Parastomal hernia prevention with permanent mesh in end colostomy: failure with late follow-up of cohorts in three randomized trials

Hernia; Mesh; ParastomalHèrnia; Malla; ParastomalHernia; Malla; ParaestomalPurpose Short-term results have been reported regarding parastomal hernia (PH) prevention with a permanent mesh. Long-term results are scarce. The objective was to assess the long-term PH occurrence after a prophylactic synthetic non-absorbable mesh. Methods Long-term data of three randomized controlled trials (RCTs) were collected. The primary outcome was the detection of PH based exclusively on a radiological diagnosis by computed tomography (CT) performed during the long-term follow-up. The Kaplan–Meier method was used for the comparison of time to diagnosis of PH according to the presence of mesh vs. no-mesh and the technique of mesh insertion: open retromuscular, laparoscopic keyhole, and laparoscopic modified Sugarbaker. Results We studied 121 patients (87 men, median age 70 years), 82 (67.8%) of which developed a PH. The median overall length of follow-up was 48.5 months [interquartile range (IQR) 14.4–104.9], with a median time until PH diagnosis of 17.7 months (IQR 9.3–49.0). The survival analysis did not show significant differences in the time to development of a PH according to the presence or absence of a prophylactic mesh neither in the overall study population (log-rank, P = 0.094) nor in the groups of each technique of mesh insertion, although according to the surgical technique, a higher reduction in the appearance of PH for the open retromuscular technique was found (log-rank, P = 0.001). Conclusion In the long-term follow-up placement of a non-absorbable synthetic prophylactic mesh in the context of an elective end colostomy does not seem effective for preventing PH

Dissection of the inferior mesenteric vein versus of the inferior mesenteric artery for the genitourinary function after laparoscopic approach of rectal cancer surgery : a randomized controlled trial

Total Mesorectal Excision (TME) is the standard surgical technique for the treatment of rectal cancer. However, rates of sexual dysfunction ofup to 50% have been described after TME, and rates of urinary dysfunction of up to 30%. Although other factors are involved, the main cause of postoperative genitourinary dysfunction is intraoperative injury to the pelvic autonomic nerves. The risk is particularly high in the inferior mesenteric artery (IMA). The aim of this study is to compare pre- and post-TME sexual dysfunction, depending on the surgical approach usedin the inferior mesenteric vessels: either directly on the IMA, or from the inferior mesenteric vein (IMV) to the IMA. Prospective, randomized,controlled study of patients with rectal adenocarcinoma with neoadjuvant chemoradiotherapy, who will be randomly assigned to one of two groups depending on the surgical approach to the inferior mesenteric vessels. The main variable is pre- and postoperative sexual dysfunction; secondary variables are visualization and preservation of the pelvic autonomic nerves, pre- and postoperative urinary dysfunction, and pre- and postoperative quality of life. The sample will comprise 90 patients, 45 per group. The aim is to demonstrate that the dissection route from the IMV towards the IMA favors the preservation of the pelvic autonomic nerves and thus reducesrates of sexual dysfunction post-surgery. Ethical and Clinical Research Committee, Parc Taulí University Hospital: ID 017/315. ClinicalTrials.gov TAU-RECTALNERV-PRESERV-2018 (TRN: ) (Date of registration 04/03/2018)

Respuesta al artículo: La concentración de tratamientos puede mejorar los resultados en cirugía compleja del cáncer

Sr. Editor: Hemos leído con gran interés la editorial de Borras y Guarga1 que creemos expresa el pensamiento de muchos cirujanos de nuestro país^, y con la que coincidimos, al mismo tiempo que quisiéramos hacer una serie de reflexiones constructivas sobre algunos aspectos que no vemos reflejados del todo en la misma. El que la concentración en determinados procedimientos disminuya la mortalidad1 3, ya es una buena razón por sí misma para plantearse la centralización, a pesar de que no todos los estudios lo demuestran4, pero no nos parece suficiente el solo hecho de que el volumen por sí mismo sea el principal criterio que defina el centro de referencia, ya que se pueden operar muchos casos, a nivel individual o de servicio, pero si los resultados no se auditan, se comparan o se hacen públicos, podemos caer en el error de que cantidad no sea igual a calidad3. Desde la Sección de Formación de la Asociación Española de Cirujanos http://www.aecirujanos.es pensamos que las unidades de un servicio que pretenda centralizar procedimientos deberían de estar certificadas al igual que sus profesionales, al mismo tiempo que disponer de tecnología puntera e innovadora que ofrezca las mejores oportunidades de tratamiento a nuestros pacientes, y esto sí que sería un requisito básico para que la centralización tuviese un sentido real, además del volumen, porque significa que los resultados de los profesionales y del centro, están auditados y se pueden ..

A mild neurofibromatosis type 1 phenotype produced by the combination of the benign nature of a leaky NF1-splice mutation and the presence of a complex mosaicism

Here we analyze the genetic and molecular basis responsible for a very benign phenotype observed in an NF1 patient. Quantification of cells carrying the NF1 mutation in different samples derived from the three embryonic layers revealed mosaicism. Furthermore, the construction of a minigene with patient's mutation (c.3198 − 314G>A) confirmed its benign nature due to the leakiness of the splicing mechanism that generated a proportion of correctly spliced transcripts. Hence, we concluded that the mild phenotype observed in this patient is the result of the presence of mosaicism together with the benign nature of a leaky NF1-splice mutation. Finally, with the aim of developing a personalized therapeutic approach for this patient, we demonstrated correction of the splicing defect by using specific antisense morpholino oligomers. Our results provide an example of the molecular complexity behind disease phenotypes and highlight the importance of using comprehensive genetic approaches to better assess phenotype-genotype correlation

The role experience of advanced practice nurses in oncology: An interpretative phenomenological study.

Aim(s): To understand the experiences of advanced practice nurses working in cancer care. Design: Phenomenological qualitative study. Methods: Three focus groups were held to collect qualitative data. Participants were recruited through theoretical non-probabilistic sampling of maximum variation, based on 12 profiles. Data saturation was achieved with a final sample of 21 oncology advanced practice nurses who were performing advanced clinical practice roles in the four centers from December 2021 to March 2022. An interpretative phenomenological analysis was performed following Guba and Lincoln's criteria of trustworthiness. The centers' ethics committee approved the study, and all participants gave written informed consent. Data analysis was undertaken with NVivo 12 software. Results: Three broad themes emerged from the data analysis: the role performed, facilitators and barriers in the development of the role and nurses' lived experience of the role. Conclusion: Advanced practice nurses are aware that they do not perform their role to its full potential, and they describe different facilitators and barriers. Despite the difficulties, they present a positive attitude as well as a capacity for leadership, which has allowed them to consolidate the advanced practice nursing role in unfavourable environments. Implications for the profession: These results will enable institutions to establish strategies at different levels in the implementation and development of advanced practice nursing roles. Reporting method: Reporting complied with COREQ criteria for qualitative research. Patient or public contributions: No patient or public contribution

Preoperative diagnostic uncertainty in T2-T3 rectal adenomas and T1-T2 adenocarcinomas and a therapeutic dilemma : Transanal endoscopic surgery, or total mesorectal excision?

Background: Endorectal ultrasound and rectal magnetic resonance are sometimes unable to differentiate between stages T2 and T3 in rectal adenomas that are possible adenocarcinomas, or between stages T1 and T2 in rectal adenocarcinomas. These cases of diagnostic uncertainty raise a therapeutic dilemma: transanal endoscopic surgery (TES) or total mesorectal excision (TME)? Methods: An observational study of a cohort of 803 patients who underwent TES from 2004 to 2021. Patients operated on for adenoma (group I) and low-grade T1 adenocarcinoma (group II) were included. The variables related to uncertain diagnosis, and to the definitive pathological diagnosis of adenocarcinoma stage higher than T1, were analyzed. Results: A total of 638 patients were included. Group I comprised 529 patients, 113 (21.4%) with uncertain diagnosis. Seventeen (15%) eventually had a pathological diagnosis of adenocarcinoma higher than T1. However, the variable diagnostic uncertainty was a risk factor for adenocarcinoma above T1 (OR 2.3, 95% CI 1.1-4.7). Group II included 109 patients, eight with uncertain diagnosis (7.3%). Two patients presented a definitive pathological diagnosis of adenocarcinoma above T1. Conclusions: On the strength of these data, we recommend TES as the initial indication in cases of diagnostic uncertainty. Multicenter studies with larger samples for both groups should now be performed to further assess this strategy of initiating treatment with TES

High frequency of acute decompensation and cancer in patients with compensated cirrhosis due to nonalcoholic fatty liver disease : A retrospective cohort study

The natural history of compensated cirrhosis due to nonalcoholic fatty liver disease (NAFLD) has not been completely characterized. The aim of the present study was to assess the incidence and risk factors of acute decompensation of cirrhosis, hepatocellular carcinoma, and extrahepatic cancers. This was a multicenter, retrospective, cohort study including 449 patients with compensated cirrhosis due to NAFLD. We calculated cumulative incidences and used competitive risk analysis to determine the risk factors associated with decompensation and cancer development. Over a median of 39 months of follow-up, 124 patients (28%) presented acute decompensation. The most frequent decompensation was ascites (21%) followed by hepatic encephalopathy (15%), variceal bleeding (9%), and spontaneous bacterial peritonitis (3%). Acute-on-chronic liver failure was diagnosed in 6% of patients during follow-up. Liver function parameters and specifically an albumin level below 40 g/L were independently associated with an increased risk of decompensation. The presence of ischemic heart disease was independently associated with acute decompensation. Seventy-eight patients (18%) developed hepatocellular carcinoma or extrahepatic cancers during follow-up (51 and 27, respectively). Conclusion : Patients with compensated cirrhosis due to NAFLD are at high risk of severe liver complications, such as the development of acute decompensation, in a relative short follow-up time. This population is at high risk of hepatic and extrahepatic cancers. The analysis of a large contemporary cohort of 449 patients with compensated cirrhosis due to non-alcoholic fatty liver disease shows a high frequency of acute decompensations (AD) and development of cancer during 39 months of follow-up. Almost 28% of the cohort developed acute decompensation and 18% developed hepatocellular carcinoma (HCC) or extrahepatic cancer. Predictors of decompensation are mainly related to liver function and portal hypertension

Cirurgia Endoscòpica i Laparoscòpica combinada per al tractament de pòlips colònics benignes complexos

La cirurgia endoscòpica i laparoscòpica combinada (CELS) s'ha desenvolupat extraordinàriament en els últims 10-15 anys com una alternativa mínimament invasiva a la resecció quirúrgica de còlon per al tractament de pòlips benignes. Aquest estudi mostra algunes de les tècniques més utilitzades i n'avalua la viabilitat, la seguretat i els resultats a curt termini en els primers 15 pacients intervinguts a l'Hospital Parc Taulí, un dels primers centres a introduir aquesta tècnica a Espanya.La cirugía endoscópica y laparoscópica combinada (CELS) se ha desarrollado extraordinariamente en los últimos 10-15 años como una alternativa mínimamente invasiva a la resección quirúrgica de colon para el tratamiento de pólipos benignos. Este estudio muestra algunas de las técnicas más utilizadas y evalúa la viabilidad, la seguridad y los resultados a corto plazo en los primeros 15 pacientes intervenidos en el Hospital Parc Taulí, uno de los primeros centros en introducir esta técnica en España