Preliminary experience with new bioactive prosthetic material for repair of hernias in infected fields

Surgisis (Cook Surgical, Bloomington, Ind., USA) is a new four-ply bioactive, prosthetic mesh for hernia repair derived from porcine small-intestinal submucosa. It is a naturally occurring extracellular matrix which is easily absorbed, supports early and abundant new vessel growth, and serves as a template for the constructive remodeling of many tissues. As such, we believe that Surgisis mesh is ideal for use in contaminated or potentially contaminated fields in which ventral, incisional, or inguinal hernia repairs are required. From November 2000 through May 2002, 25 patients (11 male, 14 female) underwent placement of Surgisis mesh for a variety of different hernia repairs. A total of 25 hernia repairs were performed in our patient population. Fourteen procedures (56%) were performed in a potentially contaminated setting (i.e. with incarcerated/strangulated bowel within the hernia or coincident with a laparoscopic cholecystectomy/colectomy). Eleven repairs (44%) were performed in a grossly contaminated field, including one in which an infected polypropylene mesh from a previous inguinal hernia repair was replaced with Surgisis and one in which necrotic bowel was discovered within the hernial sac. Median follow-up was 15 months with a range of 1–20 months. Of the 25 total repairs, there was one wound infection complicated by enterocutaneous fistula in a patient originally operated on for ischemic bowel. The fistula was in a location independent of the Surgisis mesh. There were no mesh-related complications or recurrent hernias in our early postoperative follow-up period. Surgisis mesh appears to be a promising new prosthetic material for hernia repair, especially in contaminated or potentially contaminated fields. Obviously, long-term follow-up is still required. Electronic Publication     

Incomplete excision of the gallbladder during laparoscopic cholecystectomy

Dissection and transection of the cystic duct close to the gallbladder has been advocated as a means of avoiding common bile injury during laparoscopic cholecystectomy (LC). We present three cases in which inadequate identification of the gallbladder—cystic duct junction resulted in incomplete cholecystectomy. In two patients an unsecured gallbladder infundibulum presented as cystic duct leaks and one patient developed recurrent symptomatic cholelithiasis. These cases emphasize the need for complete dissection and visualization of the cystic duct at the gallbladder prior its division and secure ligation during LC.     

Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon cancer

The authors examined the impact of the laparoscopic approach on the early outcome of resected colon carcinomas. The role of laparoscopic techniques in the treatment of colon carcinomas is questionable. Previous studies have suggested technical feasibility of surgical resections of these cancers by laparoscopic means and have implied a benefit to laparoscopic technique for patients undergoing colorectal resections. A prospective, randomized study was conducted comparing laparoscopic assisted colectomy (LAC) open colectomy (OC) for colon cancer. We present the preliminary results in relation to the short-term outcome and judge the feasibility of the laparoscopic procedure to as a way of performing accurate oncologic resection and staging. Benefit has been demonstrated with LAC in this setting. Passing flatus, oral intake, and discharge from hospital occurred earlier in LAC- than OC-treated patients The mean operative time was significantly longer in the LAC group than in the OC group. The overall morbidity was significantly lower in the LAC group. No significant differences were observed between both groups in the number of lymph nodes removed or the pathological stage following the Astler-Coller modification of the Dukes classification. The laparoscopic approach improves the short-term outcome of segmental colectomies for colon cancer. However, the further follow-up of these patients will allow us to answer in the near future whether or not the LAC may influence the long-term outcome.Presented at the annual meeting of the Society of American Gastrointestinal Surgeons (SAGES), Orlando, FL, USA, 11–14 March 1995     

Laparoscopic bilateral inguinal hernia repair: Should it be the preferred technique?

Inguinal hernias are amongst the most common conditions requiring general surgical intervention. For decades, the preferred approach was the open repair. As laparoscopy became more popular and available and more surgeons became familiarized with this modality, laparoscopic inguinal hernia repair became an alternative. The aim of this study is to assess the effectiveness of laparoscopic inguinal repair, with a focus on bilateral inguinal hernias. Initial reports have shown promising clinical outcomes compared to those of conventional repair of bilateral hernias. However, there are only a few studies concerning laparoscopic repair of bilateral hernias. It is yet to be proven that laparoscopy is the “gold standard” in the treatment of bilateral inguinal hernias. So far, the choice of an inguinal hernia repair technique has been up to each surgeon, depending on their expertise and available resources after taking into consideration each patient’s needs.     

¿Puede la cirugía mínimamente invasiva resultar en sitios inusuales de metástasis?

ObjectiveTo compare sites of metastasis for the laparoscopic (LRC) and open (ORC) approaches in a cohort of patients at a district general hospital. Morbidity and mortality for the two approaches are assessed using secondary outcomes of length of stay and complication rate. Metastasis rate and site are compared.MethodsA retrospective case note review was carried out for all patients who underwent cystectomy for bladder malignancy at Pinderfields General Hospital, Wakefield between 2010 and 2016 (n = 219). There were 150 males and 69 females in 107 minimally invasive cases and 87 open (missing data on 25 cases). Data were analysed using Microsoft Excel XLSTAT.ResultsRecurrence rate was 25.1% and did not differ significantly with approach (p = 0.89). Sites of recurrence did not differ with operative approach, the most frequent being pelvis, chest and bone. Unusual sites of recurrence included abdominal wall and sigmoid colon which both occurred in LRC. Length of stay was greater for the open approach (median LRC = 10, ORC = 13, p < 0.01). Five-year survival was 74.9%. Survival distribution did not significantly differ with operative approach (p = 0.43), and there was no significant association between operative approach and patient death within the follow-up period (p = 0.09). Stricture rate was 4.1% and was not significantly different between the two groups (p = 0.29). Median time to stricture was 130 days. Clavien-Dindo scores for complications did not differ with approach (p = 0.93), and there was no significant association between operative approach and whether complications developed (p = 0.19).ConclusionsThe adverse oncological outcomes in minimally invasive approaches suggested by some studies are not confirmed here. Those in the LRC group were discharged sooner, though this did not translate into differences in morbidity or survival. Analysis of the association between individual complications and length of stay may clarify this further. Shorter hospital stay is also likely to have significant financial implications.Despite no significant difference in outcomes, the findings demonstrate potential benefits of LRC. Extensions of this study could include: cost-benefit analysis, examination of individual complications’ effect on length of stay; and analysis of approach-specific factors contributing to perioperative deaths.     

完全腹腔镜根治性膀胱切除加体内改良回肠通道术的学习效果分析

目的分析术者对完全腹腔镜根治性膀胱切除(LRC)+改良回肠通道术(MIC)的学习效果。方法回顾性分析首都医科大学附属北京朝阳医院2014年4月至2019年10月42例接受完全LRC+MIC患者的临床资料。男34例,女8例;年龄(63.4±9.1)岁。其中术者1行34例手术,术者2行8例。将术者1的34例按时间顺序分为3组,第1~12例为A组,第13~23例为B组,第24~34例为C组;术者2实施的8例为D组。4组中有腹部手术史者分别为0、1、4、3例,差异有统计学意义(P<0.05);4组年龄、体质指数、美国麻醉医师协会评分等差异均无统计学意义(P>0.05)。改良术式的重要步骤包括光源透射下离断肠系膜、输出袢固定的条件下行输尿管-输出袢反流性对端吻合、缝合后腹膜缺口。比较各组患者手术时间、构建回肠通道时间、出血量、并发症发生比例、淋巴结清扫数量、切缘阳性比例等重要手术指标。结果各组手术均顺利完成,均无中转开放手术。A~C组手术时间分别为330.0(320.0,360.0)、300.0(250.0,308.0)、270.0(216.0,324.0)min,差异有统计学意义(P=0.010);3组构建回肠通道时间分别为136.5(131.3,147.5)、92.0(79.0,119.0)、79.0(72.0,115.0)min,差异有统计学意义(P<0.001)。手术时间和构建回肠通道时间组间两两比较,A、B组,A、C组差异均有统计学意义(P<0.05),B、C组差异无统计学意义(P>0.05)。3组出血量[200.0(125.0,300.0)、100.0(100.0,150.0)、200.0(100.0,400.0)ml]、并发症发生比例[4/12、4/11、3/11]、淋巴结清扫数量[(19.0±10.7)、(16.0±9.8)、(23.3±8.5)枚]、切缘阳性比例(1/12、1/11、2/11)的比较,差异均无统计学意义(P>0.05)。D组手术时间420.0(350.0,450.0)min,与A组比较差异有统计学意义(P<0.05)。D组出血量200.0(112.5,350.0)ml,并发症发生比例2/8,淋巴结清扫数量(13.8±7.1)个,切缘阳性比例1/8,与A组比较差异均无统计学意义(P>0.05)。结论完全LRC+MIC学习效果明显,随着手术例数的增加,手术时间及构建回肠通道时间显著下降;该术式具有较好的可重复性和安全性。     

Positive microscopic surgical margins: Is there an association with survival in resected small gastrointestinal stromal tumors?

BackgroundFew studies evaluate the relationships between surgical approach, histologic margin, and overall survival in gastrointestinal stromal tumor. We test the hypothesis that margin positive resection is associated with compromised overall survival.MethodsWe queried the National Cancer Data Base to identify patients undergoing resections for gastrointestinal stromal tumors ≤3 cm in size between 2010 and 2015. Multivariable logistic regression was used to identify factors associated with positive microscopic margins on final pathology. Cox proportional hazard methods were used to evaluate factors associated with overall survival.Results2064 patients met inclusion criteria; 135 (6.5%) had a microscopically positive surgical margin. On multivariable regression, minimally invasive approach was not associated with risk of a positive margin (OR 1.06 95% CI [0.71, 1.59]). On Cox analysis, positive margin status was not associated with OS (R1: 1.03, CI [0.46–2.31], reference R0).ConclusionsPositive microscopic surgical margins are not associated with compromised overall survival in patients undergoing resection of small gastrointestinal stromal tumors. Minimally invasive surgical approaches do not compromise oncologic outcomes in these cases.     

Intra-articular infiltration analgesia for arthroscopic shoulder surgery: a systematic review and meta-analysis

Phrenic-sparing analgesic techniques for shoulder surgery are desirable. Intra-articular infiltration analgesia is one promising phrenic-sparing modality, but its role remains unclear because of conflicting evidence of analgesic efficacy and theoretical concerns regarding chondrotoxicity. This systematic review and meta-analysis evaluated the benefits and risks of intra-articular infiltration in arthroscopic shoulder surgery compared with systemic analgesia or interscalene brachial plexus block. We sought randomised controlled trials comparing intra-articular infiltration with interscalene brachial plexus block or systemic analgesia (control). Cumulative 24-h postoperative oral morphine equivalent consumption was designated as the primary outcome. Secondary outcomes included visual analogue scale pain scores during the first 24 h postoperatively; time-to-first analgesic request; patient satisfaction; opioid-related side-effects; block-related adverse events; and any indicators of chondrotoxicity. Fifteen trials (863 patients) were included. Compared with control, intra-articular infiltration reduced 24-h postoperative analgesic consumption by a weighted mean difference (95%CI) of −30.9 ([−38.9 to −22.9]; p < 0.001). Intra-articular infiltration also reduced the weighted mean difference (95%CI) pain scores up to 12 h postoperatively, with the greatest reduction at 4 h (−2.2 cm [(−4.4 to −0.04]); p < 0.05). Compared with interscalene brachial plexus block, there was no difference in opioid consumption, but patients receiving interscalene brachial plexus block had better pain scores at 2, 4 and 24 h postoperatively. There was no difference in opioid- or block-related adverse events, and none of the trials reported chondrotoxic effects. Compared with systemic analgesia, intra-articular infiltration provides superior pain control, reduces opioid consumption and enhances patient satisfaction, but it may be inferior to interscalene brachial plexus block patients having arthroscopic shoulder surgery.     

解剖性保留控尿肌群技术在腹腔镜根治性前列腺切除术中的临床应用价值

目的 探讨腹腔镜前列腺癌根治术（LRP）中解剖性保留控尿肌群技术对术后早期控尿功能恢复的影响,及其肿瘤学安全性。方法 回顾性队列研究。纳入2016年1月—2020年6月浙江大学医学院附属金华医院泌尿外科采用LRP治疗的前列腺癌患者共292例,将其中采用解剖性保留控尿肌群技术的83例纳入观察组;对另外209例接受经典前列腺癌根治术的患者与观察组患者进行1∶1倾向性评分匹配,选择其中83例纳入对照组。全组共166例,年龄45~75（64.0±7.3）岁,BMI 21~31（24.4±2.4）kg/m²。对比分析2组患者手术时间、术中出血量、术后病理TNM分期、Gleason评分、术后留置导尿时间、手术并发症和手术切缘阳性（PSM）率;采用Kaplan-Meier法评估患者3年、5年无生化复发（BCR）累积生存率;根据术后每天使用的尿垫数量进行控尿功能分级评估,分别于拔除导尿管后的当天（第1个24 h）、1周及1、3、6、12个月时,观察并对比2组患者控尿功能恢复情况。结果 2组患者年龄、临床分期、危险分级、膀胱颈和神经保留与否等临床基线特征比较,差异均无统计学意义（P值均>0.05）。全组166例均在腹腔镜下完成手术,术后恢复良好,无围手术期死亡病例。2组患者手术时间、术中出血量、术后病理TNM分期、术后Gleason评分、术后留置导尿时间和手术并发症比较,差异均无统计学意义（P值均>0.05）。观察组PSM率为10.84％（9/83）,低于对照组的13.25%（11/83）,但差异无统计学意义（χ²=0.23, P=0.633）。2组患者术后随访12~71个月,平均33.73个月。随访期间无死亡病例。观察组3年、5年无BCR累积生存率分别为90.2％和73.2%,对照组分别为91.4%和77.8%,2组差异无统计学意义（χ²=0.38, P=0.535）。在拔除导尿管后当天、1周及1、3、6个月,观察组完全控尿率分别为39.76%（33/83）、53.01%（44/83）、66.27%（55/83）、90.36%（75/83）和97.95%（81/83）,对照组为16.87%（14/83）、21.96%（18/83）、38.55%（32/83）、53.01%（44/83）和68.67%（57/83）;观察组控尿功能分级均优于对照组,差异均有统计学意义（Z=-4.24、-4.09、-3.78、-5.61、-4.99,P值均<0.001）;拔管后12个月,2组完全控尿率分别为98.80%（82/83）和93.98%（78/83）,控尿功能分级比较差异无统计学意义（Z=-1.67,P=0.094）。术后3个月,观察组控尿（完全+社交）率达100％（83/83）,高于对照组的73.49%（61/83）,差异有统计学意义（χ²=25.36, P<0.001）。结论 LRP中解剖性保留控尿肌群技术的应用有助于患者术后早期恢复控尿功能,且不影响手术的肿瘤学安全性。