Concomitant Ventral Hernia Repair and Gastrointestinal Cancer Surgery: A Systematic Review of Approaches and Safety.

Obesity has become a global comorbidity with increasing prevalence over the last decade. It is associated with an elevated risk for the development of ventral hernias. Bariatric surgery aims to address obesity through surgical intervention, which has become increasingly safe over time. However, a comparative meta-analysis with a double-arm evaluation of concomitant ventral hernia repair (VHR) and weight loss surgery is not yet available in the literature. Hence, we performed a systematic review and meta-analysis of simultaneous VHR and bariatric surgery. Cochrane, Embase, Scopus, Scielo, and PubMed were systematically searched for studies comparing concomitant bariatric surgery and VHR with bariatric surgery alone or staged repair. Outcomes assessed for comparative meta-analysis were surgical site infection (SSI), dehiscence, readmission and reoperation, deep venous thrombosis (DVT) and pulmonary embolism (PE), overall mortality, operative time, and length of hospital stay (LOS). SSI was also analyzed separately as a superficial or deep infection. We also performed a single-arm meta-analysis of incarceration within the staged repair groups with a bariatric surgery as the first procedure and a single-arm meta-analysis of recurrence following concomitant bariatric surgery and VHR. Statistical analysis was performed with R Studio. 805 studies were screened and 26 were thoroughly reviewed. Six studies were included, comprising a total of 131,323 patients, of whom 3002 (2.3%) underwent simultaneous bariatric and VHR procedures. Simultaneous repair was associated with an increase of 39.4min (95% CI 26.17 to 52.63; p < 0.01) in the operative time. We found an increased readmission rate for the concomitant procedures (OR 1.48; 95% CI 1.1 to 1.99; p < 0.01), but no differences were found in reoperation rates (OR 2.97; 95% CI 1.0 to 8.84; p = 0.05). Concomitant procedures were also associated with higher DVT (OR 2.54; 95% CI 1.36 to 4.72; p < 0.01) and PE rates compared to separated procedures (OR 3.08; 95% CI 1.57 to 6.05; p < 0.01). No differences were found in overall SSI (OR 1.1; 95% CI 0.59 to 2.12; p = 0.74) and superficial (OR 0.94; 95% CI 0.48 to 1.84; p = 0.86) or deep (OR 7.02; 95% CI 0.36 to 136.1; p = 0.2) SSI. No statistically significant differences were found in dehiscence rates between the groups (OR 0.2; 95% CI 0.01 to 4.16; p = 0.3). Concomitant procedures were associated with an increase of 0.35days in LOS (95% CI 0.1 to 0.59; p = 0.004) and with increased mortality odds (OR 3.99; 95% CI 1.92 to 8.3; p < 0.01). The proportional meta-analysis found an incarceration rate of 22.95 (95% CI 10.9 to 42) for the patients who delayed the VHR and a recurrence rate of 7.61 per 100 patients (95% CI 1.6 to 29.6) for the patients who underwent concomitant surgery. Our systematic review and meta-analysis found an increase in DVT, PE, readmission, operative time, LOS, and mortality for concomitant procedures. Incarceration rates of 22.95 were found for delayed VHR. Further research is needed to analyze individual bariatric surgery and VHR techniques and draw a more precise conclusion on this subject.

Ventral hernias (VH) are frequently encountered in patients with morbid obesity. Concomitant ventral hernia repair (VHR) and bariatric surgery (BS) is practiced but still controversial. Wound-related complications (seroma, hematoma, wound infection) and hernia recurrence rates are possible inhibitor factors. We aimed to estimate the rate of complications from concomitant BS (laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy) and VHR and identify patient subgroups at higher risk of complications from synchronous repair. A retrospective analysis of successive 106 patients who underwent concomitant BS + VHR at our institute (09/2007 to 09/2015) was performed using data from patients' record. Parameters considered were: type of repair (open/laparoscopic and primary closure/mesh), size and type of hernia (< 5cm, 5-10cm, > 10cm and primary/incisional), patient gender and comorbidities. One hundred and six patients underwent concomitant BS and VHR. Fifty-nine had laparoscopic VHR and 47 open. Hernias recurred in 5 (8.47%) laparoscopic and 7 (14.89%) open VHR. Wound-related complications were common in open (15%) vs. laparoscopic (11.7%) VHR. Patients with VH recurrence included 8 (75%) with defects > 5cm, 10 (83%) female, and all had BMI > 45. Six patients had wound infection, 5 of which had type 2 diabetes mellitus. Six patients had hematoma, 5 of which underwent mesh repairs. Finally, four patients developed seroma (BMI > 48, defects > 5cm, laparoscopic mesh repair). Synchronous VHR and BS in a bariatric unit is feasible with low recurrence rate. Laparoscopic VHR has lower complication rates than open, apart from seroma formation. Patients with diabetes have higher risk of infection.

Background/Objectives: Surgical Site Infections (SSIs) rank among the most common complications following stoma takedown and lead to increased morbidity, increased Length of Hospital Stay (LOS), and higher healthcare costs. Negative Pressure Wound Therapy (NPWT) systems have emerged as a promising option for optimizing wound management and minimizing SSI rates. This systematic review and meta-analysis compares postoperative outcomes of NPWT and conventional Non-Pressure Dressings following stoma reversal. Methods: A search of the literature published up to 1 September 2024 was conducted across MEDLINE/PubMed, and the Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus, as well as ClinicalTrials.gov. Only Randomized Controlled Trials (RCTs) were included. The primary outcome was SSI rate, while secondary outcomes included time to complete wound healing, LOS, and patient-reported wound cosmesis. Quality assessment was performed using the Cochrane Risk of Bias 2 (RoB 2) tool. The results were synthesized using means and Standard Deviations for continuous variables, counts and percentages for categorical variables, and presented as Odds Ratios (OR) or Mean Differences (MD) with 95% Confidence Intervals, using random or fixed effects models based on heterogeneity (I2). Results: Six RCTs, including 328 patients, were ultimately eligible for inclusion. No significant difference was revealed in SSI rates between the NPWT and conventional dressing groups (OR = 0.95; 95% CI: 0.27-3.29; p = 0.94; I2 = 38%). Time to complete wound healing was significantly lower in the NPWT group compared to conventional dressings (MD = -3.78 days; 95% CI: -6.29 to -1.27; p = 0.003). Two studies reported a lower rate of wound healing complications other than SSIs in the NPWT group (OR = 0.22; 95% CI: 0.05-1.09; p = 0.06). No substantial differences were observed in terms of LOS (MD = -0.02 days; 95% CI: -1.22 to 1.17; p = 0.97) and patient-reported wound cosmesis (SMD = 0.31; 95% CI: -0.49 to 1.11; p = 0.44). The review's limitations include potential risk of bias, variability in study designs, and heterogeneity between studies. Conclusions: NPWT contributes to improved wound management through reducing wound healing time compared to Non-Pressure Dressings after stoma reversal, although it does not appear to substantially impact SSI rates, LOS, or patient-assessed wound cosmesis. Further large-scale, multicenter RCTs are necessary to validate these results and identify patient populations most likely to benefit from NPWT application.

Closed suction drains (CSD) are commonly used in ventral hernia repair (VHR), with or without prolonged postoperative prophylactic antibiotics (PPA) for the duration of their use. We examine the evidence that PPA with CSD reduce surgical site infection (SSI) in patients undergoing VHR. We also examine the evidence assessing the association between SSI and CSD in VHR. A systematic review of PubMed, CIHNL, and Cochrane databases was performed to identify studies analyzing rates of SSI with CSD in patients undergoing abdominal VHR and related procedures with or without the concomitant use of PPA. The primary outcome was the rate of SSI. Five studies totaling 772 patients were identified, 525 patients were confirmed to have CSD, and 434 patients received prolonged antibiotics while drains were in place. PPA had no significant effect on SSI in two studies and were associated with decreased SSI in one study (Odds ratio 0.235, 95% confidence interval 0.090-0.617, P = 0.003). Two studies documented a higher rate of SSI in patients with CSD (79% vs 49% and 19% vs 10%) on univariate analysis. One study demonstrated a very low risk of SSI despite CSD (4.2%) and another demonstrated no increased risk with or without CSD. The use of drains is not clearly associated with an increased risk of SSI in VHR, and there is limited evidence to support antibiotic use while the drains are in place to decrease the potential risk. Prospective randomized studies are needed to more clearly assess these associations.

BackgroundSurgical antimicrobial prophylaxis (SAP) is an effective infection prevention strategy used to reduce postoperative surgical site infection. Inappropriate use of SAP is a concern in low-middle-income countries (LMICs) due to increased mortality risks, adverse reactions, re-admission rates and length of hospital stay. Antimicrobial Stewardship Programs (ASP) have been shown to be effective in improving the appropriate use of antibiotics including the use of SAP. The aim of this review was to evaluate the impact of ASP on the appropriate use of SAP and its implication on patient outcomes in LMICs.MethodThe protocol for this review was registered in PROSPERO. Studies published between 1st January 2010 and 31st December 2023 were searched electronically from Medline, Central Cochrane Library, web of science, CINAHL and APA PsychInfo databases. Studies were included if they assessed the impact of ASP interventions on SAP use in low- and middle-income countries (LMICs). Studies were evaluated using the Risk of Bias in Non-Randomized Studies–of Interventions (ROBINS-I) tool for non-randomized and before and after studies as well as the Cochrane Risk of Bias 2 (ROB 2) tool for randomized studies. Findings were summarized in tables.ResultsTwenty studies comprising of seventeen before-after studies, two interrupted time series, and one randomized controlled trial were included. Penicillins and cephalosporins were the most commonly used antibiotics for SAP. Most (50%) of the studies were conducted in Asia followed by Africa (45%). While 80% of the studies showed the impact of ASP on compliance to SAP guidelines, only 45% showed an impact on antibiotic utilization. Again, 50% and 60% showed an impact on reducing antibiotic costs and patient length of stay at hospitals respectively. Patient outcomes including rates of surgical site infections and mortality showed no significant change. The studies showed a high risk of bias mainly due to the choice of study designs.ConclusionASP interventions in LMICs are effective in improving SAP guideline adherence, antibiotic utilization and their cost. Deliberate effort must be made to improve on the quality of future interventional studies in these settings to guide practice and encourage other LMICs to conduct such studies to assess the influence of different geographical contexts on SAP use.

Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair. A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma. Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger's test showed the absence of publication bias in the study outcomes. This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair. ID CRD42024517640.

Open ventral hernia repair (VHR) is often performed in conjunction with other abdominal procedures. Clinical outcomes and financial implications of VHR are becoming better understood; however, financial implications of concomitant VHR during other abdominal procedures are unknown. This study aimed to evaluate the financial implications of adding VHR to open abdominal procedures. This IRB-approved study retrospectively reviewed hospital costs to 180-day post-discharge of standalone VHRs, isolated open abdominal surgeries (bowel resection or stoma closure, removal of infected mesh, hysterectomy or oophorectomy, panniculectomy or abdominoplasty, open appendectomy or cholecystectomy), performed at our institution from October 1, 2011 to September 30, 2014. The perioperative risk data were obtained from the local National Surgery Quality Improvement Program (NSQIP) database, and resource utilization data were obtained from the hospital cost accounting system. 345 VHRs, 1389 open abdominal procedures as described, and 104 concomitant open abdominal and VHR cases were analyzed. The VHR-only group had lower ASA Class, shorter operative duration, and a higher percentage of hernias repaired via separation of components than the concomitant group (p < 0.001). The median hospital cost for VHR-alone was $12,900 (IQR: $9500-$20,700). There were significant increases to in-hospital costs when VHR was combined with removing an infected mesh (63%) or with bowel resections or stoma closures (0.7%). The addition of VHR did not cause a significant change in 180-day post-discharge costs for any of the procedures. This study noted decreased costs when combining VHR with panniculectomy or abdominoplasty and hysterectomy or oophorectomy. For removal of infected mesh and bowel resection or stoma closure, waiting, when feasible, is recommended. Given the impending changes in financial reimbursements in healthcare in the United States, it is prudent that future studies evaluate further the clinical and fiscal benefit of concomitant procedures.

Background: Ventral hernia repair (VHR) is one of the most common surgical procedures performed in the United States. Surgical site infections (SSI) carry significant morbidity for the patient and pose a very challenging problem for the surgeon, associated with up to 6.6% of cases. Thus, surgeons should be well versed in the risk factors implicated in SSI after VHR. Given the high burden of diabetes, obesity, and smoking in our patient population, we sought to study the rate of SSI and the risk factors that led to SSI in our population. Study Design: This is a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for the years 2014-2019. We identified patients who underwent VHR at a single institution in the Bronx, New York. The rate of SSI was calculated, and then, risk factors for SSI were identified using logistic regression analysis. Results: A total of 3936 patients underwent VHR. Incisional hernias made up 41% of the cohort, and there were 37.4% laparoscopic repairs. During the 30-day follow-up, SSI was identified in 101 patients (2.6%). Factors associated with SSI include emergent surgery (adjusted odds ratio [aOR] = 2.57), body mass index >35 kg/m2 (aOR = 2.38), insulin-dependent diabetes mellitus (aOR = 2.36), and incisional hernia (aOR = 1.81). In addition, a laparoscopic approach was found to be a protective factor (aOR = 0.43, 95% confidence interval 0.25-0.75). Surprisingly, different from other studies, smoking cigarettes was not associated with SSI in our cohort. Conclusions: The rate of SSI after VHR in our institution is 2.6%, which is within that reported in the literature. Most of the variables associated with SSI are modifiable and are similar to those previously reported. Laparoscopic repairs appear to be protective for its occurrence.

Previous Methicillin-Resistant Staphylococcus aureus Infection Independent of Body Site Increases Odds of Surgical Site Infection after Ventral Hernia Repair

Immunonutrition (IMN) in gastrointestinal (GI) cancer surgery remains under-utilised and contentious. Despite previous meta-analysis reporting benefit, most recent randomised control trials (RCTs) have failed to demonstrate this and have recommended against its routine use. A contemporary meta-analysis may contribute to the recommendations for immunonutrition use and help select which patients may benefit. The objective of this study was to review IMN and its impact on post-operative outcomes in GI cancer surgery, exploring its role in both malnourished and non-malnourished populations, the optimal dose to use, cancer type of patients using IMN and the timing of IMN relative to the peri-operative period. The EMBASE and Medline databases were searched from 2000 to 2022 for RCTs evaluating IMN in adults undergoing GI cancer surgery. Thirty-seven studies were included (22 pre-operative IMN studies, 11 peri-operative IMN trials and 9 post-operative IMN trials; 4 trials had multiple IMN protocols) that reported on 3793 patients. The main outcome of post-operative infectious complications was reduced with IMN [odds ratio (OR) 0.58, 95% confidence interval (CI) 0.47-0.72]. This association was significant in subgroup analysis only with pre-operative and peri-operative administration and in trials including upper GI cancers, colorectal cancer and 'mixed GI' cancer populations, and significance was independent of nutritional status. IMN in pooled analysis reduced surgical site infection (SSI) (OR 0.65, 95% CI 0.52-0.81), anastomotic leak (OR 0.67, 95% CI 0.47-0.93) and length of stay (LOS) by 1.94 days (95% CI -3 to -0.87). Immunonutrition was associated with reduced post-operative complications. Peri-operative administration may be the preferred strategy in reducing infectious complications, anastomotic leak, SSI and LOS.

Vaginal antiseptic preparation at the time of hysterectomy: a systematic review and meta-analysis.

The national nosocomial surveillance network in Hungary: results of two years of surgical site infection surveillance

Investigation of the incidence of wound healing disorders in operative material and that of possible commonality with the nosocomial categories of operations and with the surgical site infections registered by the authors, respectively. OPERATIVE MATERIAL AND METHOD: The data of 33,336 operations, made in their ward, are analysed by the authors. By way of introduction the question of nomenclature is discussed which is not uniform in the literature. Referring to the most accepted infection surveillance systems they state that wound healing disorders represent a different idea than surgical site infections. The method of their prospective investigation is described as follows: at the time of the emission of the patient every wound healing disorder is registered in a collective protocol and in a short case history. Then they are monthly summarised. The data were elaborated in one year, in 5 years, in 10 years and in 20 years grouping interconnected with the nosocomial categories of the operations, and with the surgical site infections observed in the same period of time. The numerical results are debated in detail. These show that the 20-year summarised rate of wound healing disorders amounts to 2.2% and that of surgical site infections to 2.7%. They point out that the rates of both wound healing disorders and surgical site infections are diminishing during the second half of observation. The former is related to the improved surgical technique and to the better operative circumstances introduced during the observed two decades. The latter can be a consequence of their prospective infection register based on the CDC ad HELICS systems. Up till now no information could be found by them in the literature concerning the interaction of wound healing disorders with the nosocomial categories of the performed operations. The author's new establishment: as proceeding from category "A" towards category "D", not only the rates of surgical site infections became greater and greater, but those of wound healing disorders, too. But there is an important difference: the increase of the rates of wound healing disorders is in general meaningfully less than that of surgical site infections. Concerning the interaction of wound healing disorders with surgical site infections also another original observation was made by them: if the rate of surgical site infections is less than 2%, the identical rate of wound healing disorders is greater than the rate of surgical site infections and vice versa. If the rate of surgical site infections is greater than 2%, the rate of wound healing disorders becomes less than the rate of site infections. In conclusion the authors think that this relationship between the two sorts of rates - which can be seen in the majority (82.5%) of the rates of wound healing disorders and identical surgical site infections - seems to be fundamental. The interpretation of this observation can be done as follows: all wound healing disorders represent "loci minoris resistentiae" concerning the infection. They don't suppurate, or they scarcely suppurate in the aseptic category "A" and in the facultative septic category "B". On the other hand, more and more of their proportion becomes suppurated in the septic category "C", and even more in the seriously septic category "D". Finally they refer to their guessing, whereby, in an adequate context, the rates of wound healing disorders could be perhaps new indicators in surgical quality assurance.

Background: Surgical site infection (SSI) describes an infectious complication of surgical wounds. Although SSI is thought to be preventable, it still represents a major cause of morbidity and substantial economic burden on the health system. Wound irrigation (WI) might reduce the level of bacterial contamination, but current data on its role in reducing or preventing SSI is conflicting. Our aim was to investigate the effectiveness of WI with normal saline prior to wound closure for the reduction of SSI in patients undergoing abdominal surgery. Methods: We conducted a systematic literature search in MEDLINE, EMBASE, and CENTRAL from inception to present, and cross-checked the reference lists of all included primary studies and relevant systematic reviews. (Quasi-) randomized controlled trials (RCTs) investigating the rate of SSI when using normal saline vs. no irrigation prior to wound closure following abdominal surgery were included. Primary outcome was the rate of SSI, secondary outcome the mean length of hospital stay (LOS). Results: Four RCTs including a total of 1,260 patients were included for analysis. All studies compared wound irrigation with normal saline with no wound irrigation prior to wound closure. Their risk of bias was moderate. The relative risk of developing a SSI was lower when wound irrigation with normal saline was performed prior to wound closure although the effect was not statistically significant (risk ratio 0.73, 95%-confidence level: 0.37 to 1.43). Similarly, there was no difference in the LOS amongst both intervention arms. Conclusion: This systematic review could not identify an advantage for routine wound irrigation with normal saline over no irrigation prior to wound closure in preventing or reducing the rate of SSI. Funding Statement: Author's declare None. Declaration of Interests: The authors state The authors have no interest of conflict.

Chlorhexidine-alcohol versus povidone-iodine for pre-operative skin preparation: A systematic review and meta-analysis