Collagen fleeces do not improve colonic anastomotic strength but increase bowel obstructions in an experimental rat model

To investigate whether a collagen fleece kept in place by fibrin glue might seal off a colorectal anastomosis, provide reinforcement, and subsequently improve anastomotic healing. Wistar rats underwent a 1-cm left-sided colonic resection followed by a 4-suture end-to-end anastomosis. They were then randomly assigned to one of three treatment groups: no additional intervention (control, n = 20), the anastomosis covered with fibrin glue (fibrin glue, n = 20), the anastomosis covered with a collagen fleece, kept in place with fibrin glue (collagen fleece, n = 21). At either 3 or 7 days follow-up, anastomotic bursting pressure was measured and tissue was obtained for histology and collagen content assessment after which animals were sacrificed. Three rats in the control (15%), three in the fibrin glue (15%), and one in the collagen group (4.8%) died due to anastomotic complications (P = 0.497). Anastomotic bursting pressures were not significantly different between groups at 3 and 7 days follow-up (P = 0.659 and P = 0.427, respectively). However, bowel obstructions occurred significantly more often in the collagen group compared to the control group (14/21 vs. 3/20, P = 0.003). Collagen contents were not different between groups, but histology showed a more severe inflammation in the collagen group compared to the other groups at both 3 and 7 days follow-up. A collagen fleece kept in place by fibrin glue does not improve healing of colonic anastomoses in rats. Moreover, this technique induces significantly more bowel obstructions in rats, warranting further study before being translated to a clinical settin

META Score: An International Consensus Scoring System on Mesh-Tissue Adhesions

Background: Currently, the lack of consensus on postoperative mesh-tissue adhesion scoring leads to incomparable scientific results. The aim of this study was to develop an adhesion score recognized by experts in the field of hernia surgery. Methods: Authors of three or more previously published articles on both mesh-tissue adhesion scores and postoperative adhesions were marked as experts. They were queried on seven items using a modified Delphi method. The items concerned the utility of adhesion scoring models, the appropriateness of macroscopic and microscopic variables, the range and use of composite scores or subscores, adhesion-related complications and follow-up length. This study comprised two questionnaire-based rounds and one consensus meeting. Results: The first round was completed by 23 experts (82%), the second round by 18 experts (64%). Of those 18 experts, ten were able to participate in the final consensus meeting and all approved the final proposal. From a total of 158 items, consensus was reached on 90 items. The amount of mesh surface covered with adhesions, tenacity and thickness of adhesions and organ involvement was concluded to be a minimal set of variables to be communicated separately in each future study on mesh adhesions. Conclusion: The MEsh Tissue Adhesion scoring system is the first consensus-based scoring system with a wide backing of renowned experts and can be used to assess mesh-related adhesions. By including this minimal set of variables in future research interstudy comparability and objectivity can be increased and eventually linked to clinically relevant outcomes

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO) : 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

Background: Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups. Methods: The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion. Recommendations: Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO. Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention. Discussion: This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.Peer reviewe

Prophylactic mesh placement to avoid incisional hernias after stoma reversal: a systematic review and meta-analysis

PurposeTo provide an overview of the available literature on prevention of incisional hernias after stoma reversal, with the use of prophylactic meshes.MethodsA literature search of Pubmed, MEDLINE and EMBASE was performed. Search terms for stoma, enterostomy, mesh, prophylaxis and hernia were used. Search was updated to December 31th 2018. No time limitations were used, while English, Geman, Dutch and French were used as language restrictions. The primary outcome was the incidence of incisional hernia formation after stoma reversal. Secondary outcomes were mesh-related complications. Data on study design, sample size, patient characteristics, stoma and mesh characteristics, duration of follow-up and outcomes were extracted from the included articles.ResultsA number of 241 articles were identified and three studies with 536 patients were included. A prophylactic mesh was placed in 168 patients to prevent incisional hernias after stoma reversal. Follow-up ranged from 10 to 21months. The risk of incisional hernia in case of prophylactic mesh placement was significantly lower in comparison to no mesh placement (OR 0.10, 95% CI 0.04-0.27, p</p

Prospective nationwide outcome audit of surgery for suspected acute appendicitis

Studies comparing laparoscopic and open appendicectomy are difficult to interpret owing to several types of bias, and the results often seem of limited clinical importance. National audits can be valuable to provide insight into outcomes following appendicectomy at a population level. A prospective, observational, resident-led, nationwide audit was carried out over a period of 2 months, including all consecutive adult patients who had surgery for suspected acute appendicitis. Complications after laparoscopic and open appendicectomy were compared by means of logistic regression analysis; subgroup analyses were performed for patients with complicated appendicitis. A total of 1975 patients were included from 62 participating Dutch hospitals. A normal appendix was seen in 3·3 per cent of patients. Appendicectomy was performed for acute appendicitis in 1378 patients, who were analysed. All but three patients underwent preoperative imaging. Laparoscopy was used in 79·5 per cent of patients; the conversion rate was 3·4 per cent. A histologically normal appendix was found in 2·2 per cent. Superficial surgical-site infection was less common in the laparoscopic group (odds ratio 0·25, 95 per cent c.i. 0·14 to 0·44; P  < 0·001). The rate of intra-abdominal abscess formation was not significantly different following laparoscopic or open surgery (odds ratio 1·71, 0·80 to 3·63; P = 0·166). Similar findings were observed in patients with complicated appendicitis. Management of acute appendicitis in the Netherlands is preferably performed laparoscopically, characterized by a low conversion rate. Fewer superficial surgical-site infections occurred with laparoscopy, although the rate of abscess formation was no different from that following open surgery. A low normal appendix rate is the presumed effect of a mandatory preoperative imaging strateg

Critical overview of all available animal models for abdominal wall hernia research

Purpose: Since the introduction of the first prosthetic mesh for abdominal hernia repair, there has been a search for the “ideal mesh.” The use of preclinical or animal models for assessment of necessary characteristics of new and existing meshes is an indispensable part of hernia research. Unfortunately, in our experience there is a lack of consensus among different research groups on which model to use. Therefore, we hypothesized that there is a lack of comparability within published animal research on hernia surgery due to wide range in experimental setup among different research groups. Methods: A systematic search of the literature was performed to provide a complete overview of all animal models published between 2000 and 2014. Relevant parameters on model characteristics and outcome measurement were scored on a standardized scoring sheet. Results: Due to the wide range in different animals used, ranging from large animal models like pigs to rodents, we decided to limit the study to 168 articles concerning rat models. Within these rat models, we found wide range of baseline animal characteristics, operation techniques, and outcome measurements. Making reliable comparison of results among these studies is impossible. Conclusion: There is a lack of comparability among experimental hernia research, limiting the impact of this experimental research. We therefore propose the establishment of guidelines for experimental hernia research by the EHS