Association Between Inter-Recti Distance and Impaired Abdominal Core Function in Post-Partum Women With Diastasis Recti Abdominis

Background and Aim: The definition and management of Diastasis Recti Abdominis (DRA) is under debate. This study aimed to understand the correlation between the post-partum inter-recti distance (IRD) and functional impairments associated with core instability, with the hypothesis that IRD could serve as a proxy for core instability symptoms and constitute a tool in decision-making for DRA treatment. Material and Methods: A cohort of post-partum women with abdominal core instability symptoms combined with DRA were studied. The size of IRD was measured with ultrasonography and cross-sectionally analysed against functional impairments registered with the self-report Disability Rating Index (DRI), which grades the ability to perform 12 different daily activities. Results: A total of 224 women were included in the study. In univariable analysis, IRD was associated with impairment of the activities running (p = 0.007), heavy work (p = 0.036) and exercise/sports (p = 0.047), but not with dressing, walking, sitting for long periods, standing bent over a sink, carrying a suitcase, making a bed, light manual labour or heavy lifting. No significant correlations were seen in the multivariable analysis when adjustments were made for BMI and parity. Conclusion: IRD and post-partum functional impairments had no significant correlation in multivariable analysis. The post-partum core instability condition is complex and probably associated with more factors than solely the IRD. The IRD alone does not seem to be a sufficient proxy for decision-making regarding optimal treatment. A more complete instrument to assess the post-partum abdominal core is warranted.

Fibrin Sealant for Prevention of Bile Leakage After Laparoscopic Common Bile Duct Incision: Outcome of a Randomized Controlled Trial

Background: There are several methods used to extract common bile duct (CBD) stones encountered during cholecystectomy. Intraoperative cholangiotomy, cholangioscopy, and laparoscopic CBD exploration (LCBDE) are techniques that allow removal of stones from the CBD during the index procedure. However, bile leakage following CBD exploration is a common problem. The aim of this study was to assess whether fibrin sealant applied to the duct incision is safe. Methods: Patients planned for laparoscopic gallstone surgery at the Department of Surgery, Enköping Hospital, were included in the study. In cases where perioperative cholangiography showed CBD stones, LCBDE was performed through a longitudinal incision in the CBD. Randomization between closure of the incision with polyglactin sutures or with fibrin sealant was performed. After all the stones had been removed and the incision closed according to the allocation, an abdominal drain was placed close to the incision. A T tube was placed in the CBD or a straight tube into cystic duct for eventual postoperative cholangiogram. The patient and the surgeon assessing the postoperative course were blinded to the randomized allocation. Results: Altogether 51 patients were included from December 2012 to July 2016. Mean operative time was 188 minutes in the fibrin sealant group and 214 minutes in the suture group (P = .159). There was no significant difference between groups in bile flow in the abdominal drainage tube or in the CBD drain during the three first postoperative days. The time to removal of the abdominal drain did not differ significantly between groups. Conclusion: Although the present study lacks the statistical power to prove a benefit from fibrin sealant, it indicates that closure of the incision may be an option to reduce the risk for leakage. Further studies are required to confirm this. The study was retrospectively registered on clinicaltrials.gov September 5, 2015 (NCT02545153).

Minimal Incision Repair of Rectus Abdominis Diastasis (MIRRAD) as day-case surgery: A prospective study

PURPOSE

Postpartum rectus abdominis diastasis (PP-RAD) is a condition that may cause abdominal wall insufficiency, affecting daily life. When conservative treatments are unsuccessful, surgical intervention may be necessary. This study aimed to assess the safety and effectiveness of minimal incision repair of rectus abdominis diastasis (MIRRAD) as day-case surgery in women with PP-RAD.

METHODS

This study included 33 female patients aged 20-50 years with PP-RAD and an inter-rectus distance (IRD) of ≥ 3 cm. All patients had previously undergone conservative treatment without satisfactory outcomes. Each patient received the MIRRAD procedure as day-case surgery apart from one who stayed overnight due to nausea. Follow-up evaluations were conducted at 4 h, 1 week, 1 month, and 1 year after surgery.

RESULTS

The average inter-rectus distance (IRD) was 4.4 cm, with a mean diastasis length of 15 cm. Of the 33 patients included, 2 did not attend the 1 year follow-up leaving 31 for final analysis. Of these, 30 had one or more concomitant hernias. The mean operation time was 67 min. At the 1 year follow-up, 87% of patients were satisfied with the results, and 90% said they would undergo the procedure again if necessary. No surgical site infection was reported, and recovery was generally smooth. Thirty of the 31 patients were discharged within 4 to 6 h after surgery, while one patient stayed overnight.

CONCLUSION

MIRRAD appears to be a safe and effective surgical option for PP-RAD, particularly in cases without significant excess skin. Further studies with larger populations and longer follow-up are needed to confirm these findings and establish standard patient selection criteria.

[Swedish gallstone surgery during the covid-19 pandemic]

The covid-19 pandemic has necessitated reallocation of health care resources. This has raised concerns about the risks associated with postponing surgery for benign conditions that are given low priority. Data from the population-based Swedish National Register for Gallstone Surgery (GallRiks) show that the total number of procedures carried out during the initial months of each wave of the pandemic decreased. This was followed by a moderate increase in the number of procedures performed for acute cholecystitis, biliary pancreatitis, and obstructive jaundice. The consequences of the delayed surgery in the community at large and how this has affected health-related quality of life for patients having their procedure postponed remain to be evaluated, but so far it does not seem to have caused a major impact on public health.

Learning by doing: an observational study of the learning curve for ultrasonic fundus-first dissection in elective cholecystectomy

BACKGROUND

Surgical safety and patient-related outcomes are important considerations when introducing new surgical techniques. Studies about the learning curves for different surgical procedures are sparse. The aim of this observational study was to evaluate the learning curve for ultrasonic fundus-first (FF) dissection in elective laparoscopic cholecystectomy (LC).

METHODS

The study was conducted at eight hospitals in Sweden between 2017 and 2019. The primary endpoint was dissection time, with secondary endpoints being intra- and postoperative complication rates and the surgeon's self-assessed performance level. Participating surgeons (n = 16) were residents or specialists who performed LC individually but who had no previous experience in ultrasonic FF dissection. Each surgeon performed fifteen procedures. Video recordings from five of the procedures were analysed by two external surgeons. Patient characteristics and data on complications were retrieved from the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).

RESULTS

Dissection time decreased as experience increased (p = 0.001). Surgeons with limited experience showed more rapid progress. The overall complication rate was 14 (5.8%), including 3 (1.3%) potentially technique-related complications. Video assessment scores showed no correlation with the number of procedures performed. The self-assessed performance level was rated lower when the operation was more complicated (p < 0.001).

CONCLUSIONS

Our results show that dissection time decreased with increasing experience. Most surgeons identified both favourable and unfavourable aspects of the ultrasonic FF technique. The ultrasonic device is considered well suited for gallbladder surgery, but most participating surgeons preferred to dissect the gallbladder the traditional way, beginning in the triangle of Calot. Nevertheless, LC with ultrasonic FF dissection can be considered easy to learn with a low complication rate during the initial learning curve, for both residents and specialists.

[Better communication between surgery and anesthesia may provide safer surgery. The exchange of information has been mapped within the framework of "Safe abdominal surgery"]

Poor communication between surgical and anesthesia unit personnel may jeopardize patient safety.  Review reports from a national survey on patient safety performed at 17 units 2011-2013 were analyzed in order to identify strategies to reduce risks related to the interaction between surgery and anesthesia. The reports were reviewed in this study by an independent group in order to extract findings related to communication between anesthesia and surgical unit personnel. Suggested strategies to improve patient safety included: uniform national health declaration forms; consistent use of admission notes; uniform systems for documenting medical information; multidisciplinary forum for evaluation of high-risk patients; weekly and daily scheduling of surgical programs; application of the WHO check list; open dialog during surgery; oral and written reports from the surgeon to the postoperative unit; and combined mortality and morbidity conferences.

Vacuum-assisted closure versus on-demand relaparotomy in patients with secondary peritonitis-the VACOR trial: protocol for a randomised controlled trial

BACKGROUND

Secondary peritonitis is a severe condition with a 20-32% reported mortality. The accepted treatment modalities are vacuum-assisted closure (VAC) or primary closure with relaparotomy on-demand (ROD). However, no randomised controlled trial has been completed to compare the two methods potential benefits and disadvantages.

METHODS

This study will be a randomised controlled multicentre trial, including patients aged 18 years or older with purulent or faecal peritonitis confined to at least two of the four abdominal quadrants originating from the small intestine, colon, or rectum. Randomisation will be web-based to either primary closure with ROD or VAC in blocks of 2, 4, and 6. The primary endpoint is peritonitis-related complications within 30 or 90 days and one year after index operation. Secondary outcomes are comprehensive complication index (CCI) and mortality after 30 or 90 days and one year; quality of life assessment by (SF-36) after three and 12 months, the development of incisional hernia after 12 months assessed by clinical examination and CT-scanning and healthcare resource utilisation. With an estimated superiority of 15% in the primary outcome for VAC, 340 patients must be included. Hospitals in Denmark and Europe will be invited to participate.

DISCUSSION

There is no robust evidence for choosing either open abdomen with VAC treatment or primary closure with relaparotomy on-demand in patients with secondary peritonitis. The present study has the potential to answer this important clinical question.

TRIAL REGISTRATION

The study protocol has been registered at clinicaltrials.gov (NCT03932461). Protocol version 1.0, 9 January 2022.

[DYNAMICS OF ENTEROPERITONEAL TRANSLOCATION OF MICROORGANISMS ON THE EXPERIMANTAL MODEL OF ACUTE INTESTINAL OBSTRUCTION]

The article presents an analysis of the dynamics of enteroperitoneal translocation of bacteria on the model of acute intestinal obstruction (AIO) in rats by performing an experimental study on laboratory animals. Using the proposed model of AIO we have tried to determine the level of enteroperitoneal translocation as a function of the time of the impassable obstruction. The results which presented in the article clearly demonstrate that when AIO is developing in experimental animals the greatest level of translocation was revealed on the 3rd and 5th days. Statistically significant growth of the microflora in the lumen of the intestine above the level of obturation was observed on the 1st day and the whole period of observation was maintained, and it was also revealed that the level of CFU depends on the duration of the AIO and in the abdominal cavity it increases dramatically by 7 days, compared to 1 and 3 days. However, there is no significant correlation between enteroperitoneal translocation and the level of CFU in the lumen of the intestine and abdominal cavity.

Indocyanine green fluorescence improves safety in laparoscopic cholecystectomy using the Fundus First technique: a retrospective study

Introduction

As one of the most commonly performed surgeries in the world, safety during laparoscopic cholecystectomy (LC) is of utmost importance. Indocyanine green (ICG) has been used for different medical purposes including assessment of liver function since the 1950s. Its use during LC was first described in 2009 by Ishizawa. Since ICG is excreted in the bile, its fluorescent properties can be used to illuminate the bile ducts, and may reduce the risk for bile duct injury and other complications. Previous studies have compared ICG with conventional visualization showing shorter operation time and lower conversion rates during LC performed with traditional operation techniques. Results from LC performed with the Fundus First method (FF-LC) and ICG fluorescence has not been previously reported. The aim of this retrospective study was to compare LC with and without the aid of ICG fluorescence at a Swedish hospital routinely performing FF-LC.

Methods

Data from all patients operated with LC at Sundsvall General Hospital before and after the implementation of routine ICG between 2016 and 2023 were analyzed.

Results

The study included 2,009 patients; 1,455 operated with ICG (ICG-group) and 549 without (comparison group). FF-LC was used in 94.9% of all operations. The groups were comparable regarding gender, BMI, age, presence of acute cholecystitis and proportion urgent/elective surgery. ICG was found to be safe, with similar 30-day complication rates between study groups. A lower conversion rate was seen in the ICG-group (1.2% vs. 3.3%, p = 0.001) and there was a non-significant reduction in readmissions (p = 0.054). In univariate analysis, ICG was associated with prolonged operation time, but this was not supported in multivariate analysis. Time to cholangiography was prolonged in the ICG-group in both univariate and multivariate analyses.

Discussion

ICG fluorescence is an adjunct that could improve the operative safety. Implementation of routine ICG fluorescence at this Swedish hospital was found to be safe and efficient, suggesting improvement in safety during FF-LC. Further studies are needed to see if ICG increases safety in LC.

Learning curve in open groin hernia surgery: nationwide register-based study

BACKGROUND

Current recommendations regarding the number of open groin hernia repairs that surgical trainees are required to perform during their residency are arbitrarily defined and vary between different curricula. This register-based study sought to investigate the learning curve of surgeons performing open anterior mesh repair for groin hernia by assessing hernia recurrence rates, surgical complications and operating times in relation to the number of procedures performed.

METHOD

Nationwide data on open anterior mesh repair for groin hernia performed by surgical residents were collected from the Swedish Hernia Register between 2005 and 2020. The data were analysed in a cohort undergoing procedures carried out by surgeons performing their first registered repair as resident general surgeons. Repairs by surgeons with fewer than 30 repairs were excluded.

RESULTS

A total of 38 845 repairs carried out by 663 surgeons were included. Operation time decreased with increasing number of performed procedures, mean (s.d.) operation time was 79 (26) min for the first 15 procedures and 60 (23) min after 241 procedures (P <0.001). A turning point where complication rates began to decrease was seen after 60 procedures. Complication rates were 3.6 per cent (396 of 10 978) for procedures 31-60 and 2.7 per cent (157 of 5 798) for procedures 61-120 (P = 0.002). There was no significant relationship between the number of procedures performed and the rate of operation on for recurrence (P = 0.894).

CONCLUSION

Sixty performed procedures during surgical residency is a reasonable target for achieving competency to perform open anterior mesh repair for groin hernia safely without supervision.

[Decreasing number of orchiectomies in prostatic cancer. Results of 9-year registration of the disease are reviewed]

There are several controversies regarding the management of prostate cancer. Whether curative treatment (e.g. radiotherapy and total prostatectomy) prolongs survival remains uncertain. Conservative management is beset with such unresolved issues as the effect on tumour progression of early instituted hormonal treatment and of treatment deferral. Since the outcome of the different types of treatment is unclear the value of screening and early detection remains uncertain. Owing to such issues as these, and the divergent views on prostate cancer, there is an urgent need of auditing. To co-ordinate prostate cancer care in the South-east Region of Sweden, a local management programme with principles for investigation and treatment has been used since 1987. An important feature of the programme is a register containing information on all cases of prostate cancer in the region, including the patient's national registration number, date of diagnosis, basis of diagnosis (cytology, pathology), tumour stage, histological grade, first line treatment, and date and cause of death. Secondary treatment has also been recorded since 1990, and treatment with prostate specific antigen since 1992. From 1987 to 1995, a total of 5,939 cases of prostate cancer were registered, the annual total increasing from 531 to 779 in 1993, after which there was a slight overall decrease but a small increase in the proportion of local tumours. The proportion of incidental tumours followed the same pattern as the transurethral prostatectomy rate in the region. M- and N-categorisation were done to a greater extent in the under-70 than in the over-70 age group. Orchidectomy is rapidly being replaced by treatment with GnRH (gonadotrophin-releasing hormone) analogues. Over the 9-year period, the total prostatectomy rate decreased from 12.5 to 4.6 per cent. All units responsible for prostate cancer care in the south-east region regularly receive processed updates from the register providing information on diagnostic and therapeutic methods used and their effect on mortality, thus providing a basis for improving the quality of prostate cancer care. Starting in 1997, a similar registration system is to be extended to cover the entire country.