Development of incisional herniation after midline laparotomy

Background: Incisional herniation is a common complication after abdominal surgery associated with considerable morbidity. The aim of this study was to determine whether incisional hernia is an early complication, in order to understand better the aetiology of incisional hernia formation. Methods: This study involved the secondary analysis of a subset of patients included in a large RCT comparing small and large tissue bites (5 mm every 5 mm, or 1 cm every 1 cm) in patients scheduled to undergo elective abdominal surgery by midline laparotomy. The distance between the rectus abdominis muscles (RAM distance) was measured by standardized ultrasound imaging 1month and 1year after surgery. The relationship between the 1-year incidence of incisional hernia and the RAM distance at 1 month was investigated. Results: Some 219 patients were investigated, 113 in the small-bites and 106 in the large-bites group. At 1 month after surgery the RAM distance was smaller for small bites than for large bites (mean(s.d.) 1⋅90(1⋅18) versus 2⋅39(1⋅34)cm respectively; P=0⋅005). At 1year, patients with incisional hernia had a longer RAM distance at 1month than those with no incisional hernia (mean(s.d.) 2⋅43(1⋅48) versus 2⋅03(1⋅19) cm respectively; relative risk 1⋅14, 95 per cent c.i. 1⋅03 to 1⋅26, P = 0⋅015). Conclusion: A RAM distance greater than 2 cm at 1 month after midline laparotomy is associated with incisional hernia. Closure with small bites results in a smaller distance between the muscles

Advanced glycation end products as a biomarker for incisional hernia

Background: Incisional hernia is one of the most frequent complications after abdominal surgery, with incidences up to 30%. A reliable biomarker for the prediction of this complication is lacking. Advanced glycosylation end products (AGEs), also known as non-enzymatic collagen crosslinks, are correlated with aging, smoking, hyperglycemia, hyperlipidemia and oxidative stress. In this study the accumulation of AGEs and the relation between AGEs and incisional hernia were investigated. Materials and methods: In an explorato

Effects of new anti-adhesion polyvinyl alcohol gel on healing of colon anastomoses in rats

Background: Adhesions follow abdominal surgery with an incidence as high as 95%, resulting in invalidating complications such as bowel obstruction, female infertility, and chronic pain. Searches have been performed for a safe and effective adhesion barrier; however, such barriers have impaired anastomotic site healing. The primary aim of this study was to investigate the effect of a new adhesion barrier, polyvinyl alcohol gel, on healing of colonic anastomoses using a rat model. Methods: Thirty-two Wistar rats were divided in two groups. In all animals, an anastomosis was constructed in the ascending colon. The first group received no adhesion barrier, whereas in the second group, 2mL of polyvinyl alcohol gel (A-Part Gel®; Aesculap AG, Tuttlingen, Germany) was applied circularly around the anastomosis. All animals were sacrificed on the seventh post-operative day, and the abdomen was inspected for signs of anastomotic leakage. The anastomotic bursting pressure, the adhesions around the anastomosis, and the collagen content of the excised anastomosis were measured. Results: No significant differences were observed between the two groups in the incidence of anastomotic leakage, the anastomotic bursting pressure (p=0.08), or the collagen concentration (p=0.91). No significant reduction in amount of adhesions was observed in the rats receiving polyvinyl alcohol gel. Conclusions: This experimental study showed no significant differences in anastomotic leakage, anastomotic bursting pressure, or collagen content of the anastomosis when using the adhesion barrier polyvinyl alcohol around colonic anastomoses. The barrier did not prevent adhesion formation

A multicenter randomized controlled trial evaluating the effect of small stitches on the incidence of incisional hernia in midline incisions

Contains fulltext : 95575.pdf (publisher's version ) (Open Access)BACKGROUND: The median laparotomy is frequently used by abdominal surgeons to gain rapid and wide access to the abdominal cavity with minimal damage to nerves, vascular structures and muscles of the abdominal wall. However, incisional hernia remains the most common complication after median laparotomy, with reported incidences varying between 2-20%. Recent clinical and experimental data showed a continuous suture technique with many small tissue bites in the aponeurosis only, is possibly more effective in the prevention of incisional hernia when compared to the common used large bite technique or mass closure. METHODS/DESIGN: The STITCH trial is a double-blinded multicenter randomized controlled trial designed to compare a standardized large bite technique with a standardized small bites technique. The main objective is to compare both suture techniques for incidence of incisional hernia after one year. Secondary outcomes will include postoperative complications, direct costs, indirect costs and quality of life. A total of 576 patients will be randomized between a standardized small bites or large bites technique. At least 10 departments of general surgery and two departments of oncological gynaecology will participate in this trial. Both techniques have a standardized amount of stitches per cm wound length and suture length wound length ratio's are calculated in each patient. Follow up will be at 1 month for wound infection and 1 year for incisional hernia. Ultrasound examinations will be performed at both time points to measure the distance between the rectus muscles (at 3 points) and to objectify presence or absence of incisional hernia. Patients, investigators and radiologists will be blinded during follow up, although the surgeon can not be blinded during the surgical procedure. CONCLUSION: The STITCH trial will provide level 1b evidence to support the preference for either a continuous suture technique with many small tissue bites in the aponeurosis only or for the commonly used large bites technique

Blood Transfusions and Prognosis in Colorectal Cancer Long-Term Results of a Randomized Controlled Trial

Objective: Perioperative blood transfusions may adversely affect survival in patients with colorectal malignancy, although definite proof of a causal relationship has never been reported. Background: We report the long-term outcomes of a randomized controlled trial performed between 1986 and 1991 to compare the effects of allogeneic blood transfusions and an autologous blood transfusion program in colorectal cancer patients. Methods: All 475 randomized patients operated upon for colorectal cancer were tracked via a national computerized record-linkage system to investigate survival and cause of death. Kaplan-Meier survival curves were constructed and multivariate Cox regression analysis was performed to study 20 years' overall survival. Colorectal cancer-specific survival was analyzed over the 10-year time period after surgery. Results: The overall survival percentage at 20 years after surgery was worse in the autologous group (21%) compared to the allogeneic group (28%) (P = 0.041; log-rank test). Cox regression, allowing for tumor stage, age, and sex, resulted in a hazard ratio (autologous vs allogeneic group) for overall mortality of 1.24 (95% confidence interval 1.00-1.54; P = 0.051). Colorectal cancer-specific survival at 10 years for the whole study group was 48% and 60% for the autologous and allogeneic group, r Conclusions: At long-term follow-up colorectal cancer patients did not benefit from autologous transfusion compared with standard allogeneic transfusion. On the contrary, the overall and colorectal cancer-specific survival rates were worse in the patients in the autologous transfusion group

Iron therapy as treatment of anemia: A potentially detrimental and hazardous strategy in colorectal cancer patients

textabstractIn colorectal cancer patients, iron therapy, and especially intravenous iron therapy, is increasingly used to treat anemia and reduce the use of blood transfusions. However, iron has also been shown to be an essential nutrient for rapidly proliferating tissues and cells. In this respect, anemia of inflammation, characterized by limited duodenal iron uptake and sequestration of iron into the reticuloendothelial system, might be regarded as a potentially effective defense strategy of the human body against tumor growth. We therefore hypothesize that iron therapy, by supporting colorectal tumor growth and increasing the metastatic potential, may worsen tumor prognosis in colorectal cancer patients. This hypothesis is particularly supported for colorectal cancer by laboratory, epidemiological and animal studies, demonstrating the role of iron in all aspects of tumor development growth. Compared to non-malignant colon cells, tumor cells differ in the levels and activity of many iron import and export proteins, resulting in an increase in intracellular iron level and enhanced proliferation. In addition, it is demonstrated that iron is able to amplify Wnt signaling in tumors with Apc mutation, a critical mutation in the development of colorectal cancer. If our hypothesis is to be confirmed, current practice of iron administration, as treatment for anemia and as replacement of blood transfusions, can be hazardous and should be completely reconsidered