Neuropathy After Herniorrhaphy: Indication for Surgical Treatment and Outcome

Background: Chronic neuropathy after hernia repair is a neglected problem as very few patients are referred for surgical treatment. The aim of the present study was to assess the outcome of standardized surgical revision for neuropathic pain after hernia repair. Methods: In a prospective cohort study we evaluated all patients admitted to our tertiary referral center for surgical treatment of persistent neuropathic pain after primary herniorrhaphy between 2001 and 2006. Diagnosis of neuropathic pain was based on clinical findings and a positive Tinel's sign. Postoperative pain was evaluated by a visual analogue scale (VAS) and a pain questionnaire up to 12months after revision surgery. Results: Forty-three consecutive patients (39 male, median age 35years) underwent surgical revision, mesh removal, and radical neurectomy. The median operative time was 58min (range: 45-95min). Histological examination revealed nerve entrapment, complete transection, or traumatic neuroma in all patients. The ilioinguinal nerve was affected in 35 patients (81%); the iliohypogastric nerve, in 10 patients (23%). Overall pain (median VAS) decreased permanently after surgery within a follow-up period of 12months (preoperative 74 [range: 53-87] months versus 0 [range: 0-34] months; p<0.0001). Conclusions: The results of this cohort study suggest that surgical mesh removal with ilioinguinal and iliohypogastric neurectomy is a successful treatment in patients with neuropathic pain after hernia repai

Transanal endoscopic microsurgical excision of rectal tumors: Indications and results

Transanal endoscopic microsurgery (TEM) allows local excision of rectal tumors located 4 to 18 cm above the anal verge. The technique is not yet generally established because of the necessary special instrumentation and tools, the unusual technical aspects of the approach, and the stringent patient selection criteria. The aim of this prospective, descriptive study was to analyze the currently accepted indications for TEM and to evaluate the use of this procedure for treating rectal cancer. Over a 4-year period 50 patients aged 31 to 86 years (mean 64 years) underwent TEM for treatment of rectal tumors located 12 cm above the anal verge (range 4-18 cm). The local complication rate was 4%. Altogether, 76% of lesions were benign, and 24% were T1 and T2 tumors. Of 12 cancer cases, 4 required reoperation by total mesorectal resection; the other 8 are currently under follow-up management. Over the follow-up period of 30.6 months (range 11-54 months) the recurrence rate of T1 tumors was 8.3%. TEM is a minimally invasive surgical technique that may benefit a small, specific population of patients with rectal tumors. Compared with conventional transanal resection, TEM provides superior exposure of tumors higher up in the rectum (i.e., up to 18 cm from the anal verge). The greater precision of resection combined with low morbidity (10%, relative to that of anterior resection) and short duration of hospitalization (5.5 days) make this technique a reliable and in some cases more effective surgical approach than laparotomy and low anterior resectio

Systematic Review of Delayed Postoperative Hemorrhage after Pancreatic Resection

Introduction: This review assesses the presentation, management, and outcome of delayed postpancreatectomy hemorrhage (PPH) and suggests a novel algorithm as possible standard of care. Methods: An electronic search of Medline and Embase databases from January 1990 to February 2010 was undertaken. A random-effect meta-analysis for success rate and mortality of laparotomy vs. interventional radiology after delayed PPH was performed. Results: Fifteen studies comprising of 248 patients with delayed PPH were included. Its incidence was of 3.3%. A sentinel bleed heralding a delayed PPH was observed in 45% of cases. Pancreatic leaks or intraabdominal abscesses were found in 62%. Interventional radiology was attempted in 41%, and laparotomy was undertaken in 49%. On meta-analysis comparing laparotomy vs. interventional radiology, no significant difference could be found in terms of complete hemostasis (76% vs. 80%; P = 0.35). A statistically significant difference favored interventional radiology vs. laparotomy in term of mortality (22% vs. 47%; P = 0.02). Conclusions: Proper management of postoperative complications, such as pancreatic leak and intraabdominal abscess, minimizes the risk of delayed PPH. Sentinel bleeding needs to be thoroughly investigated. If a pseudoaneurysm is detected, it has to be treated by interventional angiography, in order to prevent a further delayed PPH. Early angiography and embolization or stenting is safe and should be the procedure of choice. Surgery remains a therapeutic option if no interventional radiology is available, or patients cannot be resuscitated for an interventional treatmen

Wound Infection After Excision and Primary Midline Closure for Pilonidal Disease: Risk Factor Analysis to Improve Patient Selection

Background: Excision and primary midline closure for pilonidal disease (PD) is a simple procedure; however, it is frequently complicated by infection and prolonged healing. The aim of this study was to analyze risk factors for surgical site infection (SSI) in this context. Methods: All consecutive patients undergoing excision and primary closure for PD from January 2002 through October 2008 were retrospectively assessed. The end points were SSI, as defined by the Center for Disease Control, and time to healing. Univariable and multivariable risk factor analyses were performed. Results: One hundred thirty-one patients were included [97 men (74%), median age=24 (range 15-66) years]. SSI occurred in 41 (31%) patients. Median time to healing was 20days (range 12-76) in patients without SSI and 62days (range 20-176) in patients with SSI (P<0.0001). In univariable and multivariable analyses, smoking [OR=2.6 (95% CI 1.02, 6.8), P=0.046] and lack of antibiotic prophylaxis [OR=5.6 (95% CI 2.5, 14.3), P=0.001] were significant predictors for SSI. Adjusted for SSI, age over 25 was a significant predictor of prolonged healing. Conclusion: This study suggests that the rate of SSI after excision and primary closure of PD is higher in smokers and could be reduced by antibiotic prophylaxis. SSI significantly prolongs healing time, particularly in patients over 25year

Prevention of infectious complications after laparoscopic appendectomy for complicated acute appendicitis—the role of routine abdominal drainage

Purpose: Complicated acute appendicitis is still associated with an increased morbidity. If laparoscopy has been accepted as a valid approach, some questions remain concerning intra-abdominal abscess formation. Routine prophylactic drainage of the abdomen has been proposed. However, this practice remains a matter of debate, poorly validated in the literature. With the present study, we investigated the impact of drainage in laparoscopic appendectomy for complicated appendicitis. Method: This is a case match study of consecutive patients operated on by laparoscopy in a single institution. One hundred and thirty patients operated for complicated appendicitis (local peritonitis without perforation, with perforation, or with periappendicular abscess) with prophylactic intraperitoneal drainage were matched one by one to 130 patients operated without drainage. Uncomplicated appendicitis and generalized peritonitis were excluded. Primary endpoint was surgical complications and secondary endpoints were transit recovery time and length of hospital stay. Results: Patients without drain had significantly less overall complications (7.7% vs. 18.5%, p = 0.01). Moreover, the absence of drainage was of significant benefit for transit recovery time (2.5 vs. 3.5days, p = 0.0068) and length of hospital stay (4.2 vs. 7.3days, p < 0.0001). Conclusion: No benefits were observed for prophylactic drainage of the abdominal cavity during emergency laparoscopic treatment of complicated appendicitis. For this reason, this practice may be abandone

Measures to Prevent Surgical Site Infections: What Surgeons (Should) Do

Background: The present study was designed to evaluate surgeons' strategies and adherence to preventive measures against surgical site infections (SSIs). Materials and methods: All surgeons participating in a prospective Swiss multicentric surveillance program for SSIs received a questionnaire developed from the 2008 National (United Kingdom) Institute for Health and Clinical Excellence (NICE) clinical guidelines on prevention and treatment of SSIs. We focused on perioperative management and surgical technique in hernia surgery, cholecystectomy, appendectomy, and colon surgery (COL). Results: Forty-five of 50 surgeons contacted (90%) responded. Smoking cessation and nutritional screening are regularly propagated by 1/3 and 1/2 of surgeons, respectively. Thirty-eight percent practice bowel preparation before COL. Preoperative hair removal is routinely (90%) performed in the operating room with electric clippers. About 50% administer antibiotic prophylaxis within 30min before incision. Intra-abdominal drains are common after COL (43%). Two thirds of respondents apply nonocclusive wound dressings that are manipulated after hand disinfection (87%). Dressings are usually changed on postoperative day (POD) 2 (75%), and wounds remain undressed on POD 2-3 or 4-5 (36% each). Conclusions: Surgeons' strategies to prevent SSIs still differ widely. The adherence to the current NICE guidelines is low for many procedures regardless of the available level of evidence. Further research should provide convincing data in order to justify standardization of perioperative managemen

Right Hepatectomy in Patients over 70 Years of Age: An Analysis of Liver Function and Outcome

Background: As a consequence of the increase in life expectancy, hepatobiliary surgeons have to deal with an emerging aged population. We aimed to analyze the liver function and outcome after right hepatectomy (RH) in patients over 70years of age. Methods: From January 2006 to December 2009, we prospectively collected data of 207 consecutive elective hepatectomies. In patients who had RH, cardiac risk was assessed by a dedicated preoperative workup. Liver failure (LF) was defined by the "fifty-fifty” criteria at postoperative day 5 (POD) and morbidity by the Clavien-Dindo classification. Liver function tests (LFTs) and short-term outcome were retrospectively analyzed in patients over (elderly group, EG) and younger (young group, YG) than 70years of age. Results: Eighty-seven consecutive RH were performed during the study period. Indication for surgery included 90% malignancy in 47% of patients requiring preoperative chemotherapy. ASA grade>2 (44 vs. 16%, p=0.027), ischemic heart disease (17 vs. 5%, p=0.076), and preoperative cardiac failure (26 vs. 2%, p<0.001) were more frequent in the EG (n=23) than in the YG (n=64). Both groups were similar regarding rates of normal liver parenchyma, chemotherapy and intraoperative parameters. The overall morbidity rates were comparable, but the serious complication (grades III-V) rate was relatively higher in the EG (39 vs. 25%, p=0.199), particularly in patients with diabetes mellitus (100 vs. 29%, p=0.04) and those who had additional nonhepatic surgery (67 vs. 35%, p=0.110) and transfusions (44 vs. 30%, p=0.523). The 90-day mortality rate was similar (9% in the EG vs. 3% in the YG, p=0.28) and was related to heart failure in the EG. LFTs showed a similar trend from POD 1 to 8, and patients ≥70years of age had no liver failure. Conclusions: Age ≥70years alone is not a contraindication to RH. However, major morbidity is particularly higher in the elderly with diabetes. This high-risk group should be closely monitored in the postoperative course. Liver function is not altered in the elderly patient after R

A tailored approach for the treatment of indirect inguinal hernia in adults—an old problem revisited

Purpose: A patent processus vaginalis peritonei (PPV) presents typically as an indirect hernia with an intact inguinal canal floor during childhood. Little is known however about PPV in adults and its best treatment. Methods: A cohort study included all consecutive patients admitted for ambulatory open hernia repair. In patients with a PPV, demographics, hernia characteristics, and outcome were prospectively assessed. Annulorrhaphy was the treatment of choice in patients with an internal inguinal ring diameter of <30mm. Results: Between 1998 and 2006, 92 PPVs (two bilateral) were diagnosed in 676 open hernia repairs (incidence of 14%). Eighty nine of the 90 patients were males, the median age was 34years (range: 17-85). A PPV was right-sided in 67% and partially obliterated in 66%. Forty-one patients had an annulorrhaphy and 51 patients had a tension-free mesh repair. The median operation time was significantly shorter in the annulorrhaphy group (38 vs. 48min, P<.0001). In a median follow-up period of 56months (27-128), both groups did not differ concerning recurrence (1/41 vs. 2/51), chronic pain (3/41 vs. 4/51), and hypoesthesia (5/41 vs. 9/51). There was however a clear trend to less neuropathic symptoms in favor of annulorrhaphy (0/41 vs. 5/51, P < 0.066). Conclusions: PPV occurs in 14% of adults undergoing hernia repair. In selected patients, annulorrhaphy takes less time and is associated with equally low recurrence but less potential for neuropathic symptom

Rapid Colonization with Methicillin-Resistant Coagulase-Negative Staphylococci After Surgery

Background: Antimicrobial resistance may compromise the efficacy of antibiotic prophylaxis before surgery. The aim of this study was to measure susceptibility and clonal distribution of coagulase-negative staphylococci (CoNS) colonizing the skin around the surgery access site before and after the procedure. Methods: From March to September 2004, a series of 140 patients undergoing elective major abdominal surgery were screened for CoNS colonization at admission and 5days after surgery. All isolates were tested for antibiotic susceptibility and genotyped by pulsed-field gel electrophoresis (PFGE). Results: Colonization rates with CoNS at admission and after surgery were 85% and 55%, respectively. The methicillin-resistant CoNS rate increased from 20% at admission to 47% after surgery (P=0.001). The PFGE pattern after surgery revealed more patients colonized with identical clones: 8/140 patients (8/119 strains) and 26/140 patients (26/77 strains), respectively (P<0.001). Conclusions: Our results suggest rapid recolonization of disinfected skin by resistant nosocomial CoNS. Larger studies, preferably among orthopedic or cardiovascular patients, are required to clarify whether standard antibiotic prophylaxis with first- or second-generation cephalosporins for CoNS infections may be compromised if the patient requires an additional intervention 5days or more after the initial surger