European Hernia Society guidelines on prevention and treatment of parastomal hernias

Background

International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project.

Methods

The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants.

Results

End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed.

Conclusion

An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

     

Successful management of brain metastasis from malignant germ cell tumours with standard induction chemotherapy

Because of possible long-term toxicity, cranial radiotherapy (RT) was withheld as part of standard treatment for brain metastasis (BM) from non-seminomatous germ cell tumours (NSGCT). This study evaluates this change in management in our institute. Twenty-two consecutive patients with BM from NSGCT were analysed. Ten patients presented with BM at initial diagnosis (group 1), two patients developed BM at extra-cranial complete remission (CR) (group 2), and ten patients during treatment of the primary tumour without achieving CR (group 3). All patients received cisplatin-based induction chemotherapy. In group 1, three patients with a single metastasis and three patients with multiple BM underwent craniotomy. Five patients received chemotherapy and whole brain RT (WBRT), and five patients received chemotherapy without WBRT. In group 2, both patients underwent craniotomy for a relapse with multiple BM. One patient received additional high-dose (HD) chemotherapy with WBRT, and the other HD chemotherapy without WBRT. In group 3, one patient underwent craniotomy, seven patients received WBRT, and four patients additional HD chemotherapy. In group 1, five of ten patients (50%) achieved CR (follow-up 49–245 months), in four of those five without WBRT. In group 2, both patients achieved CR (follow-up 146 and 211 months). In group 3, one of ten patients (10%) achieved CR after HD chemotherapy and WBRT (follow-up 107 months). It is concluded that cure in patients with BM from NSGCT can be achieved with standard induction chemotherapy without WBRT.     

The influence of 2020 coronavirus lockdown on presentation of oral and maxillofacial trauma to a central London hospital

The novel coronavirus COVID-19 was first identified in China in December 2019. Its spread resulted in a pandemic, with the United Kingdom entering a period of national lockdown on 23 March 2020 to reduce disease burden on the National Health Service (NHS). King’s College Hospital is a Major Trauma Centre serving an inner-city population of 700,000 with 120,000 patients attending the emergency department (ED) annually. We aimed to determine the effect of lockdown on OMFS trauma presentations and lessons learned from emergency service provision during a pandemic. All referrals to the oral and maxillofacial surgical (OMFS) team from ED during the first six weeks of the lockdown period – 23 March 2020 - 3 May 2020 – were compared with the same six-week period in 2019. A total of 111 referrals were made to OMFS during the first six weeks of the lockdown period in 2020 compared with 380 referrals in 2019. Of these, 50.5%, (n = 192) were related to facial trauma in 2019 vs (63.1%, n = 70) in 2020. Fewer patients were admitted under OMFS: 17.4% (n = 35) in 2019 vs 2.9% (n = 2) in 2020, and a greater number of patients were discharged from OMFS care directly from the ED: 63.2% (n = 127) in 2019 vs 82.9% (n = 58) in 2020. There was profound effect of the lockdown on referrals to OMFS from the ED, in number and type of diagnosis. This is potentially reflective of the increased availability of acute/emergency dental services in South-East London during the lockdown period. This gives us valuable insight for service planning in the event of further restrictions.     

The effects of AIDS prevention programs by lay health advisors for migrants in The Netherlands

Two studies describe the effectiveness of acquired immunodeficiency syndrome (AIDS) prevention programs by lay health advisors (LHAs) for migrants in The Netherlands. The effects of such AIDS programs were evaluated (Study 1) and compared with the effects of professional health advisors (PHAs, i.e. medical doctors or nurses) (Study 2). The first study concerned Turkish and Moroccan migrants and showed positive effects on knowledge, behavioral control, and social norm towards condom use. Iraqi refugees participated in the second study that concerned a direct comparison of LHA- and PHA-based programs. Both programs result in positive effects in terms of attitude change and knowledge, but the LHA program resulted in a stronger intention to discuss AIDS with children. Analyses predicting intention to use condoms provide evidence that LHA programs lead to a stronger relation between attitudes and intention. This suggests that LHA-based AIDS programs are more successful in inducing internally motivated intentions to safe sex practices, such as condom use.     

Inhibition of Cortical Laser‐Evoked Potentials by Transcutaneous Electrical Nerve Stimulation

Objectives. This study attempts to confirm the hypothesis that transcutaneous electrical stimulation (TENS) of peripheral Aβ fibers inhibits nociceptive processing, by quantifying the change of laser‐evoked potential (LEP) components, using a 980‐nm diode laser. Materials and Methods. Cutaneous heat stimuli were delivered to the dorsum of the right hand in 13 volunteers. LEPs and pain intensity ratings were recorded before, during, and after the use of TENS (110 Hz) at the dorsolateral forearm. Area under the curve (AUC), LEP amplitudes (N2P2), and peak latencies (N2, P2) were calculated. The paired samples t‐test was used for statistical analysis. Results. A significant reduction of LEP amplitudes and AUC was found during and after the use of TENS (p < 0.05). After 10 min of TENS this was associated with a clinically relevant decrease of pain intensity. Conclusions. Our data suggest that TENS inhibits nociceptive processing. Ten minutes of TENS exerts a clinically relevant pain reduction.     

Prophylactic mesh to prevent parastomal hernia after end colostomy: a meta-analysis and trial sequential analysis

Hernia - Prevention of parastomal hernia (PSH) formation is crucial, given the high prevalence and difficulties in the surgical repair of PSH. To investigate the effect of a preventive mesh in PSH...