Andrographolide exhibits antinociceptive effects in neuropathic rats via inhibiting class Ⅱ MHC associated response and regulating synaptic plasticity

BACKGROUND

Neuropathic pain (NP) due to nerve injury, disrupts neural plasticity by triggering the release of inflammatory mediators. Alongside the hypothesis that neuro-inflammation contributes to this disruption, Andrographolide (Andro), a traditional bioactive compound derived from Andrographis paniculata, has garnered attention for its potent anti-inflammatory properties. However, whether Andro could ameliorate NP by regulating neuroinflammation remains unknown.

PURPOSE

This study aimed to investigate whether and how Andro regulates neuroinflammation and alleviates NP.

METHODS

The analgesic effects of Andro on NP were evaluated using both the spinal nerve ligation (SNL) and formalin rat models. A combination of network pharmacology, RNA sequencing, and experimental validation was employed to elucidate the underlying mechanism behind Andro's analgesic effects. Additionally, various techniques such as functional ultrasound, immunohistochemistry, quantitative real-time polymerase chain reaction (qPCR), patch clamp, and electron microscopy were employed to investigate the specific neural cell types, neural functions, and changes in neural plasticity influenced by Andro.

RESULTS

Network pharmacology analysis unveiled the crucial roles played by shared targets of Andro and pain in regulating pain-related inflammation, including microglia activation, neuroinflammation, immune modulation, and synaptic transmission. Furthermore, we confirmed Andro's superior efficacy in pain relief compared to the traditional analgesic drug, Gabapentin. In these models, Andro was observed to modulate the haemodynamic response triggered by SNL. Transcriptome analysis and molecular docking studies indicated the involvement of major histocompatibility complex class II (MHCII) genes (Db1, Da, and Bb). Electron microscopy revealed improvements in synaptic ultrastructure, and electrophysiological investigations showed a selective reduction in glutamatergic transmission in neuropathic rats after following Andro treatment. The integration of systems pharmacology analysis and biological validation collectively demonstrated that the mechanism of pain relief involves immune modulation, enhancement of synaptic plasticity, and precise regulation of excitatory neurotransmission.

CONCLUSION

In conclusion, this study has demonstrated that Andro, by targeting MHCII genes, may serve as a promising therapeutic candidate for neuropathic pain.

Matching males and females undergoing non mesh primary unilateral inguinal hernia repair: evaluating sex differences in preoperative and acute postoperative pain

PURPOSE

The objective was to compare pain and related psychological factors during the preoperative and acute postoperative period between male and female patients, who underwent non mesh primary unilateral inguinal hernia repair.

METHODS

After ethics approval, informed consent was obtained, and data were collected. Male and female participants were compared by manually matching one-to-one on 10 variables. Descriptive statistics (mean ± standard deviation and frequency) as well as numerical rating scales from 0 to 10 were used. Comparison tests were performed using Chi-square or Fisher's Exact test for categorical data and independent samples t-test or non-parametric equivalent tests for numerical scores. p < 0.05 is reported as statistically significant. To control type I error, Bonferroni correction was used.

RESULTS

72 participants with 36 matched pairs were included. Sex differences were found for operation length (p = .006), side of operation (p = .002), and hernia type (p = .013). Significant differences between the sexes were not found at the preoperative or postoperative time for resilience, pain interference or pain severity related measures, postoperative hernia pain incidence, pain catastrophizing, depression and anxiety symptoms, or return to normal activities.

CONCLUSION

When controlling for known confounders and using a conservative Type I error rate, pain and related factors between the sexes did not differ significantly.

Comparison of postoperative outcomes between tissue glue and suture for mesh fixation in open tension-free inguinal hernia repair: a prospective analytical study

Introduction

A hernia is an abnormal protrusion of the viscus through the normal or abnormal opening of its containing cavity. Lichtenstein tension-free mesh repair is a commonly performed surgery for hernia. Various studies have revealed atraumatic fixation of the mesh produces less pain without compromising the outcomes.

Methods

This is a prospective analytical study conducted in a tertiary hospital over a year. Eighty patients with primary inguinal hernia undergoing open mesh repair were enrolled and divided into two groups with 40 patients in each group. Mesh fixation was done with N-butyl 2 cyano-acrylate glue in one group, while polypropylene 2-0 suture in the other group. Postoperative pain, the number of dosages of analgesia required, the incidence of hematoma/seroma formation, surgical site infection, and length of hospital stay were compared between the two groups. Data were analyzed using SPSS 25.

Results

Visual analog scores were significantly reduced in the glue group at 12 h and 24 h (P<0.05) with a reduction of the mean number of analgesic doses from 6.42±0.984 in the suture group to 5.95±0.597 in the glue group (P<0.05). The operating time was significantly reduced from 70.03±4.376 minutes in the suture group to 58.43±4.540 min in the glue group (P<0.05), while there was no significant difference in the length of hospital stay. Five percent of cases in the suture group developed seroma while no SSI was reported in this study.

Conclusions

This study demonstrates mesh fixation with cyanoacrylate glue in open hernioplasty for primary groin hernias is associated with reduced immediate postoperative pain, dose of analgesia required, and operating time in comparison to fixation with suture.

N-Butyl-2-Cyanoacrylate Adhesive Versus Absorbable Tacks in Laparoscopic Groin Hernia Repair: A Multicenter Randomized Clinical Trial

Objective

We aimed to determine whether n-butyl-2-cyanoacrylate (NB2C) adhesive is a safe and effective mechanism for nonpenetrating mesh and peritoneal fixation during laparoscopic groin hernia repair.

Background

Chronic pain after laparoscopic groin hernia repair has been associated with penetrating fixation, but there had been no US Food and Drug Administration-approved devices for nonpenetrating fixation in this context.

Methods

Patients undergoing laparoscopic transabdominal preperitoneal (TAP) or totally extraperitoneal (TEP) groin hernia repair with mesh at 1 of 5 academic medical centers were randomized to mesh (TAP/TEP) and peritoneal (TAP) fixation with NB2C adhesive or absorbable tacks. The primary outcome was improvement in pain (visual analog scale [VAS]) at 6 months. The noninferiority margin was 0.9 (α = 0.025; β = 80%). Recurrence, successful use of the device, quality of life, and rates of adverse events (AEs) were secondary outcomes.

Results

From 2019 to 2021, 284 patients were randomized to either NB2C adhesive or absorbable tacks (n = 142/142). Patient and hernia characteristics were comparable, and 65% were repaired using a TAP approach. The difference in VAS improvement at 6 months with NB2C adhesive was not inferior to absorbable tacks in intention-to-treat and per-protocol analyses, respectively (0.25 [95% CI, -0.33 to 0.82]; P = 0.013; 0.22 [95% CI, -0.36 to 0.80], noninferiority P = 0.011). There were no differences in secondary outcomes including recurrence, successful use of each device to fixate the mesh and peritoneum, quality of life, and additional VAS pain scores. Rates of adverse and serious AEs were also comparable.

Conclusions

NB2C adhesive is safe and effective for mesh fixation and peritoneal closure during laparoscopic groin hernia repair.

Effect of Compression Garments on Post-Abdominoplasty Outcomes: A systematic Review of the current Evidence

Introduction

It is commonly believed that using abdominal binders or compression garments (CGs) after an abdominoplasty could encourage fluid to drain, which would prevent fluid from building up at the surgical site and reduce the risk of seroma and other similar problems.

Objective

To evaluate the effect of the use of abdominal binders or CG on the post-operative outcomes following abdominoplasty.

Design

Systematic review.

Method

Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to select relevant studies from 2004 to 2024. Data from the included studies were extracted to assess the quality and risk of bias using a modified Jadaad score.

Main outcome

Post-operative seroma formation.

Secondary outcome

Ventilatory function, intra-abdominal pressure (IAP), and subcutaneous edema were the outcomes of interest.

Results

Only 5 trials totaling 130 patients were included in this review. Utilizing post-operative CG following abdominoplasty showed a non-significant tendency to decrease seroma development, ventilatory function, and subcutaneous edema. The limited evidence available also suggested that using post-operative CG increases IAP.

Conclusion

Weak evidence supports the beneficial use of abdominal binders following abdominoplasty.

Limitations

Low-quality scientific evidence available from the scant data and low caliber of the literature support the use of CG post-abdominoplasty. Therefore, unified outcome reporting and rigid randomized clinical trials are necessary to obtain valid data.

Management of groin hernia repair in Sweden: A register-based comparative analysis of public and private healthcare providers

BACKGROUND

Swedish healthcare is in a period of transition with an expanding private sector. This study compares quality of outcome after groin hernia repair performed in a public or private healthcare setting.

METHODS

A cohort study based on data from the Swedish National Hernia Register combined with Patient-Reported Outcome Measures (PROMs) 1 year after groin hernia repair. Between September 2012 and December 2018, a questionnaire was sent to all patients registered in the hernia register 1 year after surgery. Endpoints were reoperation for recurrence, chronic pain, and patient satisfaction.

RESULTS

From a total of 87,650 patients with unilateral groin hernia repair, 61,337 PROM answers (70%) were received from 71 public and 28 private healthcare providers. More females, acute and recurrent cases, and patients with high American Society of Anesthesiology (ASA) scores were operated under the national healthcare system. The private sector had more experience surgeons with higher annual volume per surgeon, shorter time on waiting lists, and shorter operation times. No difference was seen in patient satisfaction. Groin hernia repair performed in a private clinic was associated with less postoperative chronic pain (OR 0.85, 95% CI 0.8-0.91) but a higher recurrence rate (HR 1.41; 95% CI 1.26-1.59) in a multivariable logistic regression analysis.

CONCLUSION

Despite private clinics having a higher proportion of experienced surgeons and fewer complex cases, the recurrence rate was higher, whereas the risk for chronic postoperative pain was higher among patients treated in the public sector.

Benefits and risks of using laparoscopic ultrasonography versus intraoperative cholangiography during laparoscopic cholecystectomy for gallstone disease: a systematic review and meta-analysis

BACKGROUND

Intraoperative laparoscopic ultrasonography (LUS) or intraoperative cholangiography (IOC) can be used for visualisation of the biliary tract during laparoscopic cholecystectomy. The aim of this systematic review was to compare use of LUS with IOC.

METHODS

PubMed, Embase, the Cochrane Library, and Web of Science were searched (last update: April 2024). PICO: P = patients undergoing intraoperative imaging of the biliary tree during laparoscopic cholecystectomy for gallstone disease; I = intervention: LUS; C = comparison: IOC; O = outcomes: mortality, bile duct injury, retained gallstone, conversion to open cholecystectomy, procedural failure, operation time including imaging time. Included articles were critically appraised using checklists. Conclusions were based on studies without major risk of bias. Meta-analyses were performed using random effects models. Certainty of evidence was assessed according to GRADE.

RESULTS

Sixteen non-randomised studies met the PICO. Two before/after studies (594 versus 807 patients) contributed to conclusions regarding mortality (no events; very low certainty evidence), bile duct injury (1 versus 0 events; very low certainty evidence), retained gallstone (2 versus 2 events; very low certainty evidence), and conversion to open cholecystectomy (6 versus 21 events; risk ratio: 0.38 (95% confidence interval: 0.15-0.95); I2 = 0%; low certainty evidence). Seven additional studies, using intra-individual comparisons, contributed to conclusions regarding procedural failure; risk ratio: 1.12 (95% confidence interval: 0.70-1.78; I2 = 83%; very low certainty evidence). No studies reported operation time. Mean imaging time for LUS and IOC, reported in 12 studies, was 4.8‒10.2 versus 10.9‒17.9 min (mean difference: - 7.8 min (95% confidence interval: - 9.3 to - 6.3); I2 = 95%; moderate certainty evidence).

CONCLUSION

It is uncertain whether there is any difference in mortality/bile duct injury/retained gallstone using LUS compared with IOC, but LUS may be associated with fewer conversions to open cholecystectomy and is probably associated with shorter imaging time.

Proof of concept of an experimental prototype for the prevention of parastomal hernia

PURPOSE

The aim of this study was to analyse the complications and problems associated with the use of an experimental prototype designed for the prevention of parastomal hernia (PSH), one of the most frequent complications in ostomates.

METHODS

A single-centre, non-comparative, proof-of-concept interventional pilot study of an experimental prototype designed to be used in conjunction with an abdominal compression binder to prevent PSH was conducted. The "Ostomy Fixation Device for Hernia Prevention" (patent P201531826) is a semi-rigid ostomy protector, to be used in conjunction with a compression binder. It is designed to adapt to the dimensions of standard ostomy bags from different brands and serves to transmit, in a localised manner, the support coming from the compression binder in the peristomal area without putting pressure on the collection bag. The main outcome measures were efficacy, safety, and patient-users' opinion/perception.

RESULTS

Ten patients were studied for 12 months. Mean age was 61 years (± 11.59), 70% (7) were male, 80% (8) ostomised for colorectal cancer, 90% (9) underwent planned surgery and 80% (8) had a colostomy.

EFFICACY

the incidence of HPE was 10% (1).

SAFETY

no participant experienced pain, discomfort, itching, stinging, leakage, pouch detachment, allergy to components, or injury to the stoma or peristomal skin due to rubbing or pressure. 90% (n = 9) were considered "very satisfied" or "satisfied" with the device.

CONCLUSIONS

An innovative device designed in collaboration between healthcare professionals and end-users has been shown to be safe and effective in reducing PSH in the group of ostomates studied.

Long-Term Outcomes Following Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana

Objective

To assess long-term outcomes following inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana.

Background

Task sharing of surgical care with nonsurgeons can increase access to essential surgery. Long-term safety and outcomes of task sharing are not well-described for hernia repair.

Methods

This prospective cohort study was conducted in Ho, Ghana. After completing a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repairs with mesh on men with primary, reducible hernias. The primary outcome of this study was hernia recurrence at 5 years. The noninferiority limit was 5 percentage points. Secondary endpoints included pain and self-assessed health status at 5 years.

Results

A total of 242 operations in 241 participants were included, including 119 hernia repairs performed by the medical doctors and 123 performed by the surgeons. One hundred and sixty-nine participants (70.1%) were seen in follow-up at 5 years, 29 participants (12.0%) had died and 43 (17.8%) were lost to follow-up. The overall 5-year recurrence rate was 4.7% (n = 8). The absolute difference in recurrence rate between the medical doctor group (2 [2.3%]) and the surgeon group (6 [7.3%]) was -5.0 (1-tailed 95% confidence interval, -10.5; P = 0.06), demonstrating noninferiority of the medical doctors. Participants experienced improvements in groin pain and self-assessed health status that persisted at 5 years.

Conclusions

Long-term outcomes of elective mesh inguinal hernia repair in men performed by medical doctors and surgeons in Ghana were excellent. Task sharing is a critical tool to address the substantial morbidity of unmet hernia surgery needs in Ghana.

Abdominoplasty versus endoscopic approach to diastasis recti repair: A comparative study of outcomes

Diastasis recti (DR) is characterized by the deviation of the abdominal rectus muscle due to widening of the linea alba and laxity of the abdominal wall musculature.1,2 This condition affects the quality of life, in terms of performance of activities of daily living and physical tasks.3-7 Several techniques have been described to correct DR.11 This prospective research aimed at comparing the traditional approaches vs endoscopic plication for DR repair in terms of safety, effectiveness and satisfaction of the patients based on patient-reported outcome measures via the BODY-Q abdomen scale.

Materials and Methods

We performed a retrospective multicenter study in 2 departments of aesthetic and plastic surgery, Department of Plastic Surgery, San Carlo of Nancy Hospital, Rome (group I) and Hospital Británico de Buenos Aires, Argentina group II). A total of 85 consecutive patients treated using abdominoplasty access (group I) and 85 consecutive patients treated using an endoscopic approach (group II) were enrolled in the study. The minimum follow-up was 12 months.

Results

Descriptive statistics were used to report the counts and frequencies for categorical data. Continuous normally and non-normally distributed data were described as means with standard deviations and medians with interquartile ranges as appropriate. All analyses were performed using the STATA/IC 16.0 software.

Conclusion

Our multicenter experience reveals that open and minimally invasive approaches are viable options. Identifying the optimal approach for DR repair should also rely on the patient's desired treatment outcome.

Perioperative Risk Factors for Persistent Postsurgical Pain After Inguinal Hernia Repair: Systematic Review and Meta-Analysis

Persistent postsurgical pain (PPSP) is one of the most bothersome and disabling long-term complications after inguinal hernia repair surgery. Understanding perioperative risk factors that contribute to PPSP can help identify high-risk patients and develop risk-mitigation approaches. The objective of this study was to systematically review and meta-analyze risk factors that contribute to PPSP after inguinal hernia repair. The literature search resulted in 303 papers included in this review, 140 of which were used for meta-analyses. Our results suggest that younger age, female sex, preoperative pain, recurrent hernia, postoperative complications, and postoperative pain are associated with a higher risk of PPSP. Laparoscopic techniques reduce the PPSP occurrence compared to anterior techniques such as Lichtenstein repair, and tissue-suture techniques such as Shouldice repair. The use of fibrin glue for mesh fixation was consistently associated with lower PPSP rates compared to tacks, staples, and sutures. Considerable variability was observed with PPSP assessment and reporting methodology in terms of study design, follow-up timing, clarity of pain definition, as well as pain intensity or interference threshold. High or moderate risk of bias in at least one domain was noted in >75% of studies. These may limit the generalizability of our results. Future studies should assess and report comprehensive preoperative and perioperative risk factors for PPSP adjusted for confounding factors, and develop risk-prediction models to drive stratified PPSP-mitigation trials and personalized clinical decision-making. PERSPECTIVE: This systematic review and meta-analysis summarizes the current evidence on risk factors for persistent pain after inguinal hernia repair. The findings can help identify patients at risk and test personalized risk-mitigation approaches to prevent pain. PROSPERO REGISTRATION: htttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=154663.

The evaluation of risk factors in fascia dehiscence after abdominal surgeries

Background

Despite the advances in surgical techniques and risk control practices in recent years, open wounds following abdominal laparotomy still have a high prevalence. The purpose of this study is to investigate the risk factors of fascia dehiscence (FD) in abdominal surgery patients.

Methods

In this observational study, a total of 60 emergency and elective laparotomy patients were enrolled. For all patients, with (treatment) or without (control) wound dehiscence, a checklist was used to extract data from medical records regarding underlying diseases, suturing method, emergency or elective surgical procedure, duration of surgery less than 180 min, intraoperative bleeding, wound closure method, hernia repair, age, sex, smoking history, comorbidities, type of surgery, colostomy placement, wound complications, re-operation, mortality, wound complications including wound infection, wound dehiscence, incisional hernia, and anastomotic leak, and preoperative readiness assessments such as laboratory tests including C-reactive protein (CRP), Albumin (Alb), etc., were completed, and then comparisons were made.

Results

Patients were examined in two groups: 14 patients (70%) in wound dehiscence with age 40-60 and 6 patients (30%) in non-wound dehiscence with age 60-75. Eight patients (40%) underwent elective surgery, and 12 patients (60%) underwent emergency surgery (P=0.2). Fourteen patients (70%) experienced mortality (P<0.001) and 13 patients (65%) had Alb less than 3 (P<0.001). Fourteen patients (70%) had drain installation (P=0.02). It was determined that the increase in CRP levels (compared to pre-dehiscence levels) was observed in 17 out of 20 cases, with the highest difference being CRP=91 and an average increase of 30. None of the patients suspected of anastomotic leakage were confirmed to have it. Dehiscence was typically diagnosed between the 4th and 7th days post-surgery. The colon and rectum were significantly more associated with dehiscence, while the stomach had the lowest association among surgical sites.

Conclusion

Based on this study, FD is more common in patients treated in the emergency room than in elective procedures. Mortality occurred more in patients with FD, and there is a significant relationship between FD with albumin less than 3 and drain placement.

XIOSIS: An X-Ray-Based Intra-Operative Image-Guided Platform for Oncology Smart Material Delivery

Image-guided interventional oncology procedures can greatly enhance the outcome of cancer treatment. As an enhancing procedure, oncology smart material delivery can increase cancer therapy's quality, effectiveness, and safety. However, the effectiveness of enhancing procedures highly depends on the accuracy of smart material placement procedures. Inaccurate placement of smart materials can lead to adverse side effects and health hazards. Image guidance can considerably improve the safety and robustness of smart material delivery. In this study, we developed a novel generative deep-learning platform that highly prioritizes clinical practicality and provides the most informative intra-operative feedback for image-guided smart material delivery. XIOSIS generates a patient-specific 3D volumetric computed tomography (CT) from three intraoperative radiographs (X-ray images) acquired by a mobile C-arm during the operation. As the first of its kind, XIOSIS (i) synthesizes the CT from small field-of-view radiographs;(ii) reconstructs the intra-operative spacer distribution; (iii) is robust; and (iv) is equipped with a novel soft-contrast cost function. To demonstrate the effectiveness of XIOSIS in providing intra-operative image guidance, we applied XIOSIS to the duodenal hydrogel spacer placement procedure. We evaluated XIOSIS performance in an image-guided virtual spacer placement and actual spacer placement in two cadaver specimens. XIOSIS showed a clinically acceptable performance, reconstructed the 3D intra-operative hydrogel spacer distribution with an average structural similarity of 0.88 and Dice coefficient of 0.63 and with less than 1 cm difference in spacer location relative to the spinal cord.

Mortality risk of patients with intestinal obstruction

BACKGROUND

Intestinal obstruction represents a severe intestinal disease associated with higher mortality rates. However, the determinants of mortality in patients with intestinal obstruction remain inadequately understood. This study sought to elucidate the potential risk factors associated with mortality in the context of intestinal obstruction during the COVID-19 pandemic.

METHODS

A retrospective analysis was performed on a cohort of 227 patients diagnosed with intestinal obstruction at the First Hospital of Hebei Medical University, spanning the period from September 7, 2022, to January 7, 2023. The primary endpoint of the study was mortality within four weeks following discharge. Univariate and multivariable logistic regression models were utilized to evaluate the risk factors associated with mortality outcomes.

RESULTS

A cohort of 227 patients diagnosed with intestinal obstruction (median age, 59.02 years [IQR, 48.95-70.85 years]) was included in our study. Malignant bowel obstruction (MBO) and COVID-19 were identified as independent risk factors for mortality among these patients. Notably, the mortality rate increased significantly to 38.46% when MBO was concomitant with COVID-19. Furthermore, postoperative pulmonary complications (PPC) (OR, 54.21 [death]; 95% CI, 3.17-926.31), gastric cancer (OR, 9.71 [death]; 95% CI, 1.38-68.18), VTE (Caprini Score ≥ 5) (OR, 7.64 [death]; 95% CI, 1.37-42.51), and COVID-19 (OR, 5.72 [death]; 95% CI, 1.01-32.29) were all determined to be independent risk factors for postoperative mortality. Additionally, gastric cancer could have emerged as one of the most severe risk factors for mortality in individuals with intestinal obstruction within the cohort of cancer patients, of which gastric cancer exhibited higher mortality rates compared to individuals with other forms of cancer.

CONCLUSION

The study identifies MBO, gastric cancer, COVID-19, PPC, and VTE as potential risk factors for mortality in cases of intestinal obstruction. These findings highlight the necessity for continuous monitoring of indicators related to these mortality risk factors and their associated complications, thereby offering valuable insights for the management and treatment of intestinal obstruction.

Antibiotic prophylaxis in emergency cholecystectomy for mild to moderate acute cholecystitis: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Emergency cholecystectomy is the mainstay in treating acute cholecystitis (AC). In actual practice, perioperative prophylactic antibiotics are used to prevent postoperative infectious complications (PIC), but their effectiveness lacks evidence. We aim to investigate the efficacy of prophylactic antibiotics in emergency cholecystectomy.

METHODS

We searched PubMed, Embase, Cochrane CENTRAL, Web of Science (WOS), and Scopus up to June 14, 2023. We included randomized controlled trials (RCTs) that involved patients diagnosed with mild to moderate AC according to Tokyo guidelines who were undergoing emergency cholecystectomy and were administered preoperative and/or postoperative antibiotics as an intervention group and compared to a placebo group. For dichotomous data, we applied the risk ratio (RR) and the 95% confidence interval (CI), while for continuous data, we used the mean difference (MD) and 95% CI.

RESULTS

We included seven RCTs encompassing a collective sample size of 1747 patients. Our analysis showed no significant differences regarding total PIC (RR = 0.84 with 95% CI (0.63, 1.12), P = 0.23), surgical site infection (RR = 0.79 with 95% CI (0.56, 1.12), P = 0.19), distant infections (RR = 1.01 with 95% CI (0.55, 1.88), P = 0.97), non-infectious complications (RR = 0.84 with 95% CI (0.64, 1.11), P = 0.22), mortality (RR = 0.34 with 95% CI (0.04, 3.23), P = 0.35), and readmission (RR = 0.69 with 95% CI (0.43, 1.11), P = 0.13).

CONCLUSION

Perioperative antibiotics in patients with mild to moderate acute cholecystitis did not show a significant reduction of postoperative infectious complications after emergency cholecystectomy. (PROSPERO registration number: CRD42023438755).

Is Cholecystectomy Necessary after Choledocholithiasis Treatment for the Elderly or Patients with Many Comorbidities?

INTRODUCTION

We evaluated the prognosis after endoscopic treatment for choledocholithiasis, particularly in patients with borderline tolerance to surgery. Stone removal and cholecystectomy are generally recommended for patients with choledocholithiasis combined with gallstones to prevent recurrent biliary events. However, the prognosis after choledocholithiasis treatment in patients with borderline tolerance to surgery, such as the elderly or those with many comorbidities, remains controversial.

METHODS

We retrospectively analyzed data from patients with choledocholithiasis treated at our facility between January 2012 and December 2021. Patients who underwent endoscopic sphincterotomy were dichotomized into the cholecystectomy (CHOLE) and conservation (CONS) groups depending on whether cholecystectomy was performed, and their prognoses were subsequently compared. Furthermore, we performed a logistic regression analysis of the factors contributing to recurrent biliary events in patients with high age-adjusted Charlson Comorbidity Index (aCCI) scores.

RESULTS

Of 169 participants, 110 had gallstones and were divided into the CHOLE (n = 56) and CONS (n = 54) groups. The CONS group was significantly ordered, had more comorbidities, and higher aCCI scores, whereas the CHOLE group had fewer recurrent biliary events, although not significant (p = 0.122). No difference was observed in the recurrent incidence of grade ≥2 biliary infections and mortality related to biliary events between the groups. In patients with aCCI scores ≥5, conservation without cholecystectomy was not an independent risk factor for recurrent biliary events.

CONCLUSION

Cholecystectomy after choledocholithiasis treatment prevents recurrent biliary events, but conservation without cholecystectomy is a feasible option for patients with high aCCI scores.

Dexamethasone relieves the inflammatory response caused by inguinal hernia meshes through miR-155

BACKGROUND

Inguinal hernia is a relatively common condition. Most patients with inguinal hernia require surgery. At present, mesh repair is one of the most effective methods to treat inguinal hernia, but insertion of the mesh can cause inflammation. Dexamethasone (DEX) can treat inflammation, but the mechanism by which DEX alleviates inflammation caused by inguinal hernia mesh placement remains unclear.

METHOD

We randomly divided rats into groups: negative control (NC), inguinal hernia (IH), polypropylene mesh (PM), DEX treatment, and miR-155 treatment groups. RT-qPCR was performed to determine the expression of miR-155. ELISA was implemented to determine the secretion of IL-1β, IL-6, and IL-18. Western blotting was used to detect caspase-1, JAK1, p-JAK1, STAT3, and p-STAT3 expression. A dual-luciferase reporter gene array identified a connection between miR-155 and JAK1.

RESULTS

The results revealed that the expression of miR-155, IL-1β, IL-6, and IL-18 was upregulated in the PM group. After DEX treatment, the secretion of miR-155, caspase-1, IL-1β, IL-6, and IL-18 decreased. Dual luciferase results confirmed that miR-155 induced the targeted downregulation of JAK1, while a miR-155 mimic reversed the therapeutic effect of DEX, and the expression levels of p-JAK1 and p-STAT3 increased.

CONCLUSION

DEX regulates the JAK1/STAT3 signaling pathway through miR-155 to relieve inflammation caused by inguinal hernia meshes.

A new groin hernia classification with clinical relevance

INTRODUCTION

Groin hernia is one of the most commonly managed surgical diseases around the world. The typical question asked by patients is "Does my hernia require urgent surgery?". The currently available classifications are insufficient to stratify patients into different groups. We propose a new classification that incorporates diverse clinical elements together with anatomical and other vital information, which allows us to stratify patients into different groups.

METHOD

A task force was formed by the Hong Kong Hernia Society, working with international expert hernia surgeons. The framework of the classification system was formulated. Clinical elements that are important in groin disease stratification were identified. A comprehensive literature review was conducted using PubMed. Those which dictate the severity of the disease were selected and compiled to form the new proposed classification. Application of this classification model to a single hernia surgeon's registry in The Hong Kong Adventist Hospital Hernia Centre was done for initial evaluation.

RESULT

This new classification incorporates important clinical characteristics forming a total of nine grades of differentiation, together with the anatomical details and special information. This comprehensive system allows the stratification of patients into different groups based on disease severity. It also enables more accurate data collection for future audits, comparisons of disease progression over time, and the effect of different management strategies for different-stage patients.

CONCLUSION

This is the first classification system which incorporates essential clinical parameters, which allows the stratification of groin hernia into different stages. Further studies and validation should be performed to evaluate the usefulness and value of this classification in groin hernia management.

Reliability and validity of surface EMG assessments combined with isometric muscle strength testing in patients with abdominal rectus diastasis and asymptomatic controls

PURPOSE

Patients with abdominal rectus diastasis (ARD) may have muscular functional impairments, but clinics lack appropriate objective assessment tools. The aim was to establish the relative and absolute reliability, and convergent validity, of muscular activity using Surface Electromyography (SEMG) during isometric abdominal muscle strength testing in patients with ARD and controls without ARD.

METHODS

Twenty-six patients with ARD were matched for age, sex and BMI with controls without ARD. Participants were tested twice during isometric muscular contractions using SEMG located on six abdominal sites. Mean amplitude, fatigue, and recruitment order were analyzed. Relative reliability was evaluated with Intraclass Correlation Coefficients (ICC), while absolute reliability was estimated by calculating the Standard Error of Measurement and Minimal Detectable Change. Convergent validity was addressed in relation to participant characteristics, functional ability, and symptoms.

RESULTS

Mean SEMG amplitude for all abdominal wall muscle contractions showed moderate to excellent relative test-retest reliability, with ICC values ranging from 0.46 to 0.97. In contrast, fatigue and recruitment order displayed poor to moderate relative reliability in both groups. Absolute reliability measures were generally high. A moderate to high convergent validity (ARD: rho-value 0.41-0.70; Controls: rho-value 0.41-0.75) was observed for mean amplitude in relation to a functional sit-to-stand test, abdominal circumference, BMI, back pain, and quality-of-life.

CONCLUSIONS

The results of applying SEMG during isometric abdominal muscle support practicing the method in clinics, although additional development is needed with further standardization and more functional testing. Furthermore, the method demonstrates construct validity in patients with ARD and in age- and sex-matched controls.

Current update on the role of endoanal ultrasound: a primer for radiologists

Endoanal ultrasound (EAUS) is a valuable imaging modality for the evaluation of anal and perianal pathologies. It provides detailed information about the anatomy and physiology of the anorectal region and has been used in pre-and post-operative settings of anorectal pathologies. EAUS is not only useful in the evaluation of benign pathologies but also in loco-regional staging of anal and rectal tumors. EAUS has several advantages over MRI, including reduced cost, better patient tolerance, and improved scope of application in patients with contraindications to MRI. Despite its benefits, EAUS is not widely performed in many centers across the globe. This article aims to educate radiologists, trainees, and surgeons about the indications, contraindications, patient preparation, imaging technique, and findings of EAUS. We will also highlight the technical difficulties, diagnostic challenges, and procedural complications encountered during EAUS, along with a comparative analysis of EAUS with other imaging approaches.

Managing ischemic and necrotic incarcerated femoral hernia contents and their risk factors

PURPOSE

Incarcerated femoral hernia patients had high risk of hernia contents necrosis. We provide our experience of management ischemia and necrosis of hernia contents in emergency incarcerated femoral hernia patients, and to investigate its risk factors.

METHODS

This is a case-control study. Eighty-nine incarcerated femoral patients who underwent emergency surgery from January 2015 to December 2021 were included, and divided into normal group (60 cases) and ischemia/necrosis group (29 cases) according to the intraoperative condition of hernia contents. The surgical methods, intraoperative and postoperative conditions were compared between the two groups. Multivariate logistic regression was used to analyze the risk factors of ischemia and necrosis of hernia contents.

RESULTS

Open preperitoneal tension-free repair was the most commonly used surgical methods (68.5%) for incarcerated femoral patients. The utilization rate of laparoscopic repair in the ischemia/necrosis group was lower than that in the normal group (13.8% vs. 20.0%, P = 0.475). The proportion of mesh placement in the normal group was significantly higher than that in the ischemia/necrosis group (98.3% vs 65.5%, P < 0.001). The hernia contents resection rate (55.2% vs 1.7%), operation time (90 vs 40 min), intraoperative bleeding (5 vs 2 ml), ICU admission rate (31.0% vs 1.7%), and hospital stay (7 vs 4 d) were significantly higher in the ischemia/necrosis group than those in normal group. Results of multivariate logistic regression showed that incarceration time more than 9 h (aOR = 19.3, 95%CI: 1.9-192.9) was an independent risk factor for ischemia and necrosis of hernia contents in emergency incarcerated femoral hernia patients.

CONCLUSION

Open tension-free repair was the most commonly used surgical methods for emergency incarcerated femoral hernia patients. Ischemia and necrosis of hernia contents will increase bowel resection rate and prolong operation and hospital stay. Long incarceration time is an independent risk factor for ischemia and necrosis of hernia contents.

Post-diagnosis adiposity and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

The adiposity influence on colorectal cancer prognosis remains poorly characterised. We performed a systematic review and meta-analysis on post-diagnosis adiposity measures (body mass index [BMI], waist circumference, waist-to-hip ratio, weight) or their changes and colorectal cancer outcomes. PubMed and Embase were searched through 28 February 2022. Random-effects meta-analyses were conducted when at least three studies had sufficient information. The quality of evidence was interpreted and graded by the Global Cancer Update Programme (CUP Global) independent Expert Committee on Cancer Survivorship and Expert Panel. We reviewed 124 observational studies (85 publications). Meta-analyses were possible for BMI and all-cause mortality, colorectal cancer-specific mortality, and cancer recurrence/disease-free survival. Non-linear meta-analysis indicated a reverse J-shaped association between BMI and colorectal cancer outcomes (nadir at BMI 28 kg/m2). The highest risk, relative to the nadir, was observed at both ends of the BMI distribution (18 and 38 kg/m2), namely 60% and 23% higher risk for all-cause mortality; 95% and 26% for colorectal cancer-specific mortality; and 37% and 24% for cancer recurrence/disease-free survival, respectively. The higher risk with low BMI was attenuated in secondary analyses of RCTs (compared to cohort studies), among studies with longer follow-up, and in women suggesting potential methodological limitations and/or altered physiological state. Descriptively synthesised studies on other adiposity-outcome associations of interest were limited in number and methodological quality. All the associations were graded as limited (likelihood of causality: no conclusion) due to potential methodological limitations (reverse causation, confounding, selection bias). Additional well-designed observational studies and interventional trials are needed to provide further clarification.

Obesity and abdominal hernia in ambulatory patients, 2018-2023

PURPOSE

To determine the relationship between abdominal hernia and obesity. Although obesity is frequently cited as a risk factor for abdominal hernia, few studies have confirmed this association (Menzo et al. Surg Obes Relat Dis 14:1221-1232. 10.1016/j.soard.2018.07.005, 2018).

METHODS

A cross-sectional study of primary care ambulatory patients aged older than 16 years treated at UCLA Health from 01/01/2018 to 06/06/2023. Abdominal hernia was identified by clinic encounter ICD-10 codes (K40-K46).

RESULTS

There were 41,703 hernias identified among 1,362,440 patients (306.1 per10,000) with a mean age of 62.5 ± 16.1 years, and 57.6% were men. Nearly half (44.7%) of all abdominal hernias were diaphragmatic. There was an approximately equal distribution of the ventral (28.7%) and inguinal (24.3%) hernia. Each hernia type had a different relationship with obesity: The odds of having a ventral hernia increased with BMI in both sexes: BMI 25-29.9 kg/m2 odds ratio (OR) = 1.65, (CI 1.56-1.74); BMI 30-39.9 kg/m2 OR = 2.42 (CI 2.29-2.56), BMI 40-49.9 kg/m2 OR = 2.28 (CI 2.05-2.54) and BMI >  = 50 kg/m2 OR = 2.54 (CI 2.03-3.17) all relative to normal BMI. In contrast, the odds of having an inguinal hernia decreased with obesity relative to normal weight [obesity (BMI 30-39.9 kg/m2): OR = 0.60 (CI 0.56-0.65)], morbid obesity (BMI 40-49.9 kg/m2): OR = 0.29 (CI 0.23-0.37). The OR for diaphragmatic hernia peaks with obesity in women and overweight status in men but was found to decrease with morbid obesity [OR = 1.18 (CI 1.07-1.30)]. There was no significant difference between men and women in the prevalence of femoral hernia (men: 0.7/per10,000, women: 0.9/per10,000, p = 0.19).

CONCLUSIONS

The relationship between hernia and obesity is complex with some hernias decreasing in prevalence as obesity increases. Further research is needed to better understand this paradoxical relationship.

Incidence and predictors of chronic pain after inguinal hernia surgery: a systematic review and meta-analysis

PURPOSE

The mesh is currently the preferred treatment option for hernia repair surgery. Chronic postoperative inguinal pain (CPIP), lasting more than 3 months after surgery, is a complication that significantly impacts patients' quality of life. Currently, there is a lack of evidence-based information describing the incidence and independent predictive factors of chronic pain, posing a serious challenge in clinical practice for devising personalized prevention strategies. Hence, we conducted this systematic review and meta-analysis to investigate the incidence and predictive factors, aiming to provide a reference for developing plans to prevent chronic pain.

METHODS

We conducted a systematic search of PubMed, Cochrane, Embase, and Web of Science, with the retrieval cutoff date set at December 17, 2022. The included studies underwent assessment using the NOS scale, and subgroup analysis for the incidence was carried out based on different regions.

RESULTS

Ultimately, 18 studies were included, involving 29,466 patients. Meta-analysis showed that the pooled incidence of chronic pain was 17.01% (95%CI 12.78% ~ 21.71%). The incidence was 18.65% (95%CI 13.59% ~ 24.29%) in Europe, 14.70% (95%CI 7.87% ~ 23.17%) in Asia, and 6.04%(95%CI 4.62 ~ 7.64) in North America. Furthermore, We also found that the risk factors for CPIP are younger age [OR = 2.261 (95%CI 1.126 ~ 4.549)], presence of other postoperative complications [OR = 1.849 (95%CI 1.034 ~ 3.305)], hernial sac defect < 3 cm [OR = 1.370 (95%CI 1.012 ~ 1.853)], being female [OR = 1.885 (95%CI 1.024 ~ 3.472)], postoperative pain [OR = 1.553 (95%CI 1.276 ~ 1.889)], preoperative pain [OR = 2.321 (95%CI 1.354 ~ 3.979)], and having a history of ipsilateral inguinal hernia repair [OR = 2.706 (95% CI 1.445 ~ 5.069)].

CONCLUSIONS

The incidence of persistent pain following hernia repair surgery is high in current clinical practice, a concern that should not be overlooked. Stratified assessment tools need to be established for patients experiencing early chronic pain, and personalized follow-up strategies and preventive interventions should be developed for those with potentially high risks. These measures aim to enhance the quality of life for patients after hernia repair.

Comparing stapler and sutured mesh fixation techniques for laparoscopic TAPP repair: a study on chronic groin pain on 3-year follow-up

Trans-abdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs are the available surgeries for inguinal hernias, with both methods of laparoscopic repairs requiring mesh applications. This study analyzes the correlation between sutured versus stapler mesh fixation in a laparoscopic TAPP for unilateral groin hernia regarding chronic pain during 3-year follow-up. A total of 130 patients with laparoscopic hernia undergoing TAPP repair were randomized into 2 groups based on their fixation technique-one with sutures and the other with stapler. Postoperative complications and chronic groin pain were noted for each technique. Equal number of participants was present in the stapler and suture groups, with the majority having an ASA score of one. The mean age was 42.50 ± 13.86 years, and the body mass index (BMI) was 27.47 ± 5.88. The stapler group presented a shorter mean operative time than the suture group. However, the stapler group had a significantly higher mean VAS score than the suture group. Most participants in the suture group (89.2%) had LOS for 1 day, while a 2-day LOS was significantly higher in the stapler group (12.3%) than in the suture group (9.2%). No patient reported mesh erosion, conversion, recurrence, testicular atrophy, and mesh infection. Early postoperative pain was more in stapler group along with long hospital stay, but both were non-significant. Chronic postoperative pain results and recurrence incidences over 3-year follow-up were also similar. Re-admission rates were minimal, no significant complications occurred.

Lessons learnt from the construction and implementation of a prospective ventral hernia database

PURPOSE

The New England VA Hernia Registry was created in 2011 to prospectively collect relevant details of ventral hernia repairs, with the intention to assess and improve long term outcomes. The goal of this study is to assess registry compliance.

METHODS

All ventral hernia operations performed in five VA hospitals between 2011-2022 were obtained. We assessed compliance at the hospital and surgeon level.

RESULTS

3,516 cases were performed. Overall compliance with registry entry was 37.5%, ranging from 10.8% to 67.2% across hospitals. At the hospital level, there was a negative correlation between average yearly hernia volume per surgeon and registry compliance (r2 = 0.53). Surgeon compliance varied within hospitals and over time.

CONCLUSION

Registry compliance was low and highly variable. Lack of interest, incentives, oversight, and surgeon turnover are possible factors for noncompliance. Building a registry with these factors in mind, providing timely feedback, and conducting frequent audits may improve compliance.

Minimally Invasive Stapled Abdominal Wall Repair: A New Surgical Technique

Background: Diastasis recti (DR) is a common condition, especially in women after pregnancy, often associated with concomitant hernia defects and defined as a rupture of the midline and a separation of the rectus muscle more than 2 cm. Symptoms related to this are low back pain, urinary incontinence and pelvic prolapse, as well as abdominal bulging and core instability. We analyzed clinical and functional outcomes after treatment of DR alone or associated with midline hernias in 219 patients who underwent a midline reconstruction using miSAR® technique (minimally invasive stapled abdominal wall reconstruction). Methods: Between April 2019 and April 2022, 219 patients were treated with miSAR®. All patients were requested to quantify preoperative and postoperative functional symptoms (urinary incontinence, low back pain, abdominal swelling, and respiratory distress). Results: Twenty-seven men and 192 women underwent the miSAR® technique. The mean body mass index was 23.9 kg/m2. We performed the miSAR® technique in patients affected by incisional midline hernia and umbilical hernia alone or associated with DR. Composite mesh was used in 91.8% of cases. The average operating time was 90 minutes. Seven percent of the patients had postoperative complications, including two retromuscular hematomas, two retromuscular seromas, and one postoperative bleeding event. Two patients were readmitted for bowel obstruction. After surgery, there was symptomatic improvement in urinary incontinence, low back pain, respiratory symptoms, and abdominal swelling; this improvement was confirmed at 6 months and at 1- and 2-year follow-up. At the 1-year follow-up, the overall recurrence rate was 2.83%. Conclusion: miSAR® is a feasible and effective technique and shows promising results in the treatment of DR and ventral hernia. Possible enhancements include use of preoperative Botox to treat defects larger than 6 cm. Multicentric analysis is needed to validate the technique, and longer follow-up is required to assess the recurrence rate.

Association of severe obesity with risk of conversion to open in laparoscopic cholecystectomy for acute cholecystitis

Background

Obesity is a known risk factor for cholecystitis and is associated with technical complications during laparoscopic procedures. The present study seeks to assess the association between obesity class and conversion to open (CTO) during laparoscopic cholecystectomy (LC).

Methods

Adult acute cholecystitis patients with obesity undergoing non-elective LC were identified in the 2017-2020 Nationwide Readmissions Database. Patients were stratified by obesity class; class 1 (Body Mass Index [BMI] = 30.0-34.9), class 2 (BMI = 35.0-39.9), and class 3 (BMI ≥ 40.0). Multivariable regression models were developed to assess factors associated with CTO and its association with perioperative complications and resource utilization.

Results

Of 89,476 patients undergoing LC, 40.6 % had BMI ≥ 40.0. Before adjustment, class 3 obesity was associated with increased rates of CTO compared to class 1-2 (4.6 vs 3.8 %; p < 0.001). Following adjustment, class 3 remained associated with an increased likelihood of CTO (Adjusted Odds Ratio [AOR] 1.45, 95 % Confidence Interval [CI] 1.31-1.61; ref.: class 1-2). Patients undergoing CTO had increased risk of blood transfusion (AOR 3.27, 95 % CI 2.54-4.22) and respiratory complications (AOR 1.36, 95 % CI 1.01-1.85). Finally, CTO was associated with incremental increases in hospitalization costs (β + $719, 95 % CI 538-899) and length of stay (LOS; β +2.20 days, 95 % CI 2.05-2.34).

Conclusions

Class 3 obesity is a significant risk factor for CTO. Moreover, CTO is associated with increased hospitalization costs and LOS. As the prevalence of obesity grows, improved understanding of operative risk by approach is required to optimize clinical outcomes. Our findings are relevant to shared decision-making and informed consent.

Transinguinal preperitoneal (TIPP) versus minimally invasive inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

The transinguinal preperitoneal (TIPP) technique is an open approach to groin hernia repair with posteriorly positioned mesh supposed to reduce recurrence rates. However, transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques have similar mesh positioning with the advantages of minimally invasive surgery (MIS). Hence, we performed a systematic review and meta-analysis comparing TIPP and MIS for groin hernia repair.

SOURCE

Cochrane, Embase, Scopus, Scielo, and PubMed were systematically searched for studies comparing TIPP and MIS techniques for groin hernia repair. Outcomes assessed were recurrence, chronic pain, surgical site infection (SSI), seroma, and hematoma. We performed a subgroup analysis of TAPP and TEP techniques separately. Statistical analysis was performed with R Studio.

PRINCIPAL FINDINGS

81 studies were screened and 19 were thoroughly reviewed. Six studies were included, of which two compared TIPP with TEP technique, two compared TIPP with TAPP, and two compared TIPP with both TEP and TAPP techniques. We found lower recurrence rates for the TEP technique compared to TIPP (0.38% versus 1.19%; RR 2.68; 95% CI 1.01 to 7.11; P = 0.04). Also, we found lower seroma rates for TIPP group on the overall analysis (RR 0.21; P = 0.002). We did not find statistically significant differences regarding overall recurrence (RR 1.6; P = 0.19), chronic pain (RR 1.53; P = 0.2), SSI (RR 2.51; P = 0.47), and hematoma (RR 1.29; P = 0.76) between MIS and TIPP. No statistically significant differences were found in the subgroup analysis of TAPP technique for all the outcomes.

CONCLUSION

Our systematic review and meta-analysis found no differences between TIPP and MIS approaches in the overall analysis of recurrence, SSI, and chronic pain rates. Further research is needed to analyze individual techniques and draw a more precise conclusion on this subject.

PROSPERO REGISTRATION

ID CRD42024530107, April 8, 2024.

Glanzmann's thrombasthenia: A nightmare for hernia surgeons

ABSTRACT

Glanzmann's thrombasthenia is a rare inherited disorder affecting one in one million. It is characterised by a lack of platelet aggregation due to a defect in the platelet membrane receptor complex (αIIb/βIIIa), which mediates the aggregation of platelets at the site of vessel injury. We report here the first case of successful perioperative haemostatic management of a male patient with Glanzmann's thrombasthenia, who underwent an elective laparoscopic hernia repair. The patient was posted for elective surgery considering the availability of expertise in minimally invasive surgery and accessibility to recombinant activated factor VII. The patient was operated using the extended-view totally extraperitoneal technique for inguinal hernia repair. The patient recovered successfully and reported no complication during follow-up. We conclude that with proper perioperative haematological consultation, and careful coordination between anaesthetists and surgeons, elective laparoscopic procedure can be done in patients with Glanzmann's thrombasthenia, with only recombinant factor VIIa support.

Biliary complications associated with weight loss, cholelithiasis and choledocholithiasis

Biliary complications like cholelithiasis and choledocholithiasis are more common in bariatric surgery patients due to obesity and rapid weight loss. Patients with a body mass index > 40 face an eightfold risk of developing cholelithiasis. Post-bariatric surgery, especially after laparoscopic Roux-en-Y gastric bypass (LRYGB), 30% of patients develop biliary disease due to rapid weight loss. The aim of this review is to analyze the main biliary complications that occur after bariatric surgery and its management. A review of the literature was conducted mainly from 2010 up to 2023 with regard to biliary complications associated with bariatric patients in SciELO, PubMed, and MEDLINE. Patients undergoing LRYGB have a higher incidence (14.5%) of symptomatic calculi post-surgery compared to those undergoing laparoscopic sleeve gastrectomy at 4.1%. Key biliary complications within 6 to 12 months post-surgery include: Cholelithiasis: 36%; Biliary colic/dyskinesia: 3.86%; Acute cholecystitis: 0.98%-18.1%; Chronic cholecystitis: 70.2%; Choledocholithiasis: 0.2%-5.7% and Pancreatitis: 0.46%-9.4%. Surgeons need to be aware of these complications and consider surgical treatments based on patient symptoms to enhance their quality of life.

Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair

BACKGROUND

An inguinal hernia occurs when part of the intestine protrudes through the abdominal muscles. In adults, this common condition is much more likely in men than in women. Inguinal hernia can be monitored by 'watchful waiting', but if symptoms persist or worsen, surgery is usually required, which can be open or laparoscopic. Laparoscopic (keyhole) repair of inguinal hernias in adults is generally performed using either the transabdominal preperitoneal (TAPP) or the totally extraperitoneal (TEP) method. Both methods include the use of mesh placed in front of the peritoneal lining of the abdominal wall, but for the TAPP technique, the abdominal cavity needs to be entered to place the mesh, and for the TEP technique, the whole procedure is done on the outside of the peritoneal lining of the abdominall wall. Whether one method is superior to the other has not been established, and there is debate about their relative benefits and harms. An advantage of TEP is its avoidance of the abdominal cavity; the downside is that it requires a steeper learning curve for clinicians. TAPP is considered simpler and makes it possible to inspect the contralateral side, but TAPP may have a higher risk of visceral injury compared to TEP. This is an update of a Cochrane review first published in 2005.

OBJECTIVES

To compare the benefits and harms of laparoscopic TAPP technique versus laparoscopic TEP technique for inguinal hernia repair in adults.

SEARCH METHODS

On 25 October 2022, the authors searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R); and Ovid Embase, for published randomised controlled trials. To identify studies in progress, we searched ClinicalTrials.gov and the WHO International Clinical Trial Registry Platform (ICTRP).

SELECTION CRITERIA

All prospective randomised, quasi-randomised, and cluster-randomised trials that compared the laparoscopic TAPP technique with the laparoscopic TEP technique for inguinal hernia repair in adults were eligible for inclusion. We included studies that involved a mix of different types of groin hernia if we could extract data for the inguinal hernias. Studies may have also included a group of participants receiving hernia repair by open surgery, but these groups were not included in our review.

DATA COLLECTION AND ANALYSIS

Both review authors independently evaluated trial eligibility, extracted data from included studies, and assessed the risk of bias in the included studies. The review's primary outcomes were serious adverse events, chronic pain (persisting for at least six months after surgery), and hernia recurrence. We also assessed a variety of secondary outcomes at perioperative, early postoperative, and late postoperative time points. We performed statistical analyses using the random-effects model, and expressed the results as odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence for key outcomes as high, moderate, low or very low.

MAIN RESULTS

We included 23 studies in this review update, which randomised 1156 people to TAPP and 1110 people to TEP, all requiring repair of inguinal hernias. Study sample sizes varied from 40 to 316 participants. The vast majority of study participants were male. We judged most studies to be at 'high' or 'unclear' risk of bias. Our judgements of the certainty of the evidence were low or very low for all outcomes we assessed. There may be little to no difference between TAPP and TEP laparoscopic techniques for serious adverse events (0.4% versus 0.7%; OR 0.58, 95% CI 0.15 to 2.32, P = 0.45, I2 = 0%; 19 studies, 1735 participants; low certainty of evidence); and hernia recurrence (1.2% versus 1.1%; OR 1.14, 95% CI 0.49 to 2.62, P = 0.97, I2 = 0%; 17 studies, 1712 participants; low certainty of evidence). The evidence is very uncertain about the effects of TAPP versus TEP techniques on chronic pain (OR 0.62, 95% CI 0.20 to 1.97, P = 0.68, I2 = 0%; 6 studies, 860 participants; very low certainty of evidence). In terms of secondary outcomes, the evidence is very uncertain for TAPP versus TEP techniques for perioperative visceral and vascular injury (15 studies, 1523 participants; very low certainty of evidence), and for haematoma or seroma during the early (≤ 30 days) postoperative phase (OR 0.86, 95% CI 0.54 to 1.37, P = 0.3861, I2 = 0%; 15 studies, 1423 participants; very low certainty of evidence). TEP technique may carry a higher risk of conversion to another hernia repair method (either TAPP technique or open surgery) when compared to TAPP (2.5% versus 0.7%; OR 0.28, 95% CI 0.09 to 0.84, P = 0.02, I2 = 0%; 13 studies, 1178 participants; low certainty of evidence). Only two studies (474 participants) reported quality of life in the late (> 30 days) postoperative phase; overall, there was an improvement in quality of life from the pre- to post-operative assessment, but the evidence suggests little to no difference between the techniques (low certainty of evidence).

AUTHORS' CONCLUSIONS

This review update found that there may be little to no difference between the TAPP and TEP techniques for serious adverse events, hernia recurrence, or chronic pain (low- to very-low-certainty evidence). Decisions about which method to use will most likely reflect surgeon and patient preference until high-certainty evidence becomes available. There may be a higher risk of needing to convert from TEP to TAPP or open surgery when compared to the risk of needing to convert from TAPP to open surgery (low-certainty evidence). If surgeons opt for TEP as their standard laparoscopic method, they could consider having a strategy for how to handle the potential need for conversion. This might include proficiency in the TAPP approach or having informed the patient about the risk of conversion to open surgery. For surgeons or surgical departments, the choice of a laparoscopic technique should involve shared decision-making with patients and their families or carers. Future research could focus on patient-reported outcomes, such as quality of life.

Preoperative risk evaluation and optimization for patients with liver disease

The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient's liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.

The initial experience of robot-assisted transabdominal transversalis fascial and preperitoneal repair for small ventral hernia

PURPOSE

Despite the widespread of ventral hernia repairs globally, the approach method, dissection planes, defect closure, and the choice and placement layer of mesh are an ongoing debate. We reported the details of surgical techniques, safety and feasibility for robot-assisted transabdominal transversalis fascial and preperitoneal repair (R-TATFPP) for small ventral hernia.

METHODS

This study included 5 cases of R-TATFPP repair among 22 cases performed by robot-assisted ventral hernia repair from 2018 to 2023 with the approval of the Institutional Review Board at St. Luke's International University and clinical ethical committee at St. Luke's International Hospital (19-R147, 22-012).

RESULTS

There were four males and one female, with mean age of 64.4 ± 10.0 years, inclusive of two umbilical and three incisional hernias. Mean height, weight, body mass index (BMI), hernia defect length, width, operation time, console time, and hospital stay were 171.2 ± 11.8 cm, 82.4 ± 13.4 kg, 28.0 ± 2.1 kg/m2, 2.8 ± 1.4 cm, 3.0 ± 1.3 cm, 180 min, 133.8 min, and 2.4 days, respectively. No conversion nor complication was observed except for one acute urinary retention.

CONCLUSION

Robot-assisted transversalis fascial and preperitoneal repair was safe and feasible for small ventral hernia with the minimal disruption to the abdominal wall architecture and structures.

Association of preoperative cholangitis with outcomes and expenditures among patients undergoing pancreaticoduodenectomy

BACKGROUND

This study aimed to characterize the association of preoperative acute cholangitis (PAC) with surgical outcomes and healthcare costs.

METHODS

Patients who underwent pancreaticoduodenectomy (PD) between 2013 and 2021 were identified using 100% Medicare Standard Analytic Files. PAC was defined as the occurrence of at least 1 episode of acute cholangitis within the year preceding surgery. Multivariable regression analyses were used to compare postoperative outcomes and costs relative to PAC.

RESULTS

Among 23,455 Medicare beneficiaries who underwent PD, 2,217 patients (9.5%) had at least 1 episode of PAC. Most patients (n = 14,729 [62.8%]) underwent PD for a malignant indication. On multivariable analyses, PAC was associated with elevated odds of surgical site infection (odds ratio [OR], 1.14; 95% CI, 1.01-1.29), sepsis (OR, 1.17; 95% CI, 1.01-1.37), extended length of stay (OR, 1.13; 95% CI, 1.01-1.26), and readmission within 90 days (OR, 1.14; 95% CI, 1.04-1.26). Patients with a history of PAC before PD had a reduced likelihood of achieving a postoperative textbook outcome (OR, 0.83; 95% CI, 0.75-0.92) along with 87.8% and 18.4% higher associated preoperative and postoperative healthcare costs, respectively (all P < .001). Overall costs increased substantially among patients with more than 1 PAC episode ($59,893 [95% CI, $57,827-$61,959] for no episode vs $77,922 [95% CI, $73,854-$81,990] for 1 episode vs $101,205 [95% CI, $94,871-$107,539] for multiple episodes).

CONCLUSION

Approximately 1 in 10 patients undergoing PD experienced an antecedent PAC episode, which was associated with adverse surgical outcomes and greater healthcare expenditures.

Balancing Expectations: Navigating Medically Necessary Torso Procedures with Cosmetic Components in the Military Healthcare System

Background

Surgeons performing federal insurance-financed procedures involving medically necessary and cosmetic components must navigate patient expectations to avoid postoperative disappointment. This challenge is amplified in military healthcare, where different surgical specialties concurrently address the same diagnosis, while the Department of Defense policy on cosmetic fees and TRICARE's definition of excluded services adds further complexity. With the increasing prevalence of elevated body mass index, focus is directed toward diagnoses involving the torso, specifically gynecomastia in male individuals, and diastasis of the rectus abdominis muscles (DRAM) in female individuals.

Methods

The study involves a team of experienced board-certified surgeons conducting a narrative review of surgical procedures addressing gynecomastia and DRAM. Relevant literature from 2000 to 2023 is reviewed, focusing on patient satisfaction regarding outcome of medically necessary and cosmetic aspects.

Results

For gynecomastia, distinguishing between true and pseudogynecomastia is critical. A protocol is presented based on the Simon classification, offering evidence-based guidelines for surgical interventions. Similarly, for DRAM, a minimally invasive approach balances deployment readiness and surgical recovery. The presence of a symptomatic panniculus, however, requires more invasive intervention. The downstream ramification of limited Current Procedural Terminology codes for these interventions is discussed.

Conclusions

In medically necessary procedures funded through federal health plans such as TRICARE, the primary goal is functional improvement, not the final torso contour. Clear communication and preoperative counseling are crucial to managing patient expectations. Providers in military healthcare must navigate the complex landscape of patient expectations, policy guidelines, and duty readiness while maintaining the standard of care.

The Importance of Multidisciplinary Management for Placenta Increta: A Case Report

This case involves a 34-year-old pregnant woman, gravida 6 para 5, with a gestational age of 32 weeks plus one day. After imaging studies, doctors suspected that she had an abnormal placentation and referred her to a secondary hospital for further management. Surgeons there performed a successful elective cesarean section and a total abdominal hysterectomy with a multidisciplinary approach in mind.

New models for prediction of postoperative pulmonary complications in lung resection candidates

Introduction

In recent years, ventilatory efficiency (minute ventilation (V'E)/carbon dioxide production (V'CO2 ) slope) and partial pressure of end-tidal carbon dioxide (P ETCO2 ) have emerged as independent predictors of postoperative pulmonary complications (PPC). Single parameters may give only partial information regarding periprocedural hazards. Accordingly, our aim was to create prediction models with improved ability to stratify PPC risk in patients scheduled for elective lung resection surgery.

Methods

This post hoc analysis was comprised of consecutive lung resection candidates from two prior prospective trials. All individuals completed pulmonary function tests and cardiopulmonary exercise testing (CPET). Logistic regression analyses were used for identification of risk factors for PPC that were entered into the final risk prediction models. Two risk models were developed; the first used rest P ETCO2 (for patients with no available CPET data), the second used V'E/ V'CO2 slope (for patients with available CPET data). Receiver operating characteristic analysis with the De-Long test and area under the curve (AUC) were used for comparison of models.

Results

The dataset from 423 patients was randomly split into the derivation (n=310) and validation (n=113) cohorts. Two final models were developed, both including sex, thoracotomy, "atypical" resection and forced expiratory volume in 1 s/forced vital capacity ratio as risk factors. In addition, the first model also included rest P ETCO2 , while the second model used V'E/V'CO2 slope from CPET. AUCs of risk scores were 0.795 (95% CI: 0.739-0.851) and 0.793 (95% CI: 0.737-0.849); both p<0.001. No differences in AUCs were found between the derivation and validation cohorts.

Conclusions

We created two multicomponental models for PPC risk prediction, both having excellent predictive properties.

The Impact of Intraoperative Glucagon on the Diagnostic Accuracy of Intraoperative Cholangiogram for the Diagnosis of Choledocholithiasis: Experience from a Large Tertiary Care Center

A proportion of patients who undergo intraoperative cholangiogram (IOC) do not have bile duct stones at the time of endoscopic retrograde cholangiopancreatography (ERCP), either due to the spontaneous passage of stones or a false-positive IOC. Glucagon has been utilized as an inexpensive tool to allow the passage of micro-choledocholithiasis to the duodenum and resolve filling defects caused by stones or air bubbles. The purpose of our study is to understand the change in diagnostic accuracy of IOC to detect choledocholithiasis with intraoperative glucagon. We conducted a retrospective study at a tertiary care center on adult patients who underwent laparoscopic cholecystectomy with IOC. The diagnostic accuracy of IOC was assessed before and after the administration of intravenous glucagon. Of 1455 patients, 374 (25.7%) received intraoperative glucagon, and 103 of these 374 patients (27.5%) showed resolution of the filling defect with the passage of contrast to the duodenum. Pre- and post-glucagon administration comparison showed enhancement in specificity from 78% to 83%, an increase in positive predictive value from 67.3% to 72.4%, and an improvement in the diagnostic accuracy of IOC from 81.5% to 84.3%. Our findings suggest that intraoperative glucagon administration carries the potential to reduce the rate of false-positive IOCs, thereby reducing the performance of unnecessary ERCPs.

Laparoscopic totally extraperitoneal repair for recurrent inguinal bladder hernia: A case report

We present a case of a recurrent inguinal bladder hernia that was previously unsuccessfully operated on three times and was repaired using totally extraperitoneal repair (TEP). A 79-year-old man presented with a right inguinal swelling that had been treated three times on the same side with anterior approaches. Computed tomography confirmed a recurrent inguinal bladder hernia. TEP was performed after identifying the bladder hernia preoperatively, with previous surgeries that used a plug-and-patch technique through an anterior approach. The extraperitoneal approach allowed the bladder to be reduced without injury and the hernia to be safely repaired using a 3D Max® Light Mesh. The postoperative recovery was uneventful, with no recurrence after 1 year. TEP facilitates the diagnosis and repair of bladder hernias, emphasizing the importance of preoperative diagnosis and the efficacy of endoscopic procedures in bladder hernia repair, even in recurrent cases.

Whole-body tumour burden on [18F]DCFPyL PET/CT in biochemical recurrence of prostate cancer: association with tumour biology and PSA kinetics

PURPOSE

The objective was to assess the association between molecular imaging (mi) variables on [18F]DCFPyL-PET/CT with clinical and disease characteristics and prostate specific antigen (PSA) related variables in patients with biochemical recurrence of prostate cancer (BRPC).

MATERIAL AND METHODS

We analysed patients with BRPC after radical treatment. We obtained clinical and PSA variables: International Society of Urology Pathology (ISUP) grade group, European Association of Urology (EAU) risk classification, PSA (PSA≤1ng/ml, 12), PSA doubling time (PSAdt) and PSA velocity (PSAvel). All PET/CT scans were reviewed with the assistance of automated Prostate Molecular Imaging Standardized Evaluation (aPROMISE) software and lesions' segmentation in positive scans was performed using this platform. Standardized uptake value (SUV) derived variables; tumour burden variables [whole-body tumour volume (wbTV), whole-body tumour lesion activity (wbTLA) and whole-body mi PSMA (wbPSMA)] and miTNM staging were obtained. Cut-off of PSA and kinetics able to predict PET/CT results were obtained. Associations between disease and mi variables were analysed using ANOVA, Kruskal-Wallis and Spearman's correlation tests. Multivariate analysis was also performed.

RESULTS

Two hundred and seventy-five patients were studied. [18F]DCFPyL-PET/CT were positive in 165/275 patients. In multivariate analysis, moment of biochemical recurrence, ISUP group, PSA level and PSAvel showed significant association with the detection rate. miTNM showed significant association with PSA level (p<0.001) and kinetics (p<0.001), being higher in patients with metastatic disease. Both PSA and PSAvel showed moderate correlation with wbTV, wbTLA and wbPSMA (p<0.001). A weak correlation with SUVs was found. Mean wbTV, wbTLA and wbPSMA values were significantly higher in PSA > 2ng/ml, PSAdt ≤ 6 months and PSAvel ≥ 0.2ng/ml/month groups. Also, wbTV (p=0.039) and wbPSMA (p=0.020) were significantly higher in patients with ISUP grade group 5. PSA and PSAvel cut-offs (1.15 ng/ml and 0.065 ng/ml/month) were significantly associated with a positive PET/CT.

CONCLUSION

Higher PSA values, unfavourable PSA kinetics and ISUP grade group 5 were robust predictive variables of larger tumour burden variables on [18F]DCFPyL PET/CT assessed by aPROMISE platform.

The Perceived Impact of COVID-19 on Graduate Medical Education and Recommendations for Bridging the Educational Gap

INTRODUCTION

COVID-19 generated a system-wide shock causing an unbalanced equilibrium between producing adequately trained physicians and meeting extraordinary operational needs. Previous studies report the experience of surgical residents during COVID-19 at a regional level. This study measures the learning losses related with the redeployment of highly specialized medical professionals to the care of COVID-19 patients, while we systematically investigate proposed remedial strategies.

METHODS

We administered an online cross-sectional survey in 67 countries capturing training inputs (i.e., surgeries and seminars residents participated in) before and during the pandemic and retrieved residents' expected learning outputs, career prospects and recommended remedial measures for learning losses. We compared responses of residents working in (treatment group) and out (control group) of hospitals with COVID-19 patients.

RESULTS

The analysis included 432 plastic surgery residents who were in training during the pandemic. Most of the learning losses were found in COVID-19 hospitals with 37% and 16% loss of surgeries and seminars, respectively, per week. Moreover, 74%, 44%, and 55% of residents expected their surgical skill, scientific knowledge, and overall competence, respectively, to be lower than those of residents who graduated before COVID. Residents in COVID-19 hospitals reported participating in significantly (P < 0.001) fewer surgeries and having significantly (P < 0.001) lower surgical skill relative to those not in COVID-19 hospitals.

CONCLUSIONS

The perceived lower competence and the fall-off in surgical skill and scientific knowledge among future surgeons suggest that health-care systems globally may have limited capacity to perform specialized and costly procedures in the future.

F. Simões J, Dias CC, Sampaio Alves M, Azevedo J, Cunha M, Alagoa João A, Nobre JG, Picciochi M, Sampaio Soares A, Vieira B, Peyroteo M, On behalf of PT Surg. Surgical Technique and Chronic Postoperative Inguinal Pain in Patients Undergoing Open Inguinal Hernioplasty in Portugal: A Prospective Multicentric Cohort Study

INTRODUCTION

Evidence about the advantage of Lichtenstein's repair, the guidelines' recommended technique, is scarce regarding postoperative chronic inguinal pain (CPIP). The primary aim of this study was to compare CPIP in patients undergoing Lichtenstein versus other techniques.

METHODS

Prospective multicentric cohort study including consecutive adults undergoing elective inguinal hernia repair in Portuguese hospitals (October - December 2019). Laparoscopic and mesh-free hernia repairs were excluded. The primary outcome was postoperative pain at three months, defined as a score of ≥ 3/10 in the European Hernia Society Quality of Life score pain domain. The secondary outcome was 30-day postoperative complications.

RESULTS

Eight hundred and sixty-nine patients from 33 hospitals were included. Most were men (90.4%) and had unilateral hernias (88.6%). Overall, 53.6% (466/869) underwent Lichtenstein's repair, and 46.4% (403/869) were treated with other techniques, of which 83.9% (338/403) were plug and patch. The overall rate of CPIP was 16.6% and 12.2% of patients had surgical complications. The unadjusted risk was similar for CPIP (OR 0.76, p = 0.166, CI 0.51 - 1.12) and postoperative complications (OR 1.06, p = 0.801, CI 0.69 - 1.60) between Lichtenstein and other techniques. After adjustment, the risk was also similar for CPIP (OR 0.83, p = 0.455, CI 0.51 - 1.34) and postoperative complications (OR 1.14, p = 0.584, CI 0.71 - 1.84).

CONCLUSION

The Lichtenstein technique was not associated with lower CPIP and showed comparable surgical complications. Further investigation as- sessing long term outcomes is necessary to fully assess the benefits of the Lichtenstein technique regarding CPIP.

Updates on Antibiotic Regimens in Acute Cholecystitis

Acute cholecystitis is one of the most common surgical diseases, which may progress from mild to severe cases. When combined with bacteremia, the mortality rate of acute cholecystitis reaches up to 10-20%. The standard of care in patients with acute cholecystitis is early laparoscopic cholecystectomy. Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases. Nevertheless, antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis. Patients with acute cholecystitis have a bile bacterial colonization rate of 35-60%. The most frequently isolated microorganisms are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment. In these cases, the choice of antibiotic must be made considering some factors (e.g., the severity of the clinical manifestations, the onset of the infection if acquired in hospital or in the community, the penetration of the drug into the bile, and any drug resistance). Furthermore, therapy must be modified based on bile cultures in cases of severe cholecystitis. Antibiotic stewardship is the key to the correct management of bile-related infections. It is necessary to be aware of the appropriate therapeutic scheme and its precise duration. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.

Causal relationship between obesity and anorectal abscess: a Mendelian randomization study

Background

Observational studies have indicated that obesity is a risk factor for anorectal abscess (ARB). However, it remains unclear whether a causal genetic relationship exists between obesity and ARB.

Methods

Univariate and multivariate Mendelian randomization (MR) were conducted using data from a large, published genome-wide association study (GWAS) of European ancestry to infer a causal relationship between obesity and ARB. Inverse variance weighted (IVW) analysis served as the primary analysis method, with results reported as odds ratios (OR).

Results

MR analysis revealed that body mass index (BMI) positively affects ARB (OR 1.974, 95% confidence interval (CI) 1.548-2.519, p = 4.34 × 10-8). The weighted median method (OR = 1.879, 95% CI 1.248-2.829, p = 0.002) and Bayesian model averaging (BMA) (OR = 1.88, 95% CI 1.477-2.392, p = 2.85 × 10-7) also demonstrated consistent results. Subsequently, the impact of several obesity-related characteristics on ARB was assessed. Body fat percentage (BF), whole body fat mass (FM), waist circumference (WC), and hip circumference (HC) were found to be causally associated with an increased risk of ARB. However, these associations vanished after adjusting for BMI effects.

Conclusion

The study confirms a positive causal effect of obesity on ARB, highlighting that reasonable weight control is an important strategy to reduce the incidence of ARB.

Trans rectus sheath extra-peritoneal procedure (TREPP) for inguinal hernia repair under local anesthesia with sedation in the outpatient clinic: a feasibility study

BACKGROUND

The Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) is an open procedure in which the mesh is placed in the preperitoneal space and is therefore associated with less chronic post-operative inguinal pain. TREPP is primarily performed under general or spinal anesthesia, however, it is also possible to perform under sedation and local anesthesia with potentially advantages. This retrospective feasibility pilot study investigates the safety and efficiency of TREPP under local anesthesia in the outpatient clinic in comparison with Lichtenstein.

METHODS

Between 2019 and 2022, all patients who underwent an elective inguinal hernia repair under local anesthesia in the outpatient clinic operation theatre were assessed. 34 patients in the TREPP group and 213 patients in the Lichtenstein group were included. Outcomes were complications, operating time, theatre time, and early inguinal hernia recurrence within 8 weeks and 6 months post-operatively.

RESULTS

No significant differences in complications such as wound infection, hematoma, seroma, urine retention and early recurrence between TREPP and Lichtenstein were found. Post-operative pain at 8 weeks was not significantly higher after Lichtenstein (8.8% vs. 18.8%, P = 0.22). Operating time (21.0 (IQR: 16.0-27.3) minutes vs. 39.0 (IQR: 31.5-45.0) minutes, P < 0.001) and theatre time (37.5 (IQR: 30.8-42.5) minutes vs. 54.0 (IQR: 46.0-62.0) minutes, P < 0.001) was significantly shorter for TREPP.

CONCLUSION

This pilot study showed that TREPP appears to be feasible to perform safely under local anesthesia with comparable complication rates and substantially shorter operation time than Lichtenstein. These results justify further research with a larger study population and a longer period of follow up in order to provide firm conclusions.

Saliva stress biomarkers in ERCP trainees before and after familiarisation with ERCP on a virtual simulator

Background

Stress during the early ERCP learning curve may interfere with acquisition of skills during training. The purpose of this study was to compare stress biomarkers in the saliva of trainees before and after familiarisation with ERCP exercises on a virtual simulator.

Methods

Altogether 26 endoscopists under training, 14 women and 12 men, completed the three phases of this study: Phase 1. Three different ERCP procedures were performed on the simulator. Saliva for α-amylase (sAA), Chromogranin A (sCgA), and Cortisol (sC) were collected before (baseline), halfway through the exercise (ex.), and 10 min after completion of the exercise (comp.); Phase 2. A three-week familiarisation period where at least 30 different cases were performed on the virtual ERCP simulator; and Phase 3. Identical to Phase 1 where saliva samples were once again collected at baseline, during, and after the exercise. Percentage differences in biomarker levels between baseline and exercise (Diffex) and between baseline and completion (Diffcomp) during Phase 1 and Phase 3 were calculated for each stress marker.

Results

Mean % changes, Diffex and Diffcomp, were significantly positive (p < 0.05) for all markers in both Phase 1 and Phase 3. Diffex in Phase 1 was significantly greater than Diffex in Phase 3 (p < 0.05) for sAA and sCgA. Diffcomp for sAA in Phase 1 was significantly greater than Diffcomp in Phase 3 (p < 0.05). No significant differences were found in sC concentration between Phases 1 and 3.

Conclusion

This study shows that familiarisation with the ERCP simulator greatly reduced stress as measured by the three saliva stress biomarkers used with sAA being the best. It also suggests that familiarisation with an ERCP simulator might reduce stress in the clinical setting.