Long-term outcomes of Madrid approach after TAR for complex abdominal wall hernias: a single-center cohort study

PURPOSE

Undeniably, in the last 2 decades, surgical approaches in the field of abdominal wall repair have notably improved. However, the best approach to provide a durable repair with low morbidity rate has yet to be determined. The purpose of this study is to outline our long-term results following the Transverse Abdominis Release (TAR) approach in patients with complex ventral hernias, focusing on the incidence of recurrence and overall patient satisfaction following surgery.

METHODS

This is a retrospective study on 167 consecutive patients who underwent TAR between January 2015 and December 2021 for primary or recurrent complex abdominal hernias. Of these, 117 patients who underwent the open Madrid approach with the use of a double mesh (absorbable and permanent synthetic mesh) were selected and analyzed. A quality of life questionnaire (EuraHS QoL) comparing the preoperative and the postoperative status was administered.

RESULTS

Between January 2015 and December 2021, we successfully treated 117 patients presenting with complex ventral defects using the double mesh technique (absorbable and permanent synthetic mesh). Of these, 26 (22.2%) were recurrent cases. At a median follow-up period of 37.7 months, there had been 1 (0.8%) case of recurrence and 8 cases (6.8%) of bulging. The QoL score was significantly improved when compared to the preoperative status in terms of cosmesis, body perception, and physical discomfort.

CONCLUSIONS

The Madrid approach for posterior component separation is associated with both a low perioperative morbidity and recurrence rate. In accordance with other studies, we demonstrated that the TAR with reconstruction according to the Madrid approach provides excellent results in the treatment of complex abdominal wall hernias, even at long-term follow-up.

Robotic transabdominal retromuscular rectus diastasis (r-TARRD) repair: a new approach

PURPOSE

The aim of this study is to present our innovative robotic approach for the treatment of rectus diastasis with concurrent primary or incisional ventral hernias.

METHODS

We performed 45 r-TARRD repairs for symptomatic rectus diastasis with concomitant associated ventral/incisional umbilical and/or epigastric hernias between January 2019 and January 2020. Data on patient demographics, type of hernia, operative time, complications, recurrence rate, and hospital stay were retrospectively analyzed. Follow-up was scheduled at 1, 6 months, and 1 year after surgery.

RESULTS

45 patients (13 M, 32 F) underwent r-TARRD repair. Mean age was 54.8 years (range 31-68) and mean BMI was 26.74 kg/m² (range 21.1-31). Mean ASA was 2.2 (range 1-3). In all patients we used a polypropylene mesh 25 × 15 cm, properly shaped. Mean operative time was 192 min (range 115-260). Mean hospital stay 4.2 days (range 2-7). No conversion to laparoscopy or open surgery and no major complications occurred. At 1-month follow-up one mesh infection (2.22%) was observed and it was treated conservatively. Four recurrences (8.88%) were reported at 1-year follow-up.

CONCLUSIONS

Robot-assisted TARRD repair is conceived as a novel alternative minimally invasive procedure for RD with concurrent midline defects ensuring a primary fascial defect closure and mesh implantation in a sublay position with a wide overlap. It is important to better evaluate the suture that should be used to perform the repair, and multicenter studies with standardization of patient's demographics, RD characteristics, and long-term follow-up outcomes are mandatory to assess the effectiveness and durability of r-TARDD repair.

The use of biosynthetic mesh in giant hiatal hernia repair: is there a rationale? A 3-year single-center experience

PURPOSE

Reinforced prosthetic crural repair is particularly indicated for giant hiatal hernias. The rationale is to reduce the recurrence rate in the long term. The aim of our study is to evaluate the outcomes of laparoscopic giant hiatal hernia repair using a biosynthetic mesh.

METHODS

We retrospectively analyzed 44 patients who underwent laparoscopic mesh-reinforced hiatal closure and fundoplication using a biosynthetic material. Inclusion criterion was large hiatal defects (> 5 cm). Follow-up was scheduled at 6, 12 and 36 months after surgery.

RESULTS

44 patients (29F) with a mean age of 62 years (range 14-85) and mean of BMI 24.5 kg/m² (range 21-29) underwent successful laparoscopic repair. Twenty-six (59.1%) patients had Nissen-Rossetti fundoplication, whereas 18 (40.9%) had Toupet fundoplication. Six-month questionnaire for the evaluation of symptoms was available for 43 patients (97.7%) and for 40 (90.9%) patients at 12 and 36 months. Mean preoperative symptoms score analysis was 1.68 ± 0.73. Mean scores at each follow-up time were significantly improved compared to baseline (p > 0.05). Barium swallow was available in 37 patients (84.1%) at 1 year after surgery. Radiologic recurrence was observed in two patients (4.5%). No patient had symptoms attributable to recurrence or required revisional surgery. There were no mesh-related complications at 3 years follow-up.

CONCLUSIONS

The use of biosynthetic mesh for crural reinforcement is associated with a low incidence of mesh-related complications and with a reasonably low recurrence rate (4.5%) at 36 months. However, additional data with longer follow-up are needed to determine long-term safety and efficacy.

Correction to: Occult HBV infection in the oncohematological setting

The original version of this article unfortunately contained a mistake.

In vivo evidence that the cannabinoid receptor 2-63 RR variant is associated with the acquisition and/or expansion of HIV infection

OBJECTIVES

The aim of the study was to investigate whether the rs35761398 variants of the cannabinoid receptor 2 (CB2) gene may influence the acquisition of HIV infection and the clinical presentation of HIV/hepatitis C virus (HCV) coinfection.

METHODS

We compared 166 HIV/HCV-coinfected patients with 186 HCV-monoinfected patients, all with biopsy-proven chronic hepatitis (using the Ishak scoring system), naïve for anti-HCV treatment and tested for the CB2 rs35761398 polymorphism (using the TaqMan assay).

RESULTS

The HIV/HCV-coinfected patients were more frequently male (P < 0.002), were younger (P < 0.001), and had lower median BMI (P < 0.001) and HCV RNA (P < 0.05) and higher median aspartate aminotransferase (AST; P < 0.001), alanine aminotransferase (ALT; P < 0.001) and gamma glutamyl transferase (GGT; P < 0.001) levels than the HCV-monoinfected patients. The CB2 RR variant predominated in HIV/HCV-coinfected patients (45.8% vs. 31.2% in HCV-monoinfected patients; P < 0.001) and the CB2 QR variant in HCV-monoinfected patients (57.5% vs. 38.6% in HIV/HCV-coinfected patients; P < 0.00001), and the CB2 QQ variant was equally distributed. Focusing on patients with the CB2 QQ variant, the 26 HIV/HCV-coinfected patients, compared with the 21 HCV-monoinfected patients, showed less severe liver necroinflammation [lower histological activity index (HAI)] (P < 0.05). Of the patients with the CB2 RR variant, the 76 HIV/HCV-coinfected patients, compared with the 58 HCV-monoinfected patients, were more frequently male (P < 0.05), were younger (P < 0.001), and had a lower median body mass index (BMI; P < 0.001), a higher median AST level (P < 0.001), a higher mean HAI score (P < 0.05) and a higher rate of cases with severe steatosis (P = 0.05). In an analysis of variance (anova) of HCV/HIV-coinfected and HCV-monoinfected patient data, those with the CB2 RR variant (P = 0.003) and of male sex (P = 0.002) were more prevalent in the HCV/HIV-coinfected group.

CONCLUSIONS

There is the suggestion of a positive effect of the CB2 RR variant on HIV acquisition and/or spread, which is in accordance with previous in vitro observations.

Occult HBV infection in the oncohematological setting

INTRODUCTION

Occult hepatitis B infection (OBI), a virological condition characterized by a low release of Hepatitis B Virus (HBV) from liver cells and low HBV-DNA levels in serum and/or liver tissue of HBsAg-negative subjects, may reactivate in oncohematological patients undergoing immunosuppression by aggressive chemotherapy or hematopoietic stem cell transplantation. The entity of OBI reactivation varies from an increase in HBV replication without liver damage to an active HBV replication followed by liver cell necrosis, frequently severe and in some cases life threatening. Because of a possible severe outcome associated with OBI reactivation (hepatic failure or death due to the discontinuation of chemotherapy), prophylaxis with anti-HBV nucleot(s)ide analogues is recommended in relation to the foreseeable degree of immunosuppression.

MATERIALS AND METHODS

This review article focuses on the clinical impact of OBI in the oncohematological setting and is addressed to all health care workers having in care oncohematological patients or involved in the treatment of HBV infection and OBI prophylaxis.

CONCLUSION

International guidelines have indicated lamivudine prophylaxis in hematopoietic stem cell transplantation and when high-dose corticosteroids or anti-CD20 or anti-CD52 monoclonal antibodies are used. Entecavir or tenofovir should replace lamivudine for patients with advanced liver diseases for whom reactivation of OBI may be life threatening. When anti-CD20 or anti-CD52 sparing schedules or other non-aggressive chemotherapies are used, monitoring may be indicated, but very early treatment with highly effective antiviral drugs (entecavir or tenofovir) should be administered once a reactivation of OBI has occurred.

Impact of PNPLA3 variants on liver histology of 168 patients with HIV infection and chronic hepatitis C

This study analysed the impact of PNPLA3 variants on liver histology of 168 HIV/hepatitis C virus (HCV)-coinfected patients who were naïve for HCV treatment. A athologist unaware of the patients' condition graded liver fibrosis and necroinflammation (Ishak) and steatosis (Kleiner). Patients were tested for PNPLA3 variants and genotyped for the PNPLA3 rs738409 C to G variant underlying the I148M substitution. All were hepatitis B surface antigen negative and stated no alcohol abuse. The mean age was 40.6 (37.6-44.1) years, 72.6% were males, 42% had HCV genotype 3, 38.9% HCV genotype 1 and 79.2% were receiving highly active antiretroviral therapy. The 79 patients with the PNPLA3 p.148I/M or M/M variants more frequently showed severe steatosis (score 3-4) than the 89 with PNPLA3 p.148I/I (43% vs. 24.7%, p 0.001), whereas no difference was observed in the degree of necroinflammation or fibrosis. Compared with 112 patients with lower scores, 56 with severe steatosis showed higher body mass index (p 0.03), higher rate of HCV genotype 3 (55.6% vs. 35.2%, p 0.01), PNPLA3 p.148I/M or M/M (60.7% vs. 39.3%, p 0.01) and lower CD4(+) cells/mm(3) (514.00 (390.5-673.0) vs. 500.00 (399.0-627.0); p 0.002). At multivariate analysis, body mass index (p 0.01), HCV genotype 3 (p 0.006), CD4(+) cell count (p 0.005) and PNPLA3 p.148I/M or M/M variants (p 0.01) were found to be independent predictors of severe liver steatosis. The PNPLA3 p.148 I/M or M/M variants and CD4(+) cell count were the only independent predictors of severe steatosis in patients with HCV non-3 genotypes. This is the first study to show that among HIV/HCV-coinfected patients the PNPLA3 p.148I/M or M/M variant have substantially less impact on steatosis for those with HCV genotype 3 than non-genotype 3.

Clinical and virological characteristics associated with severe acute hepatitis B

To identify early predictors of a severe or fulminant course in patients with acute viral hepatitis B (AVH-B). One hundred and thirty-eight patients with symptomatic acute hepatitis B observed from 1999 to 2012 were enrolled. For each patient, the demographics, risk factors for the acquisition of hepatitis B virus (HBV) infection, clinical, biochemical and virological data (HBV DNA, HBV DNA sequences) were recorded and analysed. The HBV mutants in the polymerase region were sought in 110 (87%) patients by direct sequencing, and the rtM204V/I mutations also by an allele-specific PCR. AVH-B was severe in 13 (9.4%) of the 138 patients enrolled, fulminant in 6 (4.3%) and with a normal clinical course in 119. The 19 patients with severe or fulminant AVH-B more frequently than the 119 with a normal course stated intravenous drug use (63.2% versus 36.1%, p 0.04) and were HBV-DNA negative (31.6% versus 11.8%, p 0.03) and anti-hepatitis C virus (HCV) positive (57.9% versus 19.3%, p 0.0008); the prevalences of different HBV genotypes and of the rtM204V/I mutant were similar in these three forms of AVH-B. A multivariate logistic regression analysis identified a pre-existing HCV chronic infection as the only factor independently associated with a severe or fulminant clinical course of AVH-B (OR 4.89, 95% CI 1.5-15.94, p 0.01). A pre-existing HCV chronic infection was identified as the only factor independently associated with a severe clinical presentation of acute hepatitis B, an association most probably due to the combination of the liver lesions caused by acute hepatitis B and the pre-existing histological abnormalities related to HCV chronic infection.

Factors influencing liver fibrosis and necroinflammation in HIV/HCV coinfection and HCV monoinfection

OBJECTIVES

To define differences in liver histology between HIV/HCV coinfection and HCV monoinfection, and to investigate possible causative factors.

METHODS

Liver biopsies (LBs) from 440 consecutive HIV/HCV-coinfected patients (Group HIV/HCV) and 374 consecutive HCV-monoinfected patients (Group HCV) were evaluated for necroinflammation and fibrosis (Ishak) by a pathologist unaware of the clinical and laboratory data. All patients were HBsAg-negative, with no history of alcohol abuse and naïve to anti-HCV treatment. At LB, 78.4% of patients in Group HIV/HCV were on an antiretroviral regimen.

RESULTS

HIV/HCV-coinfected patients compared to the HCV-monoinfected patients were younger (p < 0.0001), more frequently males (p < 0.0001), and had HCV genotype 3 (p < 0.0001); they showed a good immunological condition (CD4+ cell count: 518 ± 166 cells/mm(3)). Patients in Group HIV/HCV more frequently showed a fibrosis score ≥4 (27.5 vs. 20.6%, p < 0.05) and a necroinflammation score ≥9 (25.9 vs. 13.4%; p < 0.0001). The prevalence of patients with fibrosis score ≥4 was significantly higher in older age classes in both Group HIV/HCV (p < 0.005) and Group HCV (p < 0.05). A necroinflammation score ≥9 was significantly higher in older age classes only in Group HIV/HCV (p < 0.05). A multivariate analysis for Group HIV/HCV revealed that the patient age and nadir of CD4+ cell count were independently associated to higher degrees of fibrosis, the patient age and antiretroviral treatment were associated to higher degrees of necroinflammation, and HCV genotype 3 was associated to higher degrees of steatosis.

CONCLUSION

The data suggest a need for early anti-HCV treatment in both HCV-monoinfected and HIV/HCV-coinfected patients.

Blood born viral infections, sexually transmitted diseases and latent tuberculosis in italian prisons: a preliminary report of a large multicenter study

BACKGROUND

Recent screenings of inmates for Hepatitis C virus (HCV), Hepatitis B virus (HBV), human immunodeficiency virus (HIV), Syphilis and Latent Tuberculosis (LTB) did not provide sufficient information to improve healthcare strategies.

AIM

To obtain valuable information on the endemicity of the above mentioned Infections in prisons of Italy.

MATERIALS AND METHODS

A screening based on a peer-to-peer communication, followed by a month of blood sampling on a voluntary basis was performed to detect antibody to 4 of the 5 above mentioned infections and detect LTB by PPD (purified protein derivative) Skin Test. The present analysis regards data obtained in 9 of the 20 prisons.

RESULTS

The percentage of patients who accepted the screening varied between jails (37.3-95.2%, median 62.2), but it was higher than 10.0-20.5% obtained in the same 9 prisons using traditional methods before our intervention. The participation to the screening reached 65.3% for HBV, 64.6% for HCV, 67.4%for HIV, 55.7% for TPHA (Treponema Pallidum Hemagglutination Assay) and 42.8% for LTB. HBsAg was detected in 4.4% of 2265 subjects, anti-HCV in 22.8% of 2241, anti-HIV in 3.8% of 2339 and TPHA in 2.1% of 1932; PPD Skin Test was positive in 17.2% of 1486 subjects. The screening identified 183 subjects with an unknown infection, 56 italian and 127 foreigners to be evaluated for clinical decisions: 35 with HBV chronic infection, 34 with HCV chronic infection, 3 anti-HIV positive, 14 with syphilis and 97 with LTB.

CONCLUSIONS

The new approach to the screening, based on a peer-to-peer communication followed by blood sampling on a voluntary basis provided valuable information to improve the healthcare system in each single prison.

Tolerability and efficacy of anti-HBV nucleos(t)ide analogues in HBV-DNA-positive cirrhotic patients with HBV/HCV dual infection

We evaluated tolerability and virological and clinical impact of anti-Hepatitis B Virus (HBV) nucleos(t)ide analogues in cirrhotic patients with HBV/Hepatitis C Virus (HCV) coinfection. The virological and clinical course of 24 consecutive HBsAg/HBV-DNA/anti-HCV-positive patients with cirrhosis was compared with that of 24 HBsAg/HBV-DNA-positive, anti-HCV-negative cirrhotic patients, pair-matched for age (±5 years), sex, HBeAg/anti-HBe status and Child-Pugh class. Patients in both groups were previously untreated with oral antiviral agents at enrollment and were treated for at least 24 months (range 24-54). At the 12th and 18th month of treatment, HBV-DNA was negative in 21 (87.5%) and 23 (95.8%) patients with hepatitis B and C and in 20 (83.3%) and 22 (91.6%) in patients with isolated HBV; all patients in both groups were HBV-DNA-negative at month 24 and at subsequent observations. Treatment was well tolerated by all patients in both groups. At the last observation (for co-infected patients, median 44 months and range 24-54; for mono-infected patients, median 40 months and range 24-54), a deterioration in Child class was observed in eight (47%) of 17 patients in patients with both HBV and HCV who were HCV-RNA-positive at baseline, but in none of seven HCV-RNA-negative patients in the same group, and in one patient (4.2%) in the mono-infected patients. Reactivation of HCV infection was relatively infrequent (12.5% of cases) and never associated with a clinical deterioration. Treatment with nucleotides in HBsAg/HBV-DNA/anti-HCV-positive patients with cirrhosis showed a favourable virological effect in all cases, but a favourable clinical result only in the HCV-RNA-negative at baseline.

Factors affecting the changes in molecular epidemiology of acute hepatitis B in a Southern Italian area

To explore changes in molecular epidemiology of acute viral hepatitis B (AVH-B), hepatitis B virus (HBV) genotypes were determined by direct sequencing of the Pre-S-S region in 123 consecutive patients, with AVH-B observed in Naples or its surroundings in the last decade (group AVH-B) and in 123 HBV chronic carriers [chronic carrier of HBV (CC-B) group] from the same areas, who had been hepatitis B surface antigen-positive for more than 10 years. Genotype D was less frequently detected in patients with AVH-B than in those in the CC-B group (76.4%vs 97.5%, P < 0.0001). In the AVH-B group, intravenous drug addiction (IVDA) was the prevalent risk factor (55.3%) for acquiring HBV in the 94 patients with HBV genotype D, but it was rarely recorded (6.9%) in the 29 patients with genotypes non-D (P < 0.0001); unsafe sexual intercourse was prevalent in patients with genotype non-D (72.3%) and less frequent in those with genotype D (28.8%, P < 0.005). In the AVH-B group, the prevalence of non-D genotypes increased during the observation period from 11.1% in 1999-2003 to 41.1% in 2004-2008 (P < 0.0005), paralleling the increase in the prevalence of patients with unsafe sexual intercourse; similarly, the progressive decrease in IVDA paralleled the decrease in the prevalence of genotype D (from 88.3% in 1999-2003 to 11.7% in 2004-2008). The prevalence of HBV non-D genotypes recorded in the last 10 years in AVH-B in this area shows a progressive increase, most probably because of recent changes in HBV epidemiology, namely, the HBV mass vaccination campaign and increased immigration from areas with high HBV endemicity.

Virological and epitope evolution of HCV infection from acute hepatitis C to subsequent episodes of HCV-related acute liver cell necrosis

AIM

To evaluate the virological and clinical events occurring during a 3-year follow-up in three patients who, after symptomatic acute hepatitis C (AHC), experienced subsequent episodes of HC virus (V)-related acute liver cell necrosis.

PATIENTS AND METHODS

The three patients were investigated for viral variability in the core, E1/E2, and NS5b regions during different phases of infection, and a computer-assisted analysis of the variation of known predicted epitopes in the consensus sequence was performed.

RESULTS

The first patient showed numerous genetic variations, which may be related to the maintenance of a chronic HCV infection state and to episodes of liver disease exacerbation. The second patient showed minimal viral variations associated with apparent resolution of the infection, but the same virus isolate, based on phylogenetic analysis, produced a second acute episode after the occult phase. The third patient, after the resolution of AHC, manifested a second episode of HCV infection by a different HCV sub-genotype.

CONCLUSION

Episodes of HCV-related acute liver cell necrosis after AHC may be associated to different virological patterns, such as the establishment of a chronic HCV infection, a reactivation of an occult virus, or a reinfection by a different HCV genotype.

Useful parameters helping proctologists to identify patients with defaecatory disorders that may be treated with pelvic floor rehabilitation

BACKGROUND

No studies have specifically reported on the use of a diagnostic tool based on physiatric assessment of constipated or incontinent patients

METHODS

Sixty-seven constipated and 37 incontinent patients were submitted to a standard protocol based on proctologic examination, clinico-physiatric assessment (puborectalis contraction, pubococcygeal test, perineal defence reflex, muscular synergies, postural examination) and instrumental evaluation (anorectal manometry, anal US and dynamic defaecography). Patients were offered pelvic floor rehabilitation (thoraco-abdominoperineal muscle coordination training, biofeedback, electrical stimulation and volumetric rehabilitation).

RESULTS

After rehabilitation treatment, decreases of Wexner constipation score (p=0.0001) and Pescatori incontinence score (p=0.0001) were observed.

CONCLUSION

This diagnostic protocol might improve the selection of patients with defaecatory disorders amenable for rehabilitation treatment.

[The Nissen-Rossetti fundoplication: outcomes and lessons learned in 35 years experience with the same procedure]

AIM

The total fundoplication achieves most effective long-term control of gastro-esophageal reflux disease (GERD). However, the different types of total fundoplication lead to heterogeneous outcomes. In 1972, we standardized a personally modified Nissen-Rossetti which includes the routine use of intraoperative manometry and endoscopy to calibrate and check the wrap. This paper aims to describe the technical details and the outcomes of this procedure adopted since 35 years without modifications as a unique procedure to treat all patients with GERD.

METHODS

The study population consisted of all patients affected by GERD who underwent laparoscopic Nissen-Rossetti fundoplication by a single surgeon with one year minimum of follow-up. Technical details of the procedure and data from clinical and instrumental follow-up are described.

RESULTS

Clinical follow-up (median 83 months; range 1-13 years) was achieved in 96% of the patients. Ninety-two percent of the patients were satisfied of the procedure and would undergo the same operation. At 12 months, lower esophageal sphincter pressure increased to 27+/-5 mmHg (P<0.05), 24-h monitoring became negative in 91.6% of the patients (P<0.05). DeMeester score was 4.1+/-0.7 (P <0.05).

CONCLUSIONS

The laparoscopic Nissen-Rossetti fundoplication with the routine use of the intraoperative manometry and endoscopy, adopted as a unique procedure to treat all the patients with GERD, achieved long-term patient satisfaction in the great majority of the cases. Meticulous preoperative investigation together with a correct surgical technique are needed in securing these results.

Diagnosis of HCV related acute hepatitis by serial determination of IgM to HCV: a preliminary observation

OBJECTIVE

To verify whether serial determination of titre of IgM to HCV core protein (HCV IgM) may be useful to distinguish acute hepatitis C (AHC) from reactivation of chronic hepatitis C (r-CHC), we studied 18 consecutive patients with AHC (identified by seroconversion to anti-HCV) and 15 consecutive patients who had been anti-HCV positive for at least one year at the time of reactivation.

METHODS

Samples of serum were obtained from all patients on hospitalisation and every 5 days during the follow-up and stored at -80 degrees C: 54 samples of serum for the AHC group and 41 for the r-CHC group. Titres of HCV IgM were calculated as Index values by a commercially available enzyme immunoassay (HCV-IgM EIA 2.0, Abbott Laboratories, North Chicago, IL, USA).

RESULTS

No difference was observed between the two groups of patients as regards age, sex, risk factors for the acquisition of HCV infection, clinical and biochemical data on presentation, prevalence of cases with detectable viremia or distribution of HCV genotypes. HCV IgM was detected with an Index value of 350 or more in only 1 (6.7%) in the r-CHC group and in 17 (94.4%) in the AHC group (p<0.01). Moreover, during the early phase of the illness we observed a wide variation in the HCV IgM Index values in AHC and consistent values in r-CHC.

CONCLUSIONS

Our data indicate that AHC is characterised by high and variable titres of HCV IgM during the acute phase of the illness, which may be considered diagnostic, whereas in r-CHC the IgM titre remains stable and rarely reaches a high level.