Why we remove mesh

Purpose

As more mesh is implanted for hernia repairs, mesh-related complications may increase, with some requiring mesh removal. We describe our experience as to indications and perioperative factors that surround hernia mesh removal.

Methods

All patients who underwent hernia mesh removal from the abdomen (ventral, flank) and pelvis (inguinal, femoral, obturator, perineal) were captured from a single hernia center database.

Results

Over 4.5 years, we removed 105 mesh. Most were in males (58%), average age 53 years, with average pain score 5/10. Males most commonly had mesh removed from the pelvis (65%), and females from the abdomen (63%, P?=?0.009). Pain score was significantly higher prior to removal of hernia mesh from the pelvis (5.7 vs 4.5, P?=?0.047). Type of mesh implanted and positioning of mesh showed no difference in pain (P?>?0.05). Indications for hernia mesh removal significantly varied between the abdomen (infection, 43%) and the pelvis (pain, 91%, P?<?0.0001). Mesh reaction became a more frequent indication for mesh removal in the pelvis, reaching 1/3 of patients by 2017. Most required general anesthesia (87%), with inpatient stay (53%, mode 1 day). Open technique decreased with time (82–17%), laparoscopic decreased (20–10%), and robotic increased (0–70%).

Conclusions

This is the largest and most comprehensive study detailing why we remove mesh. We provide awareness of indications and operative options to help guide physicians as they encounter patients who may require hernia mesh removal.

     

Long term outcomes in the use of ileal ureter for radiation-induced ureteral strictures

Purpose

Radiation-induced ureteral stricture disease poses significant surgical challenges. Ureteral substitution with ileum has long been a versatile option for reconstruction. We evaluated outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction due to radiation-induced ureteral stricture versus other causes.

Methods

Between July 1989 and June 2013, 155 patients underwent consecutive ileal ureter creation. The study cohort included 104 patients with complete data sets and at least 7 months of follow up. Records were retrospectively reviewed with regard to demographics, indications, complications, and renal deterioration.

Results

Surgical indications included radiation-induced stricture in 23 (22%) and non-radiation-induced stricture in 81 (78%). Comparing ileal ureter substitution due to radiation versus other stricture etiologies, no statistical significance was observed in regard to age (45.6 vs. 51.2, p?=?0.141), hospital length of stay in days (8.8 vs. 7.7, p?=?0.216), percent GFR loss (MDRD-4 vs. -5%, p?=?0.670 and CKD-EPI-7 vs. -6%, p?=?0.914), 30-day surgical complications (26.1 vs. 30.1%, p?=?0.658), metabolic acidosis (8.7 vs. 1.2%, p?=?0.059), and renal failure requiring dialysis (4.3 vs. 1.2%, p?=?0.337). Fistula formation (13.0 vs. 3.7%, p?=?0.095), partial small bowel obstructions (21.7 vs. 7.4%, p?=?0.063), and small bowel obstructions requiring reoperation (13.0 vs. 1.2%, p?=?0.033) approached or reached statistical significance. Using Kaplan–Meier methodology, there was no difference in time to worsening renal outcome between the radiation and non-radiation groups (p?>?0.05).

Conclusion

Ureteral substitution with ileum is an effective reconstructive option for radiation-induced ureteral strictures in carefully selected patients.

     

Clinical and ultrasonographic evaluation of the pelvic floor in primiparous women: a cross-sectional study

Introduction and hypothesis

We used clinical examination and transperineal 3D/4D ultrasound (US) to evaluate pelvic floor muscles (PFM) after different delivery modes.

Methods

Women were surveyed using validated questionnaires. PFM were evaluated and classified according to the Modified Oxford Scale following 3D/4D transperineal US. For statistical analysis, Kruskal–Wallis, Mann–Whitney, chi-square, and Fisher exact tests were used.

Results

Fifty-three women were evaluated: 32 with previous vaginal delivery (VD) and 21 with cesarean section (CS) (8 nonelective and 13 elective). No significant difference among groups was observed regarding urinary incontinence (UI) after delivery (p?=?0.39), loss of muscle strength referred by the patient (p?=?0.48), or evaluated through digital examination (p?=?0.87). No patient with elective CS had avulsion, with difference between VD and elective CS (p?=?0.008). US evaluation identified no differences in bladder-neck elevation (p?=?0.69) or descent (p?=?0.65) , and no difference in genital hiatus size (p?=?0.35), levator ani thickness (p?=?0.35 –0.44), or presence of major or minor levator ani avulsion (p?=?0.10).

Conclusions

We evaluated primiparous women within 12 to 24 months of delivery and found that VD was associated with PFM avulsion. There was no difference among VD and nonelective or elective CS in symptomatology or other anatomic alterations evaluated through 3D/4D transperineal US.

     

Direct visualization transversus abdominis plane blocks offer superior pain control compared to ultrasound guided blocks following open posterior component separation hernia repairs

Purpose

Transversus abdominis plane (TAP) blockade with long-acting anesthetic can be used during open ventral hernia repair (VHR) with posterior component separation (PCS). TAP block can be performed under ultrasound guidance (US-TAP) or under direct visualization (DV-TAP). We hypothesized that US-TAP and DV-TAP provide equivalent postoperative analgesia following open VHR.

Methods

A retrospective review of patients undergoing open VHR with PCS who received TAP blocks with 266 mg of liposomal bupivacaine was performed. Data included demographics, comorbidities, length of stay (LOS), average postoperative day (POD) pain scores, and narcotic requirements (normalized to mg oral morphine). Statistical analysis utilized Student’s t test and Fisher’s exact test.

Results

Thirty-nine patients were identified (22 DV-TAP). There were no differences between the groups with respect to demographics, comorbidities, pre-operative pain medication usage (narcotic and non-narcotic) or herniorrhaphy-related data. The average POD0 pain score was lower for the DV-TAP group (2.35 vs 4.18; p?=?0.019). Narcotic requirements on POD0 (48.0 vs 103.76 mg; p?=?0.02), POD1 (128.45 vs 273.82 mg; p?=?0.03), POD4 (54.29 vs 160.75 mg; p?=?0.042), and during the complete hospitalization (408.52 vs 860.92 mg; p?=?0.013) were lower in the DV-TAP group. There were no differences between initiation of diet or LOS. During the study, no changes were made to the VHR enhanced recovery pathway.

Conclusions

DV-TAP blocks appear to provide superior analgesia in the immediate postoperative period. To achieve similar post-operative pain scores, patients in the US-TAP group required significantly more narcotic administration during their hospitalization. The study highlights DV-TAP as a valuable addition to VHR recovery pathways.

     

Exploration of Fluid Dynamics in Perioperative Patients Using Bioimpedance Analysis

Introduction

Perioperative fluid restriction is advocated to reduce complications after major surgeries. Current methods of monitoring body fluids rely on indirect volume markers that may at times be inadequate. In our study, bioimpedance analysis (BIA) was used to explore fluid dynamics, in terms of intercompartmental shift, of perioperative patients undergoing operation for hepato-pancreato-biliary (HPB) diseases.

Methods

A retrospective review was conducted, examining 36 patients surgically treated for HPB diseases between March 2010 and August 2012. Body fluid compartments were estimated via BIA at baseline (1 day prior to surgery), immediately after surgery, and on postoperative day 1, recording fluid balance during and after procedures. Patients were stratified by net fluid status as balanced (≤500 mL) or imbalanced (>550 mL) and outcomes of BIA compared.

Results

Mean net fluid balance volumes in balanced (n?=?16) and imbalanced (n?=?20) patient subsets were 231.41?±?155.44 and 1050.18?±?548.77 mL, respectively. Total body water (TBW) (p?=?0.091), extracellular water (ECW) (p?=?0.125), ECW/TBW (p?=?0.740), and intracellular water (ICW) (p?=?0.173) did not fluctuate significantly in fluid-balanced patients. Although TBW (p?=?0.069) in fluid-imbalanced patients did not change significantly (relative to baseline), ECW (p?=?0.001), ECW/TBW (p?=?0.019), and ICW (p?=?0.012) showed significant postoperative increases.

Conclusion

The exploration of fluid dynamics using BIA has shown importance of balanced fluid management during perioperative period. Increased ECW/TBW in fluid-imbalanced patients suggests possible causality for the development of ascites or fluid collections during postoperative period in patients undergoing HPB operations.

     

Sarcopenia and outcomes in ventral hernia repair: a preliminary review

Purpose

Sarcopenia, or loss of muscle mass, is associated with increased morbidity and mortality in oncologic resections and several other major surgeries. Complex ventral hernia repairs (VHRs) and abdominal wall reconstruction are often performed in patients at high risk for morbidity and recurrence, though limited data exist on outcomes related to sarcopenia. We aimed to determine if sarcopenia is associated with worse outcomes in patients undergoing VHR.

Methods

We reviewed patients undergoing VHRs from 2014 to 2015. Preoperative CT images were analyzed for cross-sectional muscle mass. Patients with and without sarcopenia underwent statistical analysis to evaluate differences in perioperative morbidity and hernia recurrence. Muscle indices were analyzed independently for outcomes.

Results

135 patients underwent VHR with/without fistula takedown, staged repairs or other concomitant procedures. 27% had sarcopenia (age 34–84, BMI 27–33, 62% male). Postoperative complications occurred in 43% of sarcopenic patients and 47% of non-sarcopenic patients (p?=?0.70). Surgical site infections (SSI) were seen in 16% of sarcopenic patients compared to 29% without sarcopenia (p?=?0.14). There was no difference in hernia recurrence between groups (p?=?0.90). However, after adjusting for diabetes and BMI, a 10 cm²/m² decrease in muscle index had 1.44 OR of postoperative complications (p?<?0.05).

Conclusions

Though prevalent in our population, sarcopenia was not associated with an increase in postoperative complications, surgical site occurences/infections,  or hernia recurrence when previously published oncologic sarcopenia cutoffs were utilized. Previously established sarcopenia outcomes in malignancy may be attributable to an altered metabolic state that is not present in hernia repair patients. Larger-scale studies are recommended to establish new sarcopenia cutoffs for VHRs.

     

Postoperative atrial fibrillation is less frequent in pulmonary segmentectomy compared with lobectomy

Objective

The aim of this study was to elucidate the characteristics and predictors of postoperative atrial fibrillation (POAF) from the standpoint of surgical mode.

Methods

Retrospective analysis was carried out on 607 patients who underwent lobectomy or segmentectomy for clinical stage IA lung cancer. We investigated the clinical factors to determine the predictors of the development of POAF.

Results

Of the 607 patients, 443 underwent lobectomy, and 164 underwent segmentectomy. POAF developed in 37 patients. Of these, 34 (7.7%) were in the lobectomy group, and 3 (1.8%) in the segmentectomy group. In the univariate analysis for predictors of POAF, age (p?<?0.01), history of ischemic heart disease (p?=?0.03), FEV1.0% (p?<?0.01) and surgical mode (p?=?0.01) showed significant differences between the groups. The multivariate analysis revealed that increasing age (p?<?0.01, HR 1.059, CI 1.015–1.106), surgical mode (p?=?0.02, HR 5.734, CI 1.350–24.361) and FEV1.0%?<?70% (p?=?0.03, HR 2.182, CI 1.067–4.461) were independent predictors of POAF.

Conclusion

POAF was significantly less following segmentectomy compared with lobectomy.

     

Hospital cost savings and other advantages of sutureless vs stented aortic valves for intermediate-risk elderly patients

Purpose

To evaluate and compare the clinical outcomes and hospital costs of using sutureless aortic valves vs conventional stented aortic valves.

Methods

Between 2007 and 2011, 52 elderly patients undergoing aortic valve replacement for aortic stenosis in our center had a sutureless valve inserted. From among 180 patients who had a stented valve inserted during the same period, 52 patients were matched to the sutureless group, based on age, gender, and operation type. We compared clinical outcomes and hospital costs between the two groups.

Results

The sutureless group had a higher Euroscore (logistic Euroscore I) risk (12.8 vs 9.7; p?=?0.02), with significantly shorter aortic cross-clamp (ACC) time (p?<?0.01), cardiopulmonary bypass (CPB) time (p?<?0.01), intensive care unit stay (p?<?0.01), intubation time (p?<?0.01), and overall hospital stay (p?=?0.05). The sutureless group also revealed a significant hospital cost saving of approximately 8200€ (p?=?0.01).

Conclusions

The clinical and hemodynamic outcomes of using the sutureless bioprosthesis were excellent. The reduced ACC and CPB times had a favorable effect on the duration of intubation and intensive care stay, resulting not only in faster recovery and discharge home, but also in a significant hospital cost reduction.

     

Identische onkologische Ergebnisse bei niedrigerer perioperativer Morbidität nach laparoskopischer Leberresektion

Background

Laparoscopic liver resection belongs to the standard repertoire in hepatobiliary surgery. The advantages and disadvantages are still the subject of controversial discussion.

Objective

The aim of the study was to compare the perioperative and long-term outcomes of laparoscopic and open liver resections.

Material and methods

All patients who underwent liver resection in the Department of Surgery at the certified liver center of the  municipal hospital Karlsruhe were analyzed. From a total of 268 hepatic resections 65 laparoscopic liver resections were identified and matched 1:1 with 65 open resections, based primarily on the extent of the resection and secondarily on diagnosis, age and gender of the patients. The demographic data, comorbidities, perioperative and long-term outcomes were compared.

Results

Both groups had comparable demographic parameters and comorbidities. Operation time, duration of intensive care stay and percentage of negative resection margins were comparable in both groups. The 30-day mortality was 0% and 90-day mortality 1.5% in both groups. The laparoscopic group showed lower intraoperative and postoperative transfusion rates (p?<?0.001), shorter hospital stay (p?<?0.001) and lower overall morbidity (p?<?0.001). The 1-, 3- and 5-year overall and tumor-free survival of patients with colorectal liver metastases was comparable (p?=?0.984; p?=?0.947). The same applied for patients with hepatocellular carcinomas (p?=?0.803; p?=?0.935).

Conclusion

Laparoscopic liver resections have identical long-term outcomes with lower overall morbidity. Laparoscopic liver resections offer advantages regarding transfusion rates, length of hospital stay and postoperative complications.

     

Prophylactic mesh placement to prevent parastomal hernia,early results of a prospective multicentre randomized trial

Purpose

Parastomal hernia (PSH) is a common complication after colostomy formation. Recent studies indicate that mesh implantation during formation of a colostomy might prevent a PSH. To determine if placement of a retromuscular mesh at the colostomy site is a feasible, safe and effective procedure in preventing a parastomal hernia, we performed a multicentre randomized controlled trial in 11 large teaching hospitals and three university centres in The Netherlands.

Methods

Augmentation of the abdominal wall with a retromuscular light-weight polypropylene mesh (Parietene Light?, Covidien) around the trephine was compared with traditional colostomy formation. Patients undergoing elective open formation of a permanent end-colostomy were eligible. 150 patients were randomized between 2010 and 2012. Primary endpoint of the PREVENT trial is the incidence of parastomal hernia. Secondary endpoints are morbidity, pain, quality of life, mortality and cost-effectiveness. This article focussed on the early results of the PREVENT trial and, therefore, operation time, postoperative morbidity, pain, and quality of life were measured.

Results

Outcomes represent results after 3 months of follow-up. A total of 150 patients were randomized. Mean operation time of the mesh group (N = 72) was significantly longer than in the control group (N = 78) (182.6 vs. 156.8 min; P = 0.018). Four (2.7 %) peristomal infections occurred of which one (1.4 %) in the mesh group. No infection of the mesh occurred. Most of the other infections were infections of the perineal wound, equally distributed over both groups. No statistical differences were discovered in stoma or mesh-related complications, fistula or stricture formation, pain, or quality of life.

Conclusions

During open and elective formation of an end-colostomy, primary placement of a retromuscular light-weight polypropylene mesh for prevention of a parastomal hernia is a safe and feasible procedure.The PREVENT trial is registered at: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2018.

     

Which factors should be considered in choosing pessary type and size for pelvic organ prolapse patients in a fitting trial?

Introduction and hypothesis

This study explored whether the optimal pessary type and size can be predicted using the specific pelvic organ prolapse quantification system (POP-Q) measurements in women with pelvic organ prolapse in a fitting trial.

Methods

We conducted a prospective study in women who had undergone pessary fitting. A total of 78 patients with stage II, III or IV symptomatic pelvic organ prolapse completed a detailed history. Data were analysed using nonparametric tests, continuity correction chi-squared tests and multivariate logistic regression.

Results

Differences in total vaginal length (TVL; p?<?0.01) and vaginal introitus width/TVL ratio (p?=?0.012) were observed between patients with and without a history of hysterectomy. Patients with a history of hysterectomy and patients with a larger vaginal introitus had more success with the Gellhorn pessary than with the ring pessary with support (p?=?0.005 and p?=?0.01, respectively). Factors determining the size of the ring pessary with support were the genital hiatus (GH) width (p?=?0.044), TVL (p?=?0.011), vaginal introitus width (p?<?0.001), and vaginal introitus width/TVL ratio (p?=?0.025). Factors determining the size of the Gellhorn pessary were the GH width (p?=?0.025), GH width/TVL ratio (p?=?0.013), vaginal introitus width (p?=?0.003), vaginal introitus width/TVL ratio (p?=?0.001), stage of apical prolapse (p?=?0.006) and stage of posterior prolapse (p?=?0.003).

Conclusions

Patients with a history of hysterectomy or with a larger vaginal introitus were more likely to achieve success with the Gellhorn pessary. The GH width and the vaginal introitus width influenced the size of both pessaries chosen. The TVL was predictive of the optimal size of the ring pessary with support but was not predictive of the optimal size of the Gellhorn pessary. Finally, the size of the Gellhorn pessary was associated with POP stage.

     

Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomized multicenter study of 1-month follow-up results

Purpose

The seroma rate following laparoscopic incisional ventral hernia repair (LIVHR) is up to 78%. LIVHR is connected to a relatively rare but dangerous complication, enterotomy, especially in cases with complex adhesiolysis. Closure of the fascial defect and extirpation of the hernia sack may reduce the risk of seromas and other hernia-site events. Our aim was to evaluate whether hybrid operation has a lower rate of the early complications compared to the standard LIVHR.

Methods

This is a multicenter randomized-controlled clinical trial. From November 2012 to May 2015, 193 patients undergoing LIVHR for primary incisional hernia with fascial defect size from 2 to 7 cm were recruited in 11 Finnish hospitals. Patients were randomized to either a laparoscopic (LG) or to a hybrid (HG) repair group. The outcome measures were the incidence of clinically and radiologically detected seromas and their extent 1 month after surgery, peri/postoperative complications, and pain.

Results

Bulging was observed by clinical evaluation in 46 (49%) LG patients and in 27 (31%) HG patients (p?=?0.022). Ultrasound examination detected more seromas (67 vs. 45%, p?=?0.004) and larger seromas (471 vs. 112 cm³, p?=?0.025) after LG than after HG. In LG, there were 5 (5.3%) enterotomies compared to 1 (1.1%) in HG (p?=?0.108). Adhesiolysis was more complex in LG than in HG (26.6 vs. 13.3%, p?=?0.028). Patients in HG had higher pain scores on the first postoperative day (VAS 5.2 vs. 4.3, p?=?0.019).

Conclusion

Closure of the fascial defect and extirpation of the hernia sack reduce seroma formation. In hybrid operations, the risk of enterotomy seems to be lower than in laparoscopic repair, which should be considered in cases with complex adhesions.

Clinical trial number

NCT02542085.

     

Patient characteristics associated with treatment choice for pelvic organ prolapse and urinary incontinence

Introduction and hypothesis

Women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI) frequently undergo more than one treatment prior to settling on their final strategy. We hypothesize that women who are younger, with worse POP and SUI symptoms will desire and choose surgical treatment.

Methods

A retrospective cohort study was performed over 1 year identifying new patients presenting with POP and/or SUI at a university hospital. Our aim was to determine patient desire for either surgical or conservative treatment, as well as the actual treatment chosen and received after the first visit and 1 year later. To identify predictors of choice, baseline demographic characteristics were obtained.

Results

Of the 203 women who met the inclusion criteria, 44.3 % (90/203) desired surgery and 55.7 % (113/203) desired conservative treatment at their first visit. Women who desired surgery were more likely to be younger (p?=?0.003), sexually active (p?=?0.001), have more advanced prolapse (p?=?0.006), and have more bothersome symptoms (p?=?0.05). Of the women who desired surgery at their first visit, 12.2 % (11/90) actually chose conservative treatment. These women were less likely to be insured (p?=?0.01). By 1 year, of the women who initially desired and subsequently chose conservative treatment, 26.5 % (30/113) had undergone surgery. The women who changed from conservative to surgical treatment were more likely to be younger (p?=?0.01), non-White (p?=?0.03), and sexually active (p?=?0.04).

Conclusions

In this study, younger, sexually active women were more likely to either opt for surgery initially or to change their treatment plan from conservative to surgical.

     

Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients

Introduction

In laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE.

Methods

A retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression.

Results

After exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (p?<?0.004) and jaundice (p?=?0.019) before surgery and longer operative times (OT, p?<?0.001); they were less likely to have incidental intraoperative diagnosis (p?=?0.031) or to have biliary colic as the reason for surgery (p?=?0.031). In the final multivariate model, leukocytosis (p?=?0.013) and OT (p?<?0.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (p?<?0.001).

Conclusion

The risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.

     

Prophylactic,Synthetic Intraperitoneal Mesh Versus No Mesh Implantation in Patients with Fascial Dehiscence

Background

Primary closure of post-operative facial dehiscence (FD) is associated with a high incidence of recurrence, revisional surgery, and incisional hernia. This retrospective study compares outcomes of implantation of non-absorbable intra-abdominal meshes with primary closure of FD. The outcomes of different mesh materials were assessed in subgroup analysis.

Methods

A total of 119 consecutive patients with FD were operated (70 mesh group and 49 no mesh group) between 2001 and 2015. Primary outcome parameter was hernia-free survival. Secondary outcome parameters include re-operations of the abdominal wall, intestinal fistula, surgical site infections (SSI), and mortality. Kaplan-Meier analysis for hernia-free survival, adjusted Poisson regression analysis for re-operations and adjusted regression analysis for chronic SSI was performed.

Results

Hernia-free survival was significantly higher in the mesh group compared to the no mesh group (P?=?0.005). Fewer re-operations were necessary in the mesh group compared to the no mesh group (adjusted incidence risk ratio 0.44, 95% confidence interval [CI] 0.20–0.93, P?=?0.032). No difference in SSI, intestinal fistula, and mortality was observed between groups. Chronic SSI was observed in 7 (10%) patients in the mesh group (n?=?3 [6.7%] with polypropylene mesh and 4 [28.6%] with polyester mesh). The risk for chronic SSI was significantly higher if a polyester mesh was used when compared to a polypropylene mesh (adjusted odds ratio 8.69, 95% CI 1.30–58.05, P?=?0.026).

Conclusion

Implantation of a polypropylene but not polyester-based mesh in patients with FD decreases incisional hernia with a low rate of mesh-related morbidity.

     

Association of osteoporosis with genetic variants of circadian genes in Chinese geriatrics

Summary

This study was designed to investigate the association of circadian gene single nucleotide polymorphisms (SNPs) with the risk of osteoporosis. We found that the rs3781638 GG genotype was positively associated with osteoporosis prevalence in females, whereas the rs2292910 AC genotype was negatively associated with osteoporosis prevalence in a geriatric cohort.

Introduction

Studies have shown that disruption of endogenous circadian rhythms may increase the risk of developing type II diabetes and obesity, which are reportedly associated with osteoporosis (OP). Thus, abnormalities of circadian genes may indirectly induce OP. Here, we investigated the association of OP with 14 SNPs located in seven circadian genes.

Methods

The research subjects, geriatric residents of Shanghai Minhang, China, diagnosed with OP (N?=?171) or osteopenia (N?=?226) or without specific diseases (N?=?200), were genotyped for 14 genetic variants of circadian genes by competitive allele-specific polymerase chain reaction. The prevalence of polymorphisms among the subject groups and the association between the SNPs and osteoporosis were investigated.

Results

Among the 14 genotyped SNPs, we found an association between the CRY2 gene rs2292910 SNP and osteoporosis (r?=??0.082, p?=?0.045) in the geriatric cohort. We found a decreased risk between cryptochrome 2 rs2292910 and OP (A/C odds ratio?=?0.647, p?=?0.044) but an increased risk between MTNR1B rs3781638 and OP (G/G odds ratio?=?2.058, p?=?0.044).

Conclusion

For the first time, we show that Cry 2 rs2292910 and MTNR1B rs3781638 are associated with osteoporosis in a Chinese geriatric cohort. Therefore, targeting the abnormalities of the CRY2 and MTNR1B genes may be a potential strategy to treat and/or to prevent osteoporosis.

     

Decreased re-operation rate for recurrence after defect closure in laparoscopic ventral hernia repair with a permanent tack fixated mesh: a nationwide cohort study

Purpose

To investigate whether defect closure in laparoscopic ventral hernia repair reduces the re-operation rate for recurrence compared with no defect closure.

Methods

Data were extracted from the Danish Ventral Hernia Database. Adults with an elective laparoscopic ventral hernia repair with tacks used as mesh fixation were included, if their first repair was between the 1st of January 2007 and the 1st of January 2017. Patients with defect closure were compared with no defect closure. Re-operation rates are presented as crude rates and cumulated adjusted re-operation rates. Sub-analyses assessed the effect of the suture material used during defect closure and also whether defect closure affected both primary and incisional hernias equally.

Results

Among patients with absorbable tacks as mesh fixation, 443 received defect closure and 532 did not. For patients with permanent tacks, 393 had defect closure and 442 did not. For patients with permanent tacks as mesh fixation, the crude re-operation rates were 3.6% with defect closure and 7.2% without defect closure (p?=?0.02). The adjusted cumulated re-operation rate was significantly reduced with defect closure and permanent tacks (hazard ratio?=?0.53, 95% confidence interval?=?0.28–0.999, p?=?0.05). The sub-analysis suggested that defect closure was only beneficial for incisional hernias, and not primary hernias. We did not find any benefits of defect closure for patients with absorbable tacks as mesh fixation.

Conclusion

This nationwide cohort study showed a reduced risk of re-operation for recurrence if defect closure was performed in addition to permanent tacks as mesh fixation during laparoscopic incisional hernia repair.

     

Endoscopic anterior component separation: a novel technical approach

Purpose

Open anterior release of the external oblique fascia to enable midline closure of large abdominal wall defects is associated with relevant morbidity due to extensive subcutaneous dissection. Using endoscopic techniques, wound complications can be minimized. However, identification of the correct entry point (e.g. for balloon trocar insertion) can be challenging especially in adipose patients. We therefore present a technical modification facilitating the entire procedure.

Methods

A novel technique for endoscopic anterior component separation using a trocar system allowing blunt and sharp dissection under direct vision is described. This brief communication also contains our initial experience and learning curve with this novel approach.

Results

Endoscopic release of the external oblique fascia was successfully performed 29 times in a total of 15 patients. Body mass index accounted for 30.8 kg/m² (median; range 21.6–42.5). Transverse width of midline defect accounted for 7 cm (median; range 4–12). Subsequent hernia repair was successfully done using sublay mesh reinforcement (n = 13) or a laparoscopic intraperitoneal onlay mesh procedure (n = 2) with midline closure in all cases. One hematoma was seen at site of release managed conservatively.

Conclusions

Using a trocar system allowing blunt and sharp dissection under direct vision may be a viable option for the endoscopic anterior component separation.

     

Transection of the deep metatarsal transverse ligament in Morton’s neuroma surgery does not increase risk of splayfoot development

Purpose

Although operative excision is regarded as the treatment of choice in Morton’s neuroma, it remains unclear whether transection of deep transverse metatarsal ligament (DTML) is a risk for metatarsal splaying and whether simultaneous surgery in adjacent intermetatarsal spaces is a risk for osteonecrosis of the adjacent metatarsals.

Methods

Fifty-seven feet in 47 patients had excision of a Morton’s neuroma, with a mean follow-up of 15.3 years. Feet were categorised depending upon whether the DTML was or was not divided. Pre-operative and post-operative intermetatarsal angles were measured on standardised weightbearing radiographs and inspected for evidence of osteonecrosis.

Results

Comparison of pre- and post-operative intermetatarsal angles in patients with surgery in the second web space showed no significant increase (transected p?=?0.659, preserved p?=?0.142). In regards to comparison of pre- and post-operative radiographic intermetatarsal angles in patients with surgery in the third web space, statistical analysis also did not show a significance increase (transected p?=?0.240, preserved p?=?0.078). Radiological assessment showed no signs of osteonecrosis of metatarsal heads, not even in cases of double-space surgery.

Conclusions

In conclusion, DTML transection does not increase the intermetatarsal angle or the risk of splayfoot development. Moreover, transection is recommended due to an enhanced overview during surgery and better clinical outcome. Our data could also prove that double-space surgery is not a risk for avascular osteonecrosis.

     

TEP or TAPP for recurrent inguinal hernia repair—register-based comparison of the outcome

Introduction

The guidelines of the international hernia societies recommend laparo-endoscopic inguinal hernia repair for recurrent hernias after open primary repair. To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair. A Swiss registry study identified only minor differences between the two techniques, thus suggesting the equivalence of the two procedures.

Materials and Methods

Between September 1, 2009 and August 31, 2013 data were entered into the Herniamed Registry on a total of 2246 patients with recurrent inguinal hernia repair following previous open primary operation in either TAPP (n?=?1,464) or TEP technique (n?=?782).

Results

Univariable and multivariable analysis did not find any significant difference between TEP and TAPP with regard to the intraoperative complications, complication-related reoperations, re-recurrences, pain at rest, pain on exertion, or chronic pain requiring treatment. The only difference identified was a significantly higher postoperative seroma rate after TAPP, which was influenced by the surgical technique, previous open primary operation and EHS-classification medial and responded to conservative treatment.

Conclusion

TEP and TAPP are equivalent surgical techniques for recurrent inguinal hernia repair following previous open primary operation. The choice of technique should be tailored to the surgeon’s expertise.