Risk Factors for Abdominal Wound Dehiscence in Children: A Case-Control Study

Contains fulltext : 81635.pdf (publisher's version ) (Closed access)BACKGROUND: In the limited literature concerning abdominal wound dehiscence after laparotomy in children, reported incidences range between 0.2-1.2% with associated mortality rates of 8-45%. The goal of this retrospective case-control study was to identify major risk factors for abdominal wound dehiscence in the pediatric population. METHODS: Patients younger than aged 18 years who developed abdominal wound dehiscence in three pediatric surgical centers during the period 1985-2005 were identified. For each patient with abdominal wound dehiscence, four controls were selected by systematic random sampling. Patients with (a history of) open abdomen treatment or abdominal wound dehiscence were excluded as control subjects. Putative relevant patient-related, operation-related, and postoperative variables for both cases and control subjects were evaluated in univariate analyses and subsequently entered in multivariate stepwise logistic regression models to identify major independent predictors of abdominal wound dehiscence. RESULTS: A total number of 63 patients with abdominal wound dehiscence and 252 control subjects were analyzed. Mean presentation of abdominal wound dehiscence was at postoperative day 5 (range, 1-15) and overall mortality was 11%. Hospital stay was significantly longer (p < 0.001) in the case group (median, 42 vs. 10 days). Major independent risk factors for abdominal wound dehiscence were younger than aged 1 year, wound infection, median incision, and emergency surgery. Incisional hernia was reported in 12% of the patients with abdominal wound dehiscence versus 3% in the control group (p = 0.001). CONCLUSIONS: Abdominal wound dehiscence is a serious complication with high morbidity and mortality. Median incisions should be avoided whenever possible

Abdominal Wound Dehiscence in Adults: Development and Validation of a Risk Model

Background: Several studies have been performed to identify risk factors for abdominal wound dehiscence. No risk model had yet been developed for the general surgical population. The objective of the present study was to identify independent risk factors for abdominal wound dehiscence and to develop a risk model to recognize high-risk patients. Identification of high-risk patients offers opportunities for intervention strategies. Methods: Medical registers from January 1985 to December 2005 were searched. Patients who had primarily undergone appendectomies or nonsurgical (e.g., urological) operations were excluded. Each patient with abdominal wound dehiscence was matched with three controls by systematic random sampling. Putative relevant patient-related, operation-related, and postoperative variables were evaluated in univariate analysis and subsequently entered in multivariate stepwise logistic regression models to delineate major independent predictors of abdominal wound dehiscence. A risk model was developed, which was validated in a population of patients who had undergone operation between January and December 2006. Results: A total of 363 cases and 1,089 controls were analyzed. Major independent risk factors were age, gender, chronic pulmonary disease, ascites, jaundice, anemia, emergency surgery, type of surgery, postoperative coughing, and wound infection. In the validation population, risk scores were significantly higher (P < 0.001) for patients with abdominal wound dehiscence (n = 19) compared to those without (n = 677). Resulting scores ranged from 0 to 8.5, and the risk for abdominal wound dehiscence over this range increased exponentially from 0.02% to 70.1%. Conclusions: The validated risk model shows high predictive value for abdominal wound dehiscence and may help to identify patients at increased risk

International guidelines for groin hernia management

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients. The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research

Complications and impact on quality of life of vertical rectus abdominis myocutaneous flaps for reconstruction in pelvic exenteration surgery

BACKGROUND: Pelvic exenteration for malignancy sometimes necessitates flap reconstruction. OBJECTIVE: This study's aim was to investigate flap-related morbidity. DESIGN: A prospective database was reviewed from 2003 to 2016. All medical charts, correspondence, and outpatient follow-up records up to May 2017 were reviewed. SETTINGS: This study was conducted at a tertiary referral unit. PATIENTS: Patients who underwent pelvic exenteration surgery were selected. INTERVENTIONS: Reconstruction was performed with a vertical rectus abdominis myocutaneous flap. MAIN OUTCOME MEASURES: Primary outcome was flap-related complications (short or long term >3 months). Secondary outcomes were hospital stay, readmission, mortality, and quality of life (Short Form-36, Functional Assessment of Cancer Therapy for patients with colorectal cancer). RESULTS: Of 519 patients undergoing pelvic exenteration surgery, 87 (17%) underwent flap reconstruction. Median follow-up was 20 months (interquartile range, 8-39 months). Median age was 60 years (interquartile range, 51-66). Flap-related complications were found in 59 patients (68%), with minor recipient-site complications diagnosed in 33 patients (38%). In the short term, 15 patients experienced major recipient-site complications (17%), including flap separation (n = 7) and partial (n = 3) or complete necrosis (n = 4). Flap removal was required in 1 patient. Obesity was the single independent risk factor for short-term flap-related complications (p = 0.02). Hospital admission was significantly longer in patients with short-term major flap complications (median 65 days, p < 0.001) compared with patients without or with minor complications. There was no 90-day mortality. Patients who required flap reconstruction reported lower baseline quality-of-life scores than patients without flap reconstruction, but both recovered over time. In the long term, minor flap-related complications occurred in 12 patients, and 11 patients had major donor-site complications. Fourteen patients developed major recipient-site complications (16%), including sacral collections, enterocutaneous fistulas, perineal ulcer, or hernia. LIMITATIONS: This was a retrospective analysis of prospectively collected data. CONCLUSIONS: Vertical rectus abdominis myocutaneous flaps in pelvic exenteration surgery have a high incidence of morbidity that has significant impact on hospital stay and a temporary impact on quality of life. Flap reconstruction should be used selectively in pelvi

Oncological and functional outcomes after high or total sacrectomy : a systematic review

Background: (Colo)rectal cancer is the fourth most deadly cancer worldwide. In an advanced stage, the tumour can come into direct contact or grow into the sacrum. Therefore, a sacrectomy can offer a curative solution. This procedure can cause serious consequences. The aim of this study was to investigate the oncological and functional outcomes after a high or low sacrectomy in patients with (colo)rectal cancer. Materials and Methods: A systematic review was performed according to the PRISMA and AMSTAR-2 guidelines. Several databases were used: Pubmed, Embase, Cochrane Library and Scopus. Articles were included and evaluated by two independent reviewers. GRADE and ROBINS-I were applied. Results: 45 articles were included with a total of 1631 patients. According to GRADE and ROBINS-I, the quality of the included studies was predominantly low to very low and all studies contained a low to serious risk of bias. Median follow-up was 31,4 months. The 30-day hospital mortality was reported with a mean of 1,06%. After a R0 resection, overall survival was achieved in 86,2%, 68% and 42,1% and disease-free survival in 75%, 51% and 43%, both after respectively 1, 3 and 5 year(s). 34% of the patients suffered from (chronic) pain or neuropathy. 96,8% were able to walk independently. However, the results suggested that more patients were dependent on walking assisting devices after performing a high versus after a low sacrectomy. Most reported bowel dysfunctions were fistula in 4,6%, bowel obstruction in 8,3% and small bowel obstruction in 14%. Bladder dysfunction was mainly reported as incontinence in 8,3% and neurogenic bladder in 23,3%. Sexual dysfunction was underreported. Conclusions: The 30-day hospital mortality was limited. The results suggested that a R0 resection has a higher chance of survival than a R1 or R2 resection. Both short- and long-term functional outcomes had a major impact on the patient’s quality of life

Increasing abdominal girth in a female patient with a gastric band = Toenemende buikomvang bij patiënte met een maagband

BACKGROUND: Insufficient weight loss after gastric band placement is generally linked to band-related complications or a persistently unhealthy diet. CASE DESCRIPTION: A 47-year-old woman with a history of gastric band placement presented with complaints of decreased mobility, dyspnoea, gastro-oesophageal reflux and a progressive increase in abdominal girth. Initially, these symptoms were attributed to an unhealthy diet. However, additional testing showed a large intra-abdominal multicystic lesion originating from the ovaries. The patient was operated and two large serous cystadenomas were removed, after which the symptoms disappeared almost immediately. CONCLUSION: Abdominal complaints after bariatric surgery can often be explained by surgical complications or unhealthy eating habits. Although the cause of certain complaints is sometimes obvious, alternative diagnoses need to be considered. If the abdominal girth in middle-aged women increases, ovarian disorders must always be considered in the differential diagnosis and appropriate additional diagnostic testing need to be carried out