Changes in the Surgical Management of Parastomal Hernias Over 15 Years: Results of 135 Cases

BACKGROUND

Over the years, various open and laparoscopic approaches toward the repair of parastomal hernias (PSH) have been described. The variety of published techniques itself can be seen as an indicator for the often low level of satisfaction reached with the surgical procedures.

METHODS

From January 1999 to January 2014, we assessed all cases of PSH repair performed at the three participating surgical departments in a retrospective analysis. The results were evaluated with regard to different surgical techniques focusing on complications and recurrences.

RESULTS

One hundred and thirty-five individuals could be included in the analysis. They were operated on with eight different surgical techniques. Laparoscopic procedures were carried out in 46.7 % (63/135) of the cases. Median follow-up was 54 months (12-146 months). We found 44 cases of recurrence (32.6 %) and 24 (17.8 %) of the patients experienced perioperative complications and 12 of them needed to return to theater. Fourteen of the 135 patients (10.4 %) were operated as emergency cases which were associated with a mortality of 28.6 % (4/14). In case of elective PSH repair, no mortality occured.

CONCLUSION

The results achieved by direct suture or the use of incised flat meshes for the repair of PSH were poor with these procedures having unacceptably high recurrence rates. With regard to the latter ostomy revision through three-dimensional funnel-shaped meshes and the laparoscopic sandwich technique showed the best results. Emergency procedures were linked to a dramatic increase in morbidity and mortality (p < 0.001).

Sports and Child Development

The role of curricular activities for the formation of education, health and behavioural outcomes has been widely studied. Yet, the role of extra-curricular activities has received little attention. This study analyzes the effect of participation in sports clubs—one of the most popular extra-curricular activities among children. We use alternative datasets and flexible semi-parametric estimation methods with a specific way to use the panel dimension of the data to address selection into sports. We find positive and robust effects on children’s school performance and peer relations. Crowding out of passive leisure activities can partially explain the effects.

Magnetic resonance-visible meshes for laparoscopic ventral hernia repair

Background and Objectives:

We aimed to evaluate the first human use of magnetic resonance–visible implants for intraperitoneal onlay repair of incisional hernias regarding magnetic resonance presentability.

Methods:

Ten patients were surgically treated with intraperitoneally positioned superparamagnetic flat meshes. A magnetic resonance investigation with a qualified protocol was performed on postoperative day 1 and at 3 months postoperatively to assess mesh appearance and demarcation. The total magnetic resonance–visible mesh surface area of each implant was calculated and compared with the original physical mesh size to evaluate potential reduction of the functional mesh surfaces.

Results:

We were able to show a precise mesh demarcation, as well as accurate assessment of the surrounding tissue, in all 10 cases. We documented a significant decrease in the magnetic resonance–visualized total mesh surface area after release of the pneumoperitoneum compared with the original mesh size (mean, 190 cm² vs 225 cm²; mean reduction of mesh area, 35 cm²; P < .001). At 3 months postoperatively, a further reduction of the surface area due to significant mesh shrinkage could be observed (mean, 182 cm² vs 190 cm²; mean reduction of mesh area, 8 cm²; P < .001).

Conclusion:

The new method of combining magnetic resonance imaging and meshes that provide enhanced signal capacity through direct integration of iron particles into the polyvinylidene fluoride base material allows for detailed mesh depiction and quantification of structural changes. In addition to a significant early postoperative decrease in effective mesh surface area, a further considerable reduction in size occurred within 3 months after implantation.

The Genomics, Epigenomics, and Transcriptomics of HPV-Associated Oropharyngeal Cancer--Understanding the Basis of a Rapidly Evolving Disease

Human papillomavirus (HPV) has been shown to represent a major independent risk factor for head and neck squamous cell cancer, in particular for oropharyngeal carcinoma. This type of cancer is rapidly evolving in the Western world, with rising trends particularly in the young, and represents a distinct epidemiological, clinical, and molecular entity. It is the aim of this review to give a detailed description of genomic, epigenomic, transcriptomic, and posttranscriptional changes that underlie the phenotype of this deadly disease. The review will also link these changes and examine what is known about the interactions between the host genome and viral genome, and investigate changes specific for the viral genome. These data are then integrated into an updated model of HPV-induced head and neck carcinogenesis.

Workplace health promotion and labour market performance of employees

This paper investigates the average effects of firm-provided workplace health promotion measures on labour market outcomes of the firms' employees. Exploiting linked employer-employee panel data that consist of rich survey-based and administrative information on firms, workers and regions, we apply a flexible propensity score matching approach that controls for selection on observables and time-constant unobserved factors. While the effects of analysing sickness absenteeism appear to be rather limited, our results suggest that health circles/courses increase tenure and job stability across various age groups. A key finding is that health circles/courses strengthen the labour force attachment of elderly employees (51-60), implying potential cost savings for public transfer schemes such as unemployment insurance or early retirement schemes.

First human magnetic resonance visualisation of prosthetics for laparoscopic large hiatal hernia repair

PURPOSE

Mesh repair of large hiatal hernias has increasingly gained popularity to reduce recurrence rates. Integration of iron particles into the polyvinylidene fluoride mesh-based material allows for magnetic resonance visualisation (MR).

METHODS

In a pilot prospective case series eight patients underwent surgical repair of hiatal hernias repair with pre-shaped meshes, which were fixated with fibrin glue. An MR investigation with a qualified protocol was performed on postoperative day four and 3 months postoperatively to evaluate the correct position of the mesh by assessing mesh appearance and demarcation. The total MR-visible mesh surface area of each implant was calculated and compared with the original physical mesh size to evaluate potential reduction of the functional mesh surfaces.

RESULTS

We documented no mesh migrations or dislocations but we found a significant decrease of MR-visualised total mesh surface area after release of the pneumoperitoneum compared to the original mesh size (mean 78.9 vs 84 cm(2); mean reduction of mesh area = 5.1 cm(2), p < 0.001). At 3 months postoperatively, a further reduction of the mesh surface area could be observed (mean 78.5 vs 78.9 cm(2); mean reduction of mesh area = 0.4 cm(2), p < 0.037).

CONCLUSION

Detailed mesh depiction and accurate assessment of the surrounding anatomy could be successfully achieved in all cases. Fibrin glue seems to provide effective mesh fixation. In addition to a significant early postoperative decrease in effective mesh surface area a further reduction in size occurred within 3 months after implantation.

Prevention of parastomal hernias with 3D funnel meshes in intraperitoneal onlay position by placement during initial stoma formation

PURPOSE

In patients with terminal ostomies, parastomal hernias (PSHs) occur on a frequent basis. They are commonly associated with various degrees of complaints and occasionally lead to life-threatening complications. Various strategies and measures have been tested and evaluated, but to date there is a lack of published evidence with regard to the best surgical technique for the prevention of PSH development.

METHODS

We conducted a retrospective analysis of prospectively collected data of eighty patients, who underwent elective permanent ostomy formation between 2009 and 2014 by means of prophylactic implantation of a three-dimensional (3D) funnel mesh in intraperitoneal onlay (IPOM) position.

RESULTS

PSH developed in three patients (3.75%). No mesh-related complications were encountered and none of the implants had to be removed. Ostomy-related complications had to be noted in seven (8.75%) cases. No manifestation of ostomy prolapse occurred. Follow-up time was a median 21 (range 3-47) months.

CONCLUSION

The prophylactical implantation of a specially shaped, 3D mesh implant in IPOM technique during initial formation of a terminal enterostomy is safe, highly efficient and comparatively easy to perform. As opposed to what can be achieved with flat or keyhole meshes, the inner boundary areas of the ostomy itself can be well covered and protected from the surging viscera with the 3D implants. At the same time, the vertical, tunnel-shaped part of the mesh provides sufficient protection from an ostomy prolapse. Further studies will be needed to compare the efficacy of various known approaches to PSH prevention.

Is the age of >65 years a risk factor for endoscopic treatment of primary inguinal hernia? Analysis of 24,571 patients from the Herniamed Registry

Introduction

Several analyses of hernia registries have demonstrated that patients older than 65 years have significantly higher perioperative complication rates compared with patients up to the age of 65. To date, no special analyses of endoscopic/laparoscopic inguinal hernia surgery or of the relevant additional influence factors have been carried out. Besides, there is no definition to determine whether 65 years should really be considered to be the age limit.

Methods

In the Herniamed Hernia Registry, it was possible to identify 24,571 patients with a primary inguinal hernia and aged at least 16 years who had been operated on between September 1, 2009, and April 15, 2013, using either the TAPP technique (n = 17,214) or TEP technique (n = 7,357). Patients in the age group up to and including 65 years (≤65 years) were compared with those older than 65 years (>65 years) in terms of their perioperative outcome. That was done first using unadjusted analysis and then multivariable analysis.

Results

Unadjusted analysis revealed significantly different results for the intraoperative (1.19 vs 1.60 %; p = 0,010), postoperative surgical (2.72 vs 4.59 %; p < 0.001) and postoperative general complications (0.85 vs 1.98 %; p < 0.001) as well as for complication-related reoperations (1.07 vs 1.37 %; p = 0,044), which were more favorable in the ≤65 years age group. However, in multivariable analysis, it was not possible to confirm that for the intraoperative complications or the reoperations. Reoperations were needed more often for bilateral procedures (p < 0.001; OR 2.154 [1.699; 2.730]), higher ASA classification (IV vs I: p = 0.004; OR 6.001 [1.786; 20.167]), larger hernia defect and scrotal hernias. The impact of these factors, in addition to that of age >65 years, was also reflected in the postoperative complication rates. The age limit for increased onset of perioperative complication rates tends to be more than 80 rather than 65 years.

Conclusion

The higher perioperative complication rate associated with endoscopic/laparoscopic inguinal hernia surgery in patients older than 65 years is of multifactorial genesis and is observed in particular as from the age of 80 years.

Stenting for Emergency Colorectal Obstruction: An Analysis of 204 Patients in Relation to Predictors of Failure and Complications

Background and Aims:

Self-expanding metallic stents are increasingly used in the management of malignant and benign colorectal obstructions. We aimed to identify relevant predictive factors for stent failure and stent-related complications.

Material and Methods:

We conducted a retrospective single-center analysis of 204 consecutive patients who underwent emergency colorectal stenting procedures because of symptomatic bowel obstructions from 1996 to 2011 at the Sisters of Charity Hospital Linz, Austria.

Results:

A total of 204 patients (median age 74 years) with 36 (17.7%) benign and 168 (82.3%) malignant obstructions were included in the study. Technical success was achieved in 92.5% and clinical success in 86.8% of the cases. Major complications occurred in 2.9% and minor ones in 19.6%. Overall mortality during a median follow-up period of 4.3 years was 73% (149 patients). Relevant predictors of increased risk of complications were extracolonic obstruction (p = 0.001), complete obstruction (p = 0.066), and inflammatory bowel disease (p = 0.05). Stent localization at the splenic flexure, a stenosis of >8 cm in length, and the need for endoscopic guidance were associated with higher rates of technical and/or clinical stenting failure.

Conclusion:

Colorectal stenting is less invasive than other means of emergency treatment for large bowel obstruction; it is generally safe and effective in different types of colorectal obstruction. However, relevant rates of failure and complications were recorded and predictors could be determined.

Small bowel obstruction after TAPP repair caused by a self-anchoring barbed suture device for peritoneal closure: case report and review of the literature

INTRODUCTION

Transabdominal preperitoneal hernioplasty (TAPP) is a common procedure for groin hernia repair in adults. The peritoneal closure after mesh placement can be performed in various ways. In any case, thorough closure is recommended to avoid mesh exposure to the viscera with the risk of adhesions and bowel incarceration into peritoneal defects. Postoperative intestinal obstructions can mainly occur due to adhesions or bowel herniation through peritoneal defects into the dissected preperitoneal space. Incarcerations can also occur as a consequence of trocar site herniation.

RESULTS AND CONCLUSION

Recently barbed self-anchoring knotless suturing devices are frequently used for peritoneal closure. The correct handling of such sutures is crucial to avoid potential complications. Despite of accurate management, bowel adherence and injuries or volvulus can occur.

METHODS

We present an unusual case of a postoperative small bowel obstruction owing to strained adhesions and ingrowth between a small bowel segment and a polyglyconate unidirectional self-anchoring barbed suture device. Medline and PudMed databases were searched using the below-mentioned keywords and the literature on efficacy and safety of barbed sutures for peritoneal closure is reviewed as well as the usage of such devices in other fields of surgery.

Parastomal hernia repair with a 3-D mesh device and additional flat mesh repair of the abdominal wall

PURPOSE

Parastomal hernias (PSHs) have been a major clinical problem. The aim of this study was to evaluate a new method of PSH repair in combination with an additional flat mesh reinforcement of the abdominal wall.

METHODS

In a pilot case series, seven patients suffering from complex PSHs (≥5 cm diameter and/or recurrence) underwent surgery and were treated by intraperitoneal onlay technique (IPOM) with a synthetic 3-D funnel-shaped mesh implant. The demographics, perioperative, and follow-up data are presented in this report.

RESULTS

The surgical strategy varied between purely laparoscopic (n = 1), laparoscopically assisted (hybrid n = 3), or open techniques (n = 3) using original or suture-reconstructed mesh devices. The funnel mesh implantations in IPOM technique were combined with attached flat meshes in the appropriate position of the abdominal wall. No procedure-related complications occurred. The mean length of hospital stay was 12 days and the mean operating time was 171 min. No recurrence of PSH or incisional hernias was observed during a mean follow-up period of 12.3 months (range from 7 to 22).

CONCLUSION

The use of a 3-D mesh implant has so far shown to be a promising option in the treatment of primary and recurrent PSHs. Its use proved to be reasonable in both laparoscopic and open IPOM technique. PSHs were preferably repaired using the original, unmodified implant, but when we also found it safe to incise, place and then suture the mesh around the pre-existing ostomy.

Transanal irrigation improves quality of life in patients with low anterior resection syndrome

AIM

Transanal irrigation (TAI) has been reported to be a cheap and effective treatment for the 'anterior resection syndrome (ARS)'. This study aimed to evaluate its effect on the quality of life (QOL) of patients suffering from ARS.

METHOD

In a prospective study involving two colorectal centres, 14 patients (11 male; median age 68 (45-80) years) were included in the study. The median duration of ARS was 19 (9-48) months. The median number of defaecations was 8 (4-12)/day and 3 (2-5)/night. All patients were trained to perform TAI using the Peristeen™ System under the guidance of a stoma nurse. Anal physiology was performed, quality of life (QOL) was estimated by the SF-36 and Rockwood (ASCRS) questionnaires and continence by the Cleveland Incontinence Score.

RESULTS

At the last follow up the median time of using TAI was 29 (15-46) months. The median volume of water used for the irrigation was 900 (500-1500) ml. There was a significant decrease in the number of defaecations during the day (baseline, 8 [4-12]; last follow up, 1 [1-2]) and at night (baseline, 3 [2-5]; last follow up, 0 [0-0]). The Cleveland Incontinence Score fell from 17 [15-20] (baseline) to 5 [4-9] (last follow up) and the mental component of the SF-36 and all domains of the Rockwood QOL instrument improved.

CONCLUSION

Transanal irrigation is an effective treatment of anterior resection syndrome and results in a marked improvement of the continence score and QOL.

Does leaving welfare improve health? Evidence for Germany

Using exceptionally rich linked administrative and survey information on German welfare recipients we investigate the health effects of transitions from welfare to employment and of assignments to welfare-to-work programmes. Applying semi-parametric propensity score matching estimators we find that employment substantially increases (mental) health. The positive effects are mainly driven by males and individuals with bad initial health conditions and are largest for males with poor health. In contrast, the effects of welfare-to-work programmes, including subsidised jobs, are ambiguous and statistically insignificant for most outcomes.