Loop Ileostomy Closure: Comparison of Cost Effectiveness between Suture and Stapler

Background: Closure of loop ileostomy can be safely performed using sutures or staplers. The aim of the present study was to compare the cost effectiveness of three different techniques. Methods: A total of 128 consecutive patients who underwent closure of loop ileostomy between January 2002 and December 2008 were analyzed retrospectively. The primary outcome parameter was operative cost. Results: Closure of ileostomy was performed in 66 patients with hand-sewn anastomosis, in 25 patients with stapler only, and in 37 patients with a combination of stapler and suture. There were no differences in terms of early and late postoperative complications. Operative time was significantly longer for "suture only” (101.4±26min) than for "stapler/suture” (−4.9min) and "stapler only” (−17.8min); the difference between the three groups is significant (p=0.05). Duration of hospital stay was not different among the three groups. Operative costs with "stapler/suture” (1,755.9±355.6 EUR) were significantly higher than with "suture only” (−254 EUR; p=0.001) and "stapler only” (−236 EUR; p=0.005). Conclusions: Operative time using the stapler only is significantly shorter than with hand-sewn anastomosis or combinations of stapler and suture. Operative costs are significantly higher for a procedure that includes suture and staple

Long-term Follow-up of Open and Laparoscopic Repair of Large Incisional Hernias

Background: Long-term results after laparoscopic repair of large incisional hernias remain to be determined. The aim of this prospective study was to compare early and late complications between laparoscopic repair and open repair in patients with large incisional hernias. Methods: Only patients with a hernia diameter of ≥5cm were included in this study and were prospectively followed. We compared 56 patients who underwent open incisional hernia repair with 69 patients who underwent laparoscopic repair. Median follow-up in the laparoscopic group was 32.5months (range 1-62months) and in the open group 65months (range 1-80months). Results: The demographic parameters were not significantly different between the two groups. However, the median hospital stay (6.0days, range 1-23days vs. 7.0days, range 1-67days; p=0.014) and incidence of surgical site infections (SSIs) (5.8% vs. 26.8%; p=0.001) were significantly lower in the laparoscopic group than in the open surgery group. Bulging of the implanted mesh was observed in 17.4% in the laparoscopic group and in 7.1% in the open group (p=NS). The recurrence rate was 18% in the open group and 16% in the laparoscopic group (p=NS). Multivariate analysis revealed that width of the hernia ≥10cm, SSI, and BMI ≥30kg/m2 were significant risk factors for hernia recurrence. Conclusions: The incidence of SSIs was significantly lower after laparoscopic incisional hernia repair. At long-term follow-up, the recurrence rate was not different between the two techniques. Abdominal bulging is a specific problem associated with laparoscopic repair of large incisional hernias. Size of the hernia, BMI, and SSI are risk factors for hernia recurrence irrespective of the techniqu

Implantation of Prophylactic Nonabsorbable Intraperitoneal Mesh in Patients With Peritonitis Is Safe and Feasible

Background: Patients with peritonitis undergoing emergency laparotomy are at increased risk for postoperative open abdomen and incisional hernia. This study aimed to evaluate the outcome of prophylactic intraperitoneal mesh implantation compared with conventional abdominal wall closure in patients with peritonitis undergoing emergency laparotomy. Method: A matched case-control study was performed. To analyze a high-risk population for incisional hernia formation, only patients with at least two of the following risk factors were included: male sex, body mass index (BMI) >25kg/m2, malignant tumor, or previous abdominal incision. In 63 patients with peritonitis, a prophylactic nonabsorbable mesh was implanted intraperitoneally between 2005 and 2010. These patients were compared with 70 patients with the same risk factors and peritonitis undergoing emergency laparotomy over a 1-year period (2008) who underwent conventional abdominal closure without mesh implantation. Results: Demographic parameters, including sex, age, BMI, grade of intraabdominal infection, and operating time were comparable in the two groups. Incidence of surgical site infections (SSIs) was not different between groups (61.9 vs. 60.3%; p=0.603). Enterocutaneous fistula occurred in three patients in the mesh group (4.8%) and in two patients in the control group (2.9%; p=0.667). The incidence of incisional hernia was significantly lower in the mesh group (2/63 patients) than in the control group (20/70 patients) (3.2 vs. 28.6%; p<0.001). Conclusions: Prophylactic intraperitoneal mesh can be safely implanted in patients with peritonitis. It significantly reduces the incidence of incisional hernia. The incidences of SSI and enterocutaneous fistula formation were similar to those seen with conventional abdominal closur

Operation time and body mass index are significant risk factors for surgical site infection in laparoscopic sigmoid resection: a multicenter study

Background: Surgical site infection (SSI) in patients who underwent colorectal surgery is a common complication associated with increased morbidity and costs. The aim of this study was to assess risk factors for SSI in laparoscopic sigmoid resection for benign disease. Methods: Using a multicenter database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery, we prospectively identified 4,488 patients who underwent laparoscopic colorectal surgery between 1995 and 2008; of these, 2,571 patients who underwent sigmoid resection for benign disease were included. Uni- and multivariate analyses were used to determine risk factors for SSI. Results: The incidence of SSI was 3.5% (90/2,571). Among SSI patients, incisional superficial infections were found in 71%, incisional deep infections in 22%, and organ-space infections in 7%. Patients' age, underlying disease, and surgeons' experience had no impact on SSI. Multivariate analyses showed that operation time >240min (odds ratio [OR] 1.7; 95% confidence interval [CI] 1.0-2.8), BMI≥27kg/m2 (OR 2.3 [1.3-4.5]), organ lesions (OR 7.9 [2.0-31.8]), and male gender (OR 2.3 [1.2-4.5]) were significant risk factors for SSI. Reoperations in the SSI group were significantly more frequent than in the Non-SSI group (30% vs. 3%; p240min, BMI ≥27kg/m2, organ lesions, and male gender. SSI was significantly associated with more reoperations, longer hospital stay, and higher mortality rat

Laparoscopic resection of hepatic alveolar echinococcosis: A single-center experience.

INTRODUCTION Alveolar echinococcosis (AE) remains a very rare disease requiring complete radical resection for curative treatment. While open approaches are common, safety and efficacy of laparoscopic resections remain unknown. METHODS This is a single-center, retrospective cohort study with patients undergoing liver resection for hepatic AE at the Department of Visceral Surgery and Medicine, Bern University Hospital from December 2002 to December 2020. Postoperative outcomes of patients following laparoscopic hepatectomy (LH) for hepatic AE were compared with those of patients undergoing open hepatectomy (OH). RESULTS A total of 93 patients underwent liver resection for hepatic AE. Laparoscopic hepatectomy was performed in 23 patients and open hepatectomy in 70 patients. While there were no significant differences in terms of gender, age and diagnostic tools, the majority of patients of the LH cohort were PNM stage 1 (78%) in contrast to only 39% in the OH cohort (p = 0.002). Patients undergoing laparoscopic hepatectomy were treated by minor liver resections in 91% and in 9% by major liver resections in comparison to the open hepatectomy cohort with 61% major liver resections and 39% minor resections. Laparoscopic hepatectomy was associated with shorter mean operation time (127 minutes vs. 242 minutes, p <0.001), lower major complication rate (0% vs. 11%, p = 0.322) and shorter mean length of hospital stay (4 days vs. 13 days, p <0.001). Patients with LH had a distinct, but not significant lower recurrence rate (0% vs. 4%, p = 0.210) during a mean follow-up of 55 months compared with a follow-up of 76 months in the OH cohort. After subgroup analysis of PNM stage 1 patients, similar results are seen with persistent shorter mean operation time (120 minutes vs. 223 minutes, p <0.001), lower major complication rate (0% vs. 8%, p = 0.759) and shorter length of hospital stay (4 days vs. 12 days, p <0.001). CONCLUSION Laparoscopy appears as a feasible and safe approach for patients with PNM stage 1 alveolar echinococcosis without impact on early disease recurrence

Infectious Disease in the Workplace: Quantifying Uncertainty in Transmission.

Understanding disease transmission in the workplace is essential for protecting workers. To model disease outbreaks, the small populations in many workplaces require that stochastic effects are considered, which results in higher uncertainty. The aim of this study was to quantify and interpret the uncertainty inherent in such circumstances. We assessed how uncertainty of an outbreak in workplaces depends on i) the infection dynamics in the community, ii) the workforce size, iii) spatial structure in the workplace, iv) heterogeneity in susceptibility of workers, and v) heterogeneity in infectiousness of workers. To address these questions, we developed a multiscale model: A deterministic model to predict community transmission, and a stochastic model to predict workplace transmission. We extended this basic workplace model to allow for spatial structure, and heterogeneity in susceptibility and infectiousness in workers. We found a non-monotonic relationship between the workplace transmission rate and the coefficient of variation (CV), which we use as a measure of uncertainty. Increasing community transmission, workforce size and heterogeneity in susceptibility decreased the CV. Conversely, increasing the level of spatial structure and heterogeneity in infectiousness increased the CV. However, when the model predicts bimodal distributions, for example when community transmission is low and workplace transmission is high, the CV fails to capture this uncertainty. Overall, our work informs modellers and policy makers on how model complexity impacts outbreak uncertainty. In particular: workforce size, community and workplace transmission, spatial structure and individual heterogeneity contribute in a specific and individual manner to the predicted workplace outbreak size distribution