Therapie von Narbenhernien mit oder ohne Implantation von Kunststoff-Netzen : Ergebnisse der Klinik für Chirurgie der RWTH Aachen 1985-2000

Any defect on the abdominal wall can always cause the herniation of intra-abdominal organs. Combined with the possibility of incarceration, this herniation should be considered as a permanent danger to the patient. Moreover, an increase in size of the defect is always seen with time, leading to increasing limitation of the patient’s physical activities, coupled with pains and other symptoms, which may even be reported at rest. Hernia repairs belong to the daily scope of surgical operations. In the federal republic of Germany, about 250,000 inguinal hernias and 50,000 incisional hernias are repaired yearly. In USA alone, some one million hernia repairs are done yearly, of which 689,000 are inguinal hernias. At the surgical department of the RWTH Aachen, hernia repairs cover up 16-19% of all the operations. Here, this is the highest percentage of operations devoted to one organ system. Of all the inguinal hernias, 10-15% are seen in children, meanwhile incisional hernias in this age group are very rare [49]. While primary hernias develop through anatomically weak points of the abdominal wall, incisional hernias are located at scars, most probably after laparotomy. The development of an incisional hernia with an incidence of 10-20% is one of the most frequent surgical complications [48], which can lead to impairment of the already healed patient. Experiences made at the surgical department of the RWTH Aachen in the past fifteen years with 500 incisional hernia patients reflect changes that have taken place in this area of surgery within the past few years. Of recent, the implantation of alloplastic materials (meshes) has come to replace the hitherto dominating mesh-free hernia repair techniques. In this study, firstly, mesh-free hernia repairs done between 1985 and 1999 will be analysed retrospectively. The Mayo-plastic and the edge-to-edge repair techniques will be analysed for recurrence hernias, postoperative complications and their functional consequences. Secondly, results of this analysis will be compared with prospectively collected data on hernia repairs done with the mesh techniques between 1992 and 2000. Thirdly, patients after mesh implantation will be studied for the influence of used biomaterial. This will include the following factors: stability, frequency of wound infections and seroma, integration of the mesh into the abdominal wall tissue, movement restrictions of the abdominal wall, the meaning of mesh size, the position of the mesh and complete closure of the peritoneum. Summary: Worldwide, the incisional hernia repair has experienced a change from suture methods to mesh techniques, in which the abdominal wall is strengthened with alloplastic materials. With the aid of an analysis of data obtained from 454 Patients operated on between 1985 and 2000, results are here presented, with particular reference to the development of recurrence hernia, the rate of local complications and consequences on the quality of lives of the patients. While mostly suture techniques were implemented in hernia repair in the years 1985-1992, mesh implantation in sublay position subsequently dominated this area of surgery in the 90ies. In the early days of mesh era, the Marlex® mesh was used. Later on, the Atrium® mesh was preferred and today, almost only the newly developed Vypro® mesh is being used. Doubling of the fascia like in the Mayo-plastic does not lead to any reduced hernia recurrence rate when compared with the edge-to edge-repair. Clinical experience could show that both repair principles lead to an equal hernia recurrence rate of over 50% after six years. The mesh repair techniques were able to reduce the hernia recurrence after the same period of time to rates below 10% independent of the mesh material used. Several factors were studied for their effect on the development of recurrence hernias. The recurrence-status played a role in the development of recurrence hernias after suture techniques as well as after mesh implantation. Due to the fact that multivariate analysis showed interaction of recurrence-status with other factors, this factor can only be judged in combination with others as a risk factor. Furthermore, our study isolated the male gender as a significant risk factor for the development of recurrence incisional hernia independent of the applied therapy principle. Obese patients (BMI > 26) and those younger than 60 years also have a higher risk for the development of recurrence incisional hernias. Among patients receiving conventional incisional hernia repair, a lower, but not significant recurrence rate could be seen for hernias smaller than, compared to those larger than 4 cm (28 and 34% respectively). In all repair techniques studied, no relationship could be found between the surgeon as a factor and the recurrence of incisional hernia. This was the same case for size of the mesh as a factor. Despite the implantation of large masses of alloplastic materials during mesh repair, wound infection rates were not more than those seen after mesh free repair techniques. All methods of hernia repair with the aid of meshes influence abdominal wall movement. Using the Vypro® mesh bettered up functional integration into the abdominal wall with a reduction of paraesthesia as well as that of mesh-related symptoms. It also prevented the development of large Seroma around the mesh. 3D-stereography allows objective studies of abdominal wall movements. After mesh implantation, mobility of the abdominal wall is impaired. Greatest impairment was observed for the heaviest mesh with the smallest pores (Marlex®). All in all, this impairment reduces for Vypro® and Atrium® after an observation period of over one year

Comparaison du TAP bloc bilatéral versus curare dans le relachement musculaire de la paroi abdominale pour la laparoscopie en chirurgie digestive (étude prospective randomisée au CHU d'Amiens)

Introduction: Le TAP bloc est reconnu comme stratégie d analgésie en chirurgie digestive mais pas encore pour son action sur le relâchement de la paroi abdominale comparée à l utilisation d un curare lors d une laparoscopie.Matériel et Méthodes: Les patients nécessitant une appendicectomie ou cholécystectomie par cœlioscopie ont été randomisés. Après l induction, un groupe recevait un curare, l autre avait un TAP bloc bilatéral sous échographie. Le critère d évaluation principal était la compliance abdominale, calculée à partir du volume initial de CO2 insufflé. Les critères secondaires étaient le score de satisfaction du chirurgien, la présence de mouvements ou contractions diaphragmatiques, les variations hémodynamiques et respiratoires, la douleur postopératoire, la consommation de morphine et les éventuelles complications. Résultats: 60 patients étaient inclus dont 4 exclus pour conversion en laparotomie. Nous n avons pas retrouvé de différence de compliance abdominale entre les 2 groupes (p=0,52). Le score de satisfaction global du chirurgien (noté sur 4) n était pas différent (1 [1 ; 2] versus 1 [1 ; 3]). La douleur postopératoire et la consommation de morphine étaient inférieures dans le groupe TAP bloc avec seulement 2 échecs à la technique. Les complications postopératoires étaient des NVPO (25 %) ou chirurgicales (36 %).Conclusion: Le TAP bloc sous échographie est une technique sûre et efficace assurant un bloc moteur favorisant le relâchement musculaire pariétal semblant aussi efficace qu une curarisation et un bloc sensitif permettant une analgésie postopératoire de qualité.AMIENS-BU Santé (800212102) / SudocSudocFranceF

Mortalité des patients opérés d'une fracture du col du fémur au bloc d'urgence (étude rétrospective sur le CHU d'Amiens en 2008)

La fracture du col du fémur est une pathologie courante du sujet âgé. Sa prise en charge chirurgicale se fait au bloc d urgence au CHU AMIENS NORD. Cette étude rétrospective sur l année 2008, se proposait d évaluer la mortalité de ces patients à 12 mois. Il fut fait un recueil, via les dossiers médicaux et informatiques des patients. Nous avons inclus en tout 309 patients pour fracture du col du fémur avec un taux de mortalité à 34% à 12 mois. La moyenne d âge des patients était de 79 ans. Il y avait 68,3% de femmes. 51% des patients avaient un score ASA à 2 et 46% ASA 3 enfin 51% avaient un score de Lee à 1. Il y a eu au total 46% d anesthésies générales. La durée d anesthésie moyenne était de 126 minutes et la durée chirurgicale moyenne était de 54 minutes. Les principaux antécédents retrouvés étaient cardio vasculaire car présents chez 73% des patients. La durée de séjour moyenne à l hôpital était de 12 jours indépendamment du type d anesthésie ou de chirurgie. Le délai de prise en charge moyen entre l entrée et la chirurgie était de 2 jours. Les principales complications retrouvées étaient hémorragiques à hauteur de 10,7 % en per opératoire et 39,5% en post opératoire. Il y a eu 14 décès durant l hospitalisation pour fracture du col du fémur, la cause principale de décès était pulmonaire. Sur les taux de mortalité et les courbes de survie, il semblerait que l âge, le score ASA, le score de Lee, la présence d un antécédent de démence, la reprise de la marche observée entre 30 et 45 jours, la présence d une transfusion sanguine en per opératoire serait des facteurs importants jouant sur la mortalité de nos patients à 12 mois.The fracture of the neck of the femur is the current pathology of the old subject. His surgical care is made in the emergency block in the CHU NORD AMIENS. This retrospective study over the year 2008, suggested estimating the mortality of these 1-year-old patients with a mortality rate at 34% for 12 month. A collection, via the medical and computing files of the patients was made. We included 309 patients for fracture of the neck of the femur. The mean age of the patients was of 79 years. There was 68,3 % of women. 51 % of the patients had a score ASA in 2 , 46% ASA 3 and 51 % had Lee's score in 1. There was all in all 46 % of general anesthesias .and 38 %. The duration of average anesthesia was of 126 minutes and the duration of average surgery was of 54 minutes. The main found histories were cardio - vascular because presents to 73 % of the patients. The duration of stay average at the hospital was of 12 days, this duration is indépendant from te type of surgery or anesthésia. The average deadline of care between the entrance and the surgery was of 2 days. The main found complications were hemorrhagic at the level of 10,7 % per operating and 39,5 % in operating comment. There were 14 deaths during the hospitalization for fracture of the neck of the femur, the main cause of death was lung. On the mortality rates and the curves of survival, it would seem that the age, the score ASA, Lee's score, presence of a history of insanity, the resumption of the walking observed between 30 and 45 days, the presence of a blood transfusion per operating would be important factors playing on the mortality of our patients in 12 month.AMIENS-BU Santé (800212102) / SudocSudocFranceF

Tourism as a factor of well-being growth

Актуальность исследования обусловлена необходимостью социально-философского осмысления взаимосвязи и взаимовлияния туризма и благополучия, поскольку туризм стал сферой жизни глобальногообщества, а социальное благополучие является фундаментальным залогом развития социума,его стабильности и процветания. Туризм востребован современным обществом, в которомбольшинство людей интересуются культурой, традициями, достопримечательностями, историейтех или иных регионов мира. В последнее время в зарубежных исследованиях все чаще уделяется вниманиевзаимосвязи туризма и благополучия, в отечественных исследованиях. По мнению М. Сирги идр., существует объективная потребность в расширении наших представлений о влиянии, котороеоказывает туристский опыт на психоэмоциональное состояние туристов по завершении путешествия:теоретические и эмпирические исследования стремятся проанализировать поведение туристовво взаимосвязи с другими сферами их жизни, а также более широко изучить последствия, которыенеизбежно оказывает туристская деятельность на жизнь людей. Путешествие как постижениесебя в мире разнообразия стран, народов и культур расширяет пространственно-временные рамкибытия человека, увеличивает субъективное восприятие мира. Человек, путешествующий сам, формируетсвое благополучие, тем самым создавая фундамент благополучия социального. Благополучиескладывается из нескольких элементов, и туризм ? феномен, который способен вывести на качественноиной уровень субъективное восприятие благополучия. По результатам последних исследованийЕвропейской кооперации науки и технологий, реализующей проект TObeWELL, выделено пятьключевых аспектов благополучия: высокий уровень жизни, здоровье, безопасность, хорошие социальныевзаимоотношения и свобода выбора. Туризм связан со многими из данных аспектов, следовательно,туризм может стать катализатором улучшения благополучия человекаThe relevance of the research is caused by the need in social and philosophical understanding of interconnectionand mutual influence of tourism and well-being, since tourism has become the sphere of life of a global society,and social well-being is the fundamental guarantee of the development of the society, its stability and prosperity.Tourism is in demand by a modern society in which most people are interested in culture, traditions,sights, history of various regions of the world. Recently in foreign studies, the attention is increasingly being paidto the interrelationship of tourism and well-being in domestic research. According to M. Sirgi et al., there is anobjective need to expand our understanding of tourist experience impact on psycho-emotional state of touristsafter the trip: theoretical and empirical studies seek to analyze the behavior of tourists in conjunction with otherspheres of their life, and more widely explore the consequences that tourism activities inevitably have on people'slives. Travel as comprehension of oneself in the world of diversity of countries, peoples and cultures, expandsthe space-time framework of human being, increases the subjective perception of the world. A person whotravels forms his own well-being, thereby creating the foundation for the well-being of the social. Well-beingconsists of several elements and tourism is a phenomenon that can bring a qualitatively different level of subjectiveperception of well-being. Based on the results of recent studies of the European cooperation in science andtechnology implementing the TOBWELL project, five key aspects of well-being were identified: high standard ofliving, health, safety, good social relations and freedom of choice. Tourism is associated with many of these aspects,hence tourism can be a catalyst for improving human well-being

Risk factors and mortality of patients undergoing hip fracture surgery: a one-year follow-up study

International audienceHip fracture (HF) remains a main issue in the elderly patient. About 1.6 million patients a year worldwide are victims of a HF. Their incidence is expected to rise with the aging of the world's population. Identifying risk factors is mandatory in order to reduce mortality and morbidity. The aim of the study was to identify risk factors of 1-year mortality after HF surgery. We performed an observational, prospective, single-center study at Amiens University Hospital (Amiens, France). After ethical approval, we consecutively included all patients with a HF who underwent surgery between June 2016 and June 2017. Perioperative data were collected from medical charts and by interviews. Mortality rate at 12 months was recorded. Univariate analysis was performed and mortality risk factors were investigated using a Cox model. 309 patients were analyzed during this follow-up. Mortality at 1 year was 23.9%. Time to surgery over 48hours involved 181 patients (58.6%) while 128 patients (41.4%) had surgery within the 48hours following the hospital admission. Independent factors associated with 1-year mortality were: age (HR at 1.059 (95%CI [1.005-1.116], p=0,032), Lee score >= 3 (HR at 1,52 (95% CI [1,052-2,198], p=0.026) and time to surgery over 48hours (HR of 1.057 (95% CI [1.007-1.108], p=0.024). Age, delayed surgical (over 48hours) management and medical history are important risk factors of 1-year mortality in this French cohor

Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia

International audienceImportance: The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial.Objective: To test the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed.Design, setting, and participants: Randomized, double-blind, noninferiority trial conducted in 10 academic centers. Patients undergoing anesthesia with RSI were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge (last follow-up, February 8, 2017).Interventions: Patients were assigned to a cricoid pressure (Sellick group) or a sham procedure group.Main outcomes and measures: Primary end point was the incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation). It was hypothesized that the sham procedure would not be inferior to the cricoid pressure. The secondary end points were related to pulmonary aspiration, difficult tracheal intubation, and traumatic complications owing to the tracheal intubation or cricoid pressure.Results: Of 3472 patients randomized, mean (SD) age was 51 (19) years and 1777 (51%) were men. The primary end point, pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group. The upper limit of the 1-sided 95% CI of relative risk was 2.00, exceeding 1.50, failing to demonstrate noninferiority (P = .14). The risk difference was -0.06% (2-sided 95% CI, -0.57 to 0.42) in the intent-to-treat population and -0.06% (2-sided 95% CI, -0.56 to 0.43) in the per protocol population. Secondary end points were not significantly different among the 2 groups (pneumonia, length of stay, and mortality), although the comparison of the Cormack and Lehane grade (Grades 3 and 4, 10% vs 5%; P 30 seconds, 47% vs 40%; P <.001) suggest an increased difficulty of tracheal intubation in the Sellick group.Conclusions and relevance: This large randomized clinical trial performed in patients undergoing anesthesia with RSI failed to demonstrate the noninferiority of the sham procedure in preventing pulmonary aspiration. Further studies are required in pregnant women and outside the operating room.Trial registration: ClinicalTrials.gov Identifier: NCT02080754