Factors influencing wound dehiscence after midline laparotomy

Visceral obesity determined in routine preoperative CT scans predicts risk of postoperative burst abdomen

Burst abdomen (BA) remains a severe postoperative complication after abdominal surgery. Obesity is a known risk factor for postoperative complications but objective parameters such as body mass index fail to predict BA after abdominal surgery. In recent literature, CT-derived body composition assessment could predict obesity-related diseases and surgical site infections. We report data from the institutional wound register, comparing patients with BA to a subgroup of patients without BA. The CT images were evaluated for intraabdominal and subcutaneous fat tissues. Univariate and multivariate risk factor analysis was performed in order to evaluate CT-derived obesity parameters as risk factor for BA. 92 patients with BA were compared to 32 controls. Patients with BA had significantly more visceral obesity (VO; p < 0.001) but less subcutaneous obesity (SCO) on CT scans. VO and SCO both were positively correlated with BMI (r = 0.452 and 0.572) but VO and SCO were inversely correlated (r = -0.189). Multivariate analysis revealed VO as significant risk factor for postoperative BA (OR 1.257; 95% CI 1.084-1.459; p = 0.003). Our analysis of patients with postoperative BA revealed VO as major risk factor for postoperative BA. Thus, preoperative CT scans gives valuable information on possible risk stratification.

[Physical Strain after Abdominal Surgery - Results of a Patient Survey]

INTRODUCTION

Incision hernias are common complications after abdominal surgery and affect the recommendations on postoperative physical strain, as it is thought that excessively early strain causes incisional hernias. However, there is no evidence to justify this. This study evaluates the effect of postoperative strain on the risk of incisional hernia.

MATERIALS AND METHODS

Patients with a laparoscopy (LS) or laparotomy (LT) were asked to complete a questionnaire on postoperative strain, complaints and quality of life. Patients with hernia surgery, or open abdomen therapy for complicated courses (Clavien-Dindo > III) were excluded.

RESULTS

393 patients completed the questionnaire (43.6%). 274 were LS and 128 LT. The incidence of incisional hernias was 5.2% (LS) and 18.0% (LT, p = 0.001). Incisional hernia patients were younger and more commonly males. 30.5% of incisional hernia patients did not return to normal physical strain postoperatively. Abdominal binders did not affect the hernia rate. The incisional hernia patients showed decreased quality of life scores in both mental and physical domains.

CONCLUSION

Early postoperative physical strain was not a risk factor for incisional hernia development in this study. However, prospective studies are needed to create necessary evidence to recommend earlier postoperative return to normal physical strain.

Small bite versus large bite stitching technique for midline laparotomy wound closure: A systematic review and meta-analysis

Mass closure with a continuous suture using large bite stitching technique has been widely accepted for midline laparotomy wound closures. However, emerging evidence suggests the use of small bite technique to reduce rates of incisional ventral hernia, surgical site infection (SSI) and burst abdomen. This meta-analysis aims to compare small versus large bite stitching techniques to assess complication rates in midline laparotomy wound closures. A comprehensive multi-database search (OVID EBM Reviews, OVID Medline, EMBASE, Scopus) was conducted from database inception to 11th October 2021 according to PRISMA guidelines. We included studies comparing post-operative complication rates of small bite versus large bite stitching techniques for midline laparotomy wound closure. Extracted data was pooled for meta-analysis evaluating rates of incisional ventral hernia, SSI and burst abdomen. We included five randomized controlled trials (RCT) in the meta-analysis and three prospective cohort studies for qualitative analysis. A total of 1977 participants composed of 961 small bite and 1016 large bite technique patients were included from the five RCTs. There was a significant reduction in the rates of incisional ventral hernia and SSI with the small bite stitch technique with odds ratios (OR) of 0.39 (95% CI [0.21-0.71]) and 0.68 (95% CI [0.51-0.91]) respectively, and a trend in favour of reduced incidence of burst abdomen with OR of 0.60 (95% CI [0.15-2.48]). Small bite stitch technique in midline laparotomy wound closure may be superior over conventional mass closure using the large bite stitch technique, with statistically significant lower rates of incisional ventral hernia and SSI.

A prospective multicentre study evaluating the outcomes of the abdominal wall dehiscence repair using posterior component separation with transversus abdominis muscle release reinforced by a retro-muscular mesh: filling a step

BACKGROUND

This study aimed to evaluate the results of posterior component separation (CS) and transversus abdominis muscle release (TAR) with retro-muscular mesh reinforcement in patients with primary abdominal wall dehiscence (AWD). The secondary aims were to detect the incidence of postoperative surgical site occurrence and risk factors of incisional hernia (IH) development following AWD repair with posterior CS with TAR reinforced by retromuscular mesh.

METHODS

Between June 2014 and April 2018, 202 patients with grade IA primary AWD (Björck's first classification) following midline laparotomies were treated using posterior CS with TAR release reinforced by a retro-muscular mesh in a prospective multicenter cohort study.

RESULTS

The mean age was 42 ± 10 years, with female predominance (59.9%). The mean time from index surgery (midline laparotomy) to primary AWD was 7 ± 3 days. The mean vertical length of primary AWD was 16 ± 2 cm. The median time from primary AWD occurrence to posterior CS + TAR surgery was 3 ± 1 days. The mean operative time of posterior CS + TAR was 95 ± 12 min. No recurrent AWD occurred. Surgical site infections (SSI), seroma, hematoma, IH, and infected mesh occurred in 7.9%, 12.4%, 2%, 8.9%, and 3%, respectively. Mortality was reported in 2.5%. Old age, male gender, smoking, albumin level < 3.5 gm%, time from AWD to posterior CS + TAR surgery, SSI, ileus, and infected mesh were significantly higher in IH. IH rate was 0.5% and 8.9% at two and three years, respectively. In multivariate logistic regression analyses, the predictors of IH were time from AWD till posterior CS + TAR surgical intervention, ileus, SSI, and infected mesh.

CONCLUSION

Posterior CS with TAR reinforced by retro-muscular mesh insertion resulted in no AWD recurrence, low IH rates, and low mortality of 2.5%. Trial registration Clinical trial: NCT05278117.

Post-operative steroids in patients with patients with severe cerebral palsy undergoing posterior spinal fusion

INTRODUCTION

Posterior spinal fusion (PSF) represents a large physiologic challenge for children with neuromuscular scoliosis (NMS). Perioperative complications are numerous with many occurring in the post-operative period due to pain and relative immobilization. This study assessed the impact of steroids on patients undergoing PSF for NMS.

METHODS

A retrospective review of consecutive patients managed at a single center with PSF for NMS was reviewed. Clinical and radiographic analysis was used to evaluate baseline demographics, curve characteristics, and post-operative course.

RESULTS

Eighty-nine patients who underwent PSF for NMS were included. Fifty-seven of these patients did not receive post-operative steroids (NS) while 32 patients were treated with post-operative steroids (dexamethasone, WS) for a median of 3 doses (median 6.0 mg/dose every 8 h after surgery). The demographic variables of the cohorts were similar with no difference in curve magnitude, number of vertebrae fused, number of osteotomies, or EBL between groups. A 70% decrease in the median post-operative morphine equivalents was observed in the steroid cohort (0.50 mg/kg WS vs 1.65 mg/kg NS, p value < 0.001). There was an association between post-operative morphine equivalents and length of stay (Spearman's rho = 0.22, p value = 0.04). There was no difference in wound healing, infection, and pulmonary or gastrointestinal complications between groups. No difference was found in pain at discharge, 30-day ED returns, or 30-day OR returns between groups.

CONCLUSIONS

Post-operative dexamethasone resulted in a 70% decrease in morphine equivalent use after PSF for NMS without any increase in perioperative wound infections.

LEVEL OF EVIDENCE

Level 3: case-control series.

Fascial dehiscence: predictable complication? Development and validation of a risk model: a retrospective cohort study

PURPOSE

Fascial dehiscence is still an important cause of morbidity and mortality in the postoperative period of abdominal surgery. Different authors have sought to identify risk factors for this entity. Two risk scores have been developed, but they include postoperative variables, which hinder preventive decision-making during the early surgical period. Our aim is to identify preoperative and intraoperative risk factors for fascial dehiscence and to develop and validate a risk prediction score that allows taking preventive behaviors.

METHODS

All adult patients, with no prior history of abdominal surgery, who underwent midline laparotomy by a general surgery division between January 2009 and December 2019 were included. Recognized preoperative risk factors for fascial dehiscence were evaluated in a univariate analysis and subsequently entered in a multivariate stepwise logistic regression model. A prognostic risk model was developed and posteriorly validated by bootstrapping. This study was conducted following the STROBE statement.

RESULTS

A total of 594 patients were included. Fascial dehiscence was detected in 41 patients (6.9%). On multivariate analysis, eight factors were identified: chronic obstructive pulmonary disease (COPD), immunosuppression, smoking, prostatic hyperplasia, anticoagulation use, sepsis, and overweight. The resulting score ranges from 1 to 8. Scores above 3 are predictive of 18% risk of dehiscence with a sensitivity of 70% and specificity of 80% (ROC 0.88).

CONCLUSIONS

We present a new preoperative prognostic score to identify patients with a high risk of fascial dehiscence. It can be a guide for decision-making that allows taking intraoperative preventive measures. External validation is still required.

Continuous and interrupted abdominal-wall closure after primary emergency midline laparotomy (CONIAC-trial): study protocol for a randomised controlled single centre trial

INTRODUCTION

The optimal closure of the abdominal wall after emergency midline laparotomy is still a matter of debate due to lack of evidence. Although closure of the fascia using a continuous, all-layer suture technique with slowly absorbable monofilament material is common, complications like burst abdomen and hernia are frequent.

METHODS AND ANALYSIS

This randomised controlled trial with a 1:1 allocation evaluates the efficacy and safety of a continuous suture with or without additional interrupted retention sutures for closure of the abdominal fascia. Patients with an indication for a primary emergency midline laparotomy are eligible to participate in this study and will be randomised intraoperatively via block randomisation. Fascia closure in the intervention group will be done with a standard continuous suture with slowly absorbable monofilament material (MonoMax 1, B. Braun, Tuttlingen, Germany) and additional interrupted retention sutures every 2 cm of the fascia using rapidly absorbable braided material (Vicryl 2, Ethicon, Norderstedt, Germany). In the control group, the fascia is closed only with the standard continuous suture with slowly absorbable monofilament material. Sample size calculations (n=111 per study arm) are based on the available literature. The primary endpoint is the rate of dehiscence of the abdominal fascia (rate of burst abdomen within 30 days or rate of incisional hernia within 12 months). Secondary endpoints are wound infections, quality of life, length of hospital stay, morbidity and mortality. Patients as well as individuals involved in data collection, endpoint assessment, data analysis and quality of life assessment will be blinded.

ETHICS AND DISSEMINATION

The study protocol, the patient information and the informed consent form have been approved by the ethics committee of the Ludwig-Maximilians-University, Munich, Germany (reference number: 20-1041). Study findings will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS00024802.

WHO UNIVERSAL TRIAL NUMBER

U1111-1259-1956.

Abdominal fascia dehiscence: is there a connection to a special microbial spectrum?

INTRODUCTION

Acute fascia dehiscence (FD) is a threatening complication occurring in 0.4-3.5% of cases after abdominal surgery. Prolonged hospital stay, increased mortality and increased rate of incisional hernias could be following consequences. Several risk factors are controversially discussed. Even though surgical infection is a known, indisputable risk factor, it is still not proven if a special spectrum of pathogens is responsible. In this study, we investigated if a specific spectrum of microbial pathogens is associated with FD.

METHODS

We performed a retrospective matched pair analysis of 53 consecutive patients with an FD after abdominal surgery in 2010-2016. Matching criteria were gender, age, primary procedure and surgeon. The primary endpoint was the frequency of pathogens detected intraoperatively, the secondary endpoint was the occurrence of risk factors in patients with (FD) and without (nFD) FD.

RESULTS

Intraabdominal pathogens were detected more often in the FD group (p = 0.039), with a higher number of Gram-positive pathogens. Enterococci were the most common pathogen (p = 0.002), not covered in 73% (FD group) compared to 22% (nFD group) by the given antibiotic therapy. Multivariable analysis showed detection of Gram-positive pathogens, detection of enterococci in primary laparotomy beside chronic lung disease, surgical site infections and continuous steroid therapy as independent risk factors.

CONCLUSION

Risk factors are factors that reduce wound healing or increase intra-abdominal pressure. Furthermore detection of Gram-positive pathogens especially enterococci was detected as an independent risk factor and its empirical coverage could be advantageous for high-risk patients.

Determinants of Postoperative Abdominal Wound Dehiscence among Patients Operated in a Tertiary Hospital

Background

Abdominal wound dehiscence is one of the dreadful complications for surgeons in their daily activities.The Objective of this study was to identify determinants of abdominal would dehiscence among patients operated at Saint Paul hospital millennium medical college.

Methods

A Matched case-control study to determine the predictors of abdominal wound dehiscence among operated patients at St. Paul's Hospital conducted. Multivariable logistic regression analysis done to calculate odds ratio and identify independent risk factors for abdominal wound dehiscnece.

Result

A total of 68 cases and 68 controls were studied. Bivariable analysis revealed Preoperative sepsis, condition at admission, an indication of surgery, post-operative wound infection, and post-operative days of hospitalization as independent risk factor for abdominal wound dehiscence. Multivariable analysis proved the presence of preoperative sepsis and an indication of surgery as an independent risk factor. In-patient mortality was 9 (13.2%) in the dehiscence group. More than 90% of patients with dehiscence stayed more than ten days in hospital, but close to half of the controls stayed less than ten days(P<0.05)

Conclusion

The presence of postoperative wound infection and an emergency surgical conditions were significant risk factors for an occurrence of postoperative abdominal wound dehiscence.

Focused follow-up of postoperative wound infection to identify signs of infection and meticulous implementation of perioperative infection prevention practices would save a lot more in a resource-limited setup.

Preoperative nutritional status assessed using the CONUT tool and its relationship with the appearance of major postoperative complications

INTRODUCTION

Malnutrition is a risk factor for the appearance of major postoperative complications; therefore, early identification and perioperative optimization of surgical patients may improve postoperative outcomes. The objective of our study was to determine the prevalence of moderate or high under nutrition alerts in patients undergoing major non-cardiac surgery, and their relationship with the appearance of major postoperative complications. Nutritional status was calculated using the CONUT tool.

MATERIAL AND METHODS

A retrospective observational study in 190 patients who underwent major non-cardiac surgery over two consecutive years. Preoperative nutritional status was calculated using CONUT, and the patients' medical records were reviewed to determine their epidemiological characteristics and major complications.

RESULTS

The under nutrition alert was moderate in 17% of patients, and high in 10%. A high under nutrition alert was an independent risk factor for treatment with vasoactive drugs (OR 3.58; 95% CI 1.18-10.89; p = 0.025), respiratory support (OR 7.63; 95% CI 1.25-46.43; p = 0.027), renal support (OR 23.29; 95% CI 2.0-271.08; p = 0.012), prolonged hospital stay (Coef 20.16; 95% CI 2.10-38.22; p = 0.029) and higher in-hospital mortality (OR 7.15; 95% CI 1.31-39.02; p = 0.023).

CONCLUSIONS

In total, 10% of patients who underwent major non-cardiac surgery presented serious preoperative deterioration in their nutritional status. A high under nutrition alert was an independent risk factor for the appearance of major postoperative complications.

Preoperative nutritional status assessed using the CONUT tool and its relationship with the appearance of major postoperative complications

INTRODUCTION

Malnutrition is a risk factor for the appearance of major postoperative complications; therefore, early identification and perioperative optimization of surgical patients may improve postoperative outcomes. The objective of our study was to determine the prevalence of moderate or high under nutrition alerts in patients undergoing major non-cardiac surgery, and their relationship with the appearance of major postoperative complications. Nutritional status was calculated using the CONUT tool.

MATERIAL AND METHODS

A retrospective observational study in 190 patients who underwent major non-cardiac surgery over two consecutive years. Preoperative nutritional status was calculated using CONUT, and the patients' medical records were reviewed to determine their epidemiological characteristics and major complications.

RESULTS

The under nutrition alert was moderate in 17% of patients, and high in 10%. A high under nutrition alert was an independent risk factor for treatment with vasoactive drugs (OR 3.58; 95% CI 1.18-10.89; p=.025), respiratory support (OR 7.63; 95% CI 1.25-46.43; p=.027), renal support (OR 23.29; 95% CI 2.0-271.08; p=.012), prolonged hospital stay (coef. 20.16; 95% CI 2.10-38.22; p=.029) and higher in-hospital mortality (OR 7.15; 95% CI 1.31-39.02; p=.023).

CONCLUSIONS

In total, 10% of patients who underwent major non-cardiac surgery presented serious preoperative deterioration in their nutritional status. A high under nutrition alert was an independent risk factor for the appearance of major postoperative complications.

Risk factors for incisional hernia according to different wound sites after open hepatectomy using combinations of vertical and horizontal incisions: A multicenter cohort study

Background: Although several risk factors for incisional hernia after hepatectomy have been reported, their relationship to different wound sites has not been investigated. Therefore, this study aimed to examine the risk factors for incisional hernia according to various wound sites after hepatectomy. Methods: Patients from the Osaka Liver Surgery Study Group who underwent open hepatectomy using combinations of vertical and horizontal incisions (J-shaped incision, reversed L-shaped incision, reversed T-shaped incision, Mercedes incision) between January 2012 and December 2015 were included. Incisional hernia was defined as a hernia occurring within 3 y after surgery. Abdominal incisional hernia was classified into midline incisional hernia and transverse incisional hernia. The risk factors for each posthepatectomy incisional hernia type were identified. Results: A total of 1057 patients met the inclusion criteria. The overall posthepatectomy incisional hernia incidence rate was 5.9% (62 patients). In the multivariate analysis, the presence of diabetes mellitus and albumin levels <3.5 g/dL were identified as independent risk factors. Moreover, incidence rates of midline and transverse incisional hernias were 2.4% (25 patients), and 2.3% (24 patients), respectively. In multivariate analysis, the independent risk factor for transverse incisional hernia was the occurrence of superficial or deep incisional surgical site infection, and interrupted suturing for midline incisional hernia. Conclusions: Risk factors for incisional hernia after hepatectomy depend on the wound site. To prevent incisional hernia, running suture use might be better for midline wound closure. The prevention of postoperative wound infection is important for transverse wounds, under the presumption of preoperative nutrition and normoglycemia.

Acute abdominal dehiscence following laparotomy: A multicentre, international retrospective study

BACKGROUND

Incisional complications are a common cause of morbidity following laparotomy. Although uncommon, acute abdominal dehiscence (AAD) is a potentially fatal post-operative complication. However, few AAD cases are described in the literature.

OBJECTIVES

To describe common features of cases of AAD following ventral midline laparotomy, management and outcomes.

STUDY DESIGN

Retrospective case series.

METHODS

Hospital records of horses that underwent a ventral midline laparotomy at nine hospitals in the UK, Ireland and USA over a 10-year period (2009-2019) were reviewed. Data were collected for pre-, intra- and post-operative factors that were considered relevant. Descriptive statistical analysis was performed.

RESULTS

A total of 63 cases of AAD were identified. AAD occurred due to tearing of sutures through the linea alba or rupture of the body wall adjacent to the suture line in 46 horses (73%). AAD occurred at a median of 5 days (0.5-70 days) post-operatively and broodmares accounted for 25% of the cases (n = 16). Surgical site infection developed prior to AAD in 28 horses (44%); leakage of peritoneal fluid occurred in 5% of horses prior to AAD being identified. Surgical repair was performed in 27 horses (43%), 10 (16%) were treated conservatively and 26 (41%) were euthanised immediately. Repair was most frequently performed using suture (n = 14), wire (n = 5) or a combination (n = 5). Overall survival to hospital discharge was 39% (24/63). Where surgical repair was performed, 15 horses (56%) survived to hospital discharge; 9 horses (90%) managed conservatively survived to hospital discharge.

MAIN LIMITATIONS

Follow-up was not performed for all cases following hospital discharge and some data were incompletely recorded in hospital files.

CONCLUSIONS

Previously stated causative factors for AAD were not consistent features in the present study. Surgical site infection following laparotomy and pregnant or early post-partum mares may be important risk factors for AAD and warrant further investigation.

Long-term follow-up of prophylactic mesh reinforcement after emergency laparotomy. A retrospective controlled study

BACKGROUND

Prevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial. The present study aimed to analyze the long-term results of prophylactic mesh used for preventing incisional hernia after emergency midline laparotomies.

METHODS

This study was a registered (NCT04578561) retrospective analysis of patients who underwent an emergency midline laparotomy between January 2009 and July 2010 with a follow-up period of longer than 2 years. Long-term outcomes and risk factors for the development of incisional hernias between patients who received a prophylactic reinforcement mesh (Group M) and suture (Group S) were compared.

RESULTS

From an initial 266 emergency midline laparotomies, 187 patients were included. The median follow-up time was 64.4 months (SD 35). Both groups had similar characteristics, except for a higher rate of previous operations (62 vs. 43.2%; P = 0.01) and operation due to a revision laparotomy (32.5 vs.13%; P = 0.02) in the M group. During follow-up, 29.9% of patients developed an incisional hernia (Group S 36.6% vs. Group M 14.3%; P = 0.002). Chronic mesh infections were diagnosed in 2 patients, but no mesh explants were needed, and no patient in the M group developed chronic pain. Long-term risk factors for incisional hernia were as follows: smoking (HR = 2.47; 95% CI 1.318-4.624; P = 0.05), contaminated surgery (HR = 2.98; 95% CI 1.142-7.8; P = 0.02), surgical site infection (SSI; HR = 3.83; 95% CI 1.86-7.86; P = 0.001), and no use of prophylactic mesh (HR = 5.09; 95% CI 2.1-12.2; P = 0.001).

CONCLUSION

Incidence of incisional hernias after emergency midline laparotomies is high and increases with time. High-risk patients, contaminated surgery, and surgical site infection (SSI) benefit from mesh reinforcement. Prophylactic mesh use is safe and feasible in emergencies with a low long-term complication rate.

TRIAL REGISTRATION

NCT04578561. www.clinicaltrials.gov.

Interrupted sutures prevent recurrent abdominal fascial dehiscence: a comparative retrospective single center cohort analysis of risk factors of burst abdomen and its recurrence as well as surgical repair techniques

Background

Burst abdomen (BA) is a severe complication after abdominal surgery, which often requires urgent repair. However, evidence on surgical techniques to prevent burst abdomen recurrence (BAR) is scarce.

Methods

We conducted a retrospective analysis of patients with BA comparing them to patients with superficial surgical site infections from the years 2015 to 2018. The data was retrieved from the institutional wound register. We analyzed risk factors for BA occurrence as well as its recurrence after BA repair and surgical closure techniques that would best prevent BAR.

Results

We included 504 patients in the analysis, 111 of those suffered from BA. We found intestinal resection (OR 172.510; 22.195–1340.796, p < 0.001), liver cirrhosis (OR 4.788; 2.034–11.269, p < 0.001) and emergency surgery (OR 1.658; 1.050–2.617; p = 0.03) as well as postoperative delirium (OR 5.058; 1.349–18.965, p = 0.016) as the main predictor for developing BA. The main reason for BA was superficial surgical site infection (40.7%). 110 patients received operative revision of the abdominal fascial dehiscence and 108 were eligible for BAR analysis with 14 cases of BAR. Again, post-operative delirium was the patient-related predictor for BAR (OR 13.73; 95% CI 1.812–104-023, p = 0.011). The surgical technique of using interrupted sutures opposed to continuous sutures showed a preventive effect on BAR (OR 0.143, 95% CI 0.026–0,784, p = 0.025). The implantation of an absorbable IPOM mesh did not reduce BAR, but it did reduce the necessity of BAR revision significantly.

Conclusion

The use of interrupted sutures together with the implantation of an intraabdominal mesh in burst abdomen repair helps to reduce BAR and the need for additional revision surgeries.

Postoperative Dexamethasone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

BACKGROUND

Surgeons have hesitated to use steroids in patients undergoing posterior spinal fusion because of the risk of wound complications. The literature has supported the use of postoperative steroids in other areas of orthopaedics on the basis of more rapid recovery and improved postoperative pain control. We hypothesized that a short course of postoperative dexamethasone following posterior spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS) would decrease opioid usage without increasing wound-healing problems.

METHODS

Consecutive patients undergoing posterior spinal fusion for the treatment of AIS from 2015 to 2018 at a single hospital were included. A review of demographic characteristics, curve characteristics, surgical data, and postoperative clinic notes was performed. Opioid usage was determined by converting all postoperative opioids given into morphine milligram equivalents (MME).

RESULTS

Sixty-five patients underwent posterior spinal fusion for the treatment of AIS without postoperative steroids (the NS group), and 48 patients were managed with 3 doses of postoperative steroids (the WS group) (median, 8.0 mg/dose). There was no difference between the groups in terms of curve magnitude, number of vertebrae fused, or estimated blood loss. There was a 39.6% decrease in total MME used and a 29.5% decrease in weight-based MME used in the group receiving postoperative steroids (82.0 mg [1.29 mg/kg] in the NS group versus 49.5 mg [0.91 mg/kg] in the WS group]; p < 0.001). This difference persisted after accounting for gabapentin, ketorolac, and diazepam usage; surgical time; curve size; levels fused; and number of osteotomies (median decrease, 0.756 mg/kg [95% CI, 0.307 to 1.205 mg/kg]; p = 0.001). Three patients in the NS group (4.6%) and 4 patients in the WS group (8.3%) developed wound dehiscence requiring wound care (p = 0.53). One patient in the NS group required surgical debridement for the treatment of an infection. Patients in the WS group were more likely to walk at the time of the initial physical therapy evaluation (60.4% versus 35.4%; p = 0.013).

CONCLUSIONS

A short course of postoperative steroids after posterior spinal fusion was associated with a 40% decrease in the use of opioids, with no increase in wound complications. Surgeons may consider the use of perioperative steroids in an effort to decrease the use of postoperative opioids following posterior spinal fusion for the treatment of AIS.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Magnitude of Abdominal Wound Dehiscence and Associated Factors of Patients Who Underwent Abdominal Operation at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia

Background

Abdominal wound dehiscence (AWD) is the separation of different layers of an abdominal wound before complete healing has taken place. It is a major cause of postoperative morbidity and mortality in sub-Saharan Africa including Ethiopia, and little is known about its prevalence and related factors in the study area.

Objectives

The aim of this study is to assess the magnitude of abdominal wound dehiscence and related factors on patients operated at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.

Methods

A hospital-based retrospective review of the chart was carried out by using the data covering three years (September 2014–September 2017) period. Data were collected from hospital medical records of sampled patients such as operation room logbooks and individual patient medical records. The collected data were checked for consistency, coded, and entered into SPSS version 20 for data processing and analysis. Descriptive analysis was conducted, and tables and graphs and summary statistics were used to depict data.

Results

A total of 41 patients developed abdominal wound dehiscence from among 4137 patients who underwent abdominal laparotomy in the hospital. Among the patients, 51.2% were in the age range of 41 and above with mean age 29.8 (SD = 1.21) and 70.7% of them were male. Abdominal wound dehiscence was more common in emergency patients (90%) and vertical incision was the most common type of incision. Over half (58.5%) of the wound dehiscence occurred within 6–10 postoperative days. The majority (95.2%) of dehisced patients underwent relaparotomy for the management of the wound dehiscence, and 48.8% of them were treated with tension suture during the second operation of abdominal closure. Four of the patients (9.7%) died after the management of the second operation.

Conclusion

The current study revealed that the overall magnitude of abdominal wound dehiscence in the study area was 0.99%. Most of the dehiscence has occurred in male patients, and older age groups were highly affected than the younger ones. Emergency admission is the most common form of admission identified in the study, and this signifies appropriate preoperative preparation of patients for an optimal outcome. However, regarding the management outcome, 9.8% of patients died in our study within the institution after the second operation which is the high mortality rate.

The Perth Surgical Wound Dehiscence Risk Assessment Tool (PSWDRAT): development and prospective validation in the clinical setting

OBJECTIVE

The worldwide volume of surgery today is considerable and postoperative wound healing plays a significant part in facilitating a patient's recovery and rehabilitation. While contemporary surgical procedures are relatively safe, complications such as surgical wound dehiscence (SWD) or breakdown of the incision site may occur despite advances in surgical techniques, infection control practices and wound care. SWD impacts on patient mortality and morbidity and significantly contributes to prolonged hospital stay. Preoperative identification of patients at risk of SWD may be valuable in reducing the risk of postoperative wound complications.

METHOD

A three-phase study was undertaken to determine risk factors associated with SWD, develop a preoperative patient risk assessment tool and to prospectively validate the tool in a clinical setting. Phases 1 and 2 were retrospective case control studies. Phase 1 determined variables associated with SWD and these informed the development of a risk assessment tool. Univariate analysis and multiple logistic regression were applied to identify predictors of surgical risk. Phase 2 used the receiver operator curve statistic to determine the predictive power of the tool. Phase 3 involved a prospective consecutive case series validation to test the inter-rater reliability and predictive power of the tool.

RESULTS

In addition to those already identified in the literature, one independent risk predictor for SWD was identified: previous surgery in the same anatomical location (p<0.001, odds ratio [OR] 4). Multiple combined factors were integrated into the tool and included: age (p<0.019, OR 3), diabetes (p<0.624, OR 2), obesity (p<0.94, OR 1.4), smoking (p<0.387, OR 2), cardiovascular disease (p<0.381 OR 3) and peripheral arterial disease (p<0.501, OR 3). The predictive power of the tool yielded 71% in a combined data sample.

CONCLUSION

Patients with previous surgery in the same anatomical location were four times more likely to incur a dehiscence. Identification of at-risk patients for complications postoperatively is integral to reducing SWD occurrence and improving health-related outcomes following surgery.

Incidence of wound dehiscence after colorectal cancer surgery: results from a national population-based register for colorectal cancer

BACKGROUND

Patient-related risk factors for wound dehiscence after colorectal surgery remain obscure.

METHODS

All open abdominal procedures for colorectal cancer registered in the Swedish Colorectal Cancer Registry (SCRCR, 5) 2007-2013 were identified. Potential risk factors for wound dehiscence were identified by cross-matching between the SCRCR and the National Patient Register (NPR). The endpoint in this study was reoperation for wound dehiscence registered in either the SCRCR or NPR and patients not reoperated were considered controls.

RESULTS

A total of 30,050 patients were included in the study. In a multivariable regression analysis, age > 70 years, male gender, BMI > 30, history of chronic obstructive pulmonary disease, history of generalised inflammatory disease, and duration of surgery less than 180 min were independently and significantly associated with increased risk for wound dehiscence. A history of diabetes, chronic renal disease, liver cirrhosis, and distant metastases was not associated with wound dehiscence. The hazard ratio for postoperative death was 1.24 for patients who underwent reoperation for wound dehiscence compared with that for controls.

DISCUSSION

Patients reoperated for wound dehiscence face a significantly higher postoperative mortality than those without. Risk factors include male gender, age > 70 years, obesity, history of chronic obstructive pulmonary disease, and history of generalised inflammatory disease. Patients at high risk for developing wound dehiscence may, if identified preoperatively, benefit from active prevention measures implemented in routine surgical practice.

Effects of Parenteral Amino Acid Administration on the Postoperative Nutritional Status and Wound Healing of Protein-Malnourished Rats

In Japan, parenteral nutrition (PN) solutions are frequently administered to patients in the postoperative short-term period. In these cases, amino acid-containing peripheral parenteral nutrition (PPN) solutions, amino acid-free maintenance solutions or combinations of the two are used. However, consensus regarding the most beneficial solution for these patients is lacking. Here, we examined the nutritional status and wound healing outcomes in protein-malnourished rats receiving postoperative administrations of PPN solution, maintenance solution or combinations of the two solutions. Protein malnutrition was induced in Sprague-Dawley rats by feeding an AIN-93G-based low-protein diet (5% casein) for 2 wk. After laparotomy, dorsal skin incision, and placement of a jugular vein catheter, the rats were divided into 3 groups. Each group was administered 113 kcal/kg/d, with group A receiving maintenance solutions without amino acid, group B receiving PPN with 1.5% amino acid, and group C receiving PPN with 3% amino acid. After 5 d post-operative administration, we measured the tensile strength of the wound area, skeletal muscle weights, and nutritional parameters. Significantly higher plasma nutritional parameters and gastrocnemius and extensor digitorum longus (EDL) muscle weights were observed in groups B and C than in group A. Group C exhibited significantly elevated tensile strength of the wound area along with up-regulation of type I collagen mRNA expression compared to group A. These findings demonstrate the nutritional status and wound healing benefits of short-term postoperative administration of PPN solutions containing amino acids in protein-malnourished rats.

Stomal Closure: Strategies to Prevent Incisional Hernia

Incisional hernias following ostomy reversal occur frequently. Incisional hernias at the site of a previous stoma closure can cause significant morbidity, impaired quality of life, lead to life-threatening hernia incarceration or strangulation and result in a significant financial burden on health care systems Despite this, the evidence base on the subject is limited. Many recognised risk factors for the development of incisional hernia following ostomy reversal are related to patient factors such as age, malignancy, diabetes, COPD, hypertension and obesity, and are not easily correctable. There is a limited amount of evidence to suggest that prophylactic mesh reinforcement may be of benefit to reduce the post stoma closure incisional hernia rate but a further large scale randomised controlled trial is due to report in the near future. There appears to be weak evidence to suggest that surgeons should favour circular, or "purse-string" closure of the skin following stoma closure in order to reduce the risk of SSI, which in turn may reduce incisional hernia formation. There remains the need for further evidence in relation to suture technique, skin closure techniques, mechanical bowel preparation and oral antibiotic prescription focusing on incisional hernia development as an outcome measure. Within this review, we discuss in detail the evidence base for the risk factors for the development of, and the strategies to prevent ostomy reversal site incisional hernias.

A nationwide analysis of re-exploration after liver transplant

BACKGROUND

A retrospective review to investigate rate and outcomes of re-exploration following liver transplantation in the United States.

METHODS

The NIS database was used to examine outcomes of patients who underwent re-exploration following liver transplantation from 2002 to 2012. Multivariate regression analysis was performed to compare outcomes of patients with and without reoperation.

RESULTS

We sampled a total of 12,075 patients who underwent liver transplantation. Of these, 1505 (12.5%) had re-exploration during the same hospitalization. Hemorrhagic (67.9%) and biliary tract anastomosis complication (14.8%) were the most common reasons for reoperation. Patients with reoperation had a significantly higher mortality than those who did not (11.6% vs. 3.8%, AOR: 3.01, P < 0.01). Preoperative coagulopathy (AOR: 1.71, P < 0.01) and renal failure (AOR: 1.57, P < 0.01) were associated with hemorrhagic complications. Peripheral vascular disorders (AOR: 2.15, P < 0.01) and coagulopathy (AOR: 1.32, P < 0.01) were significantly associated with vascular complications. Risk of wound disruption was significantly higher in patients with chronic pulmonary disease (AOR: 1.50, P < 0.01).

CONCLUSION

Re-exploration after liver transplantation is relatively common (12.5%), with hemorrhagic complication as the most common reason for reoperation. Preoperative coagulation disorders significantly increase hemorrhagic and vascular complications. Further clinical trails should investigate prophylactic strategies in high risk patients to prevent unplanned reoperation.

Effect of retension sutures on abdominal pressure after abdominal surgery

PURPOSE

To evaluate the effect of retention sutures on abdominal pressure and postoperative prognosis in abdominal surgery patients.

METHODS

This prospective cohort study included patients who were admitted to Daping Hospital from May 15, 2014 to October 11, 2014. A total of 57 patients were enrolled, including 18 patients in the "U" type retention suture group, 17 patients in the intermittent retention suture group, and 22 patients in non-retention suture group. The demographic data, clinical data and risk factors for abdominal wound dehiscence were recorded. The bladder pressure (IVP) was monitored preoperatively, intraoperatively, and four days postoperatively. Additionally, the incidence of abdominal wound dehiscence and infection 14 days after the operation was recorded.

RESULTS

During the operation, the IVP decreased and then increased; it was at its lowest 1 h after the start of the operation (5.3 mmHg ± 3.2 mmHg) and peaked after tension-reducing (8.8 mmHg ± 4.0 mmHg). The IVP values in the "U" type retention suture group and intermittent retention suture group were higher than in the non-retention suture group 4 days after operation (p < 0.005). The Visual Analogue Scale (VAS) pain scores were 3.9 ± 2.2, 3.8 ± 2.0, and 3.0 ± 1.0 in the retention suture group, intermittent retention suture group and non-retention suture group, respectively. The VAS pain scores in the "U" type tension-reducing group and intermittent tension-reducing group were higher than in the non-tension-reducing group (p < 0.005).

CONCLUSION

Although retention sutures may reduce the incidence of postoperative wound dehiscence in abdominal surgery patients, they can increase the IVP and postoperative pain.

Investigation into the optimal prosthetic material for wound healing of abdominal wall defects

The purpose of this experimental study is to investigate and compare the effects of prosthetic materials used for wound healing of abdominal wall hernias. A total of 60 rats were divided into five equal groups: Group I, control subjected to laparotomy; group II, abdominal wall defect 3×2 cm+polypropylene (PP) mesh; group III, abdominal wall defect 3×2 cm+PP mesh+hyaluronate and carboxymethylcellulose (H-CMC; Seprafilm^®); group IV, abdominal wall defect 3×2 cm+polytetrafluoroethylene (PTFE; Composix^™); and group V, abdominal wall defect 3×2 cm+polyethylene terephthalate (PET; Dacron^®). A total of 14 days after the surgery, rats were sacrificed and the meshes with the surrounding tissue were extracted in block. The breaking strength of the mesh from the fascia was recorded. The healing tissue was examined with the index of histopathology and the hydroxyproline value was analyzed using the Switzer method. Both the breaking strength and histopathological index of the wound healing were significantly improved in groups II and III compared with that in groups IV and V (P<0.001). Hydroxyproline values were the highest in group I (P<0.001). There was also a statistically significant difference between groups II and IV, and group V and the other groups (P<0.001). The present findings demonstrated that PP mesh and PP mesh+H-CMC had a superior breaking strength and improved histopathologic indices compared with PTFE and PET. Furthermore, hydroxyproline values were the lowest in the PET group. In conclusion, wound healing was improved in the PP mesh group and the PP mesh+H-CMC group compared with the PTFE and PET groups according to the present study parameters.

Negative Pressure Wound Therapy on Closed Surgical Wounds With Dead Space: Animal Study Using a Swine Model

Background

Closed incisional wound surgery frequently leaves dead space under the repaired skin, which results in delayed healing. The purpose of this study was to evaluate the effect of negative pressure wound therapy (NPWT) on incisional wounds with dead space after primary closure by evaluating the fluid volume through the suction drain, blood flow of the skin, tensile strength, and histology of the wounds.

Methods

Bilateral 25-cm-long incisional wounds with dead space were created on the back of 6 pigs by partially removing the back muscle and then suturing the skin with nylon sutures. NPWT (experimental group) or gauze dressing (control group) was applied over the closed incision for 7 days. Analysis of the wound included monitoring the amount of closed suction drain, blood perfusion unit, tensile strength of the repaired skin, and histology of the incision site.

Results

The drainage amount was significantly reduced in the experimental group (49.8 mL) compared to the control group (86.2 mL) (P = 0.046). Skin perfusion was increased in the experimental group with statistical significance compared to the control group (P = 0.0175). Collagen staining was increased in the experimental group. The tensile strength of the incision site was significantly higher in the experimental group (24.6 N at 7 days, 61.67 N at 21 days) compared to the control group (18.26 N at 7 days, 50.05 N at 21 days) (P = 0.02).

Conclusion

This study explains some of the mechanism for using NPWT in closed incision wounds with dead space. It demonstrates that NPWT significantly reduces drainage amount, increases skin perfusion, increases tensile strength, and has the tendency to promote collagen synthesis for closed wound with dead space indicating enhanced healing.

Effects of Incisional Negative-Pressure Wound Therapy on Primary Closed Defects after Superficial Circumflex Iliac Artery Perforator Flap Harvest: Randomized Controlled Study

BACKGROUND

Prolonged hematoma or seroma after primary closure is a causative element in wound complications. This study evaluated the effects of negative-pressure wound therapy on primary closed wounds after superficial circumflex iliac artery perforator flap harvest.

METHODS

This study was a prospective, randomized, clinical trial comparing conventional dressing against a single application of negative-pressure wound therapy for 5 days after primary closure. A total of 100 patients who had superficial circumflex iliac artery perforator flap harvest were enrolled.

RESULTS

There was no statistical difference between the incisional negative-pressure wound therapy and conventional dressing groups in the distribution of risk factors. Significant findings were noted for duration and amount of closed suction drainage: 6.12 ± 4.99 days (median, 4 days; range, 3 to 8 days) and 100.47 ± 140.69 cc (median, 42 cc) for wounds treated with conventional dressing versus 3.34 ± 1.35 days (median, 3 days; range, 2 to 4 days) and 23.28 ±18.36 cc (median, 20 cc) for wounds in treatment group (p = 0.0077 and p = 0.0004), respectively. After closure, an increase in skin perfusion were noted on day 5 in the treatment group (p = 0.0223). There was one case of wound dehiscence in the conventional dressing group.

CONCLUSION

The incisional negative-pressure wound therapy has a positive effect over primary closed surgical defects by significantly reducing the amount of fluid collected by closed suction drains, allowing earlier removal of drains and enhancing the skin perfusion on the repaired skin.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Retrospective review of risk factors for surgical wound dehiscence and incisional hernia

BACKGROUND

Several factors and patient characteristics influence the risk of surgical wound dehiscence and incisional hernia after midline laparotomy. The purpose of this study was to investigate whether a specified, or not specified, suture quota in the operative report affects the incidence of surgical wound complications and to describe the previously known risk factors for these complications.

METHODS

Retrospective data collection from medical records of all vascular procedures and laparotomies engaging the small intestines, colon and rectum performed in 2010. Patients were enrolled from four hospitals in the region Västra Götaland, Sweden. Unadjusted and adjusted Cox regression analyses were used when calculating the impact of the risk factors for surgical wound dehiscence and incisional hernia.

RESULTS

A total of 1,621 patients were included in the study. Wound infection was a risk factor for both wound dehiscence and incisional hernia. BMI 25-30, 30-35 and >35 were risk factors for wound dehiscence and BMI 30-35 was a risk factor for incisional hernia. We did not find that documentation of the details of suture technique, regarding wound and suture length, influenced the rate of wound dehiscence or incisional hernia.

CONCLUSIONS

These results support previous findings identifying wound infection and high BMI as risk factors for both wound dehiscence and incisional hernia. Our study indicates the importance of preventive measures against wound infection and a preoperative dietary regiment could be considered as a routine worth testing for patients with high BMI planned for abdominal surgical precedures.

Hughes Abdominal Repair Trial (HART) - Abdominal wall closure techniques to reduce the incidence of incisional hernias: study protocol for a randomised controlled trial

Background

Incisional hernias are common complications of midline closure following abdominal surgery and cause significant morbidity, impaired quality of life and increased health care costs.

The ‘Hughes Repair’ combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture. This theoretically distributes the load along the incision length as well as across it. There is evidence to suggest that this technique is as effective as mesh repair for the operative management of incisional hernias; however, no trials have compared the Hughes Repair with standard mass closure for the prevention of incisional hernia formation following a midline incision.

Methods/design

This is a 1:1 randomised controlled trial comparing two suture techniques for the closure of the midline abdominal wound following surgery for colorectal cancer. Full ethical approval has been gained (Wales REC 3, MREC 12/WA/0374). Eight hundred patients will be randomised from approximately 20 general surgical units within the United Kingdom. Patients undergoing open or laparoscopic (more than a 5-cm midline incision) surgery for colorectal cancer, elective or emergency, are eligible. Patients under the age of 18 years, those having mesh inserted or undergoing musculofascial flap closure of the perineal defect in abdominoperineal wound closure, and those unable to give informed consent will be excluded. Patients will be randomised intraoperatively to either the Hughes Repair or standard mass closure. The primary outcome measure is the incidence of incisional hernias at 1 year as assessed by standardised clinical examination. The secondary outcomes include quality of life patient-reported outcome measures, cost-utility analysis, incidence of complete abdominal wound dehiscence and C-POSSUM scores. The incidence of incisional hernia at 1 year, assessed by computerised tomography, will form a tertiary outcome.

Discussion

A feasibility phase has been completed. The results of the study will be used to inform current and future practice and potentially reduce the risk of incisional hernia formation following midline incisions.

Trial registration

Trial Registration Number: ISRCTN 25616490. Registered on 1 January 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1573-0) contains supplementary material, which is available to authorized users.

Abdominal Wound Dehiscence in Patients Receiving Long-term Steroid Treatment

Steroids inhibit primary wound healing and delay the formation of granulation tissue, but it has been controversial whether long-term steroid treatment by itself increases the risk of abdominal wound dehiscence. The aim of this study was to determine whether the pre-operative dose and post-operative total dose of steroids influence abdominal wound dehiscence. Of 28 patients who had surgery while receiving long-term steroid treatment, seven had abdominal wound dehiscence and 21 did not have dehiscence. The two groups differed significantly in the post-operative dose of steroids (404.3 ± 147.1 and 135.6 ± 118.7 mg, respectively) and the duration of wound healing (57.3 ± 18.0 and 12.4 ± 3.8 days), but no other differences were found. Abdominal wound dehiscence may be influenced by the post-operative rather than the pre-operative steroid dose.

Wound Disruption Following Colorectal Operations

OBJECTIVES

Postoperative wound disruption is associated with high morbidity and mortality. We sought to identify the risk factors and outcomes of wound disruption following colorectal resection.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to examine the clinical data of patients who underwent colorectal resection from 2005 to 2013. Multivariate regression analysis was performed to identify risk factors of wound disruption.

RESULTS

We sampled a total of 164,297 patients who underwent colorectal resection. Of these, 2073 (1.3 %) had wound disruption. Patients with wound disruption had significantly higher mortality (5.1 vs. 1.9 %, AOR: 1.46, P = 0.01). The highest risk of wound disruption was seen in patients with wound infection (4.8 vs. 0.9 %, AOR: 4.11, P < 0.01). A number of factors are associated with wound disruption such as chronic steroid use (AOR: 1.71, P < 0.01), smoking (AOR: 1.60, P < 0.01), obesity (AOR: 1.57, P < 0.01), operation length more than 3 h (AOR: 1.56, P < 0.01), severe Chronic Obstructive Pulmonary Disease (COPD) (AOR: 1.36, P < 0.01), urgent/emergent admission (AOR: 1.31, P = 0.01), and serum Albumin Level <3 g/dL (AOR: 1.27, P < 0.01). Laparoscopic surgery had significantly lower risk of wound disruption compared to open surgery (AOR: 0.61, P < 0.01).

CONCLUSION

Wound disruption occurs in 1.3 % of colorectal resections, and it correlates with mortality of patients. Wound infection is the strongest predictor of wound disruption. Chronic steroid use, obesity, severe COPD, prolonged operation, non-elective admission, and serum albumin level are strongly associated with wound disruption. Utilization of the laparoscopic approach may decrease the risk of wound disruption when possible.

Peri-operative nutrition

Patients are frequently malnourished or are at risk of malnutrition before surgery. Peri-operative nutritional support can improve their outcomes. This review focuses on new developments in peri-operative nutrition, including: patient preparation and pre-operative fasting; the role of nutritional supplementation; the optimal route and timing of nutrient delivery; and the nutritional management of specific groups including critically ill, obese and elderly patients.

Systematic Review and Meta-Regression of Factors Affecting Midline Incisional Hernia Rates: Analysis of 14,618 Patients

BACKGROUND

The incidence of incisional hernias (IHs) following midline abdominal incisions is difficult to estimate. Furthermore recent analyses have reported inconsistent findings on the superiority of absorbable versus non-absorbable sutures.

OBJECTIVE

To estimate the mean IH rate following midline laparotomy from the published literature, to identify variables that predict IH rates and to analyse whether the type of suture (absorbable versus non-absorbable) affects IH rates.

METHODS

We undertook a systematic review according to PRISMA guidelines. We sought randomised trials and observational studies including patients undergoing midline incisions with standard suture closure. Papers describing two or more arms suitable for inclusion had data abstracted independently for each arm.

RESULTS

Fifty-six papers, describing 83 separate groups comprising 14,618 patients, met the inclusion criteria. The prevalence of IHs after midline incision was 12.8% (range: 0 to 35.6%) at a weighted mean of 23.7 months. The estimated risk of undergoing IH repair after midline laparotomy was 5.2%. Two meta-regression analyses (A and B) each identified seven characteristics associated with increased IH rate: one patient variable (higher age), two surgical variables (surgery for AAA and either surgery for obesity surgery (model A) or using an upper midline incision (model B)), two inclusion criteria (including patients with previous laparotomies and those with previous IHs), and two circumstantial variables (later year of publication and specifying an exact significance level). There was no significant difference in IH rate between absorbable and non-absorbable sutures either alone or in conjunction with either regression analysis.

CONCLUSIONS

The IH rate estimated by pooling the published literature is 12.8% after about two years. Seven factors account for the large variation in IH rates across groups. However there is no evidence that suture type has an intrinsic effect on IH rates.

Age, Preoperative Subcutaneous Fat Area, and Open Laparotomy are Risk Factors for Incisional Hernia following Colorectal Cancer Surgery

BACKGROUND

Although incisional hernia (IH) is a common complication of abdominal surgery, the incidence rate and risk factors are not well known. The objectives of this study are to determine the incidence rate of IH following colorectal cancer surgery and to describe the associated risk factors.

METHODS

Between 2005 and 2010, patients who underwent surgery to treat colorectal cancer were examined. The diagnosis of IH was performed by CT scan, and the visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus were calculated using a 3D-image analysis system. Survival analysis was used to assess the incidence and risk factors of IH.

RESULTS

A total of 626 patients (326 open, 300 laparoscopic) were included in this study, with median follow-up of 54 (range 2-97) months. Forty patients were diagnosed with postoperative IH, and the cumulative, 5-year incidence of IH was 7.3 %. Univariate analysis revealed that age, body mass index, waist circumference, hip circumference, open laparotomy, wound infection, VFA, and SFA were significantly associated with incidence of IH. Multivariate analysis revealed that age [hazard ratio (HR) 1.043 (1.005-1.083), p = 0.027], open laparotomy [HR 4.410 (1.018-19.095), p = 0.047], and SFA [HR 1.013 (1.004-1.022), p = 0.005] were significant risk factors for developing IH.

CONCLUSIONS

Higher age and SFA, along with open surgery, are risk factors for developing IH.

Randomized clinical trial of the effect of gum chewing on postoperative ileus and inflammation in colorectal surgery

BACKGROUND

Postoperative ileus (POI) is a common complication following colorectal surgery that delays recovery and increases length of hospital stay. Gum chewing may reduce POI and therefore enhance recovery after surgery. The aim of the study was to evaluate the effect of gum chewing on POI, length of hospital stay and inflammatory parameters.

METHODS

Patients undergoing elective colorectal surgery in one of two centres were randomized to either chewing gum or a dermal patch (control). Chewing gum was started before surgery and stopped when oral intake was resumed. Primary endpoints were POI and length of stay. Secondary endpoints were systemic and local inflammation, and surgical complications. Gastric emptying was measured by ultrasonography. Soluble tumour necrosis factor receptor 1 (TNFRSF1A) and interleukin (IL) 8 levels were measured by enzyme-linked immunosorbent assay.

RESULTS

Between May 2009 and September 2012, 120 patients were randomized to chewing gum (58) or dermal patch (control group; 62). Mean(s.d.) length of hospital stay was shorter in the chewing gum group than in controls, but this difference was not significant: 9·5(4·9) versus 14·0(14·5) days respectively. Some 14 (27 per cent) of 52 analysed patients allocated to chewing gum developed POI compared with 29 (48 per cent) of 60 patients in the control group (P = 0·020). More patients in the chewing gum group first defaecated within 4 days of surgery (85 versus 57 per cent; P = 0·006) and passed first flatus within 48 h (65 versus 50 per cent; P = 0·044). The decrease in antral area measured by ultrasonography following a standard meal was significantly greater among patients who chewed gum: median 25 (range -36 to 54) per cent compared with 10 (range -152 to 54) per cent in controls (P = 0·004). Levels of IL-8 (133 versus 288 pg/ml; P = 0·045) and TNFRSF1A (0·74 versus 0·92 ng/ml; P = 0·043) were lower among patients in the chewing gum group. Fewer patients in this group developed a grade IIIb complication (2 of 58 versus 10 of 62; P = 0·031).

CONCLUSION

Gum chewing is a safe and simple treatment to reduce POI, and is associated with a reduction in systemic inflammatory markers and complications.

REGISTRATION NUMBER

NTR2867 (http://www.trialregister.nl).

Wound dehiscence: outcome comparison for sutured and mesh reconstructed patients

PURPOSE

Treatment guidelines for abdominal wound dehiscence (WD) are lacking. The primary aim of the study was to compare suture to mesh repair in WD patients concerning incisional hernia incidence. Secondary aims were to compare recurrent WD, morbidity, mortality and long-term abdominal wall complaints.

METHODS

A retrospective chart review of 46 consecutive patients operated for WD between January 2010 and August 2012 was conducted. Physical examination and a questionnaire enquiry were performed in January 2013.

RESULTS

Six patients were treated by vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) before definitive closure. Three patients died early resulting in 23 patients closed by suture and 20 by mesh repair. Five sutured, but no mesh repair patients had recurrent WD (p = 0.051) with a mortality of 60 %. Finally, 18 sutured and 21 mesh repair patients were eligible for follow-up. The incidence of incisional hernia was higher for the sutured patients (53 vs. 5 %, p = 0.002), while mesh repair patients had a higher short-term morbidity rate (76 vs. 28 %, p = 0.004). Abdominal wall complaints were rare in both groups.

CONCLUSIONS

Suture of WD was afflicted with a high incidence of recurrent WD and incisional hernia formation. Mesh repair overcomes these problems at the cost of more wound complications. VAWCM seems to be an alternative for treating contaminated patients until definitive closure is possible. Long-term abdominal wall complaints are uncommon after WD treatment.

Complications leading reoperation after gastrectomy in patients with gastric cancer: frequency, type, and potential causes

Purpose

Reoperations after gastrectomy for gastric cancer are performed for many types of complications. Unexpected reoperations may cause mental, physical, and financial problems for patients. The aim of the present study was to evaluate the causes of reoperations and to develop a strategic decision-making process for these reoperations.

Materials and Methods

From September 2002 through August 2010, 6,131 patients underwent open conventional gastrectomy operations at Samsung Medical Center. Of these, 129 patients (2.1%) required reoperation because of postoperative complications. We performed a retrospective analysis of the patients using an electronic medical record review. Statistical data were analyzed to compare age, sex, stage, type of gastrectomy, length of operation, size of tumor, and number of lymph node metastasis between patients who had been operated and those who had not.

Results

The variables of age, sex, tumor stage, type of gastrectomy, length of operation, and number of lymph node metastases did not differ between the 2 groups. However, the mean tumor size in the reoperation group was greater than that in the non-reoperation group (5.0±3.7 [standard deviation] versus 4.1±2.9, P=0.007). The leading cause of reoperation was surgical-site infection (n=49, 0.79%). Patients with intra-abdominal bleeding were operated on again in the shortest period after the initial gastrectomy (6.3±4.2 days). Patients with incisional hernia were not reoperated on until after 208.3±81.0 days, the longest postoperative period.

Conclusions

Tumor size was the major variable leading to reoperation after gastrectomy for gastric cancer. The most common complication requiring the reoperation was a surgical site-related complication.

[Validation of abdominal wound dehiscence's risk model]

INTRODUCTION

The aim of this study is to determine the usefulness of the risk model developed by van Ramshorst et al., and a modification of the same, to predict the abdominal wound dehiscence's risk in patients who underwent midline laparotomy incisions.

MATERIALS AND METHODS

Observational longitudinal retrospective study.

SAMPLE

Patients who underwent midline laparotomy incisions in the General and Digestive Surgery Department of the Sabadell's Hospital-Parc Taulí's Health and University Corporation-Barcelona, between January 1, 2010 and June 30, 2010. Dependent variable: Abdominal wound dehiscence.

INDEPENDENT VARIABLES

Global risk score, preoperative risk score (postoperative variables were excluded), global and preoperative probabilities of developing abdominal wound dehiscence.

RESULTS

SAMPLE

176 patients. Patients with abdominal wound dehiscence: 15 (8.5%). The global risk score of abdominal wound dehiscence group (mean: 4.97; IC 95%: 4.15-5.79) was better than the global risk score of No abdominal wound dehiscence group (mean: 3.41; IC 95%: 3.20-3.62). This difference is statistically significant (P<.001). The preoperative risk score of abdominal wound dehiscence group (mean: 3.27; IC 95%: 2.69-3.84) was better than the preoperative risk score of No abdominal wound dehiscence group (mean: 2.77; IC 95%: 2.64-2.89), also a statistically significant difference (P<.05). The global risk score (area under the ROC curve: 0.79) has better accuracy than the preoperative risk score (area under the ROC curve: 0.64).

CONCLUSION

The risk model developed by van Ramshorst et al. to predict the abdominal wound dehiscence's risk in the preoperative phase has a limited usefulness. Additional refinements in the preoperative risk score are needed to improve its accuracy.