Diastasis recti abdominis in HIV-infected men with lipodystrophy

HIV patient with prolonged infection after hemicolectomy and repair of complicated hernia. Mini-review of a rare successful surgical outcome

Introduction and importance

Surgical site infection (SSI) is an inevitable occurrence in bowel perforation with faecal soiled hernia wound(s) especially in retroviral patients. Unfortunately, the increased antibiotics and wound care demands do not prevent delayed healing, increased risk of hernia recurrence, or multiple surgeries to control the infection. The standard open or endo-laparoscopic Mesh repairs are either deferred or avoided with alternative tissue-based hernia repairs after bowel surgery. The reported success of open tissue-based repairs remains mixed. Nylon monofilament that have been used in infected wounds was chosen for the patient in anticipation of wound infection.

Case presentation

A 48-year-old man presented with a 7-days complicated hernia at the emergency unit, Margaret Marquart Catholic Hospital. Clinical examination revealed signs of shock, intestinal obstruction, and peritonism, laboratory investigation was remarkable of anaemia, septicaemia, deranged renal function, and positive retroviral test. He had concurrent right hemicolectomy and nylon darn after optimisation. The outcome we evaluated after surgery included postoperative pain, scrotal collection, anastomotic breakdown, postoperative analgesic use, wounds infection, prolonged hospital stays, recurrence, and the need for a second surgery. Though he developed prolonged deep SSI, he has intact hernia repair after 6-years.

Clinical discussion

The postoperative critical clinical events presented in this case were unexpected but might have been precipitated by his retroviral status. Thus, a weight loss of over 13 kg within 2 weeks was highly unusual. Furthermore, the positive retroviral status couple with the perforated caecum and soiled peritoneum was the cause of the surgical site infection.

Conclusion

Nylon darning in a retro-positive patient developing prolonged SSI appeared beneficial. It should be considered in patients with anticipated long period wound infection.

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Surgical site infection is a challenge in hernias with perforated viscus after repair.

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Current standard modalities of hernia repairs are used in such patient's infection are not anticipated.

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Patient with retroviral infection and wound contamination requires a different approach to ensure the intact repair.

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Nylon darn, one of the methods was used with success.

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Our patient with a prolonged infection after surgery and a 5-year post-repair success are a first of the kind reported.

The male rectus diastasis: a different concept?

PURPOSE

More interest in the treatment of rectus diastasis has been evoked lately. Following the postpartum females from a great distance, the middle-aged males living with obesity are the second most common group of rectus diastasis patients. Although gender differences are considered frequently in regard to cosmetic appearance and symptoms, it is less obvious in classifications and subsequent treatment strategies. Is a unisex approach of rectus diastasis still applicable? The lack of a firm answer warrants this review of the current literature.

METHODS

An explorative free-text multi-database bibliographic search (Pubmed/CENTRAL/EMBASE/PEDro/Scholar) was performed with the focus on the rectus diastasis in males. Anticipating the limited references, the design was a non-systematic review. All studies, regardless of study type, language or time period, describing etiology, symptoms, classification and/or treatment options were eligible for inclusion. From the articles retrieved out of this search, additional references were identified by a manual search among the cited references.

RESULTS

The multi-database search resulted in a total of 7633 records. Based on the title and abstract 95 records were full text assessed for eligibility. Eleven studies were identified as relevant, six by cross-reference and another four by hand-search were added to provide an insight in gender-specific aspects in rectus diastase. Hereditary causes are differences in collagen-like composition of types and concomitant abdominal aneurysm as well as gender differences in the linea alba architecture. Acquired etiology is distributed into both absolute pressure by visceral obesity and relative pressure caused by weight lifting or improper exercises. Furthermore, the impact of muscle thickness and age are considered as influencers of biomechanics. Gender differences can also play a role in symptoms of body image and core stability. It is known that there are anatomical differences between male and female persons; more transverse fibers are found in infra-umbilical region in women. In classifications the awareness of male rectus diastasis is limited, treatment outcome studies are scarce on males.

CONCLUSION

An overview of male-specific aspects of rectus diastasis is provided, underlining that key aspects surrounding rectus diastasis in males differ from females. Although males are the minority of rectus diastasis patients, we recommend that the male rectus diastasis as a concept should be specifically acknowledged in classifications systems and study outcome reporting to evaluate this subgroup more accurately in the future.

Diastasis recti abdominis and pelvic floor dysfunction in peri- and postmenopausal women: a cross-sectional study

Introduction: Diastasis recti abdominis (DRA) and pelvic floor dysfunction (PFD) occurs commonly with aging; however, little is known about what leads to these changes.Objective: We aimed to investigate and compare the presence or absence of DRA and PFD in peri- and postmenopausal women.Methods: This cross-sectional study involved 150 participants who answered questions on their sociodemographic and clinical profiles related to urinary and fecal incontinence and pelvic organ prolapse. Diastasis recti abdominis was diagnosed with a digital caliper.Results: Supra-umbilical diastasis occurred in 37.3% of cases, and 78.6% of participants with DRA had PFD. No significant differences existed between participants with and without DRA in terms of background and clinical variables. However, participants with DRA were 2.6 times more likely to have PFD than participants without DRA. Furthermore, the presence of DRA was significantly shown to be a risk factor for PFD on binary logistic regression analyses (p = .01, OR = 3.2).Conclusions: This cross-sectional study suggests that DRA is a predictive factor of PFD in women aged over 50 years.

Non-traumatic hernia of the lateral abdominal wall in a patient infected with the human immunodeficiency virus

Introduction There are several classifications for abdominal hernias, and a non-traumatic lateral wall hernia (LAWH) is a rare type. We report the first case of a patient with LAWH infected with the human immunodeficiency virus (HIV). Case History A 53-year-old HIV-infected male presented with an abdominal mass. The patient had a history of treatment with combination antiretroviral therapy. A LAWH was diagnosed based on physical examination and findings of computed tomography. Open mesh repair was undertaken successfully. The patient had no evidence of a recurrent hernia during 11 months of follow-up. Conclusions High intra-abdominal pressure and weak connective tissue can lead to LAWHs. Antiretroviral therapy and lipodystrophy can cause LAWHs in HIV-infected patients.

The Immediate Effects on Inter-rectus Distance of Abdominal Crunch and Drawing-in Exercises During Pregnancy and the Postpartum Period

STUDY DESIGN

Longitudinal descriptive exploratory study.

OBJECTIVES

To evaluate in primigravid women the immediate effect of drawing-in and abdominal crunch exercises on inter-rectus distance (IRD), measured at 4 time points during pregnancy and in the postpartum period.

BACKGROUND

There is scant knowledge of the effect of different abdominal exercises on IRD in pregnant and postpartum women.

METHODS

The study included 84 primiparous participants. Ultrasound images were recorded with a 12-MHz linear transducer, at rest and during abdominal drawing-in and abdominal crunch exercises, at 3 locations on the linea alba. The IRD was measured at 4 time points: gestational weeks 35 to 41, 6 to 8 weeks postpartum, 12 to 14 weeks postpartum, and 24 to 26 weeks postpartum. Separate 2-way, repeated-measures analyses of variance (ANOVAs) were performed for each exercise (drawing-in and abdominal crunch) and each measurement location to evaluate the immediate effects of exercises on IRD at each of the 4 time points. Similarly, 2-way ANOVAs were used to contrast the effects of the 2 exercises on IRD.

RESULTS

Performing the drawing-in exercise caused a significant change in width of the IRD at 2 cm below the umbilicus, narrowing the IRD by a mean of 3.8 mm (95% confidence interval [CI]: 1.2, 6.4 mm) at gestational weeks 35 to 41, and widening the IRD by 3.0 mm (95% CI: 1.4, 4.6 mm) at 6 to 8 weeks postpartum, by 1.8 mm (95% CI: 0.6, 3.1 mm) at 12 to 14 weeks postpartum, and by 2.5 mm (95% CI: 1.4, 3.6 mm) at 24 to 26 weeks postpartum (P<.01). Performing the abdominal crunch exercise led to a significant narrowing of the IRD (P<.01) in all 3 locations at all 4 time points, with the exception of 2 cm below the umbilicus at postpartum weeks 24 to 26. The average amount of narrowing varied from 1.6 to 20.9 mm, based on time and location.

CONCLUSION

Overall, there was a contrasting effect of the 2 exercises, with the abdominal crunch exercise consistently producing a significant narrowing of the IRD. In contrast, the drawing-in exercise generally led to a small widening of the IRD.

Concurrent validity of calipers and ultrasound imaging to measure interrecti distance

STUDY DESIGN

Clinical measurement, concurrent validity criterion standard.

OBJECTIVE

To determine the concurrent validity of digital nylon calipers in comparison to ultrasound imaging (USI) for the measurement of interrecti distance (IRD).

BACKGROUND

Diastasis rectus abdominis is the abnormal increase in the width of the linea alba, measured as IRD. A diastasis rectus abdominis can compromise mechanical trunk function in both genders. IRD has been accurately measured with USI but requires costly equipment and extensive examiner training. Digital nylon calipers are inexpensive and easy to use, but their use to measure IRD has not been validated.

METHODS

A sample of convenience of 56 individuals (11 men, 45 women) was measured. A single examiner was assigned to each tool (calipers or USI), and IRD was measured at 2 locations (above and below the umbilicus) under 2 conditions (abdominal muscles at rest and abdominal muscles contracted). All measurements were made during a single session, and examiners were blinded to measurements with the other tool.

RESULTS

Above the umbilicus, the measurements of IRD with calipers were similar to those made with USI, with intraclass correlation coefficients (model 3,2) of 0.79 with abdominal muscles at rest and 0.71 with abdominal muscles contracted. The absolute mean difference between the caliper and USI measurements of IRD above the umbilicus was 0.03 cm larger with the calipers when the abdominal muscles were at rest and 0.03 cm smaller when the abdominal muscles were contracted. The values of IRD obtained with the caliper and USI techniques were not comparable when obtained below the umbilicus.

CONCLUSION

The calipers are a valid tool for measuring IRD above the umbilicus in males and females. Measuring IRD with calipers below the umbilicus should not be considered valid, using USI as the criterion standard. This may reflect anatomical variation of the linea alba or a limitation of the calipers to assess IRD at the same depth as USI.

Increased risk of abdominal wall hernia associated with combination anti-retroviral therapy in HIV-infected patients-results from a Swedish cohort-study

PURPOSE

To determine if anti-retroviral therapy (ART) in HIV-infected patients is associated with an increased risk for development of abdominal wall hernia.

METHODS

A cohort study of 1072 HIV-infected patients in Sweden. Information was collected by questionnaires to patients and treating physicians, chart reviews by study physicians and regular blood tests for metabolic disorders. Adjusted relative risks were estimated by Cox proportional hazards models.

RESULTS

Sixty-three patients (5.9%) developed abdominal wall hernia during the study period, 34 inguinal and 29 midline. Compared to the male general population, inguinal hernia was twice as common in the male study population, standardized incidence ratio (SIR) 2.0 (95% confidence interval (CI) 1.4-2.8). An increased incidence rate of abdominal wall hernia was found in patients exposed to ART, 11.3 per 1000 person-years (PY) compared with therapy naïves, 2.1 per 1000 PY. When adjusting for confounding risk-factors, ART containing protease inhibitors (PIs) during the 2nd and 3rd year of treatment was associated with the development of midline hernia with a hazard ratio (HR) of 10.7 (95%CI 1.3-85.7), and of inguinal hernia with an HR of 4.4 (95%CI 1.1-16.6). Other independent risk factors were age and diabetes/impaired fasting glucose for midline hernia, and age and a previous diagnosis of AIDS for inguinal hernia.

CONCLUSIONS

We found an increased risk of developing abdominal wall hernia associated with PI-containing ART. The size of the study-population did not permit any conclusions regarding non-PI-containing ART.

Prevalence of diastasis recti abdominis in a urogynecological patient population

A urogynecologist's examination typically includes assessment of the abdominal musculature, including the determination of whether a diastasis recti abdominis (DRA) is present. The purposes of the current study were to examine the (1) prevalence of DRA in a urogynecological population, (2) differences in select characteristics of patients with and without DRA, and (3) relationship of DRA to support-related pelvic floor dysfunction diagnoses. A retrospective chart review was conducted by an independent examiner. Fifty-two percent of the patients examined presented with DRA. Patients with DRA were older, reported higher gravity and parity, and had weaker pelvic floor muscles than patients without DRA. Sixty-six percent of all the patients with DRA had at least one support-related pelvic floor dysfunction (SPFD) diagnosis. There was a relationship between the presence of DRA and the SPFD diagnoses of stress urinary incontinence, fecal incontinence, and pelvic organ prolapse.