Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Fibrin glue obliteration is safe, effective and minimally invasive as first line treatment for pilonidal sinus disease in children

BACKGROUND / PURPOSE

Sacrococcygeal pilonidal sinus disease (PSD) has an incidence of 1.2-2.5/1000 in children. Onset is around puberty. Symptoms of recurrent abscess and chronic suppuration may interfere with education and social integration. Treatments should cause minimal disruption while having good cure and recurrence rates. Curettage and Fibrin glue obliteration (FGO) show promising results in adults. We present our experience of its use in children.

METHODS

Review of all pediatric patients receiving FGO of pilonidal sinus performed by a single surgeon from September 2014 to February 2018.

RESULTS

Eighteen patients were identified. Median age was 16 (range 15-17), 55.6% were male. All procedures were completed as day cases. Median operative duration was 14 .1 (6-29) min. Twelve patients required only 1 procedure, 4 required 2 procedures, 1 required 5 procedures and 1 elected for formal excision after 2 FGO treatments. Median return to normal activities was 3 days, with 1 day school absence. Two patients developed minor surgical site infections. Median follow-up was 52 weeks (17-102), during which time there was 1 recurrence (5.6%).

CONCLUSION

This study demonstrates FGO is a safe, effective procedure for pediatric PNS, with results comparable to off-midline flap techniques and without the need for extensive tissue excision and the associated morbidity.

LEVEL OF EVIDENCE

IV.

Safe investigation of isolated change in bowel habit with a flexible sigmoidoscopy? A systematic review and meta-analysis

INTRODUCTION

Public awareness campaigns have led to increasing referrals of patients to colorectal surgery for possible cancer. Change in bowel habit, is traditionally described as a symptom of a left sided bowel cancer. If this is the case in practice, it raises the potentially attractive option of investigating such patients with flexible sigmoidoscopy only. This study sought to systematically review the literature describing tumour location of patients with bowel cancer presenting with left-sided symptoms to establish the safety of potential investigation of these patients with flexible sigmoidoscopy alone.

METHODS

A systematic review of studies reporting both the presenting symptoms of patients with bowel cancer and the location of their cancer in the bowel was prospectively registered (CRD42017072492). MEDLINE, EMBASE and CENTRAL were searched with no date or language restriction.

RESULTS

Seven studies were included. Isolated change in bowel habit (with or without rectal bleeding) was a presenting symptom of 73% (95% CI 41-96%, I2 = 99%) of left-sided cancers but also in 13% (95% CI 2-30%, I2 = 96%) of right-sided cancers. In all patients with cancer who presented with isolated change in bowel habit (with or without rectal bleeding), the cancer was right sided in 8% (95% CI 4-12%, I2 = 69%).

CONCLUSIONS

There is a higher than expected risk that if a cancer is diagnosed in a patient presenting with either an isolated change in bowel habit or a combination of change in bowel habit with rectal bleeding, the cancer may be right sided.