Biosynthetic meshes in contaminated fields: where are we now? A systematic review and meta-analysis in humans

PURPOSE

Selection of an appropriate mesh reinforcement for hernia repair in contaminated fields is a significant problem for surgeons. To date the proper mesh for contaminated fields has not been found. Biosynthetic meshes have emerged as new treatment option in contaminated fields. This study aims to evaluate the postoperative outcomes of biosynthetic meshes in contaminated fields.

METHODS

Systematic electronic search (PubMed, Medline, Embase, Scopus), according to PRISMA criteria, was performed. A literature search of scientific papers was performed by two reviewers until April 2021. Articles were chosen based on reference to biosynthetic meshes, their use in infected fields, and in human subjects. GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of studies. According to CDC-Centers for Disease Control classes patients were divided into two subgroups, group 1 (CDC class 2) and group 2 (CDC classes 3-4).

RESULTS

The research included 21 articles and 1619 patients were analyzed. Long-term follow-up showed a significant higher recurrence rate than short-term follow-up. P < 0.001. Meta-analysis of these studies showed that the SSI were significantly higher in CDC classes 3-4 than CDC class 2 (P < 0.01). No differences were found in SSO (P = 0.06) and recurrence (P = 0.37) rate among the two groups. Phasix™ was the most common mesh in 15 studies. The mean follow-up was 23.0 months. The surgical site infection (SSI) rate was 17.3%. The surgical site occurrence (SSO) rate was 32.4%. Recurrence rate was 11.5%.

CONCLUSION

This is the first systematic review and meta-analysis on the clinical outcomes of abdominal wall repair using biosynthetic mesh in contaminated-infected settings. The results show good results in patients at high risk of postoperative wound complications. The aim of this study is to add to the growing literature on biosynthetic mesh a picture of current literature evidence to help future researchers performing further studies on this topic.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Acute supralevator abscess: the little we know

INTRODUCTION

Acute supralevator abscess (SLA) is an uncommon and complicated form of anorectal sepsis. Its correct management is crucial to avoid complex iatrogenic fistula formation. A comprehensive review of the literature was conducted to determine the incidence of SLA and the surgical outcome with particular reference to the direction of drainage.

METHODS

A search of Medline, PubMed and the Cochrane Library was performed to identify all studies reporting surgical drainage of SLA.

FINDINGS

A total of 19 studies were identified, including 563 patients. The only two prospective studies reported an incidence of SLA of 10% and 3% in 68 and 100 patients, respectively, with anorectal sepsis. In 17 retrospective studies, the incidence ranged from 0% to 28%. Magnetic resonance imaging (MRI) was performed routinely in only one study. The surgical anatomical classification of the abscess was described in six studies diagnosed at surgery. The direction of surgical drainage whether 'inwards' (into the lumen) or 'outwards' (into the ischioanal fossa) was stated in only six studies. In two of these, the direction of drainage was contradictory to the recommendation made by Parks et al. Recurrent sepsis was reported in eight studies and ranged from 0% to 53%.

CONCLUSIONS

Detailed and prospective data on acute SLA are lacking. Its real incidence is unclear and it is not possible to analyse surgical outcomes conclusively according to different direction of drainage. The routine use of MRI in complicated anorectal sepsis would specify the surgical anatomy of SLA before any drainage is carried out.

Defining core patient descriptors for perforated peptic ulcer research: international Delphi

BACKGROUND

Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.

METHODS

Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.

RESULTS

Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.

CONCLUSION

This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

PROPHYlactic Implantation of BIOlogic Mesh in peritonitis (PROPHYBIOM): a prospective multicentric randomized controlled trial

BACKGROUND

Patients undergoing emergency surgery for peritonitis are at increased risk of abdominal wall-related complications. In patients with peritonitis, the risk of incisional hernia (IH) is extremely elevated. The evaluation of quality of life of patients with incisional hernia showed lower mean scores on physical components of health-related quality of life and body image. Furthermore, the arise of a post-operative abdominal wall complication (i.e., wound dehiscence, evisceration and IH) greatly increases morbidity and mortality rates and prolongs the hospitalization.

METHODS

The present study aims to evaluate the efficacy of the use of a swine dermal collagen prosthesis implanted preperitoneally as a prophylactic procedure in urgency/emergency setting against abdominal wall complications in patients operated with contaminated/infected field in peritonitis. The sample size was defined in 90 patients divided in two arms (prosthesis positioning versus normal wall abdominal closure). The follow-up will be performed at 3, 6, and 12 months after surgery. The percentage of incisional hernias, wound infections, and adverse events will be investigated by physical examination and ultrasound.

DISCUSSION

The objective is to evaluate the possibility to reduce the incisional hernia rate in patients undergoing urgent/emergent laparotomy in contaminated/infected field with peritonitis by using swine dermal collagen prosthesis preperitoneal positioning as a prophylactic procedure.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04681326. Registered (retrospectively after first patient recruited) on 23 December 2020.

Central neurocytoma of the fourth ventricle. Case history

Central neurocytomas are low-grade tumours of neuronal origin, affecting mainly young patients and usually located in the lateral or third ventricle. We report a rare case of central neurocytoma at the fourth ventricle level. Magnetic resonance imaging showed a homogeneously enhancing mass lesion at the fourth ventricle. Gross-total surgical removal was achieved. The histological diagnosis was of central neurocytoma but the lesion showed a fairly elevated Ki-67 index (6%). Given this finding, close neuroimaging monitoring was performed and at the moment the patient is free of recurrence.

Hemorrhagic unilateral moyamoya: report of one case

A 29 year old woman presented with an intracerebral hemorrhage. Angiographic findings were consistent with unilateral moyamoya. The patient was managed non-surgically and discharged with the indication of periodical followup angiography. Moyamoya is a rare entity that must be considered in the differential diagnosis of ischemic or hemorrhagic cerebrovascular events. At present, the natural history of unilateral moyamoya is not well established in relation to the progression to a bilateral form and to rebleeding risk. Periodical follow-up angiography (conventional or MRI) seems a reasonable management strategy.

Spinal epidural hematoma following coronary thrombolysis. A case report

A case of cervicothoracic spontaneous spinal epidural hematoma (SSEH) following coronary thrombolysis with r-TPA and intravenous heparin is reported. The clinical picture is discussed, as well as the importance of rapid neuroradiological diagnosis (with spinal MRI being the method of choice) and surgical treatment. Anyway, in these patients, thorough cardiac function evaluation and rapid correction of any clotting disorder is necessary prior to surgery. With the increasing use of fibrinolytic therapy this complication would be more frequent. This underlines the importance of prompt recognition and adequate treatment.

Growing-fracture of the orbital roof with post-traumatic encephalocele in an adult patient. Case report

Growing fractures are a rare entity, usually occurring in paediatric age. Localisation at the orbital region is even rarer. We report the case of a growing fracture of the orbital roof with post-traumatic encephalocele in an adult patient, the 1(st) similar case in adulthood at our knowledge. Clinical and neuroimaging aspects are described, underlining the role of MRI in displaying intraorbital encephalocele. Surgical treatment with relevant technical notes is discussed as well.

Integration of image transmission into a protocol for head injury management: a preliminary report

Neurosurgical care is limited in many parts of the world to one or two hospitals serving a large geographic area. The quality of neurosurgical response to emergencies depends on the reliability and completeness of the information received from referral hospitals. The aim of this study is to show how application of guidelines for head injury management in an entire area can be usefully combined with transmission of images from the peripheral to the central hospital. From January 1998 to December 2000, 1665 CT examinations were sent via image transfer to the Neurosurgical Unit; 637 first examinations (47%) and 206 second examinations (70%) were related to acute trauma cases. Out of 637 first examinations, 150 patients were actually transferred to the Neurosurgery Unit (23%), whereas of 206 second examinations, only 10 patients were secondarily transferred (5%). In the absence of the outcomes of patients located outside the Neurosurgical Unit, we studied in detail these 10 patients. They are, in fact, the only way for us to partially measure the impact of our system. Only in a single case could the death be attributed to a delay in transferring the patient. We then studied the factors influencing the decision of patient transfer. Mean GCS was 11 both for transferred and non transferred cases. The mean age of all patients was 52 years (median 48, SD 20.5 years); mean age of non-transferred patients was 54 years and for transferred patients it was 41 years (p < 0.01). The same statistically significant difference concerning age applied to any type of pathology sent via image link. In conclusion our data show that it is feasible to co-ordinate in an entire area the treatment of head injured patients. Available systems for CT images link are reliable and mostly useful. Unnecessary transfers can be avoided and the neurosurgeons can evaluate the images of a number of patients who have always been treated outside our Units. This results in more work for the neurosurgeons on duty, but also in a better quality service for the whole area. The lack of follow-up for patients not admitted to Neurosurgery is the limitation on a quality assessment of the system.

Biosynthesis and structural characterization of medium-chain-length poly(3-hydroxyalkanoates) produced by Pseudomonas aeruginosa from fatty acids

In this study, we investigated the ability of Pseudomonas aeruginosa ATCC 27853 to grow and synthesize poly(3-hydroxyalkanoates) (PHAs) from saturated fatty acids with an even number of carbon atoms, from eight to 22, and from oleic acid. In a non-limiting medium, all carbon sources but docosanoic acid supported cell growth and PHA production, with eicosanoic acid giving the highest yield. In magnesium-limiting conditions, higher yields were obtained from sources with up to 16 carbon atoms. Composition was estimated by gas chromatography of methanolyzed samples and (13)C nuclear magnetic resonance. The 3-hydroxyalkanoate units extended from hexanoate to tetradecanoate or tetradecenoate, with octanoate and decanoate as the predominant components. Weight average molecular weights ranged from 78,000 to 316,000. Fast atom bombardment mass spectrometry of partially pyrolyzed samples, coupled to statistical analysis, showed that these PHAs are random copolymers.

Characterization by mass spectrometry of poly(3-hydroxyalkanoates) produced by Rhodospirillum rubrum from 3-hydroxyacids

The sequence distributions of two microbial copolyesters obtained by fermentation of Rhodospirillum rubrum, grown with 3-hydroxyhexanoic or 3-hydroxyheptanoic acids, were determined by analyzing the oligomers prepared by partial pyrolysis or partial methanolysis of these copolyesters using fast atom bombardment mass spectrometry (FAB-MS). Oligomers up to pentamers were identified in the case of partial pyrolysis and up to tetradecamers in the case of partial methanolysis. The comparison between the experimental and calculated peak intensities of FAB mass spectra allows the calculation of compositions and sequence distributions, which in these copolyesters follow Bernoullian statistics, indicating that they are random terpolyesters.

[Role of calcium in the regulation of oxoglutarate oxidation in the rabbit's gastric mucosa]

The stimulation of oxyntic cell by gastric secretagogues is associated to the activation of oxidative metabolism. The mechanisms of this activation are not exactly known. In the present work, we investigated the possible direct effect of Ca2+ on both oxoglutarate oxidation in rabbit gastric glands and oxoglutarate dehydrogenase activity (OGDH) in isolated gastric mitochondria. Both carbachol and Ca2+ ionophores (A23187 and ionomycin) significantly stimulated oxoglutarate oxidation in a dose-dependent manner. This effect was only observed in the presence of low substrate concentrations. BAPTA-AM, an intracellular calcium chelator, significantly inhibited the rate of oxoglutarate oxidation. OGDH activity was stimulated by physiological concentrations of Ca2+ in a dose-dependent manner. This effect was reduced by ruthenium red, an inhibitor of mitochondrial Ca2+ uptake, and it was additionally increased by spermine, a stimulant of Ca2+ influx to the mitochondria. The results support the hypothesis that Ca2+ plays a direct role in the activation of oxidative metabolism in the oxyntic cell.

[Role of calcium in the regulation of oxoglutarate oxidation in the rabbit gastric mucosa]

The stimulation of the oxyntic cell by gastric secretagogues is associated to the activation of oxidative metabolism. The mechanisms of this activation are not exactly known. In the present work, we investigated the possible direct effect of Ca2+ on both oxoglutarate oxidation in rabbit gastric glands and oxoglutarate dehydrogenase activity (OGDH) is isolated gastric mitochondria. Both carbachol and Ca2+ ionophores (A23187 and ionomycin) significantly stimulated oxoglutarate oxidation in a dose-dependent manner. This effect was only observed in the presence of low substrate concentrations. BAPTA-AM, an intracellular calcium chelator, significantly inhibited the rate of oxoglutarate oxidation. OGDH activity was stimulated by physiological concentrations of Ca2+ in a dose-dependent manner. This effect was reduced by ruthenium red, an inhibitor of mitochondrial Ca2+ uptake, and it was additionally increased by spermine, a stimulant of Ca2+ influx to the mitochondria. The results support the hypothesis that Ca2+ plays a direct role in the activation of oxidative metabolism in the oxyntic cell.