Reporting guideline for interventional trials of primary and incisional ventral hernia repair

BACKGROUND

Primary and incisional ventral hernia trials collect unstandardized inconsistent data, limiting data interpretation and comparison. This study aimed to create two minimum data sets for primary and incisional ventral hernia interventional trials to standardize data collection and improve trial comparison. To support these data sets, standardized patient-reported outcome measures and trial methodology criteria were created.

METHODS

To construct these data sets, nominal group technique methodology was employed, involving 15 internationally recognized abdominal wall surgeons and two patient representatives. Initially a maximum data set was created from previous systematic and panellist reviews. Thereafter, three stages of voting took place: stage 1, selection of the number of variables for data set inclusion; stage 2, selection of variables to be included; and stage 3, selection of variable definitions and detection methods. A steering committee interpreted and analysed the data.

RESULTS

The maximum data set contained 245 variables. The three stages of voting commenced in October 2019 and had been completed by July 2020. The final primary ventral hernia data set included 32 variables, the incisional ventral hernia data set included 40 variables, the patient-reported outcome measures tool contained 25 questions, and 40 methodological criteria were chosen. The best known variable definitions were selected for accurate variable description. CT was selected as the optimal preoperative descriptor of hernia morphology. Standardized follow-up at 30 days, 1 year, and 5 years was selected.

CONCLUSION

These minimum data sets, patient-reported outcome measures, and methodological criteria have allowed creation of a manual for investigators aiming to undertake primary ventral hernia or incisional ventral hernia interventional trials. Adopting these data sets will improve trial methods and comparisons.

Allotransplantation of donor rectus fascia for abdominal wall closure in transplant patients: A systematic review

BACKGROUND

Abdominal wall closure after intestinal, multivisceral or liver transplantation can be a major challenge. Different surgical techniques have been described to close complex abdominal wall defects, but results remain variable. Two promising transplant techniques have been developed using either non-vascularized or vascularized donor rectus fascia. This systematic review aimed to evaluate the feasibility, safety, and effectiveness of the two techniques.

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Human studies published between January 2000 and April 2020 were included. Methodological quality appraisal was done using an adapted 10-item standardized checklist.

RESULTS

The search resulted in 9 articles including 74 patients. Both techniques proved to be feasible and had similar results. After non-vascularized rectus fascia allotransplantation, there was a slightly higher rate of surgical site infections in the earlier reports. Overall, there were few complications, no fascial graft related rejections or deaths. The included articles scored low on quality appraisal, mostly due to the small number of cases and scarcely reported outcome parameters.

CONCLUSIONS

This systematic literature review reports two emerging new techniques for complex abdominal wall closure in transplant patients, with promising results. Standardized data collection in a prospective manner could give us more detailed information about short- and long-term outcomes. Preclinical animal studies are necessary for a thorough investigation of the mechanisms of graft integration, the risk of hernia development and the alloimmune response against the graft.

A systematic review of outcome reporting in incisional hernia surgery

Background

The incidence of incisional hernia is up to 20 per cent after abdominal surgery. The management of patients with incisional hernia can be complex with an array of techniques and meshes available. Ensuring consistency in reporting outcomes across studies on incisional hernia is important and will enable appropriate interpretation, comparison and data synthesis across a range of clinical and operative treatment strategies.

Methods

Literature searches were performed in MEDLINE and EMBASE (from 1 January 2010 to 31 December 2019) and the Cochrane Central Register of Controlled Trials. All studies documenting clinical and patient-reported outcomes for incisional hernia were included.

Results

In total, 1340 studies were screened, of which 92 were included, reporting outcomes on 12 292 patients undergoing incisional hernia repair. Eight broad-based outcome domains were identified, including patient and clinical demographics, hernia-related symptoms, hernia morphology, recurrent incisional hernia, operative variables, postoperative variables, follow-up and patient-reported outcomes. Clinical outcomes such as hernia recurrence rates were reported in 80 studies (87 per cent). A total of nine different definitions for detecting hernia recurrence were identified. Patient-reported outcomes were reported in 31 studies (34 per cent), with 18 different assessment measures used.

Conclusions

This review demonstrates the significant heterogeneity in outcome reporting in incisional hernia studies, with significant variation in outcome assessment and definitions. This is coupled with significant under-reporting of patient-reported outcomes.

Negative Pressure Wound Therapy vs Conventional Wound Treatment in Subcutaneous Abdominal Wound Healing Impairment: The SAWHI Randomized Clinical Trial

Question

Is negative pressure wound therapy (NPWT) an effective and safe treatment option for subcutaneous abdominal wound healing impairment (SAWHI) after surgery?

Findings

In the randomized clinical SAWHI study that included 507 adults, wounds were closed significantly faster and more often in the NPWT arm (36.1 days for 92 of 256 study participants) than with conventional wound treatment (39.1 days for 54 of 251 participants). The number of participants with wound-related adverse events was higher in the NPWT arm (48 of 234) than in the conventional wound treatment arm (27 of 201).

Meaning

For SAWHI after surgery, NPWT is an effective treatment alternative to conventional wound treatment but causes more wound-related adverse events.

Importance

Negative pressure wound therapy (NPWT) is an established treatment option, but there is no evidence of benefit for subcutaneous abdominal wound healing impairment (SAWHI).

Objective

To evaluate the effectiveness and safety of NPWT for SAWHI after surgery in clinical practice.

Design, Setting, and Participants

The multicenter, multinational, observer-blinded, randomized clinical SAWHI study enrolled patients between August 2, 2011, and January 31, 2018. The last follow-up date was June 11, 2018. The trial included 34 abdominal surgical departments of hospitals in Germany, Belgium, and the Netherlands, and 539 consecutive, compliant adult patients with SAWHI after surgery without fascia dehiscence were randomly assigned to the treatment arms in a 1:1 ratio stratified by study site and wound size using a centralized web-based tool. A total of 507 study participants (NPWT, 256; CWT, 251) were assessed for the primary end point in the modified intention-to-treat (ITT) population.

Interventions

Negative pressure wound therapy and conventional wound treatment (CWT).

Main Outcomes and Measures

The primary outcome was time until wound closure (delayed primary closure or by secondary intention) within 42 days. Safety analysis comprised the adverse events (AEs). Secondary outcomes included wound closure rate, quality of life (SF-36), pain, and patient satisfaction.

Results

Of the 507 study participants included in the modified ITT population, 287 were men (56.6%) (NPWT, 155 [60.5%] and CWT, 132 [52.6%]) and 220 were women (43.4%) (NPWT, 101 [39.5%] and CWT 119 [47.4%]). The median (IQR) age of the participants was 66 (18) years in the NPWT arm and 66 (20) years in the CWT arm. Mean time to wound closure was significantly shorter in the NPWT arm (36.1 days) than in the CWT arm (39.1 days) (difference, 3.0 days; 95% CI 1.6-4.4; P < .001). Wound closure rate within 42 days was significantly higher with NPWT (35.9%) than with CWT (21.5%) (difference, 14.4%; 95% CI, 6.6%-22.2%; P < .001). In the therapy-compliant population, excluding study participants with unauthorized treatment changes (NPWT, 22; CWT, 50), the risk for wound-related AEs was higher in the NPWT arm (risk ratio, 1.51; 95% CI, 0.99-2.35).

Conclusions and Relevance

Negative pressure wound therapy is an effective treatment option for SAWHI after surgery; however, it causes more wound-related AEs.

Trial Registration

ClinicalTrials.gov Identifier: NCT01528033

META Score: An International Consensus Scoring System on Mesh-Tissue Adhesions

BACKGROUND

Currently, the lack of consensus on postoperative mesh-tissue adhesion scoring leads to incomparable scientific results. The aim of this study was to develop an adhesion score recognized by experts in the field of hernia surgery.

METHODS

Authors of three or more previously published articles on both mesh-tissue adhesion scores and postoperative adhesions were marked as experts. They were queried on seven items using a modified Delphi method. The items concerned the utility of adhesion scoring models, the appropriateness of macroscopic and microscopic variables, the range and use of composite scores or subscores, adhesion-related complications and follow-up length. This study comprised two questionnaire-based rounds and one consensus meeting.

RESULTS

The first round was completed by 23 experts (82%), the second round by 18 experts (64%). Of those 18 experts, ten were able to participate in the final consensus meeting and all approved the final proposal. From a total of 158 items, consensus was reached on 90 items. The amount of mesh surface covered with adhesions, tenacity and thickness of adhesions and organ involvement was concluded to be a minimal set of variables to be communicated separately in each future study on mesh adhesions.

CONCLUSION

The MEsh Tissue Adhesion scoring system is the first consensus-based scoring system with a wide backing of renowned experts and can be used to assess mesh-related adhesions. By including this minimal set of variables in future research interstudy comparability and objectivity can be increased and eventually linked to clinically relevant outcomes.

Treatment of rectus diastasis: should the midline always be reinforced with mesh? A systematic review

BACKGROUND

Two main trends are described for the treatment of diastasis recti: plication versus midline mesh reinforcement. Indications for these procedures have not been clearly described. This study reviewed the outcomes in the treatment of rectus diastasis with plication versus mesh by the assessment of durability, complications, and patient-reported outcomes.

MATERIALS AND METHODS

A systematic review of literature on the treatment of diastasis recti was performed searching through PubMed, Embase, Web of Science, and Cochrane databases. This resulted in 53 eligible articles and predefined inclusion criteria led to the selection of 24 articles. Primary outcomes included recurrence and perioperative complications and secondary outcomes were defined as patient satisfaction, chronic pain, and quality of life.

RESULTS

A total of 931 patients were surgically treated for rectus divarication (age range: 18 - 70 years). The most frequently noted comorbidity was obesity and 10.6 percent were smokers. Recurrence was reported in 5 percent of the patients. The most frequent complication was seroma (7 percent), followed by abdominal hypoesthesia (6 percent), and surgical site infection (2 percent). Chronic pain was reported in 4 percent of the patients. Satisfaction was assessed subjectively in the majority of patients and was generally rated as high. Follow-up period ranged from 3 weeks to 20 years.

CONCLUSIONS

Durability, safety, and high patient satisfaction support surgical correction of rectus diastasis and could not favor a treatment method. Inter-rectus distance could not be identified as the indicator for technique, which emphasizes that other factors might add to the entity of abdominal wall protrusion more than previously thought.

Outcomes of a new slowly resorbable biosynthetic mesh (Phasix™) in potentially contaminated incisional hernias: A prospective, multi-center, single-arm trial

BACKGROUND

Resorbable biomaterials have been developed to reduce the amount of foreign material remaining in the body after hernia repair over the long-term. However, on the short-term, these resorbable materials should render acceptable results with regard to complications, infections, and reoperations to be considered for repair. Additionally, the rate of resorption should not be any faster than collagen deposition and maturation; leading to early hernia recurrence. Therefore, the objective of this study was to collect data on the short-term performance of a new resorbable biosynthetic mesh (Phasix™) in patients requiring Ventral Hernia Working Group (VHWG) Grade 3 midline incisional hernia repair.

MATERIALS AND METHODS

A prospective, multi-center, single-arm trial was conducted at surgical departments in 15 hospitals across Europe. Patients aged ≥18, scheduled to undergo elective Ventral Hernia Working Group Grade 3 hernia repair of a hernia larger than 10 cm² were included. Hernia repair was performed with Phasix™ Mesh in sublay position when achievable. The primary outcome was the rate of surgical site occurrence (SSO), including infections, that required intervention until 3 months after repair.

RESULTS

In total, 84 patients were treated with Phasix™ Mesh. Twenty-two patients (26.2%) developed 32 surgical site occurrences. These included 11 surgical site infections, 9 wound dehiscences, 7 seromas, 2 hematomas, 2 skin necroses, and 1 fistula. No significant differences in surgical site occurrence development were found between groups repaired with or without component separation technique, and between clean-contaminated or contaminated wound sites. At three months, there were no hernia recurrences.

CONCLUSION

Phasix™ Mesh demonstrated acceptable postoperative surgical site occurrence rates in patients with a Ventral Hernia Working Group Grade 3 hernia. Longer follow-up is needed to evaluate the recurrence rate and the effects on quality of life. This study is ongoing through 24 months of follow-up.

Surgical Strategy for Contralateral Groin Management in Patients Scheduled for Unilateral Inguinal Hernia Repair: An International Web-Based Surveymonkey® Questionnaire: Strategy for Contralateral Groin Management during Inguinal Hernia Repair

BACKGROUND

A contralateral occult inguinal hernia is frequently observed in patients planned for a unilateral laparoscopic inguinal hernia repair. Surgical strategy for contralateral groin management in patients scheduled for an endo-laparoscopic unilateral inguinal hernia repair is controversial and based on questionable evidence. This study aimed to gather international opinion concerning the surgical strategy for the contralateral asymptomatic side when no hernia or lipoma is clinically evident at the preoperative examination or anamnesis.

METHODS

An international Internet-based questionnaire was sent to all the members of the European Hernia Society, the Americas Hernia Society, and the Asia Pacific Hernia Society. The clinical scenario for responders was a patient with a unilateral symptomatic inguinal hernia planned for endo-laparoscopic repair with no preoperative symptoms/lump on the contralateral side.

RESULTS

A total of 640 surgeons replied (response rate = 26%), of whom 506 were included for analysis. Most surgeons had performed > 300 repairs. The preferred surgical technique was evenly distributed between laparoscopic total extraperitoneal repair and laparoscopic transabdominal preperitoneal repair. In total, 54% preferred to implant a prophylactic mesh on the contralateral side when an occult hernia was found, 47% when a lipoma was found, and 6% when no occult hernia/lipoma was identified.

CONCLUSIONS

Mesh implementation was preferred by half of the endo-laparoscopic hernia surgeons for a contralateral occult hernia and/or lipoma. Although not supported by strong evidence, mesh implantation on the asymptomatic contralateral side might be cost-effective and perhaps beneficial in the long term but could be offset by increased risk of chronic pain and sexual dysfunction.

Laparoscopic or open paediatric inguinal hernia repair - a systematic review

INTRODUCTION

Inguinal hernia repair is the most common surgical procedure in paediatric patients. Despite limited evidence, an increasing number of surgeons suggest laparoscopic repair as an alternative to the gold standard of open repair. This review critically analysed post-operative clinical outcome on open versus laparoscopic inguinal hernia repair in paediatric patients. Before initiating the study, recurrence was defined as the primary outcome, and secondary outcomes were early post-operative pain, operation time and surgical site infections.

METHODS

The PRISMA guidelines were followed. Using strict inclusion and exclusion criteria, the following databases were searched: MEDLINE, Cochrane Library, Web of Science and Embase (May 2019). Retrospective and uncontrolled studies were excluded.

RESULTS

Five studies were identified, four randomised controlled trials (n = 272) and one controlled prospective study (n = 85) which included a total of 357 patients. Generally, the studies included few patients, were highly heterogenic and were overall of moderate quality. With a follow-up time ranging from three months to 14 years, there was no difference in recurrence rate after unilateral open (0-2%) versus unilateral laparoscopic (0-4%) or bilateral open versus bilateral laparoscopic repair (n = 281; p > 0.05 in all studies). There were no other significant differences in any of the outcomes, including post-operative pain (p > 0.05).

CONCLUSIONS

There is no solid evidence that clinical outcome is improved after laparoscopic paediatric inguinal hernia repair compared with the gold standard.

Long-term outcomes of very low birth weight infants with spontaneous intestinal perforation: A retrospective case-matched cohort study

BACKGROUND

Spontaneous intestinal perforation (SIP) is an intestinal complication that occurs in very ill preterms. We investigated whether SIP survivors have worse neurodevelopmental and gastrointestinal outcomes and a poorer quality of life than controls.

METHODS

A retrospective case-matched cohort study was performed involving infants treated for SIP in a NICU between August 1994 and April 2014. Controls and SIP patients were matched to gestational age, gender, and birth period. Medical records were reviewed. Telephone surveys were conducted to evaluate the medical condition, quality of life (PedsQL™ 4.0), neuropsychiatric and gastrointestinal outcome. McNemar's and Wilcoxon tests were performed, and generalized linear models were computed.

RESULTS

Forty-nine SIP patients were included. The percentages of children with multiple disabilities (40% vs. 17%, OR = 3.3) and requiring physiotherapy (86% vs. 60%, OR = 4.77) were higher in the SIP group than in the control group. Intraventricular hemorrhage (IVH) led to a worse neurodevelopmental outcome regardless of SIP (OR = 8.79 for disability), and female gender was a protective factor against disability (OR = 0.06). Reported quality of life and gastrointestinal comorbidities did not differ between the two groups.

CONCLUSION

SIP survivors tend to be at risk of multiple disabilities. IVH and female gender influence the neurodevelopmental outcome regardless of SIP.

LEVELS OF EVIDENCE

Level III: case-control study.

What do pediatric surgeons think about sexual issues in dealing with patients with anorectal malformations? The ARM-Net consortium members’ opinion

PURPOSE

Since pediatric surgeons aim to follow their patients with anorectal malformations (ARM) into adulthood the aim of this study was to investigate how pediatric surgeons deal with sexual issues related to ARM.

METHODS

In 2018, a questionnaire was developed by the working group "Follow-up and sexuality" of the ARM-Net consortium and sent to all consortium-linked pediatric surgeons from 31 European pediatric surgical centers. Obtained data were statistically analyzed.

RESULTS

Twenty-eight of 37 pediatric surgeons (18 males/10 females) answered the questionnaire. The majority of pediatric surgeons (82%) think they should talk about sexual issues with their patient. More than 50% of pediatric surgeons do not feel at all or only moderately confident discussing the topic of sexuality. Most pediatric surgeons require more support (96%) and wish to be trained in sexuality and sexual issues (78%) to feel confident towards their ARM-patients/parents. For optimal care, sexual issues with ARM-patients should be managed by a multidisciplinary team.

CONCLUSIONS

Pediatric surgeons feel that sexuality is an important issue for their ARM-patients, which they are primarily responsible of but should be managed in concert with a multidisciplinary team. A training in sexuality is wished to feel more confident about this specific issue.

A post-market, prospective, multi-center, single-arm clinical investigation of Phasix™ mesh for VHWG grade 3 midline incisional hernia repair: a research protocol

Background

Incisional heia is a frequent complication of midline laparotomy. The use of mesh in hernia repair has been reported to lead to fewer recurrences compared to primary repair. However, in Ventral Hernia Working Group (VHWG) Grade 3 hernia patients, whose hernia is potentially contaminated, synthetic mesh is prone to infection. There is a strong preference for resorbable biological mesh in contaminated fields, since it is more able to resist infection, and because it is fully resorbed, the chance of a foreign body reaction is reduced. However, when not crosslinked, biological resorbable mesh products tend to degrade too quickly to facilitate native cellular ingrowth. Phasix™ Mesh is a biosynthetic mesh with both the biocompatibility and resorbability of a biological mesh and the mechanical strength of a synthetic mesh. This multi-center single-arm study aims to collect data on safety and performance of Phasix™ Mesh in Grade 3 hernia patients.

Methods

A total of 85 VHWG Grade 3 hernia patients will be treated with Phasix™ Mesh in 15 sites across Europe. The primary outcome is Surgical Site Occurrence (SSO) including hematoma, seroma, infection, dehiscence and fistula formation (requiring intervention) through 3 months. Secondary outcomes include recurrence, infection and quality of life related outcomes after 24 months. Follow-up visits will be at drain removal (if drains were not placed, then on discharge or staple removal instead) and in the 1st, 3rd, 6th, 12th, 18th and 24th month after surgery.

Conclusion

Based on evidence from this clinical study Depending on the results this clinical study will yield, Phasix™ Mesh may become a preferred treatment option in VHWG Grade 3 patients.

Trial registration

The trial was registered on March 25, 2016 on clinicaltrials.gov: NCT02720042.

Meta-analysis on Materials and Techniques for Laparotomy Closure: The MATCH Review

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate closure materials and suture techniques for emergency and elective laparotomies. The primary outcome was incisional hernia after 12 months, and the secondary outcomes were burst abdomen and surgical site infection.

METHODS

A systematic literature search was conducted until September 2017. The quality of the RCTs was evaluated by at least 3 assessors using critical appraisal checklists. Meta-analyses were performed.

RESULTS

A total of 23 RCTs were included in the meta-analysis. There was no evidence from RCTs using the same suture technique in both study arms that any suture material (fast-absorbable/slowly absorbable/non-absorbable) is superior in reducing incisional hernias. There is no evidence that continuous suturing is superior in reducing incisional hernias compared to interrupted suturing. When using a slowly absorbable suture for continuous suturing in elective midline closure, the small bites technique results in significantly less incisional hernias than a large bites technique (OR 0.41; 95% CI 0.19, 0.86).

CONCLUSIONS

There is no high-quality evidence available concerning the best suture material or technique to reduce incisional hernia rate when closing a laparotomy. When using a slowly absorbable suture and a continuous suturing technique with small tissue bites, the incisional hernia rate is significantly reduced compared with a large bites technique.

What is the evidence for the use of biologic or biosynthetic meshes in abdominal wall reconstruction?

INTRODUCTION

Although many surgeons have adopted the use of biologic and biosynthetic meshes in complex abdominal wall hernia repair, others have questioned the use of these products. Criticism is addressed in several review articles on the poor standard of studies reporting on the use of biologic meshes for different abdominal wall repairs. The aim of this consensus review is to conduct an evidence-based analysis of the efficacy of biologic and biosynthetic meshes in predefined clinical situations.

METHODS

A European working group, "BioMesh Study Group", composed of invited surgeons with a special interest in surgical meshes, formulated key questions, and forwarded them for processing in subgroups. In January 2016, a workshop was held in Berlin where the findings were presented, discussed, and voted on for consensus. Findings were set out in writing by the subgroups followed by consensus being reached. For the review, 114 studies and background analyses were used.

RESULTS

The cumulative data regarding biologic mesh under contaminated conditions do not support the claim that it is better than synthetic mesh. Biologic mesh use should be avoided when bridging is needed. In inguinal hernia repair biologic and biosynthetic meshes do not have a clear advantage over the synthetic meshes. For prevention of incisional or parastomal hernias, there is no evidence to support the use of biologic/biosynthetic meshes. In complex abdominal wall hernia repairs (incarcerated hernia, parastomal hernia, infected mesh, open abdomen, enterocutaneous fistula, and component separation technique), biologic and biosynthetic meshes do not provide a superior alternative to synthetic meshes.

CONCLUSION

The routine use of biologic and biosynthetic meshes cannot be recommended.

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.

Triclosan-coated sutures and surgical site infection in abdominal surgery: the TRISTAN review, meta-analysis and trial sequential analysis

INTRODUCTION

Surgical site infection (SSI) is a frequent complication of abdominal surgery causing increased morbidity. Triclosan-coated sutures are recommended to reduce SSI. The aim of this systematic review and meta-analysis was to evaluate the evidence from randomized controlled trials (RCT) comparing the rate of SSI in abdominal surgery when using triclosan-coated or uncoated sutures for fascial closure.

METHODS

A systematic literature search was conducted using Medline, EMBASE, the Cochrane library, CINAHL, Scopus and Web of Science including publications until August 2017. The quality of the RCTs was evaluated using critical appraisal checklists from SIGN. Meta-analyses and trial sequential analysis were performed with Review Manager v5.3 and TSA software, respectively.

RESULTS

Eight RCTs on abdominal wall closure were included in the meta-analysis. In an overall comparison including both triclosan-coated Vicryl and PDS sutures for fascial closure, triclosan-coated sutures were superior in reducing the rate of SSI (OR 0.67; 0.46-0.98). When evaluating PDS sutures separately, there was no effect of triclosan-coating on the rate of SSI (OR 0.85; 0.61-1.17). Trial sequential analysis showed that the required information size (RIS) of 797 patients for triclosan-coated Vicryl sutures was almost reached with an accrued information size (AIS) of 795 patients. For triclosan-coated PDS sutures an AIS of 2707 patients was obtained, but the RIS was estimated to be 18,693 patients.

CONCLUSION

Triclosan-coated Vicryl sutures for abdominal fascial closure decrease the risk of SSI significantly and based on the trial sequential analysis further RCTs will not change that outcome. There was no effect on SSI rate with the use of triclosan-coated PDS sutures for abdominal fascial closure, and it is unknown whether additional RCTs will change that.

Pericardio-Amniotic Shunting for Incomplete Pentalogy of Cantrell

A 27-year-old woman, gravida 2, para 0, presented with an incomplete Pentalogy of Cantrell with an omphalocele, diaphragmatic hernia, and a pericardial defect at 32 weeks' gestation. A large pericardial effusion compressed the lungs and had led to a reduced lung growth with an observed-to-expected total lung volume of 28% as measured by MRI. The effusion disappeared completely after the insertion of a pericardio-amniotic shunt at 33 weeks. After birth, the newborn showed no signs of pulmonary hypoplasia and underwent a surgical correction of the defect. Protracted wound healing and a difficult withdrawal from opioids complicated the neonatal period. The child was discharged on postnatal day 105 in good condition. This case demonstrates that in case of Pentalogy of Cantrell with large pericardial effusion, the perinatal outcome might be improved by pericardio-amniotic shunting.

Microvillus inclusion disease: a subtotal enterectomy as a bridge to transplantation

BACKGROUND

Microvillus inclusion disease (MVID) is a known congenital cause of intractable diarrhea resulting in permanent intestinal failure. There is need for a lifelong total parenteral nutrition (TPN) from diagnosis and the prognosis is poor. Most patients die by the second decade of life as a result of complications of parenteral alimentation including liver failure or sepsis. The only available treatment at this moment is a small bowel transplantation. But before that moment, the patients often suffer from a persistent failure to thrive and electrolyte disturbances despite continuous TPN.

METHODS AND RESULTS

We report what we believe is a first case of an extensive small bowel resection in a 5-month-old boy with proven MVID to act as a bridge to (liver-) intestinal transplantation to treat failure to thrive and intractable diarrhea.

CONCLUSIONS

An extensive small bowel resection can be done to enhance the chance of survival leading up to the transplantation by managing fluid and electrolyte imbalance. It facilitates medical management of these patients and makes a bowel transplantation possible at a later stage.

The role of osmotic self-inflatable tissue expanders in intestinal transplant candidates

Intestinal transplantation (ITx) is often associated with decreased abdominal domain, rendering abdominal closure difficult. Pre-transplant placement of tissue expanders (TE) can overcome this challenge; however it can be associated with life-threatening complications. This review aimed to comprehensively summarize all available literature on TE in ITx candidates and include the technical details of osmotic, self-inflatable TE -a technique undescribed before. PubMed, EMBASE and CCTR were searched until April 30, 2016. Based on structured data abstraction and detailed analysis, eighteen cases of TE (inflatable) in ITx candidates were found. Localisation of placement was: subcutaneously in 11; intraperitoneally in 4; 1 patient had 1 TE placed retromuscularly and 1 intraperitoneally; 1 patient had biplanar TE (intraperitoneally placed and extending retromuscularly) and in 1 localisation was unreported. Complication rate was high (61%), injection- or intraperitoneal-related, resulting in life-threatening infections/hematoma. With successful expansion, physiological graft protection -by skin+/-fascia- was always achieved. In completion of this review, we describe our own experience with two patients (7.5-, 34-year-old females), in whom osmotic TE were placed subcutaneously pre-ITx. No TE-related complications occurred and both patients underwent uncomplicated ITx with respectively primary skin and skin + fascia closure. The pros and cons of each TE type and placement are discussed, resulting in the overall conclusions that TE offer an important benefit in graft-protection following ITx. Osmotic TE are safer than conventional prostheses by avoiding percutaneous injections. Subcutaneous placement seems to be safer and more reliable.

The role of osmotic self-inflatable tissue expanders in intestinal transplant candidates

Intestinal transplantation (ITx) is often associated with decreased abdominal domain, rendering abdominal closure difficult. Pre-transplant placement of tissue expanders (TE) can overcome this challenge; however it can be associated with life-threatening complications. This review aimed to comprehensively summarize all available literature on TE in ITx candidates and include the technical details of osmotic, self-inflatable TE -a technique undescribed before. PubMed, EMBASE and CCTR were searched until April 30, 2016. Based on structured data abstraction and detailed analysis, eighteen cases of TE (inflatable) in ITx candidates were found. Localisation of placement was: subcutaneously in 11; intraperitoneally in 4; 1 patient had 1 TE placed retromuscularly and 1 intraperitoneally; 1 patient had biplanar TE (intraperitoneally placed and extending retromuscularly) and in 1 localisation was unreported. Complication rate was high (61%), injection- or intraperitoneal-related, resulting in life-threatening infections/hematoma. With successful expansion, physiological graft protection -by skin+/-fascia- was always achieved. In completion of this review, we describe our own experience with two patients (7.5-, 34-year-old females), in whom osmotic TE were placed subcutaneously pre-ITx. No TE-related complications occurred and both patients underwent uncomplicated ITx with respectively primary skin and skin + fascia closure. The pros and cons of each TE type and placement are discussed, resulting in the overall conclusions that TE offer an important benefit in graft-protection following ITx. Osmotic TE are safer than conventional prostheses by avoiding percutaneous injections. Subcutaneous placement seems to be safer and more reliable.