determine the awareness of laparoendoscopic procedures among Polish surgeons and to ascertain their everyday clinical practice. Material and methods The data were collected at the national hernia conference in 2016, during an interactive session for surgeons with a special interest in herniology. They could respond to the survey items using the VoxVote application. All items and response options were displayed on participants’ smartphones. The questions were related to transabdominal preperitoneal/totally extraperitoneal (TAPP/TEP) hernia repair. The surgeons responded to 27 questions regarding routine inguinal hernia repair. One hundred and six surgeons from all regions of Poland participated in the survey. Results 19.2% of respondents never inform patients about the possibility of performing laparoendoscopic repair. 45.2% admitted that they had referred a patient with a difficult inguinal hernia to another hospital or surgeon. Seventy-five percent stated they would be willing to perform TAPP/TEP if the reimbursement rates were more favourable. In bilateral hernias, 61.6% of the respondents perform a two-step open repair, while only 25% perform a single-stage laparoendoscopic repair of bilateral hernia. In women, only 13.3% perform laparoendoscopic hernia repairs, and 19.0% do not use mesh. Conclusions The skill level to perform TAPP/TEP repair is still inadequate among Polish surgeons. The absence of accurate data makes it impossible to verify whether the treatment methods used are compliant with the guidelines.

Activity of metalloproteinases and adiponectin in obese patients— a possible factor of incisional hernias after bariatric procedures

PurposeMetalloproteinases are a key component of the pathogenesis of abdominal hernias. Obesity is considered a risk factor in herniogenesis and hernia recurrence. The aim of this study was to evaluate the serum concentrations of metalloproteinase-2 (MMP-2), MMP-9, MMP-13, and adiponectin in morbidly obese and nonoverweight controls.Materials and methodsThe participants were recruited from among patients undergoing bariatric and non-bariatric surgery and divided into two groups: I (body mass index (BMI)≥35 kg/m2, n=40) and II (BMI<25 kg/m2, n=30). Serum concentrations of MMP-2, MMP-9, MMP-13, and adiponectin were measured using enzyme-linked immunosorbent assay (ELISA).ResultsA statistically significant difference between groups was observed for MMP-2 concentration. The median MMP-9 concentration was higher in the obese group, but the difference was not statistically significant. Median MMP-13 concentrations did not differ between groups. Serum adiponectin concentration was insignificantly higher in the non-obese group.ConclusionsThe elevated serum MMP-2 and MMP-9 concentrations in obese individuals may be related to the higher incidence of incisional hernias in this population.摘要目的主要研究病态肥胖患者与正常人血清中金属蛋白 酶2(MMP-2)、MMP-9、MMP-13 和脂联素的 浓度。创新点建立血清中MMP-2、MMP-9、MMP-13 和脂联 素的浓度与肥胖和切口疝的关系。方法参与实验的人员为进行肥胖手术的患者和不进行 肥胖手术的患者,并将他们分为两组:I(体重 指数(BMI)≥35 kg/m2,n=40)和II (BMIlt;25 kg/m2, n=30),并使用酶联免疫吸附实验测定受试人员 体内血清中MMP-2、MMP-9、MMP-13 和脂联 素的浓度。结论MMP-2 的浓度在肥胖组中更高,且在两组血清 中有显著性差异。虽然MMP-9 的浓度在肥胖组 中更高,但是两组之间没有显著性差异。MMP-13 在两组间没有差异。血清中脂联素的浓度在非肥 胖组更高,但无显著性差异。因此,血清中 MMP-2和MMP-9的浓度在肥胖人群中与更高的 切口疝发病率有关。

Biofilm formation on biomaterials used in hernia surgery

Deep surgical site infection (DSSI) in patients undergoing hernioplasty with implantation of biomaterials is a complication taking place with biofilm formation. Despite the indicated increase in the frequency of isolation of S. aureus and E. coli bacteria as etiological factors of DSSI, there have been few studies published so far that evaluated biofilm formation by these microorganisms on the surface of different biomaterials. The aim of this study was to evaluate and compare biofilm formation on the surface of biomaterials used in hernia surgery by clinical isolates of S. aureus and E. coli. 70 strains of S. aureus and E. coli were used; they differed in chromosomal DNA within the species. The evaluation of biofilm formation on the surface of the monofilament polypropylene mesh, multifilament mesh (polypropylene, polyester and composite) and a patch of expanded polytetrafluoroethylene was made using qualitative and quantitative methods and by means of a scanning electron microscope. The strains differ in terms of biofilm formation within the species. Strains of S. aureus formed a biofilm more strongly than E. coli. The investigated strains formed biofilm stronger on the surface of the multifilament implants than on polypropylene monofilament mesh. Formation of biofilm by clinical isolates of S. aureus and E. coli on the surface of biomaterials used in hernia surgery varies depending on the strain and species of bacteria as well as the structure and the hydrophobicity of biomaterial.

Asymptomatic infection of a surgical mesh implant

Zakazenie obejmujące implantat jest jednym z najpowazniejszych powiklan towarzyszących stosowaniu biomaterialow w chirurgii przepuklin. Zakazenie implantatu moze miec rozny przebieg kliniczny. W pracy przedstawiono przypadek bezobjawowego zakazenia siatki chirurgicznej zastosowanej do zaopatrzenia przepukliny okolopepkowej. Zakazenie zostalo rozpoznane przypadkowo podczas operacji z powodu nawrotu przepukliny. Badania metodą jakościową z uzyciem chlorku 2,3,5-trojfenylotetrazoliowego (TTC), metodą ilościową oraz z uzyciem skaningowego mikroskopu elektronowego wykazaly obecnośc biofilmu bakteryjnego na powierzchni implantatu zastosowanego do pierwotnego zaopatrzenia przepukliny. Jego obecnośc na powierzchni implantatu uchronila drobnoustroje przez dzialaniem ukladu odpornościowego pacjenta i byla odpowiedzialna za bezobjawowy przebieg zakazenia biomaterialu. Zdaniem autorow wszystkie implantaty usuwane podczas operacji z powodu nawrotu przepukliny nalezy poddac badaniu mikrobiologicznemu, nawet gdy nie stwierdza sie makroskopowych cech zakazenia. Do badan diagnostycznych powinna zostac wlączona metoda redukcji TTC, co pozwala ograniczyc liczbe wynikow falszywie ujemnych.