Chronic pain and quality of life (QoL) after transinguinal preperitoneal (TIPP) inguinal hernia repair using a totally extraperitoneal, parietalized, Polysoft ® memory ring patch

Introduction

Little is known about both incidence of chronic pain and quality of life (QoL) after the transinguinal preperitoneal (TIPP) technique using a totally extraperitoneal, parietalized, memory ring patch.

Materials and methods

Among 622 (428 unilateral and 194 bilateral) hernia repairs (HR) in 525 patients, 92 % had a postoperative clinical control. Thereafter, two sets of postal self-assessed questionnaires were sent.

Results

A total of 531 HR were studied with a mean follow-up of 17 ± 8 months. Only one recurrence was detected. In 151 (28.4 %) HR the patients alleged various symptoms, but in only 10 (1.9 %) HR they considered their discomfort more bothersome than the hernia they had before, and in just 2 (0.4 %) HR they judged their result as bad (one patch removal for sepsis and one for hematoma). Only mild pain (including no painful discomfort such as a foreign body sensation) or moderate pain was frequent. Pain was self-graded as severe in four cases. None of them reported any regular consumption of antalgics. None of them judged their result as bad. Dysesthesia (numbness 19, paresthesia 20) mentioned in 39 HR (7 %), associated with pain in 16 HR, was said to be more bothersome than the hernia treated in just 3 HR (0.6 %). The results of the entire series were self-assessed as good or excellent in 97 % of the HR.

Conclusion

In our TIPP series, both the incidence of recurrences (0.2 %) and that of severe chronic pain (≤0.7 %) were very low, as well as patients’ QoL was excellent. In our experience, the postoperative course was as painless as that of laparoscopic TEP we had been performing previously, but TIPP appeared more suited to day-case surgery.     

Does surgeon frustration and satisfaction with the operation predict outcomes of open or laparoscopic inguinal hernia repair?

BACKGROUND: A surgeon's level of frustration when performing an operation and level of satisfaction at completion may be correlated with patients' outcomes. We evaluated the relationship between the attending surgeons' frustration and satisfaction and recurrence and complications of open and laparoscopic inguinal hernia repair. STUDY DESIGN: Men with detectable inguinal hernias were randomized to undergo open or laparoscopic herniorrhaphy at 14 Veterans Affairs hospitals. After completion of the procedure, surgeons were asked to assess their level of frustration during the operation and their overall satisfaction with the operative result. Two subjective scales ranging from 1 (not frustrated/not satisfied) to 5 (very frustrated/very satisfied) were used to independently assess both parameters. Reasons for surgeon frustration were evaluated. Patients were followed for 2 years for recurrence and complications. RESULTS: Of 1,983 patients who underwent hernia repair, 1,622 were available for analysis; 808 had open repair and 813 had laparoscopic repair. Surgeons reported less frustration and more satisfaction with open than with laparoscopic repair (p = 0.0001 and 0.0001, respectively). Frustration was associated with a higher rate of hernia recurrence at 2 years (adjusted odds ratio, 2.01, 95% CI, 1.15-3.51) in open repair, and a higher overall rate of postoperative complications (adjusted odds ratio, 1.27, 95% CI, 1.03-1.56) in both open and laparoscopic hernia repair. Satisfaction was not correlated with recurrence or complications. CONCLUSIONS: The level of a surgeon's frustration during performance of an inguinal herniorrhaphy was a better predictor of outcomes of the operation than was satisfaction with the procedure. Sources of intraoperative frustration should be controlled to improve outcomes.     

Laparoscopic repair of hiatus hernia: Does mesh type influence outcome? A meta-analysis and European survey study

Background

Synthetic mesh (SM) has been used in the laparoscopic repair of hiatus hernia but remains controversial due to reports of complications, most notably esophageal erosion. Biological mesh (BM) has been proposed as an alternative to mitigate this risk. The aim of this study is to establish the incidence of complications, recurrence and revision surgery in patients following suture (SR), SM or BM repair and undertake a survey of surgeons to establish a perspective of current practice.

Methods

An electronic search of EMBASE, MEDLINE and Cochrane database was performed. Pooled odds ratios (PORs) were calculated for discrete variables. To survey current practice an online questionnaire was sent to emails registered to the European Association for Endoscopic Surgery.

Results

Nine studies were included, comprising 676 patients (310 with SR, 214 with SM and 152 with BM). There was no significant difference in the incidence of complications with mesh compared to SR (P = 0.993). Mesh significantly reduced overall recurrence rates compared to SR [14.5 vs. 24.5 %; POR = 0.36 (95 % CI 0.17–0.77); P = 0.009]. Overall recurrence rates were reduced in the SM compared to BM groups (12.6 vs. 17.1 %), and similarly compared to the SR group, the POR for recurrence was lower in the SM group than the BM group [0.30 (95 % CI 0.12–0.73); P = 0.008 vs. 0.69 (95 % CI 0.26–1.83); P = 0.457]. Regarding surgical technique 503 survey responses were included. Mesh reinforcement of the crura was undertaken by 67 % of surgeons in all or selected cases with 67 % of these preferring synthetic mesh to absorbable mesh. One-fifth of the respondents had encountered mesh erosion in their career.

Conclusions

Both SM and BM reduce rates of recurrence compared to SR, with SM proving most effective. Surgical practice is varied, and there remains insufficient evidence regarding the optimum technique for the repair of hiatal hernia.

     

Does age or gender of the patient influence the outcome of type II superior labrum anterior and posterior repair?

Aims:

To assess whether patients above 50 years of age, particularly female, would benefit from repair of their SLAP tears.

Settings and Design:

Review of patients'' records followed by telephone interview at a minimum of two years after surgery.

Materials and Methods:

Seventy-two consecutive patients who had their SLAP repaired were retrospective reviewed by an independent examiner. Follow up was by telephone interview with pain and functional results measured according to the Oxford Shoulder Questionnaire. The patients were asked whether they would undergo the same operation if they had a similar injury.

Statistical Analysis Used:

OKS - One way ANOVA, followed by Tukey HSD multiple comparisons were used to assess the Oxford Shoulder score. Kruskal-Wallis Test was used to assess the final VAS Pain Score. Student''s T tests for Oxford scores before and after surgery.

Results:

Between 2007-2008, 38 male patients and 34 female patients with an average age of 53 (19-75) years had their SLAP repair. Good to excellent results in Oxford shoulder scores were reported in 94%. 68 0f 72 patients would undergo the same if they had a similar injury. No statistical correlation was found between the patient''s age, gender and outcome scores.

Conclusions:

Neither the patients'' gender nor their age above 50 affected the outcome after surgery.     

Does Pseudomonas aeruginosa colonization influence morbidity and mortality in the intensive care unit patient? Experience from an outbreak caused by contaminated oral swabs

BACKGROUND: Contaminated oral swabs caused a nationwide monoclonal Pseudomonas aeruginosa outbreak involving 27 Norwegian hospitals. The aim of the study was to study the consequences on mortality and morbidity of the introduction of this P. aeruginosa strain to intensive care unit (ICU) patients. METHODS: Forty-four out of 96 patients admitted to the general ICU of Akershus University Hospital during the outbreak, ventilated for more than 24 h and with at least one microbiological sample, were included and followed until death or hospital discharge. All isolated P. aeruginosa strains were genotyped. Demographic data, admission diagnosis, Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA) score, comorbidities, and antibiotics used in the first week were recorded. RESULTS: The outbreak strain was found in 18 patients (41%) of whom seven became infected. Median time to the first positive culture was 4 days. These 18 patients spent a significantly longer time on mechanical ventilation (P =0.03) and had a significantly higher hospital mortality, 55.5% vs. 19.2% (P =0.03), than non-colonized patients. The number of patients with severe underlying disease was significantly higher (P =0.01) and the decline in SOFA score was significantly slower in the pseudomonas group (P =0.02). Irrespective of colonization status, patients with severe underlying disease had a significantly higher mortality (58%) than those without (16%) (P =0.009). CONCLUSION: Use of contaminated oral swabs led to a high rate of early airways colonization. Patients with severe underlying disease were more likely to become colonized, but whether colonization has any influence on hospital mortality requires further study.     

Is there an end of the “learning curve” of endoscopic totally extraperitoneal (TEP) hernia repair?

Background

An important challenge of totally extraperitoneal (TEP) hernia repair is the learning curve. The European guidelines suggest that the learning curve ranges between 50 and 100 procedures, with the first 30–50 being critical. Others suggest that optimal outcomes are achieved after 200 or more TEP procedures.

Methods

All TEP repairs performed between 2005 and 2009 were included in this study. The effect of (surgeon) expertise on perioperative complications, conversion to open anterior repair, and operative time was assessed to evaluate the extent of the learning curve of TEP repair.

Results

Intraoperative complications occurred in <1 % of the 3,432 patients and postoperative complications were observed in 243 (7 %) patients. With a median follow-up of 2 years after TEP, 19 patients (0.55 %) had a recurrence. During the study period, at the end of which all four surgeons had treated 900–1,000 patients, intraoperative complications and recurrences did not decline. On the other hand, the median operative time decreased from 30 to 20 min (p < 0.001). The conversion rate (1.6–0.2 %, p = 0.018) and postoperative complication rate (11.6–4.2 %, p < 0.001) also declined. The decline was observed for all four surgeons, irrespective of their initial expertise with TEP. The largest decrease in the conversion rate was seen after at least 250 TEP procedures; the postoperative complication rate and operative time showed a linear and significant decline throughout the study period. A more or less “steady state” was observed after approximately 450 procedures per surgeon.

Conclusions

Even after more than 400 individually performed TEP procedures, there is progress in reducing the conversion rate, the incidence of short-term postoperative complications, and operative time, indicating a rather long learning curve.     

Concurrent bariatric surgery and paraesophageal hernia repair: an analysis of the Metabolic and Bariatric Surgery Association Quality Improvement Program (MBSAQIP) database

BackgroundParaesophageal hernias (PEH) are common among patients with obesity. Most patients with severe obesity and a PEH will have the PEH repaired at the time of bariatric surgery. However, it is unclear whether there is increased risk when repairing a PEH during bariatric surgery.ObjectivesTo examine short-term outcomes of patients undergoing bariatric surgery with concurrent PEH repair versus bariatric surgery alone.SettingAccredited bariatric centers across the United States and Canada.MethodsPatients who underwent bariatric surgery with concurrent PEH repair were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Using a propensity-score matching algorithm, these patients were matched with a cohort who underwent bariatric surgery only, controlling for age, sex, and other co-morbidities. Overall, 30-day incidence of major complications was the primary outcome. Secondary outcomes included mortality, length of operation, reoperations, and readmissions.ResultsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database identified 222,320 bariatric procedures without PEH and 42,732 procedures with concurrent PEH repair. With one-to-one propensity score matching, 42,379 pairs were selected. Background characteristics, including age, sex, preoperative body mass index, and preoperative co-morbidities, did not differ statistically between matched cohorts. There was no statistically significant difference in 30-day major complications (3.5% versus 3.4%, P = .317).ConclusionsOur analysis indicates that the incidence of major complications for bariatric surgery with concurrent PEH repair is similar to bariatric surgery alone. Overall, this study demonstrates the safety of concurrent bariatric surgery and PEH repair.     

Evaluation of bone repair after application of a norbixin membrane scaffold with and without laser photobiomodulation (λ 780 nm)

Biocompatible membranes are widely used in medicine to stimulate bone repair. Several studies have demonstrated that laser photobiomodulation (PBM) also stimulates osteoblast proliferation and osteogenesis at the fracture site, leading to a greater deposition of bone mass and accelerating the process of bone consolidation. This work assessed the therapeutic effect of 780-nm laser PBM and a polystyrene membrane coated with norbixin and collagen (PSNC) on bone healing in rats with calvarial bone defect. Histological staining, Raman spectroscopy, and scanning electron microscopy (SEM) were used to evaluate the bone repair process. Four experimental treatment groups were compared: C, control; M, membrane only; L, laser PBM only; and ML, membrane + laser PBM. A bone defect was created in the calvaria of each animal, with each group subdivided into two subgroups that underwent euthanasia after 15 and 30 days treatment. The L and ML groups were irradiated (λ?=?780 nm, ED?=?6 J/cm², P?=?60 mW, t?=?4 s) postoperatively on alternate days until they were euthanized. The bone concentration of hydroxyapatite (CHA) showed a clear gradation with increasing phosphate area in the order B (normal cortical bone)?>?L?>?M?>?ML?>?C for both periods. The PSNC membrane was effective in reducing the inflammatory process and served as a scaffold for bone repair. The laser PBM also showed positive effects on the bone repair process with increased deposition and organization of the newly formed bone. However, laser PBM failed to improve the bioactive properties of the membrane scaffold.     

Does Lengthening and Then Plating (LAP) Shorten Duration of External Fixation?

Background  

Classic bone lengthening requires patients wear external fixation for the distraction and consolidation phases and there is fracture risk after frame removal. Our technique of lengthening with the Taylor Spatial Frame^TM and then insertion of a locked plate allows earlier removal of the external fixator during consolidation. Plate insertion is accomplished through a clean pin-free zone avoiding contamination and before frame removal maintaining bone position.     

Can the physiologic ability and surgical stress (E-PASS) scoring system predict operative morbidity after distal pancreatectomy?

Purpose  

Mortality rates after pancreatic resection are now lower than 5% in high-volume centers; however, morbidity remains high. This stresses the importance of identifying accurate predictors of operative morbidity after pancreatic resection. The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system was developed for a comparative audit of general surgical patients. Our previous study confirmed its usefulness for predicting morbidity after pancreaticoduodenectomy. In the present study, we evaluated whether the E-PASS scoring system can predict the occurrence of complications after distal pancreatectomy (DP).