Surgical Recurrence Research Articles

A Comprehensive, Evidence-Based Literature Review of the Surgical Treatment of Rectus Diastasis.

Rectus diastasis is a common condition that can result in a protruding abdomen, causing cosmetic and functional disability. Although it is usually repaired during abdominoplasty or herniorrhaphy, there is a lack of consensus with regard to the repair indications and optimal surgical techniques. The goal of this study is to provide an updated review of the surgical techniques used for rectus diastasis repair and their comparative efficacy. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, Embase, and Cochrane databases were searched for articles that discussed the surgical management of rectus diastasis and reported on either outcomes, complications, or recurrence rates. Data detailing surgical techniques were extracted, and pooled analyses of complication and recurrence rates were performed, controlling for surgical approach, common variations in technique, and an associated herniorrhaphy. Thirty-seven studies describing 45 techniques were included. An open rectus diastasis repair was performed in 24 of the studies. After controlling for an associated herniorrhaphy, there was no statistically significant difference in surgical complication and recurrence rates between open and laparoscopic approaches (p = 0.165 and p = 0.133, respectively). Although a double-layer suture closure was associated with a significantly lower rate of complications (p = 0.002), no significant difference was found for suture type absorbability. Surgical repair of rectus diastasis is safe and effective through both open and laparoscopic approaches. Although suture type absorbability does not affect complication or recurrence rates, a double-layer suture closure can decrease surgical complications. The pooled analysis of complication and recurrence rates can help improve informed consent and patient education.

Thoracic Endometriosis: A Review Comparing 480 Patients Based on Catamenial and Non-Catamenial Presentation

Study Objective To revisit thoracic endometriosis cases in literature and compare symptoms, diagnosis, pathology, treatment and follow-up based on the catamenial or non-catamenial nature of the disease. Design A PubMed/MEDLINE search was conducted using the key words: diaphragm endometriosis, thoracic endometriosis, thoracic endometriosis syndrome, catamenial pneumothorax. Setting n/a Patients or Participants 480 cases of thoracic endometriosis were included in this review. 61 presented with non-catamenial symptoms and 419 had catamenial symptoms. Patients were compared based on the presence of chest pain, dyspnea, hemoptysis, pneumothorax history, pneumothorax type, use and types of imaging techniques, pre- and postoperative medication, type of surgery, presence of endometriosis in pathological evaluation, location of thoracic endometriosis, follow-up period and recurrence. Interventions Types of surgeries evaluated in this review were laparoscopy (LS), laparotomy (LT), video-assisted thoracoscopic surgery (VATS), thoracotomy. Measurements and Main Results A significantly higher number of patients presented with preoperative chest pain (79.7%), dyspnea (52.2%) and pneumothorax (78.9%) in the catamenial group (p <0.001). Pneumothorax occurred more frequently on the right side in both groups. 285 patients (68%) in the catamenial group received a positive imaging finding whereas this number was significantly less in the non-catamenial group (59%, p = 0.003). Majority of patients in both groups didn't receive any pre-/post-operative medication. VATS was the most common surgery in the catamenial group (56.6%). Whereas LT/LS was more frequently performed in the non-catamenial group (70.5%). Majority of the patients in both groups received a pathological finding of endometriosis Conclusion Catamenial and non-catamenial nature of the disease caused a significant difference in presenting symptoms, preoperative evaluation, surgical and medical treatment and recurrence. Although most of patients presented with catamenial disease, majority of the non-catamenial patients also received a positive pathological finding. Therefore, it is important to keep thoracic endometriosis in mind when dealing with patients with non-catamenial symptoms. To revisit thoracic endometriosis cases in literature and compare symptoms, diagnosis, pathology, treatment and follow-up based on the catamenial or non-catamenial nature of the disease. A PubMed/MEDLINE search was conducted using the key words: diaphragm endometriosis, thoracic endometriosis, thoracic endometriosis syndrome, catamenial pneumothorax. n/a 480 cases of thoracic endometriosis were included in this review. 61 presented with non-catamenial symptoms and 419 had catamenial symptoms. Patients were compared based on the presence of chest pain, dyspnea, hemoptysis, pneumothorax history, pneumothorax type, use and types of imaging techniques, pre- and postoperative medication, type of surgery, presence of endometriosis in pathological evaluation, location of thoracic endometriosis, follow-up period and recurrence. Types of surgeries evaluated in this review were laparoscopy (LS), laparotomy (LT), video-assisted thoracoscopic surgery (VATS), thoracotomy. A significantly higher number of patients presented with preoperative chest pain (79.7%), dyspnea (52.2%) and pneumothorax (78.9%) in the catamenial group (p <0.001). Pneumothorax occurred more frequently on the right side in both groups. 285 patients (68%) in the catamenial group received a positive imaging finding whereas this number was significantly less in the non-catamenial group (59%, p = 0.003). Majority of patients in both groups didn't receive any pre-/post-operative medication. VATS was the most common surgery in the catamenial group (56.6%). Whereas LT/LS was more frequently performed in the non-catamenial group (70.5%). Majority of the patients in both groups received a pathological finding of endometriosis Catamenial and non-catamenial nature of the disease caused a significant difference in presenting symptoms, preoperative evaluation, surgical and medical treatment and recurrence. Although most of patients presented with catamenial disease, majority of the non-catamenial patients also received a positive pathological finding. Therefore, it is important to keep thoracic endometriosis in mind when dealing with patients with non-catamenial symptoms.

Abdominal Dermis-Fat Graft Versus Conventional Temporalis Myofascial Flap Interposition in Temporomandibular Joint Ankylosis: A Prospective Clinical Comparative Study.

Temporomandibular joint (TMJ) ankylosis is an extremely disabling condition with almost complete inability to open the jaws causing difficulty in chewing, speech, poor oral hygiene and cosmetic disfigurement. Temporalis myofascial flap still remains the most common interpositional material used; however, patients usually complain of pain during movement, unesthetic bulging in the temporal region and trismus due to scar contracture. The main aim of the study was to evaluate the efficacy of abdominal dermis-fat graft and compare it with temporalis myofascial flap as to see which of the two grafts offers more advantages and provides better postoperative results following TMJ ankylosis surgery. A total of 30 diagnosed cases of TMJ ankylosis were randomly divided into two groups of 15 patients each. All the patients underwent TMJ ankylosis release under general anesthesia followed by abdominal dermis-fat interposition in Group A and temporalis muscle in Group B. The patients were assessed for pre-operative and postoperative mouth opening (immediate and 6month postoperative), pain during physiotherapy, donor and surgical site complications and recurrence of ankylosis. The mean maximum inter-incisal opening in dermis-fat group was significantly higher than temporalis group both at immediate and 6month postoperative periods (p = 0.041, 0.001). Physiotherapy was less painful in dermis-fat group than in temporalis group, and the differences in VAS scores among the 2 groups showed high statistical significance (p < 0.001). Hypertrophic scar developed at the donor site in 2 patients in dermis-fat group; however, it was located below the beltline and hardly noticeable. A total of 9 patients (4 in Group A and 5 in Group B) developed temporary facial nerve weakness, and no case of re-ankylosis was noted in either group. Dermis-fat graft in temporomandibular joint ankylosis showed better results than conventional temporalis myofascial flap in terms of postoperative mouth opening, physiotherapy and jaw function with esthetically acceptable results.

Temporal Bone Adenoma: A Comprehensive Analysis of Clinical Aspects and Surgical Outcome on a Very Rare Entity.

Objective The aim of this study is to present our experience in dealing with middle ear adenomas (MEAs), very rare tumors of the middle ear. Methods The medical notes of individuals with MEAs treated in tertiary referral; academic settings were retrospectively reviewed. We recorded the presenting symptoms, imaging findings, and pathology results. We additionally examined our surgical outcomes, follow-up period, recurrence, and morbidity. Results We identified four patients with MEAs: two males and two females with an average age of 36.25 years (range = 27-51 years). Despite the detailed imaging studies, including computed tomography and magnetic resonance imaging with intravenous contrast administration, a biopsy was essential in setting the diagnosis. Total surgical resection was achieved in all patients without any recurrence over an average of 6 years (range = 3-10 years). Complete ipsilateral deafness was the commonest surgical morbidity due to footplate infiltration by the tumor. Conclusion Total surgical resection is the treatment of choice in MEAs to minimize the risk for recurrence; this can come with morbidity, mostly sensorineural deafness. Given the very limited literature, long-term follow-up is recommended.

Impact of Preoperative Metatarsus Adductus on Surgical Correction after Triplanar Tarsometatarsal Arthrodesis

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Early radiographic outcomes of hallux valgus correction focusing on multiplanar deformity have shown promising results. Surgical correction for patients with preexisting metatarsus adductus is considered more challenging and results in higher recurrence rates following hallux valgus surgery. The purpose of this study was to evaluate the impact of preoperative metatarsus adductus on surgical correction following triplanar first tarsometatarsal (TMT) arthrodesis with early weightbearing for hallux valgus.Methods:A retrospective review was performed of 57 patients (62 feet) aged 39.7 +- 18.9 years who underwent triplanar first TMT arthrodesis between 2015 and 2017 at four institutions. After the operation, patients were allowed early full weightbearing in a walking boot. Patients were grouped based on preoperative metatarsus adductus angles for comparison. Preoperative imaging was reviewed and compared to radiographic imaging at 12 months postoperative. Hallux valgus angle (HVA), intermetatarsal angle (IMA), tibial sesamoid position (TSP), lateral round sign, and sesamoid subluxation (axial) were evaluated. For statistical analysis, one-way analysis of variance (ANOVA) and chi-square tests were performed using JMP 11.0.0 (SAS Institute Inc., Cary, NC).Results:Patients with a preoperative metatarsus adductus angle greater than 20 degrees had significantly higher HVA at 12 months (p = 0.0165). There were no differences in IMA or TSP at 12 months based on preoperative metatarsus adductus (p = 0.7687 and p = 0.8703, respectively). Overall recurrence rate for hallux valgus was 3.2% (2/62 patients), and both of these patients had a preoperative metatarsus adductus greater than 20 degrees. There was significantly more sesamoid axial subluxation at 12 months for patients with preoperative metatarsus adductus greater than 20 degrees (p = 0.0092). Overall, the symptomatic non- union rate was 1.7% (1/62 patients).Conclusion:Preoperative metatarsus adductus greater than 20 degrees resulted in higher HVA and recurrence rates at 12 months after triplanar tarsometatarsal arthrodesis. For patients with preexisting metatarsus adductus, additional consideration should be given to ensure the sesamoids are properly reduced under the crista. Future studies should compare the long-term impact of metatarsus adductus on surgical correction, recurrence, and complications after triplanar tarsometatarsal arthrodesis.

Inflammatory markers for predicting surgical outcome and recurrence in ovarian cancer

Inflammatory markers for predicting surgical outcome and recurrence in ovarian cancer

Analysis of pathological and clinical characteristics of cervical conization according to age group in Japan

ObjectiveWith increased screening, more patients with precancerous or early cervical cancer are now being identified. Age at pregnancy, and thus number of patients requiring fertility preservation, have also increased, resulting in more diagnostic and therapeutic cervical conization (conization) procedures. We here investigated the pathological and clinical characteristics of patients undergoing conization, with a focus on age. The objectives of our study were to identify the risk factors potentially involved in cervical intraepithelial neoplasia (CIN) recurrence or persistence, additional treatment after conization, the effects of conization on pregnancy, and the actual status of conization in Japan. Study designA “Subcommittee for Investigation of Cervical Conization” within the Gynecologic Oncology Committee in the Japan Society of Obstetrics and Gynecology investigated pathological and clinical characteristics of conization at 205 institutions in Japan. We analyzed pathological and clinical characteristics according to age ≤50 and >50 years. ResultsPatients aged 20–40 years accounted for 12904 (87%) of the 14,832 study patients (median: 37 years, range: 16–88 years). However, 1838 (12.4%) were aged >50 years. The commonest post-operative diagnosis was CIN grade 3 in all age groups. Rates of invasive cancer, post-operative detection of more advanced lesions, positive surgical margins, additional treatment, and recurrence were significantly higher in patients aged ≥50 years than those aged <50 years (all p < 0.01), whereas rates of post-operative complications did not differ significantly between age groups. The relationship between cerclage and the incidence of amniorrhexis or premature birth did not differ significantly in any age group. ConclusionPost-conization management of patients aged ≥50 years requires considering the high rates of detection of more advanced lesions post-operatively, positive surgical margins, and recurrence. Cerclage should not be performed post-conization without careful consideration.

Microsurgical Excision of Olfactory Groove Meningiomas, Comparative Studies of Different Surgical Approaches

Introduction: To review the surgical approaches, techniques, outcomes and recurrence rates in a series of 11 olfactory groove meningioma (OGM) patients operated from January 2010 to April 2019. Methods: Eleven patients underwent craniotomy and micro-neurosurgical removal of olfactory groove meningioma. Tumor diameter varied from 5 to 8.5 cm among 11 cases, 2 cases underwent Transglabellar/ Subcranial approach, 3 cases by bifrontal approach, 1 case unifrontal approach, 2 extended endonasal and 3 cases fronto-lateral approach. Result: Total removal was possible in all cases except 2 cases. Histopathology revealed typical meningioma (WHO grade 1). There was 1 operative mortality and no permanent focal neurological deficit except anosmia. 3 patients developed CSF leak and two cases meningitis which were resolved by lumber drain and antibiotic therapy. Conclusion: Extended endonasal approach or transglabellar/ subcranial approach were sufficient for gross total removal of OGM which is associated with bony hyperostosis, paranasal extension and optic canal. Bang. J Neurosurgery 2020; 10(1): 9-19

Surgical Treatment for Crohn's Disease: A Role of Kono-S Anastomosis in the West.

More than 80% of patients with Crohn's disease (CD) will require surgical intervention during their lifetime, with high rates of anastomotic recurrence and stenosis necessitating repeat surgery. Current data show that pharmacotherapy has not significantly improved the natural history of postoperative clinical and surgical recurrence of CD. In 2003, antimesenteric hand-sewn functional end-to-end (Kono-S) anastomosis was first performed in Japan. This technique has yielded very desirable outcomes in terms of reducing the incidence of anastomotic surgical recurrence. The most recent follow-up of these patients showed that very few had developed surgical recurrence. This new approach is superior to stapled functional end-to-end anastomosis because the stumps are sutured together to create a stabilizing structure (a "supporting column"), serving as a supportive backbone of the anastomosis to help prevent distortion of the anastomotic lumen due to disease recurrence and subsequent clinical symptoms. This technique requires careful mesenteric excision for optimal preservation of the blood supply and innervation. It also results in a very wide anastomotic lumen on the antimesenteric side. The Kono-S technique has shown efficacy in preventing surgical recurrence and the potential to become the new standard of care for intestinal CD.

Management of abdominal wound dehiscence: update of the literature and meta-analysis.

Abdominal wound dehiscence (AWD) is associated with significant morbidity and mortality. We aimed to provide a contemporary overview of management strategies for AWD. PubMed, EMBASE, the Cochrane library and a clinical trials registry were searched from 2009 onwards using the key words "abdominal wound dehiscence", "fascial dehiscence" and "burst abdomen". Study outcomes included surgical site infection (SSI), recurrence, incisional hernia and 30-day mortality. Studies reported by the EHS clinical guidelines on AWD were included and compared with. OpenMetaAnalyst was used for meta-analysis to calculate statistical significance and odds ratios (OR). Nineteenstudies were includedreporting on a total of 632 patients: 16 retrospective studies, one early terminated randomized controlled trial, one review and the European Hernia Society guidelines. Nine studies reported use of synthetic mesh (n = 241), two of which used vacuum-assisted mesh-mediated fascial traction (VAWCM) (n = 19), six without VAWCM (n = 198) and one used synthetic mesh with both VAWCM (n = 6) and without VAWCM (n = 18); two used biological mesh (n = 19). Seven studies reported primary suture closure (n = 299). Three studies reported on an alternative method (n = 91). Follow-up ranged between 1 and 96months. Meta-analysis was performed to compare the primary suture group with the synthetic mesh group. Heterogeneity was low to moderate depending on outcome. The overall SSI rate in the primary suture group was 27.6% versus 27.9% in the synthetic mesh group, resulting in mesh explantation in five patients; OR 0.65 (95% CI 0.23-1.81). Incisional hernia rates were 11.1% in the synthetic mesh group (19/171) and 30.7% in the primary suture group (67/218); OR 4.01 (95% CI 1.70-9.46). Recurrence rate did not show a statistically significant difference at 2.7% in the synthetic mesh group (3/112), compared to 10.2% in the primary suture group (21/206); OR 1.81 (95% CI 0.18-17.80). Mortality rates varied between 11.2% and 16.7% for primary suture group versus synthetic mesh; OR 1.85 (95% CI 0.91-3.76). Included studies were of low to very low quality. The use of synthetic mesh results in a significantly lower rate of incisional hernia, whereas SSI rate was comparable to primary suture repair.

Shave Excision Versus Elliptical Excision of Nonpigmented Intradermal Melanocytic Nevi: Comparative Assessment of Recurrence and Cosmetic Outcomes

Nonpigmented intradermal melanocytic nevi (IMN) are benign lesions often removed for cosmetic reasons. There is no consensus as to the best technique for IMN excision. To compare cosmetic outcomes and risk of recurrence after shave excision versus elliptical excision of IMN. In this randomized clinical trial, patients underwent shave excision or elliptical excision with sutured closure of IMN of the face or back. Recurrence, patient satisfaction, cosmetic outcome, postoperative discomfort, scar size, discoloration, and presence of hypertrophic or keloid scars were evaluated at 3, 6, and 9 months. Overall, 145 nevi were removed from 45 patients (86.7% women, mean age 52.1 ± 12.5 years). The recurrence rate was 11.7%, occurring only after shave excision; 94.1% of recurrences were observed at 3-month follow-up. Shave excision was associated with less discomfort 48 hours after intervention but a greater likelihood of involved lateral and deep margins (p < .001). Scars were larger after elliptical excision and suture than after shave excision (p < .01). The mean patient satisfaction was higher in the shave excision group (p < .004). Shave excision of IMN is associated with higher rates of involved surgical margins and recurrence than elliptical excision but provides superior cosmesis and patient satisfaction.

Kono-S anastomosis for Crohn's disease: a systemic review, meta-analysis, and meta-regression.

The Kono-S anastomosis was introduced in 2011 as an alternative anastomosis in Crohn's disease (CD) surgery. Since then, prevailing evidence of the favorable results of the Kono-S anastomosis has been published from around the world. We conducted this study to analyze the effectiveness of the Kono-S anastomosis, by searching Medline, Embase, CNKI, and google scholar. Binominal data were analyzed after Freeman-Tukey double-arcsine transformation. Comparative data were analyzed using the Mantel-Haenszel model for dichotomous outcomes and the mean difference for continuous outcomes. We identified 676 patients who underwent surgery with a Kono-S anastomosis. Surgical recurrence was pooled at an average of 0% (CI: 0.00-0.01) and a reduced mean Rutgeerts score of 1.375 (CI: 0.727-2.023) after Kono-S anastomosis. Endoscopic recurrence after sensitivity analysis was 5% (CI: 0.00-0.15). Complications were rare, with a 3% incidence of ileus (CI: 0.01-0.05), a 4% incidence of small bowel obstruction (CI: 0.01-0.10), a 1% incidence of an anastomotic leak incidence (CI: 0.00-0.03), and a 10% incidence of postoperative infection (CI: 0.03-0.20). Evidence from this meta-analysis favors the Kono-S anastomosis for CD patients, especially for ileocolic anastomosis. Thus, clinicians should consider the applicability of Kono-S anastomosis in respective institutions.

Repair Methods in Parastomal Hernia Surgery

Background-Aim: Parastomal hernias (PSH) are incisional hernias that must be classified separately from the other abdominal wall hernias. The high recurrence rate of PSH is the most important problem after suture repair or relocation of the stoma; whereas open or laparoscopic mesh repair results in much lower recurrence rates. The aim of this study is to investigate PSH predisposing factors, surgical repair methods, postoperative complications and recurrence in surgery practice.&#x0D; Methods: Patient demographics, operation time before the first surgery, operation method, and the recurrence rate seen in patients who underwent PSH surgery in a 10-year time/ period (2008-2018) were investigated from the patient records. Except for emergency cases, 2 years of disease-free time was set for PSH surgery in malignant cases to be sure that no malignancy was present in the time of operation. &#x0D; Results: 14 PSHs were treated surgically using mesh repair in all cases. There were 6 male and 8 female patients with a mean age of 71.7 years (range:45-84;median:78). Open sublay polypropylene mesh placement technique was performed in 12 patients and intraperitoneal composite mesh (using either keyhole or Sugarbaker techniques) was placed laparoscopically in 2 patients. Superficial wound infections were developed in 4 patients (28.5 %) and 2 patients developed recurrence (14.2%).&#x0D; Conclusion: There is no effective method defined for the surgery of PSH but the laparoscopic approach has been proposed as a promising alternative to open technique as it causes less abdominal wall trauma. Whether performed open or laparoscopic; mesh repair is the optimal standard for PSH surgery.

Oncological impact of inflammatory biomarkers in elderly patients treated with radical cystectomy for urothelial bladder cancer

ABSTRACT Objective To evaluate the impact of preoperative markers of systemic inflammation on complications and oncological outcomes in patients aged ≥75 years treated with radical cystectomy (RC) for urothelial bladder cancer (UBC). Patients and methods The clinical data of 694 patients treated with open RC for UBC at our institution between January 2008 and December 2015 were retrospectively reviewed. Patients aged <75 years, with distant metastases, other-than-urothelial histological type, comorbidities that could affect the systemic inflammatory markers, and patients who received neoadjuvant chemotherapy were excluded. Multivariable regression models were built for the prediction of major postoperative surgical complications, disease recurrence, cancer-specific mortality (CSM), and overall mortality (OM). Results The median (interquartile range [IQR]) age at surgery was 79 (75–83) years. Major postoperative surgical complications were registered in 41.9% of the patients. The 5-year overall survival, cancer-specific survival and recurrence-free survival rates were 42.4% (95% confidence interval [CI] 34.7–49.9%), 70.3% (95% CI 62.3–76.9%), and 59.8% (95% CI 52.4–66.5), respectively. At multivariable analysis, higher levels of fibrinogen and a modified Glasgow Prognostic Score (mGPS) of 1 and 2 at baseline were independently associated with higher risk of major postoperative complications and of CSM. The inclusion of mGPS and fibrinogen to a standard multivariable model for recurrence and for CSM increased discrimination from 69.4% to 73.0% and from 71.3% to 73.9%, respectively. Preoperative neutrophil-to-lymphocyte ratio of >3 was independently associated with OM (hazard ratio 1.38, 95% CI 1.01–1.77; P = 0.01). Conclusions In a cohort of elderly patients with UBC treated with RC, fibrinogen and mGPS appeared to be the most relevant prognostic measurements and increased the accuracy of clinicopathological preoperative models to predict major postoperative complications, disease recurrence and mortality. Abbreviations ASA: American Society of Anesthesiologists; CCI: Charlson Comorbidity Index; CIS: carcinoma in situ; CRP: C-reactive protein; CSM: cancer-specific mortality; CSS: cancer-specific survival; ECOG PS: Eastern Cooperative Oncology Group Performance Status; HDL: high-density lipoprotein; (S)HR: (subdistribution) hazard ratio; LND: lymphadenectomy; LVI: lymphovascular invasion; mGPS: modified Glasgow Prognostic Score; NLR: neutrophil-to-lymphocyte ratio; NOC: non-organ-confined; OM: overall mortality; OR: odds ratio; OS: overall survival; RC: radical cystectomy; RNU: radical nephroureterectomy; UBC: urothelial bladder cancer; UTUC: upper urinary tract urothelial carcinoma

Elemental diet therapy plays a significant role in preventing surgical recurrence of Crohn's disease in the era of biologics.

Most patients with Crohn's disease (CD) experience surgical recurrence. In this era of novel therapies, we conducted this study to clarify which treatments effectively decrease the risk of surgical recurrence in patients with CD. The subjects of this retrospective study were 37 patients with CD. We created cumulative surgery rate curves and performed univariate and multivariate analyses. Univariate analysis revealed that patients who consumed an elemental diet (ED; ≥ 900kcal/day), anti-tumor necrosis factor-alpha, and thiopurines had a significantly better prognosis than those who did not (p = 0.011, p = 0.025, and p = 0.0080, respectively). Multivariate analysis revealed that ED therapy and thiopurines were independent significant factors for controlling surgical recurrence (p = 0.046 and p = 0.032, respectively). Additional analyses showed that the most promising ED therapeutic dose was ≥ 1200kcal/day, while an ED therapeutic dose of ≥ 900kcal/day was acceptable. Although univariate analyses revealed that all three treatment strategies had significant effects on surgical recurrence in patients with CD, multivariate analysis revealed that only ED therapy was significantly associated with surgical recurrence rates. Thus, ED therapy plays an important role in the management of CD, even in the era of biological therapies.

Intention-to-treat curative liver resection in patients with "very early" intrahepatic cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC) is a rare type of liver cancer. "Very early" ICC, defined as a solitary lesion of ≤ 2cm in diameter, appears to have a favorable outcome. This study aimed to assess the outcome of patients with "very early" ICC treated with curative surgical resection in an intention-to-treat analysis. All patients with ICC undergoing surgical resection at the Hospital Clínic of Barcelona (Spain) between April 2000 and December 2018 were reviewed, and those with evident "very early" ICC in preoperative imaging studies were selected. Results of histopathologic examination of the surgical specimen, postoperative complications, recurrence, and survival were assessed. Of the 89 patients operated for ICC during the study period, 7 (7.9%) met the "very early" criteria at preoperative imaging. Two (TNM 7th) and four (TNM 8th) patients were classified as stage I, following histological examination of their resected specimens. One patient presented with postoperative morbidity (grade II Clavien-Dindo). The median (IQR) hospital stay was 5days (3-7). After a median follow-up of 23months (IQR 11.9-80.6), recurrence was diagnosed in one case at 8.3months after surgery. The overall survival at 1, 3, and 5years was 85.7%, 68.6%, and 68.6%, respectively. Intention-to-treat curative surgery in "very early" ICC is associated with good results in terms of survival and recurrence. However, most patients presented more advanced stages in the definitive pathological analysis, associated with a lower survival. Future prospective multicenter studies are required to validate these encouraging data.

Desarda’s versus Lichtenstein’s mesh repair for inguinal hernia: A longitudinal study.

Objectives: To compare the tissue based Desarda repair with Lichtenstein mesh technique for inguinal hernia in terms of operation time, hospital stay, return to normal activities, cost and post-operative complications such as seroma formation, surgical site infection and recurrence. Study Design: Randomized Controlled trial. Setting: Department of General Surgery Hayatabad Medical Complex, Peshawar, Pakistan. Period: June 2017 to June 2019. Material &amp; Methods: Total of 150 male patients were selected using Non probability consecutive sampling technique. Patients were randomized into two groups using lottery method. 75 patients in group A underwent hernia repair with Desarda no mesh technique and 75 patients in group B underwent hernia repair by performing Lichtenstein mesh technique. Patients were followed up after 2 weeks, 1 month, 3 months, 6 months and 1 year. Data was evaluated using version 22 of SPSS and expressed as a standard deviation, mean. Independent-sample T test was used to compare continuous variables. Categorical variables were compared using Fischer’s exact test. P value of less than 0.05 was considered significant. Results: The mean age of Desarda group was 44.59±10.58 years while it was 44.44±10.30 years in the Lichtenstein group (P=0.932).Mean Operative time was less for Desarda repair (42.08 ± 3.42 min) when compared to Lichtenstein repair (49.01 ± 4.77min) (p=0.000). The average hospital stay after Desarda repair was 2.08±0.27 days and after Lichtenstein repair it was 3.00±0.40 days (p=0.000). After Desarda procedure the average duration to return to work was 11.10±2.32 days while it was 13.92±2.24 days in Lichtenstein procedure (p&lt;0.0001). The total cost of the operation was (Rs 3893±293) in Desarda group and (Rs 7844±175) in the Lichtenstein group (p=0.000). When compared for observed postoperative complications like seroma, wound infection and recurrence in both groups all the p-values were &gt; 0.05 and were non-significant statistically. Conclusion: In comparison to Lichtenstein mesh repair, Desarda technique is cost effective, easy to learn, patients have less hospital stay, less chances of post-operative complications and early return to basic physical activities However Desarda technique is not possible in patients having thin external oblique aponeurosis with divided fibers and here Lichtenstein technique is better option. Further long term randomized control trials are required on large-scale to evaluate this technique further.

Using the preoperative prognostic nutritional index as a predictive factor for non-cancer-related death in post-curative resection gastric cancer patients: a retrospective cohort study

BackgroundGastric cancer (GC) is the third leading cause of cancer-related mortality worldwide. Therefore, identifying the predictive factors for surgical morbidity, disease recurrence, and long-term survival is necessary for preventing GC patient mortality. We aimed to evaluate the factors that contribute to the poor prognoses of GC patients.MethodsIn this retrospective cohort study, the data of 182 patients who underwent curative gastrectomy for GC was reviewed. The data included patients’ cancer stage and preoperative prognostic nutritional index (PNI) score. We identified the prognostic factors using a univariate analysis and the multivariable Cox proportional hazards model. The associations between PNI and other clinicopathologic factors for GC were compared via logistic regression analysis. Kaplan-Meier curves were used to evaluate patients’ survival in relation to these factors. The median follow-up period was 3.5 years. Multivariable cumulative incidence method based on Fine and Gray’s method was performed to evaluate the association between non GC-related death and potential prognostic factors.ResultsThere were significant differences in overall survival (OS) between comorbidities (myocardial infarction: P = 0.040, liver disease: P = 0.017), cancer stages (I vs. II: P = 0.049, I vs. III: P < 0.001), tumor size (P = 0.002), lymphatic vessel infiltration (P < 0.001), serum CA 19–9 (P = 0.024), and PNI scores (P = 0.002). Moreover, only PNI score was determined to be an independent prognostic factor for survival. Furthermore, stage I GC patients with high PNI scores had significantly longer OS than those with low PNI scores (P < 0.001), but these groups were not significantly different in terms of recurrence-free survival (P = 0.756). Stage II and III GC patients showed no significant difference in terms of OS and recurrence-free survival, regardless of PNI scores. Finally, Fine and Gray’s method revealed that PNI score was an independent prognostic factor for non-GC-related death (P < 0.001).ConclusionsPreoperative PNI is effective in predicting the prognosis of post-curative gastrectomy GC patients and can be used to predict non-GC-related death and the OS of post-curative gastrectomy patients with stage I GC.

Colonoscopy-guided therapy for the prevention of post-operative recurrence of Crohn's disease.

About half of patients with Crohn's disease (CD) require surgery within 10 years of diagnosis. Resection of the affected segment is highly effective, however the majority of patients experience clinical recurrence after surgery. Most of these patients have asymptomatic endoscopic recurrence weeks or months before starting with symptoms. This inflammation can be detected by colonoscopy and is a good predictor of poor prognosis.Therapy guided by colonoscopy could tailor the management and improve the prognosis of postoperative CD. To assess the effects of prophylactic therapy guided by colonoscopy in reducing the postoperative recurrence of CD in adults. The following electronic databases were searched up to 17 December 2019: MEDLINE, Embase, CENTRAL, Clinical Trials.gov, WHO Trial Registry and Cochrane IBD specialized register. Reference lists of included articles, as well as conference proceedings were handsearched. Randomised controlled trials (RCTs), quasi-RCTs and cohort studies comparing colonoscopy-guided management versus management non-guided by colonoscopy. Two review authors independently considered studies for eligibility, extracted the data and assessed study quality. Methodological quality was assessed using both the Cochrane 'Risk of bias' tool for RCTs and Newcastle-Ottawa scale (NOS) for cohort studies. The primary outcome was clinical recurrence. Secondary outcomes included: endoscopic, surgical recurrence and adverse events. We calculated the risk ratio (RR) for each dichotomous outcome and extracted the hazard ratio (HR) for time-to-event outcomes. All estimates were reported with their corresponding 95% confidence interval (CI). Data were analysed on an intention-to-treat (ITT) basis. The overall quality of the evidence was evaluated using GRADE criteria. Two RCTs (237 participants) and five cohort studies (794 participants) met the inclusion criteria. Meta-analysis was not conducted as the studies were highly heterogeneous. We included two comparisons. Intensification of prophylactic-therapy guided by colonoscopy versus intensification guided by clinical recurrence One unblinded RCT and four retrospective cohort studies addressed this comparison. All participants received the same prophylactic therapy immediately after surgery. In the colonoscopy-based management group the therapy was intensified in case of endoscopic recurrence; in the control group the therapy was intensified only in case of symptoms. In the RCT, clinical recurrence (defined as Crohn's Disease Activity Index (CDAI) > 150 points) in the colonoscopy-based management group was 37.7% (46/122) compared to 46.1% (21/52) in the control group at 18 months' follow up (RR 0.82, 95% CI: 0.56 to 1.18, 174 participants, low-certainty evidence). There may be a reduction in endoscopic recurrence at 18 months with colonoscopy-based management (RR 0.73, 95% CI 0.56 to 0.95, 1 RCT, 174 participants, low-certainty evidence). The certainty of the evidence for surgical recurrence was very low, due to only four cohort studies with inconsistent results reporting this outcome. Adverse events at 18 months were similar in both groups, with 82% in the intervention group (100/122) and 86.5% in the control group (45/52) (RR 0.95, 95% CI:0.83 to 1.08, 1 RCT, 174 participants, low-certainty of evidence).The most common adverse events reported were alopecia, wound infection, sensory symptoms, systemic lupus, vasculitis and severe injection site reaction. Perforations or haemorrhages secondary to colonoscopy were not reported. Initiation of prophylactic-therapy guided by colonoscopy versus initiation immediately after surgery An unblinded RCT and two retrospective cohort studies addressed this comparison. The control group received prophylactic therapy immediately after surgery, and in the colonoscopy-based management group the therapy was delayed up to detection of endoscopic recurrence. The effects on clinical and endoscopic recurrence are uncertain (clinical recurrence until week 102: RR 1.16, 95% CI 0.73 to 1.84; endoscopic recurrence at week 102: RR 1.16, 95% CI 0.73 to 1.84; 1 RCT, 63 participants, very low-certainty evidence). Results from one cohort study were similarly uncertain (median follow-up 32 months, 199 participants). The effects on surgical recurrence at a median follow-up of 50 to 55 months were also uncertain in one cohort study (RR 0.79, 95% CI 0.38 to 1.62, 133 participants, very low-certainty evidence). There were fewer adverse events with colonoscopy-based management (54.8% (17/31)) compared with the control group (93.8% (30/32)) but the evidence is very uncertain (RR 0.58, 95% CI 0.42 to 0.82; 1 RCT, 63 participants). Common adverse events were infections, gastrointestinal intolerance, leukopenia, pancreatitis and skin lesions. Perforations or haemorrhages secondary to colonoscopy were not reported. Intensification of prophylactic-therapy guided by colonoscopy may reduce clinical and endoscopic postoperative recurrence of CD compared to intensification guided by symptoms, and there may be little or no difference in adverse effects. We are uncertain whether initiation of therapy guided by colonoscopy impacts postoperative recurrence and adverse events when compared to initiation immediately after surgery, as the certainty of the evidence is very low. Further studies are necessary to improve the certainty of the evidence of this review.

The treatment results of patients with postoperative ventral hernias after multi-stage surgery of open abdominal gunshot wounds (improvement of hernioplasty-technique)

Aim: to compare a new technique of the tension-free abdominal wall repair for postoperative ventral hernia after multi-stage surgery of open abdominal gunshot wounds with the open traditional and laparoscopic approaches.Materials and methods. Treatment results of the 86 patients with postoperative ventral hernias after multi-stage surgery of the open abdominal gunshot wounds, which were divided into 2 groups. The main group included 42 patients in whom surgical treatment was carried out according to the developed method of the tension-free abdominal wall repair for postoperative ventral hernia after multi-stage surgical treatment of the open abdominal gunshot wounds. 1st and 2nd comparison group included 44 patients who were undergone an open traditional allohernioplasty and laparoscopic approaches with the composite mesh installation. Treatment results were followed up until 1 year after surgery.Results. In the main group of patients early postoperative complications were observed in 3 (25.0%): postoperative seroma – 2 (16.7%), postoperative wound infiltrate – 1 (8.3). Among patients of 1st and 2nd comparison group cases of postoperative complications were diagnosed in 11 (61.1%): 2 (11.1%) patients – festering wounds, 4 (22.2%) – peri-implant seroma, 3 (16.7%) – infiltration of the surgical wound, 1 (5.6%) – skin edges necrosis, 1 (5.6%) – failure of sutures of the surgical wound. The recurrences of ventral hernias were obtained in 3 (16.7%) patients from comparison group. However, there were no cases of postoperative ventral hernia recurrence in the main group of patients (p = 0.03).Conclusion. А new technique of the tension-free abdominal wall repair for postoperative ventral hernia without disadvantages after multi-stage surgery of the open abdominal gunshot wounds, which allows to reduce the frequency of postoperative complications of surgical treatment and recurrence of the disease.