Prevention and surgical treatment of parastomal hernias

Abstract Parastomal hernia (PSH) is not merely a complication but rather an inevitable consequence of a stoma, occurring in up to 50% of ostomies. However, the surgical treatment for PSH has high complication and recurrence rates. Prophylactic mesh placement at the index surgery has been used to reduce the incidence of PSH, but despite its promising early results, the significance of PSH prevention has been questioned. The aim of this thesis was to discover the long-term results of PSH prevention and the nationwide results of surgical treatment for PSH. Additionally, the thesis explored whether emergency surgery for diverticulitis is a significant risk factor for PSH. Study I investigated the long-term efficiency and safety of the intra-abdominal keyhole technique for preventing PSH after laparoscopic abdominoperineal resection (APR) for rectal adenocarcinoma. Although the mesh lowered the PSH repair rate and the risk of stomal prolapse, the technique failed to decrease PSH incidence during long-term follow-up. Studies II and III reported nationwide retrospective registry data for end ostomy (Study II) and ileal conduit (Study III) PSH repairs performed in nine Finnish hospitals. The results were poor, with high recurrence, complication, and reoperation rates, and the keyhole technique was associated with a significant risk of recurrence. Therefore, this technique should not be used for PSH repair. Study IV was a systematic review of parastomal and incisional hernia incidences after emergency surgery for Hinchey III–IV diverticulitis. The review revealed that hernia incidences have been widely ignored in the literature. To conclude, the results of both the prevention and surgical treatment of PSH were unsatisfactory. Therefore, future studies should find better solutions and new techniques to prevent and treat PSH. Further studies on emergency surgery for diverticulitis should pay attention to hernia incidence and its prevention.Tiivistelmä Avannetyrä on lähes väistämätön paksusuolen pääteavanteen seuraus. Koska avannetyrän leikkaushoitoon liittyy paljon sekä tyrän uusiutumisia että komplikaatioita, avannetyrä on pyritty välttämään ennalta ehkäisevillä verkoilla. Vaikka ensimmäiset tulokset ennalta ehkäisevistä verkoista ovat olleet lupaavia, niiden hyöty on sit-temmin kyseenalaistettu. Väitöskirjan tarkoituksina oli selvittää avannetyrän ennalta ehkäisyn ja korjauksen tuloksia Suomessa. Lisäksi selvitimme, onko paksusuolen umpipussitaudin päivystysleikkaus erityinen riskitekijä avannetyrän muodostumiselle. Osatyössä I julkaisimme avannetyriä ennalta ehkäisevän verkon pitkäaikaistulokset. Tutkimuspotilaat leikattiin tähystystekniikalla peräsuolisyövän vuoksi 2010–2013. Vaikka verkon todettiin ehkäisevän sekä avanteen pullistumista että myöhempää leikkaushoidon tarvetta avannetyrän vuoksi, verkko ei ehkäissyt avannetyrien ilmaantumista pitkän aikavälin seurannassa. Osatöissä II ja III julkaisimme yhdeksästä sairaalasta kootun rekisteriaineiston tulokset pääteavanteiden (osatyö II) ja ohutsuolen virtsa-avanteiden (osatyö III) avannetyrien leikkaushoidosta. Tulokset ovat huonoja, ja avannetyrän leikkaus johtaa usein avannetyrän uusiutumiseen, leikkauskomplikaatioihin ja uusintaleikkauksiin. Usein käytetyn niin kutsutun keyhole-tekniikan tulokset olivat erityisen huonoja, eikä sitä tulisi käyttää enää avannetyrän leikkaushoidossa. Osatyössä IV selvitettiin paksusuolen umpipussitaudin vuoksi päivystysleikkaukseen joutuvien avanne- ja arpityräriskiä systemaattisessa kirjallisuuskatsauksessa. Tutkimus paljasti, että avannetyrien toteamista ei ole aikaisemmissa tutkimuksissa huomioitu riittävästi. Koska sekä avannetyrän ennalta ehkäisyn ja hoidon tuloksissa on parantamisen varaa, lisätutkimusta tarvitaan erityisesti parempien tekniikoiden kehittämiseksi. Paksusuolen umpipussitautitutkimuksen tulee jatkossa huomioida myös avannetyräriski ja avannetyrän ennalta ehkäisy

Vatsaontelon sulkeminen:miten ehkäisen arpityrän?

Tiivistelmä Suomessa leikataan vuosittain noin 1 650 arpityrää. Euroopan Tyräyhdistys (European Hernia Society, EHS) julkaisi vuonna 2015 laajaan kirjallisuuskatsaukseen pohjautuvan suosituksen vatsaontelon sulusta arpityrien välttämiseksi. Sen mukaan arpityrän ehkäisyssä on oleellista sulkea laparotomiahaava käyttämällä hitaasti sulavaa monofilamenttilankaa vähintään neljä kertaa haavan mitan verran. Lisäksi jos potilaan arpityräriski on suuri, vatsaontelon sulun yhteydessä ulompaan lihaskalvoon tai lihaksen alle kiinnitettävät verkot saattavat vähentää myöhempiä arpityriä. Verkoista näyttävät eniten hyötyvän potilaat, joiden arpityräriski on erityisen suuri joko tietyntyyppisen leikkauksen tai perussairauden takia. Tutkimustieto tyriä ehkäisevien verkkojen hyödyistä ja turvallisuudesta on vielä niukkaa, mutta käyttökokemusten ja tutkimustulosten karttuessa verkkojen käyttö saattaa yleistyä.Abstract European Hernia Society (EHS) published 2015 a recommendation of abdominal wall closure based on a wide literature review. According to the recommendation, a correct wound closure technique with sufficient length of slowly absorbable monofilament suture is highly recommended for all patients regardless of later risk of abdominal wall hernias. Preventive meshes may decrease the incidence of abdominal wall hernias when used on patients at special risk for incisional hernia, either due to surgical procedure or individual risk factors. As the evidence on the effectiveness and safety of preventive meshes is growing, they are likely to be more commonly used

Case control study investigating the clinical utility of NPWT in the perineal region following abdominoperineal resection for rectal adenocarcinoma:a single center study

Abstract Background: Perineal wound complications are common after abdominoperineal resection (APR) for rectal adenocarcinoma. Delayed wound healing may postpone postoperative adjuvant therapy and, therefore, lead to a worse survival rate. Negative-pressure wound therapy (NPWT) has been suggested to improve healing, but research on this subject is limited. Methods: The aim of this study was to assess whether NPWT reduces surgical site infections (SSI) after APR for rectal adenocarcinoma when the closure is performed with a biological mesh and a local flap. A total of 21 consecutive patients had an NPWT device (Avelle, Convatec™) applied to the perineal wound. The study patients were compared to a historical cohort in a case–control setting in relation to age, body mass index, tumor stage, and length of neoadjuvant radiotherapy. The primary outcome was the surgical site infection rate. The secondary outcomes were the wound complication rate, the severity of wound complications measured by the Clavien–Dindo classification, length of hospital stay, and surgical revision rate. Results: The SSI rate was 33% (7/21) in the NPWT group and 48% (10/21) in the control group, p = 0.55. The overall wound complication rate was 62% (13/21) in NPWT patients and 67% (14/21) in the control group, p > 0.90. The length of hospital stay was 15 days in the NPWT group and 13 in the control group, p = 0.34. The wound severity according to the Clavien–Dindo classification was 3b in 29% (6/21) of the NPWT group and in 38% (8/21) of the control group. A surgical revision had to be performed in 29% (6/21) of the cases in the NPWT group and 38% (8/21) in the control group, p = 0.73. Conclusion: NPWT did not statistically decrease surgical site infections or reduce wound complication severity in perineal wounds after APR in this case–control study. The results may be explained by technical difficulties in applying NPWT in the perineum, especially in female patients. NPWT devices should be further developed to suit the perineal anatomy before their full effect can be assessed

Incidence of parastomal and incisional hernia following emergency surgery for Hinchey III-IV diverticulitis:a systematic review

Abstract Purpose: The aim of this systematic review was to evaluate the risk of parastomal (PSH) and incisional hernias (IH) after emergency surgery for Hinchey III–IV diverticulitis, with comparison between the Hartmann procedure and other surgical techniques. Methods: The Cochrane Library, Embase, PubMed (MEDLINE), Web of Science and Scopus databases were systematically searched. The primary endpoint was parastomal hernia incidence. The secondary endpoint was incisional hernia incidence. Results: Five studies (four randomized controlled trials and one retrospective cohort) with a total of 699 patients were eligible for inclusion. The PSH rate was 15%–46% for Hartmann procedure, 0%–85% for primary anastomosis, 4% for resection, and 2% for laparoscopic lavage. The IH rates were 5%–38% for Hartmann procedure, 5%–27% for primary anastomosis, 9%–12% for primary resection, and 3%–11% for laparoscopic lavage. Conclusions: Both the parastomal and incisional hernia incidences are poorly evaluated and reported, and varied greatly between the studies

Open versus robotic-assisted laparoscopic posterior component separation in complex abdominal wall repair

Abstract Background: Transversus abdominis release (TAR) is a surgical technique used in the treatment of complex ventral hernias. The aim of this study was to compare outcomes of open (oTAR) versus robotic-assisted (rTAR) posterior component separation by TAR. Methods: Consecutive patients at two European hernia centres who underwent bilateral TAR were included. The primary endpoint was the duration of postoperative hospital stay. Results: Data from 90 rTAR and 79 oTAR operations were evaluated. Patient demographics were similar between groups in terms of age, sex, BMI, and co-morbidities. There were more smokers, and hernias were larger in the oTAR group (width 8.7 cm versus 10.0 cm; P = 0.031, length 11.6 cm versus 14.1 cm; P = 0.005). Duration of postoperative hospital stay was significantly shorter in the rTAR group (3.4 days versus 6.9 days; P < 0.001). Short-term serious complications (Clavien–Dindo grade III and above) were more frequent (20.3 per cent versus 7.8 per cent; P = 0.018), and there were more surgical site infections (12.7 per cent versus 3.3 per cent; P = 0.010) in the oTAR group. During a median follow-up of 19 months in the rTAR group and 43 months in the oTAR group, reoperation (4.4 per cent versus 8.9 per cent; P = 0.245), and recurrence rates (5.6 per cent versus 5.1 per cent; P > 0.009) were similar. Conclusion: Patients with ventral incisional hernias who undergo bilateral rTAR had significantly shorter postoperative hospital stays and fewer short-term complications compared with patients undergoing bilateral oTAR

Perioperative oral nutritional support for patients diagnosed with primary colon adenocarcinoma undergoing radical surgical procedures -Peri-Nutri Trial:study protocol for a randomized controlled trial

Abstract Background: Colon cancer is one of the most common cancers in Finland and worldwide. Cancer-related malnutrition is a well-known risk factor for increased morbidity and mortality after surgery, and it is associated with complications and longer hospitalizations. There are no established recommendations on how to improve the nutritional status of colon cancer patients’ during the perioperative phase. Administration of simple oral nutritional supplements has been suggested to reduce complication rates, but evidence to support this practice is scarce. Methods: The Peri-Nutri trial is a prospective, multicenter, randomized, controlled trial. Its primary endpoint is to evaluate whether perioperative oral nutritional support (ONS) decreases the number of complications during the 30-day follow-up after surgery. Secondary endpoints are to study the effect of ONS on quality of life after surgery, length of stay in institutional care, 90-day mortality rate, five-year disease-free survival and overall survival. The patients with a Nutritional risk screening 2002 (NRS-2002) questionnaire result between 2 and 5 (≥ 3 are classified at risk of malnutrition) will be randomized (1:1 ratio) into either the intervention or control group. The intervention group will receive preoperative ONS two weeks before the operation, and nutritional support will continue 10 days after the operation. The control group will not receive ONS. A total of 318 patients will be randomized into two groups and patients are followed five years. Discussion: Peri-Nutri study evaluate the impact of ONS to short-term and long-term postoperative morbidity and mortality rates of colon cancer patients undergoing curative surgery. If ONS will decrease patients’ morbidity and mortality, that has a huge impact on patients’ quality of life and also to financial cost

Prophylactic retrorectus mesh versus no mesh in midline emergency laparotomy closure for prevention of incisional hernia (PREEMER):study protocol for a multicentre, double-blinded, randomized controlled trial

Abstract Background: Despite the fact that emergency midline laparotomy is a risk factor for an incisional hernia, active research on hernia prevention in emergency settings is lacking. Different kinds of meshes and mesh positions have been studied in elective abdominal surgery, but no randomized controlled trials in emergency settings have been published thus far. Methods: The PREEMER trial (registration number NCT04311788) is a multicentre, patient- and assessor-blinded, randomized controlled trial to be conducted in six hospitals in Finland. A total of 244 patients will be randomized at a 1 : 1 ratio to either the retrorectus mesh group, featuring a self-gripping prophylactic mesh, or to the no mesh (control) group, both closed by small-stitch 4 : 1 closure with continuous slowly absorbable monofilament suturing. The primary outcome of the PREEMER trial is the incidence of incisional hernia 2 years after surgery, which will be detected clinically and/or radiologically. Secondary outcomes are the Comprehensive Complication Index score, incidence of surgical-site infections and fascial dehiscence within 30 days of surgery; the incisional hernia repair rate and mesh- or hernia-related reoperations within the 2- and 5-year follow-ups; the incidence of incisional hernia within the 5-year follow-up; and quality of life measured by RAND-36, the Activities Assessment Scale and the PROMIS questionnaire within 30 days and 2 and 5 years from surgery. Additionally, health–economic explorative measures will be explored. Conclusions: The PREEMER trial will provide level 1 evidence on incisional hernia prevention in an emergency setting. Registration number: NCT04311788 (http://www.clinicaltrials.gov). Registered 7 March 202

Synthetic mesh versus biological mesh to prevent incisional hernia after loop-ileostomy closure:a randomized feasibility trial

Abstract Background: Incisional hernia is a frequent complication after loop-ileostomy closure, rationalizing hernia prevention. Biological meshes have been widely used in contaminated surgical sites instead of synthetic meshes in fear of mesh related complications. However, previous studies on meshes does not support this practice. The aim of Preloop trial was to study the safety and efficacy of synthetic mesh compared to a biological mesh in incisional hernia prevention after loop-ileostomy closure. Methods: The Preloop randomized, feasibility trial was conducted from April 2018 until November 2021 in four hospitals in Finland. The trial enrolled 102 patients with temporary loop-ileostomy after anterior resection for rectal cancer. The study patients were randomized 1:1 to receive either a light-weight synthetic polypropylene mesh (Parietene Macro™, Medtronic) (SM) or a biological mesh (Permacol™, Medtronic) (BM) to the retrorectus space at ileostomy closure. The primary end points were rate of surgical site infections (SSI) at 30-day follow-up and incisional hernia rate during 10 months’ follow-up period. Results: Of 102 patients randomized, 97 received the intended allocation. At 30-day follow-up, 94 (97%) patients were evaluated. In the SM group, 1/46 (2%) had SSI. Uneventful recovery was reported in 38/46 (86%) in SM group. In the BM group, 2/48 (4%) had SSI (p > 0.90) and in 43/48 (90%) uneventful recovery was reported. The mesh was removed from one patient in both groups (p > 0.90). Conclusions: Both a synthetic mesh and biological mesh were safe in terms of SSI after loop-ileostomy closure. Hernia prevention efficacy will be published after the study patients have completed the 10 months’ follow-up

Sarcopenia and myosteatosis are associated with neutrophil to lymphocyte ratio but not Glasgow prognostic score in colorectal cancer patients

Abstract Cancer patients commonly present sarcopenia, myosteatosis, and systemic inflammation, which are risk factors of poor survival. In this study, sarcopenia and myosteatosis were defined from preoperative body computed tomography scans of 222 colorectal cancer (CRC) patients and analyzed in relation to tumor and patient characteristics, markers of systemic inflammation (modified Glasgow prognostic score (mGPS), neutrophil–lymphocyte ratio (NLR), serum levels of C-reactive protein (CRP), albumin, and 13 cytokines, and survival. Of the systemic inflammation markers, sarcopenia and/or myosteatosis associated with elevated NLR (p = 0.005) and low albumin levels (≤35 g/L) (p = 0.018), but not with mGPS or serum cytokine levels. In addition, myosteatosis was associated with a proximal tumor location (p = 0.039), serrated tumor subtype (p < 0.001), and severe comorbidities (p = 0.004). Multivariable analyses revealed that severe comorbidities and serrated histology were independent predictors of myosteatosis, and older age and elevated NLR were independent indicators of sarcopenia. Myosteatosis associated with shorter overall survival in univariable analysis (HR 1.959, 95% CI 1.24–3.10, p = 0.004) but not in multivariable analysis (p = 0.075). We conclude that sarcopenia and myosteatosis were associated with inflammatory marker NLR, but not with mGPS. Moreover, patients with serrated CRC may have an increased risk of myosteatosis. Myosteatosis or sarcopenia were not independent predictors of patient survival