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Background: Incarceration of inguinal, umbilical and cicatricial hernias is a frequent problem. However, little is known about the relationship between the use of mesh and outcome after surgery. The goal of this study was to describe the relationship between the use of mesh in incarcerated hernia and the clinical outcome.Patients and Methods: Correspondence, operation reports and patient files between January 1995 and December 2005 of patients presented at one academic and one teaching hospital in Rotterdam were searched for the following keywords: incarceration, strangulation and hernia. The patient characteristics, clinical presentation, pre-operative findings and clinical course were scored and analysed.Results: A total of 203 patients could be identified: 76 inguinal, 52 umbilical, 39 incisional, 14 epigastric, 14 femoral, five trocar and three spigelian hernias. In the statistical analysis, epigastric, femoral, trocar and spigelian hernias were pooled, due to their small group sizes. One patient was excluded from the analysis because the hernia was not corrected during operation. In total, 99 hernias were repaired using mesh versus 103 primary suture repairs. Twenty-five wound infections were registered (12.3%). One mesh was removed during a reintervention for anastomotic leakage, although no signs of wound infection were present. Nine patients died, none of them due to wound-related problems [one cardiovascular, one ruptured aneurysm, two anastomotic leakage, two sepsis e causa incognita (e.c.i.), three pulmonary complications]. Univariate analysis showed that female patients (P = 0.007), adipose patients (P = 0.016), patients with an umbilical hernia (P = 0.01) and patients who underwent a bowel resection (P = 0.015) had a significantly higher rate of wound infections. The type of repair (e.g. primary suture or mesh), use of antibiotic prophylaxis, gender, ASA class and age showed no significant relation with post-operative wound infection. After logistic regression analysis, only bowel resection (P = 0.020) showed a significant relation with post-operative wound infection.Conclusions: Wound infection rates are high after the correction of acute hernia, but clinical consequences are relatively low. Mesh correction of an acute hernia seems to be safe and should be considered in every incarcerated hernia. [ABSTRACT FROM AUTHOR]

Objective: A prospective study was undertaken to assess the interobserver variability in CT scan interpretation in patients with suspected acute appendicitis. Methods: 103 adult patients with suspected acute appendicitis underwent unenhanced helical multislice CT scanning of the abdomen. All patients subsequently underwent laparoscopy by a surgeon who was blind to the diagnosis suggested by the CT scan. All CT scans were interpreted by group A, B and C radiologists with different levels of expertise. Results: Acute appendicitis was diagnosed on multislice CT scans in 69%, 74% and 80% by group A, B, and C radiologists, respectively. At laparoscopy, 83% of patients were diagnosed with acute appendicitis. For group A, B and C radiologists, the specificity of CT scanning for the diagnosis of acute appendicitis was 94%, 94% and 100%, respectively, the sensitivity was 81%, 88% and 95%, the positive predictive value was 98.6%, 98.7% and 100%, and the negative predictive value was 50%, 68% and 81%. The difference in the proportion of positive outcomes between observer groups A and C was significant. During laparoscopy, 12 patients were diagnosed with other diseases. These were all correctly diagnosed by group C radiologists; groups A and B radiologists missed the diagnosis of colitis in one patient. All other disorders were diagnosed correctly. Conclusions: The sensitivity of CT interpretations for the diagnosis of acute appendicitis differs considerably between radiologists. This interobserver variability has to be taken into account during implementation of routine CT scanning in patients with suspected acute appendicitis. Only in centres with expert CT radiologists is the implementation of routine CT scanning in patients with suspected acute appendicitis justified. [ABSTRACT FROM AUTHOR]

Background: Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects.Methods: A randomized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis. I) A conservative strategy with antibiotics: hospital admission, supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral, if tolerated (for a total duration of antibiotic treatment of 10 days). II) A liberal strategy without antibiotics: admission only if needed on clinical grounds, supportive measures only. Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging. Only patients with stages 1a and 1b according to Hinchey's classification or "mild" diverticulitis according to the Ambrosetti criteria are included. The primary endpoint is time-to-full recovery within a 6-month follow-up period. Full recovery is defined as being discharged from the hospital, with a return to pre-illness activities, and VAS score below 4 without the use of daily pain medication. Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention, morbidity, costs, health-related quality of life, readmission rate and acute diverticulitis recurrence rate. In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85% and a confidence level of 95%. With an estimated one percent of patients lost to follow up, a total of 533 patients will be included.Conclusion: A clinically relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected. The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach.Trial Registration: Trial Registration Number: NCT01111253. [ABSTRACT FROM AUTHOR]

Background In 1995 the concept of a 'critical view of safety' (CVS) in Calot's triangle was introduced to prevent bile duct injury in laparoscopic cholecystectomy. The aim of this study was to determine the most reliable method for recording CVS. Methods Operation notes, video images and photo prints from 50 consecutive elective non-converted laparoscopic cholecystectomies were analysed. Results Operation notes alone did not suffice to record CVS. As an adjunct, video proved superior to photo print with regard to quality. Nevertheless, photo prints were practically and logistically much easier to produce than video. Moreover, when good quality images were achieved, photo print recorded CVS more conclusively than video. Discussion Operation notes, video and photo print are complementary, and the combination records CVS conclusively in nearly every case. [ABSTRACT FROM AUTHOR]

Aim: Patients undergoing surgery experience perioperative anxiety and pain. Music has been shown to reduce perioperative anxiety, pain and medication requirement. This study assessed the feasibility and effectiveness of implementing a perioperative music intervention., Method: A prospective pre- and post-implementation pilot study was conducted to assess adherence to the intervention and the initial effect of music on postoperative pain scores (Numerical Rating Scale, 0-10) compared to a control group. Secondary outcomes encompassed pain scores throughout hospital admission, anxiety levels, medication usage, complications and hospital stay length., Results: Adherence to the music intervention was preoperative 95.2%, intraoperative 95.7%, postoperative 31.9% and overall 29.7%. The intervention did influence postoperative pain. Patient's willingness to receive music was high (73%), they appreciated the intervention (median 8.0, interquartile range 7.0-9.0) and healthcare professionals were willing to apply the intervention. Music significantly reduced postoperative anxiety (2.0 vs. 3.0, p = 0.02) and the consumption of benzodiazepines on the first postoperative day (number of patients: zero [0%] vs. five [10%], p = 0.04)., Conclusion: Implementation of music resulted in reduced postoperative anxiety and decreased consumption of benzodiazepines, and the strategy was feasible, but adjustments are needed to improve postoperative adherence. Both patients and healthcare professionals had a positive attitude towards the intervention., (© 2024 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: Current challenges in meningioma treatment, including post-surgical complications and cognitive impairments, highlight the need for new treatment alternatives. Immunological interventions have shown promise. However, there is a knowledge gap in characterizing infiltrating immune cells in meningioma and their interplay. Further studies on immune cells in single-cell suspensions from digested meningioma tissues could identify targetable mechanisms for non-surgical treatment options with fewer side effects. This study aimed to optimize a protocol for faster digestion of meningioma tissues into viable single-cell suspensions and to identify infiltrating immune cell populations., Methods: We modified a commercial kit intended for whole skin dissociation to digest resected meningioma tissues into viable single-cell suspensions. Tumor-infiltrating immune cell populations were characterized using flow cytometry., Results: Flow cytometry analyses revealed that the digested tissue was composed of viable immune cells, including predominantly CD14 + macrophages and CD3 + T cells, with minor populations of CD56 + NK cells and CD19 + B cells. In both of the two patient samples tested, half of the tumor-associated macrophages were TIM-3 + , with a small proportion co-expressing CD83. Women were more likely to have a lower proportion of immune cells, B cells, and NK cells. Female patients with a high proportion of immune cells had a higher proportion of macrophages., Conclusion: We successfully optimized a protocol for generating single-cell suspensions with viable immune cells from meningioma tissues, revealing infiltrating antigen-presenting cells with an immunosuppressive phenotype, and lymphocytes. This short protocol allows advanced analyses of tumor-infiltrating cells using techniques such as single-cell RNA sequencing and flow cytometry, which require live, dissociated cells.

Objective: This study aimed to evaluate all mesh-related problems during reoperations after mesh-reinforcement 15 years after the start of the PRIMA trial. SUMMARY BACKGROUND DATA Prophylactic mesh reinforcement during closure of a midline laparotomy has proven to reduce the incidence of incisional hernia, especially in high-risk patients, but long-term mesh-related morbidity is largely unknown., Methods: Patients receiving a prophylactic onlay or retro-rectus mesh in the PRIMA trial between 2009 and 2012 were included on an as-treated basis from participating centers that made reoperation notes available. Main outcomes were the incidences of complications requiring mesh explantation, mesh-related ileus, and mesh-related problems during laparotomy for other diagnoses., Methods: Out of 373 patients randomized to prophylactic mesh reinforcement, 242 were included: 127 with onlay and 115 patients with retrorectus mesh. Median follow-up is 27 months (IQR 12-78). Thirty-four patients underwent reoperation for any reason during entire follow-up, 22 after onlay (17.3%) and 12 after retrorectus mesh (10.4%). Reoperation rate for complications that required mesh explantation was 4/127 (3.1%) after onlay and 0/115 (0%) after retrorectus mesh. Mesh-related ileus occurred in none of the onlay group, and 3/115 (2.6%) in the retrorectus group. During subsequent laparotomies for other primary diagnoses, adhesions to the mesh were noted in 3/10 patients in the onlay group and 1/5 patients in the retro-rectus group. Overall, the mesh was removed in 10/127 (7.9%) in the onlay group and 7/115 (6.1%) patients in the retro-rectus group., Conclusions: In high-risk patients receiving a prophylactic mesh during midline laparotomy closure, low incidences of mesh-related complications requiring reoperation and mesh-related problems during unrelated subsequent laparotomies were found, for both the onlay and retrorectus techniques., Competing Interests: Funding statement: The authors report no conflicts of interest. Furthermore, no funding was received from any (non) profit organisation. The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Suture tension has a direct influence on the sutured tissue. For abdominal wall closure, suture tension should be optimal without causing tissue necrosis, which can result in surgical site infection or incisional hernia. The purpose of the present study is to evaluate a device that can measure suture tension in-situ and in real-time., Materials and Methods: A cheap, commercially available analog-to-digital converter was used, in conjunction with a force sensing resistor. A sensor probe housing was designed and 3D-printed. In order to test the sensor, a mechanical, computer controlled human abdominal wall model called the AbdoMAN was used., Results: An implantable suture tension sensor was developed, keeping cost-effectiveness in mind. This sensor can translate tension in the suture into a downward force, applied to the force sensing resistor. The sensor's raw readout was characterized using a set of weights, from which a formula correlating the readout to a specific force, was derived. Preliminary validation was successfully performed using the AbdoMANmodel, which showed a progressive rise in suture tension when the intra-abdominal pressure was artificially increased over time., Conclusion: The implantable suture tension sensor appeared to be capable of recording real time changes in suture tension, and the. validation process of this sensor has been initiated. With the information from devices like this, a much better understanding of the issues at play in the development of incisional hernia can be gained., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Incisional hernia (IH) after abdominal surgery is a frequent surgical complication. Risk factors associated with IH are midline incisions, patients with an abdominal aneurysm of the aorta, and high BMI. Preventive measures include the use of the small-bites suture technique and/or placing a prophylactic mesh for reinforcement of the midline closure. Although recommended for high-risk patients, many surgeons are still reluctant to place a prophylactic mesh due to related complications. To counter these concerns, new synthetic resorbable meshes are being developed, such as the Deternia Self-Gripping Resorbable Mesh ("investigational device"). However, the effectiveness of this mesh in IH prevention has not been proved., Methods: The Mesh Augmented Reinforcement of Abdominal Wall Suture Line (MARS) study is a European, multicentre, prospective, single-arm study. A total of 120 patients scheduled for elective midline laparotomy, and for that reason at risk of developing IH, will be recruited in ~12 sites after informed consent. The sample size was estimated based on greater than 80% power, two-sided alpha of 0.05, an expected 12 month IH rate of 8% and a predefined performance goal of 18% (10% clinical margin). Midline incisions will be closed by the small bites closure technique with a minimum 4:1 suture-to-wound length ratio and reinforced by mesh placement in the retrorectus position. The primary outcome will be IH occurrence at 12-month postoperatively, evaluated both clinically and by ultrasound. Secondary outcomes will include mesh-related and postoperative complications, surgical characteristics, IH incidence at 2 and 3 years after surgery, and quality of life., Discussion: Currently, no conclusive evidence is available for synthetic resorbable meshes in a prophylactic setting to prevent IH. The MARS study will be the first prospective cohort study to investigate resorbable synthetic meshes and small bites closure to reduce IH incidence., Competing Interests: This work was supported by Sofradim Production S.A.S.U., a Medtronic plc company (Trevoux, France). All authors (or their institutions) received support to provide input on the design of the study.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To assess the 5-year recurrence rate of incisional hernia repair in Ventral Hernia Working Group (VHWG) 3 hernia with a slowly resorbable mesh., Summary Background Data: Incisional hernia recurs frequently after initial repair. In potentially contaminated hernia, recurrences rise to 40%. Recently, the biosynthetic Phasix mesh has been developed that is resorbed in 12-18 months. Resorbable meshes might be a solution for incisional hernia repair to decrease short- and long-term (mesh) complications. However, long-term outcomes after resorption are scarce., Methods: Patients with VHWG grade 3 incisional midline hernia, who participated in the Phasix trial (Clinilcaltrials.gov: NCT02720042) were included by means of physical examination and computed tomography (CT). Primary outcome was hernia recurrence; secondary outcomes comprised of long-term mesh complications, reoperations, and abdominal wall pain [visual analogue score (VAS): 0-10]., Results: In total, 61/84 (72.6%) patients were seen. Median follow-up time was 60.0 [interquartile range (IQR): 55-64] months. CT scan was made in 39 patients (68.4%). A recurrence rate of 15.9% (95% confidence interval: 6.9-24.8) was calculated after 5 years. Four new recurrences (6.6%) were found between 2 and 5 years. Two were asymptomatic. In total, 13/84 recurrences were found. No long-term mesh complications and/or interventions occurred. VAS scores were 0 (IQR: 0-2)., Conclusions: Hernia repair with Phasix mesh in high-risk patients (VHWG 3, body mass index >28) demonstrated a recurrence rate of 15.9%, low pain scores, no mesh-related complications or reoperations for chronic pain between the 2- and 5-year follow-up. Four new recurrences occurred, 2 were asymptomatic. The poly-4-hydroxybutyrate mesh is a safe mesh for hernia repair in VHWG 3 patients, which avoids long-term mesh complications like pain and mesh infection., Competing Interests: Disclosure: The authors state that they have no proprietary interest in the products named in this article., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Incisional hernia occurs approximately in 40% of high-risk patients after midline laparotomy. Prophylactic mesh placement has shown promising results, but long-term outcomes are needed. The present study aimed to assess the long-term incisional hernia rates of the previously conducted PRIMA trial with radiological follow-up., Methods: In the PRIMA trial, patients with increased risk of incisional hernia formation (AAA or BMI ≥27 kg/m 2 ) were randomised in a 1:2:2 ratio to primary suture, onlay mesh or sublay mesh closure in three different countries in eleven institutions. Incisional hernia during follow-up was diagnosed by any of: CT, ultrasound and physical examination, or during surgery. Assessors and patients were blinded until 2-year follow-up. Time-to-event analysis according to intention-to-treat principle was performed with the Kaplan-Meier method and Cox proportional hazard models. Trial registration: NCT00761475 (ClinicalTrials.gov)., Findings: Between 2009 and 2012, 480 patients were randomized: 107 primary suture, 188 onlay mesh and 185 sublay mesh. Five-year incisional hernia rates were 53.4% (95% CI: 40.4-64.8), 24.7% (95% CI: 12.7-38.8), 29.8% (95% CI: 17.9-42.6), respectively. Compared to primary suture, onlay mesh (HR: 0.390, 95% CI: 0.248-0.614, p < 0.001) and sublay mesh (HR: 0.485, 95% CI: 0.309-0.761, p = 0.002) were associated with a significantly lower risk of incisional hernia development., Interpretation: Prophylactic mesh placement remained effective in reducing incisional hernia occurrence after midline laparotomy in high-risk patients during long-term follow-up. Hernia rates in the primary suture group were higher than previously anticipated., Funding: B. Braun., Competing Interests: None of the authors declare conflict of interest., (© 2023 The Author(s).)

Background: Inguinal hernia belongs to the most common surgical pathology worldwide. Approximately, one third is asymptomatic. The value of watchful waiting (WW) in patients with asymptomatic or mildly symptomatic inguinal hernia has been established in a few randomised controlled trials (RCTs). The aim of this study was to assess long-term outcomes of a RCT comparing WW and elective surgery., Methods: In the original study, men aged ≥50 years with an asymptomatic or mildly symptomatic inguinal hernia were randomly assigned to WW or elective repair. In the present study, the primary outcome was the 12-year crossover rate to surgery, secondary outcomes were time-to-crossover, patient regret, pain, quality of life and incarceration. Dutch Trial Registry: NTR629., Findings: Out of 496 originally analysed patients, 488 (98.4%) were evaluable for chart review (WW: n = 258, surgery: n = 230), and 200 (41.0%) for telephone contact (WW: n = 106, surgery: n = 94) between November 2021 and March 2022 with a median 12 years follow-up (IQR 9-14). After 12 years, the estimated cumulative crossover rate to surgery was 64.2%, which was higher in mildly symptomatic than in asymptomatic patients (71.7% versus 60.4%, HR 1.451, 95% CI: 1.064-1.979). Time-to-crossover was longer in asymptomatic patients (50% after 6.0 years versus 2.0 years, p = 0.019). Patient regret was higher in the WW group (37.7 versus 18.0%, p = 0.002), as well as pain/discomfort (p = 0.031). Quality of life did not differ (p = 0.737). In the WW group, incarceration occurred in 10/255 patients (3.9%)., Interpretation: During 12-year follow-up, most WW patients crossed over to surgery, significantly earlier with mildly symptomatic hernia. Considering the relatively low incarceration rate, WW might still be an option in asymptomatic patients with a clear preference and being well-informed about pros and cons., Funding: The initial trial was funded by the Netherlands Organisation for Health Research and Development (ZonMW). This long-term study did not receive funding., Competing Interests: The authors declare no conflict of interest., (© 2023 The Author(s).)

Purpose: The current operative report often inadequately reflects events occurring during laparoscopic cholecystectomy (LC). The addition of intraoperative video recording to the operative report has already proven to add important information. It was hypothesized that real-time intraoperative voice dictation (RIVD) can provide an equal or more complete overview of the operative procedure compared to the narrative operative report (NR) produced postoperatively., Methods: SONAR is a multicenter prospective observational trial, conducted at four surgical centers in the Netherlands. Elective LCs of patients aged 18 years and older were included. Participating surgeons were requested to dictate the essential steps of LC during surgery. RIVDs and NRs were reviewed according to the stepwise LC guideline of the Dutch Society for Surgery. The cumulative adequacy rates for RIVDs were compared with those of the postoperatively written NR., Results: 79 of 90 cases were eligible for inclusion and available for further analysis. RIVD resulted in a significantly higher adequacy rate compared to NR for the circumferential dissection of the cystic duct and artery (NR 32.5% vs. RIVD 61.0%, P = 0.016). NR had higher adequacy rates in reporting the transection of the cystic duct (NR 100% vs. RIVD 77.9%, P =  < 0.001) and the removal of the gallbladder from the liver bed (NR 98.7% vs. RIVD 68.8%, P < 0.001). The total adequacy was not significantly different between the two reporting methods (NR 78.0% vs. RIVD 76.4%, P = 1.00)., Conclusion: Overall, the adequacy of RIVD is comparable to the postoperatively written NR in reporting surgical steps in LC. However, the most essential surgical step, the circumferential dissection of the cystic duct and artery, was reported more adequately in RIVD., (© 2023. The Author(s).)

Aim: To assess the added value of Near InfraRed Fluorescence (NIRF) imaging during laparoscopic cholecystectomy., Methods: This international multicentre randomized controlled trial included participants with an indication for elective laparoscopic cholecystectomy. Participants were randomised into a NIRF imaging assisted laparoscopic cholecystectomy (NIRF-LC) group and a conventional laparoscopic cholecystectomy (CLC) group. Primary end point was time to 'Critical View of Safety' (CVS). The follow-up period of this study was 90 postoperative days. An expert panel analysed the video recordings after surgery to confirm designated surgical time points., Results: A total of 294 patients were included, of which 143 were randomized in the NIRF-LC and 151 in the CLC group. Baseline characteristics were equally distributed. Time to CVS was on average 19 min and 14 s for the NIRF-LC group and 23 min and 9 s for the CLC group (p 0.032). Time to identification of the CD was 6 min and 47 s and 13 min for NIRF-LC and CLC respectively (p < 0.001). Transition of the CD in the gallbladder was identified after an average of 9 min and 39 s with NIRF-LC, compared to 18 min and 7 s with CLC (p < 0.001). No difference in postoperative length of hospital stay nor occurrence of postoperative complications was found. ICG related complications were limited to one patient who developed a rash after injection of ICG., Conclusion: Use of NIRF imaging in laparoscopic cholecystectomy provides earlier identification of relevant extrahepatic biliary anatomy: earlier achievement of CVS, cystic duct visualisation and visualisation of both cystic duct and cystic artery transition into the gallbladder., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aim: Minimally invasive colorectal surgery reduces surgical trauma with better preservation of abdominal wall integrity, but the extraction site is still at risk of incisional hernia (IH). The aim of this study was to determine pooled incidence of IH for each type of extraction site and to compare rates of IH after midline, nonmidline and Pfannenstiel extraction., Method: A systematic review and meta-analysis was conducted using the PRISMA guidelines. Single-armed and multiple-armed cohort studies and randomized controlled trials regarding minimally invasive colorectal surgery were searched from five databases. Outcomes were pooled and compared with random-effects, inverse-variance models. Risk of bias within the studies was assessed using the Cochrane ROBINS-I and RoB 2 tool., Results: Thirty six studies were included, with a total 11,788 patients. The pooled extraction site IH rate was 16.0% for midline (n = 4081), 9.3% for umbilical (n = 2425), 5.2% for transverse (n = 3213), 9.4% for paramedian (n = 134) and 2.1% for Pfannenstiel (n = 1449). Nonmidline extraction (transverse and paramedian) showed significantly lower odds ratios (ORs) for IH when compared with midline extraction (including umbilical). Pfannenstiel extraction resulted in a significantly lower OR for IH compared with midline [OR 0.12 (0.50-0.30)], transverse [OR 0.25 (0.13-0.50)] and umbilical (OR 0.072 [0.033-0.16]) extraction sites. The risks of surgical site infection, seroma/haematoma or wound dehiscence were not significantly different in any of the analyses., Conclusion: Pfannenstiel extraction is the preferred method in minimally invasive colorectal surgery. In cases where Pfannenstiel extraction is not possible, surgeons should avoid specimen extraction in the midline., (© 2022 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Introduction: This study aims to develop a robust preoperative prediction model for anastomotic leakage (AL) after surgical resection for rectal cancer, based on established risk factors and with the power of a large prospective nation-wide population-based study cohort., Materials and Methods: A development cohort was formed by using the DCRA (Dutch ColoRectal Audit), a mandatory population-based repository of all patients who undergo colorectal cancer resection in the Netherlands. Patients aged 18 years or older were included who underwent surgical resection for rectal cancer with primary anastomosis (with or without deviating ileostomy) between 2011 and 2019. Anastomotic leakage was defined as clinically relevant leakage requiring reintervention. Multivariable logistic regression was used to build a prediction model and cross-validation was used to validate the model., Results: A total of 13.175 patients were included for analysis. AL was diagnosed in 1319 patients (10%). A deviating stoma was constructed in 6853 patients (52%). The following variables were identified as significant risk factors and included in the prediction model: gender, age, BMI, ASA classification, neo-adjuvant (chemo)radiotherapy, cT stage, distance of the tumor from anal verge, and deviating ileostomy. The model had a concordance-index of 0.664, which remained 0.658 after cross-validation. In addition, a nomogram was developed., Conclusion: The present study generated a discriminative prediction model based on preoperatively available variables. The proposed score can be used for patient counselling and risk-stratification before undergoing rectal resection for cancer., Competing Interests: Declaration of competing interest On behalf of the REPAIR research group of the Erasmus University Medical Center (Rotterdam, the Netherlands), I am very pleased to send you this manuscript entitled “A preoperative prediction model for anastomotic leakage after rectal cancer resection based on 13.175 patients” for peer review to European Journal of Surgical Oncology on behalf of the following authors V.T. Hoek, M.D, S. Buettner, M.D. Phd.D, C.L. Sparreboom M.D. Ph.D., R. Detering, M.D. Ph.D., A.G. Menon, M.D. Ph.D., G.J. Kleinrensink Ph.D., M.W.J.M. Wouters, M.D. Ph.D., J.F. Lange, M.D. Ph.D., J.K. Wiggers M.D. Ph.D. All authors have read and complied with the author guidelines and did declare there is no conflict of interest., (Copyright © 2022. Published by Elsevier Ltd.)

Background: Tumor resection is the common approach in patients with colorectal malignancy. Profound insight into inflammatory changes that accompany the normal post-operative stress response will establish reference parameters useful for identification of putative complications. Alterations in circulating monocytes might be indicative as these cells are considered to be the most responsive leukocytes to trauma. Therefore, the aim of this study is to assess the monocyte subset kinetic and phenotypic changes in response to surgery., Methods: Fifty patients undergoing colorectal tumor resection were included in a multicenter prospective cohort study. Blood samples were collected early in the morning prior to surgery and the next days through postoperative day three for flowcytometric analysis. Leukocyte subtypes were identified and expression of activation stage-related markers by monocyte subsets was quantified., Results: Changes in leukocyte subset composition and monocyte subset phenotypes were most prominent at the first day postoperatively, after which these parameters typically returned to normal or near-normal preoperative values. The immunophenotypic alterations after surgery were most notable in classical and intermediate monocytes. These included up-regulation of activation markers CD64 and CD62L, but down-regulation of HLA-DR and CD54. Markers of de-activation, CD163 and CD206, were consistently increasingly expressed., Discussion/conclusion: The current study gives detailed insight into the peripheral blood leukocyte response after colorectal cancer surgery. This form of short-term stress induces a rapid and significant redistribution of immune cells. Immunophenotypic alterations in monocytes as a response to surgery suggest a mixed profile of cellular activation and de-activation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Edomskis, Dik, Sparreboom, Nagtzaam, van Oudenaren, Lambrichts, Bayon, van Dongen, Menon, de Graaf, Coene, Lange and Leenen.)

Background: This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial., Methods: Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group., Results: Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan-Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy., Conclusion: Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option., (© 2022. The Author(s).)

Background: Inguinal hernia (IH) repair is a common surgical procedure. Focus has shifted from recurrences to chronic postoperative inguinal pain (CPIP). To assess the natural course of CPIP and identify patient factors influencing the onset of CPIP, an observational registry-based study was performed., Materials and Methods: Data prospectively collected from the Club-Hernie national database was retrieved from 2011 until 2021. Patients who underwent elective surgery for inguinal hernia were divided in an irrelevant pain group and relevant pain group. Relevant pain at one year and two years were compared with patients with irrelevant pain at all-time points (preoperatively, one month, one year and two years). Quality of life questions were compared between relevant pain at one year and two years., Results: 4.016 patients were included in the analysis. Mean age was 65.1 years, 90.3% of patients was male. Factors correlated with CPIP onset were age, gender, ASA, recurrent surgery, surgical technique, nerve handling and fixation type. Relevant pain at one month was a greater risk for CPIP than preoperative pain (12.3% vs 3.6%). In the majority of patients (83.2%) CPIP was ameliorated at two years. Hernia related complaints differed significantly between CPIP at one year and two years., Conclusion: Postoperative pain after one month was a greater risk factor for CPIP development than preoperative pain. CPIP at one year seems to have a different pain etiology than CPIP at two years. Patient and surgical factors influence the onset of CPIP at one year, however the natural course of these complaints shows great decline at two years, largely without reinterventions., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: A successful innovative medical device is not only technically challenging to develop but must also be readily usable to be integrated into health care professionals' daily practice. Through a user-centered design (UCD) approach, usability can be improved. However, this type of approach is not widely implemented from the early stages of medical device development., Objective: The case study presented here shows how UCD may be applied at the very early stage of the design of a disruptive medical device used in a complex hospital environment, while no functional device is available yet. The device under study is a connected sensor system to detect colorectal anastomotic leakage, the most detrimental complication following colorectal surgery, which has a high medical cost. We also aimed to provide usability guidelines for the initial design of other innovative medical devices., Methods: UCD was implemented by actively involving health care professionals and all the industrial partners of the project. The methodology was conducted in 2 European hospitals: Grenoble-Alpes University Hospital (France) and Erasmus Medical Center Rotterdam (the Netherlands). A total of 6 elective colorectal procedures and 5 ward shifts were observed. In total, 4 workshops were conducted with project partners and clinicians. A formative evaluation was performed based on 5 usability tests using nonfunctional prototype systems. The case study was completed within 12 months., Results: Functional specifications were defined for the various components of the medical device: device weight, size, design, device attachment, and display module. These specifications consider the future integration of the medical device into current clinical practice (for use in an operating room and patient follow-up inside the hospital) and interactions between surgeons, nurses, nurse assistants, and patients. By avoiding irrelevant technical development, this approach helps to promote cost-effective design., Conclusions: This paper presents the successful deployment over 12 months of a UCD methodology for the design of an innovative medical device during its early development phase. To help in reusing this methodology to design other innovative medical devices, we suggested best practices based on this case., (©Christel Schwartz-Lasfargues, Camille Roux-Gendron, Pim Edomskis, Isabelle Marque, Yves Bayon, Johan F Lange, Jean Luc Faucheron, Bertrand Trilling. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 08.07.2022.)

Aim: Perioperative anxiety and pain are still prevalent among patients undergoing surgery. Inflammatory bowel disease and colorectal cancer patients are known to have higher anxiety rates than the general population. Perioperatively applied music intervention has been proven to be effective in reducing perioperative anxiety and pain, resulting in a decrease of intra-operative sedative use, postoperative opioid requirement and neurohormonal stress response. IMPROVE evaluates the adherence to music intervention in colorectal perioperative standard care during systematic implementation., Method: The Consolidated Framework for Implementation Research (CFIR) was used for implementation in three steps. This study addresses the first step in which barriers and facilitators for implementing perioperative music were identified by surveying patients who underwent colorectal surgery and healthcare professionals involved in perioperative care. Also, perioperative anxiety scores were assessed and data on perioperative pain was collected from the patients' medical records., Results: Fifty patients and 69 professionals (response rate 68.3%) were surveyed. For patients, all domains of the CFIR were facilitating implementation. The median reported preoperative and postoperative anxiety scores were 4.5 (1.0-7.0) and 3.0 (1.0-5.75) respectively. The median postoperative pain score on the first postoperative day was 2.8 (2.0-3.7). Also, for professionals most domains were facilitating, except for some factors related to work climate and culture among nurses., Conclusions: In this study it was identified that facilitating factors for implementing music in standard perioperative care were more prominent in both patients and healthcare professionals and therefore successful implementation is probable. Also, this study provides a guideline for assessing facilitators and barriers in other settings., (© 2022 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Objective: To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair., Summary Background Data: Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For noncomplex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking., Methods: Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models., Results: Ninety-three studies representing 12,440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% [95% confidence interval (CI): 2.2%-4.2%, n = 11,049] after minimally 12months and 4.1%, (95%CI: 2.9%-5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2%-6.4%, n = 4891) and 5.5% (95%CI: 4.4%-6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair [odds ratios (OR): 0.27, 95%CI: 0.15-0.51, P < 0.001] and equal recurrence rates compared to intraperitoneal onlay mesh (IPOM) repair (OR: 0.92, 95%CI: 0.75-1.12, P = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03 -3.14, P = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7%-2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8%-2.8%, n = 982), albeit based on non-randomized studies., Conclusions: Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except SSI. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Information on the long-term performance of biosynthetic meshes is scarce. This study analyses the performance of biosynthetic mesh (Phasix™) over 24 months., Methods: A prospective, international European multi-center trial is described. Adult patients with a Ventral Hernia Working Group (VHWG) grade 3 incisional hernia larger than 10 cm 2 , scheduled for elective repair, were included. Biosynthetic mesh was placed in sublay position. Short-term outcomes included 3-month surgical site occurrences (SSO), and long-term outcomes comprised hernia recurrence, reoperation, and quality of life assessments until 24 months., Results: Eighty-four patients were treated with biosynthetic mesh. Twenty-two patients (26.2%) developed 34 SSOs, of which 32 occurred within 3 months (primary endpoint). Eight patients (11.0%) developed a hernia recurrence. In 13 patients (15.5%), 14 reoperations took place, of which 6 were performed for hernia recurrence (42.9%), 3 for mesh infection (21.4%), and in 7 of which the mesh was explanted (50%). Compared to baseline, quality of life outcomes showed no significant difference after 24 months. Despite theoretical resorption, 10.7% of patients reported presence of mesh sensation in daily life 24 months after surgery., Conclusion: After 2 years of follow-up, hernia repair with biosynthetic mesh shows manageable SSO rates and favorable recurrence rates in VHWG grade 3 patients. No statistically significant improvement in quality of life or reduction of pain was observed. Few patients report lasting presence of mesh sensation. Results of biosynthetic mesh after longer periods of follow-up on recurrences and remodeling will provide further valuable information to make clear recommendations., Trial Registration: Registered on clinicaltrials.gov (NCT02720042), March 25, 2016., (© 2021. The Author(s).)

Background: The aim of the present study is to present the three years follow-up a randomised controlled trial that compared Hartmann's Procedure (HP) with sigmoidectomy with primary anastomosis (with or without defunctioning ileostomy) (PA) in a randomised design to determine the optimal treatment strategy for perforated diverticulitis with purulent or fecal peritonitis., Methods: Data were prospectively gathered for the first 12 months after randomization and retrospectively collected up to 36 months. The primary long-term endpoint was stoma free rate 36 months after the index procedure. Secondary outcomes were patients with a stoma at 36 months, percentage of stoma reversals, related reinterventions, parastomal/incisional hernia rates, total in hospital days including all readmissions regardless their relation to the intervention, overall morbidity and mortality., Results: Three years follow-up was completed in 119 of the originally 130 included patients, with 57 (48%) in the PA-group and 62 (52%) patients in the HP-group. 36 months stoma free rate was significantly better for patients undergoing PA compared with HP (PA 92% vs HP 81%, hazard ratio 2.326 [95% CI 1.538-3.517]; log-rank p < 0·0001). Stoma reversal rates did not significantly differ (PA 31/40(78%) versus HP 45/61(74%), p = 0.814). Overall cumulative morbidity (PA 21/57(36%) versus HP 30/62(48%), p = 0.266) and mortality (PA 6/57(11%) versus HP 7/62 (11%), p = 1.000) did not differ between groups. However, more parastomal hernias occurred in the HP-group (HP 10/62(16%) vs PA 1/57(2%), p = 0.009) and the mean total in hospital days after three years follow-up was significantly lower in the PA-group compared to the HP-group (PA 14 days (IQR 9.5-22.5) versus HP 17 days (IQR 12.5-27.5)), p = 0.025)., Conclusion: Long-term results showed that in haemodynamically stable, immunocompetent patients primary anastomosis is superior to Hartmann's procedure as treatment for perforated diverticulitis with respect to long-term stoma free rate, overall hospitalization and parastomal hernias., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aim: This study aimed to identify whether CRP-trajectory measurement, including increase in CRP-level of 50 mg/l per day, is an accurate predictor of anastomotic leakage (AL) in patients undergoing resection for rectal cancer., Methods: A prospective multicentre database was used. CRP was recorded on the first three postoperative days. Sensitivity, specificity, positive and negative predictive values, and area under the receiver operator characteristic (ROC) curve were used to analyse performances of CRP-trajectory measurements between postoperative day (POD) 1-2, 2-3, 1-3 and between any two days., Results: A total of 271 patients were included in the study. AL was observed in 12.5% (34/271). Increase in CRP-level of 50 mg/l between POD 1-2 had a negative predictive value of 0.92, specificity of 0.71 and sensitivity of 0.57. Changes in CRP-levels between POD 2-3 were associated with a negative predictive value, specificity and sensitivity of 0.89, 0.93 and 0.26, respectively. Changes in CRP-levels between POD 1-3 showed a negative predictive value of 0.94, specificity of 0.76 and sensitivity of 0.65. In addition, 50 mg/l changes between any two days showed a negative predictive value of 0.92, specificity of 0.66 and sensitivity of 0.62. The area under the ROC curve for all CRP-trajectory measurements ranged from 0.593-0.700., Conclusion: The present study showed that CRP-trajectory between postoperative days lacks predictive value to singularly rule out AL. Early and safe discharge in patients undergoing rectal surgery for adenocarcinoma cannot be guaranteed based on this parameter. High negative predictive values are mainly caused by the relatively low prevalence of AL., (© 2021 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: Incisional hernia (IH) occurs approximately in 15% of patients after midline surgery. Surgical treatment for IHs include a solely open or solely laparoscopic approach with mesh placement. Recently, hybrid (combined laparoscopic and open) approaches have been introduced. This systematic review evaluates perioperative complications of hybrid incisional hernia repair (HIHR)., Methods: EMBASE, Medline via OvidSP, Web of Science, Cochrane and Google Scholar databases were searched. Studies providing data on intra- and postoperative complications in patients who underwent HIHR were included. Data on intra- and postoperative complications were extracted and meta-analyses were performed. Study quality was assessed with the Newcastle Ottowa Scale, ROBINS-I tool, and Cochrane risk of bias. PROSPERO registration: CRD42020175053., Results: Eleven studies (n = 1681 patients) were included. Five studies compared intra-operative complications between HIHR and laparoscopic incisional hernia repair (LIHR) with a pooled incidence of 1.8% in HIHR group and 2.8% in LIHR group (p = 0.13). Comparison of postoperative prevalence of surgical site occurrences (SSOs) (23% versus 26%, p = 0.02) and surgical site occurrences requiring interventions (SSOPIs) (1.5% versus 4.1%, p < 0.01) were in favour of the HIHR group. Overall postoperative complications seemed to occur less frequent in the HIHR group, though no hard statements could be made due to the vast heterogeneity in reporting between studies., Conclusion: Although the majority of studies were retrospective and included a small number of patients, HIHR seemingly led to less SSOs and SSOPIs. This systematic review forms a strong invitation for more randomized controlled trials to confirm the benefits of this approach., (© 2021. The Author(s).)

Background: To obtain tension-free closure for giant incisional hernia repair, anterior or posterior component separation is often performed. In patients with an extreme diameter hernia, anterior component separation and posterior component separation may be combined. The aim of this study was to assess the additional medialization after simultaneous anterior component separation and posterior component separation., Methods: Fresh-frozen post mortem human specimens were used. Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), anterior component separation and posterior component separation, the order in which the component separation techniques were performed was reversed for the contralateral side. Medialization was measured at 3 reference points., Results: Anterior component separation provided most medialization for the anterior rectus sheath, posterior component separation provided most medialization for the posterior rectus sheath. After combined component separation techniques total median medialization ranged between 5.8 and 9.2 cm for the anterior rectus sheath, and between 10.1 and 14.2 cm for the posterior rectus sheath (depending on the level on the abdomen). For the anterior rectus sheath, additional posterior component separation after anterior component separation provided 15% to 16%, and additional anterior component separation after posterior component separation provided 32% to 38% of the total medialization after combined component separation techniques. For the posterior rectus sheath, additional posterior component separation after anterior component separation provided 50% to 59%, and additional anterior component separation after posterior component separation provided 11% to 17% of the total medialization after combined component separation techniques. Retro-rectus dissection alone contributed up to 41% of maximum obtainable medialization., Conclusion: Anterior component separation provided most medialization of the anterior rectus sheath and posterior component separation provided most medialization of the posterior rectus sheath. Combined component separation techniques provide marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)