P-084 OPEN PARASTOMAL HERNIA REPAIR: STOMA RELOCATION WITH CST, MODIFIED RIVES SUBLAY MESH TECHNIQUE WITH CST OR MODIFIED SUGARBAKER INTRAPERITONEAL MESH TECHNIQUE WITH CST

Aim

To presents results of various open surgical techniques for parastomal hernia repair.

Material and Method

Between January 2014 and January 2020, 22 patients with parastomal hernias were treated by three various operative techniques: a) stoma relocation using component separation techniques (CST); b) modified Rives sublay mesh technique with CST; c) modified Sugarbaker intraperitoneal composite mesh repair with or withouth CST. Stoma relocation and CST was performed in two patients, modified Rives sublay technique and CST in 15 patients and modified Sugarbaker technique with or without CST in five patients.

Results

Hernia recurrence was developed in one of two patients treated by stoma relocation and CST and in two of 15 patients treated by modified Rives sublay mesh technique and CST. In five patients treated by modified Sugarbaker technique no complications occured. Mean follow up was 28 months.

Conclusion

Modified Rives sublay technique with CST and modified Sugarbaker technique with or withouth CST provide good results in treatment of patients with parastomal hernia.

OC-013 INDIVIDUAL STRATEGY FOR PATIENTS WITH ABDOMINAL WALL EVENTRATION – DIFFERENT COMPONENTS SEPARATION TECHNIQUE WITH MESH AUGMENTATION

Aim

To present individual approach for patients with abdominal wall eventration using various anterior component separation techniques (aCST) with mesh augmentation.

Materials and Methods

Between January 2008 and April 2022, 194 patients with abdominal wall eventration underwent surgery by single surgeon. Surgical treatment consists: a) enlargement of the abdominal cavity using different aCST (Ramirez CST, modified CST in the presence of enterostomies, “open book” modification CST, “method of wide myofascial release” or combination of these techniques); b) mesh augmentation (sublay or onlay hernioplasty); c) prolonged muscle relaxation and mechanical respiratory support in intensive care unit.

Results

Type of abdominal wall reconstruction: 143 Ramirez CST, 35 modification CST in the presence of enterostomies, 11“open book” CST modification, 5 “method of wide myofascial release”, 159 onlay mesh hernioplasty and 35 sublay mesh hernioplasty. Mean hernia defect size was 255 cm2 (100–750). During the mean follow-up of 31 months, 78 (40%) patients had one or more complications: intraabdominal hypertension 8 (4,1%), seroma 13 (6,7%), hematoma 10 (5,1%), wound/mesh infections 21 (10,8%), skin necrosis 40 (20,6%), pain 3 (1,6%), and recurrence 5 (2,6%). There were 10 (5,1%) postoperative deaths. The cause of dead was significant comorbidity in 8 patients and postoperative compartment syndrome in two.

Conclusion

Eventration disease is a complex surgical problem and its treatment is associated with significant complications. Individual strategy for each patient based on multidisciplinary approach using different component separation techniques with mesh augmentation may improve postoperative results.

OC-051 MANAGEMENT OF EPIGASTRIC, UMBILICAL, SPIGELIAN AND SMALL INCISIONAL HERNIA AS A DAY CASE PROCEDURE: RESULTS OF LONG–TERM FOLLOW–UP AFTER OPEN PREPERITONEAL FLAT MESH TECHNIQUE

Aim

To investigate short and long-term outcome after the open preperitoneal flat mesh technique (OPPFMT) for umbilical, epigastric, spigelian, small incisional and “port-site” hernia performed as a day case procedure.

Materials and Methods

We retrospectively analyzed records of patients who underwent OPFMT for umbilical, epigastric, Spigelian, small incisional and “port-site” hernia. All patients were operated under local anesthesia in ambulatory settings. The operative technique is as follows: polypropylene flat mesh exceeding the size of the hernia defect for 2–3 cm in all directions is placed into a pre-peritoneal position above the intrabdominaly repositioned hernia sac (mesh is placed into hernia sac) and fixed by at least 8 transfascial “U” sutures.

Results

In the period from January 2004 to April 2022, 531 patients with ventral hernias (272 with umbilical, 155 with epigastric, 69 with small incisional, 17 with “port site” and 18 with Spigelian hernia) underwent surgery. During the median follow-up of 44 months, 8 (1,5%) hematomas, 2 (0,4%) seromas, 2 (0,4%), superfitial wound infections, 8 (1,5%) mesh infections and 24 (4,6%) recurrences occurred.

Conclusion

Management of epigastric, umbilical, spigelian and small incisional hernia with OPFMT under local anesthesia as a day case procedure is a safe and associated with favorable long-term outcome.

OC-025 STRATEGY FOR SURGICAL TREATMENT OF GIANT INGUINOSCROTAL HERNIA - SERIES OF 21 CONSECUTIVE PATIENTS DURING 15 YEARS

Aim

To present our strategy for surgical treatment of patients with giant inguinoscrotal hernia whose hernia defect is ≥10 cm or who have a loss of domain.

Material and methods

Between January 2006 - January 2022, 21 consecutive patients with giant inguinoscrotal hernia and high risk of postoperative intra-abdominal hypertension were managed. The hernia was repaired in the following manner: modified Rives technique performed through direct inguinal approach in 10 patients; additional procedures were needed to reduce the volume of organs returned to the abdomen in four patients; the primary abdominal cavity was enlarged by various components separation techniques with or without mesh hernioplasty in seven patients.

Results

The hernia defect size was in range 7–17 cm. In three patients the contents of the hernia sac accounted for more than 50% of the intestines: entire large bowel without the rectum, ileum, jejunum except proximal 15 cm and greater omentum). Postoperative complications occurred in eight patients were: scrotal hematoma, deep mesh infection, seroma and hydrocele. There were three postoperative deaths: 12 hours, 17 and 42 days after the surgery because ischemic enteritis, cerebrovascular stroke and heart failure, respectively.

Conclusion

Our strategy consisting of modified Rives technique performed through direct inguinal approach with or without additional procedures to reduce the volume of organs returned to the abdomen or to enlarge the primary abdominal cavity can be a good solution for giant inguinoscrotal hernias. Procedure is followed by the risk of deadly complications and requires trained team in intesive care unit.

P-073 THE MODIFIED SUBLAY TECHNIQUE FOR THE MANAGEMENT OF MAJOR SUBCOSTAL INCISIONAL HERNIA: LONG-TERM FOLLOW-UP RESULTS OF 41 CONSECUTIVE PATIENTS

Aim

To present the concept of original technique in the management of major incisional subcostal hernias bassed on sublay position of large haevy-weight polypropylene mesh between the two myofascial layers in the anterolateral abdominal wall.

Material and methods

Between January 2010 and May 2022, 41 consecutive patients underwent the modified sublay technique for major incisional subcostal hernia (minimal defect surface100 cm2 or minimal defect width or height 10 cm). The operative technique is: a) hernia sac dissetion and reposition into the abdominal cavity; b) rectus muscle and rectus muscle stump dissection from posterior rectus sheath, rectus muscle atachement dissection from thoracic wall and external oblique muscle dissection from internal oblique muscle around hernia defect at the side of the hernia defect; c) separate posterior and anterior rectus sheaths reconstruction at the midline; d) reconstruction of the posterior miofascial layer suturing internal oblique/transversal muscle and posterior rectus sheaths; e) large haevy-weight polypropilene mesh placement between posterior and anterior miofascial layer; e) reconstruction of the anterior miofascial layer by suturing external oblique muscle and anterior rectus sheaths.

Results

A median (range) hernia defect surface was 160 (100–500) cm2. A median operative time was 120 (90–330) minutes. The morbidity rate was 19.5%. A median (range) postoperative hospital stay was 7 (2–24) days. After the median follow-up of 50 (1–124) months, two patients (4,9%) developed recurrent hernia.

Conclusions

The modified sublay technique using large heavyweight polypropylene mesh provides good results in the management of major subcostal abdominal wall defects.

OC-012 THE COMBINATION OF THE THREE MODIFICATIONS OF THE COMPONENT SEPARATION TECHNIQUE IN THE MANAGEMENT OF COMPLEX SUBCOSTAL WALL DEFECT

Aim

To present a concept combining three modifications of the component separation technique (CST) in one procedure as an original solution for the management of complex subcostal abdominal wall defect.

Material and Methods

Between January 2010 and January 2022, seven patients with complex subcostal hernia defects compromised by infection, radiation, or chemotherapy underwent surgery in which three modifications of CST were combined into one procedure. Major complex subcostal hernia was defined by either width or length of the defect being greater than 10 cm. The following were the stages of the operative technique: (a) the “method of wide myofascial release” at the side of the hernia defect; (b) “openbook variation” of the component separation technique at the opposite side of the hernia defect; (c) a modified component separation technique for closure of midline abdominal wall hernias in the presence of enterostomies; (d) suturing of the myofascial flaps to each other to cover the defect; and (e) repair augmentation with an absorbable mesh in the onlay position.

Results

The median (range) length and width of the complex subcostal hernias were 15 cm (10–19) and 15 cm (8–24), respectively. The overall morbidity rate was 57.1% (wound infection, seroma and skin necrosis). There was no hernia recurrence during the median follow-up time of 19 (range 3–84) months.

Conclusion

The operative technique integrating three modifications of CST in one procedure with onlay absorbable mesh reinforcement is a feasible solution for the management of complex subcostal abdominal wall defect.

P-088 HOW TO REPAIR A LATERAL INCISIONAL ABDOMINAL WALL HERNIA?

Aim

To present our original method for surgical treatment of patients with lateral incisional hernia (LIH)

Material and Method

Patients with LIH and simultaneous presence of a middle incisional hernia (MIH) were treated by our original technique based on the principles of anterior component separation technique and sublay technique: a) skin and subcutaneous tissue incision along the midline and MIH dissection; b) subcutaneous tissue dissection in the lateral direction to the Spiegel line or the LIH lateral edge on the side of the LIH; c) vertical incision of the external oblique muscle (EOM) lateral to the Spiegel line or the LIH; d) the rectus muscle (RM) dissection from its posterior sheath on the opposite side of the LIH; e) suturing the posterior rectus sheath on the opposite side of the LIH with RM on the side of the LIH; f) suturing of the internal oblique muscle with the lateral edge of the RM on the side of the LIH; g) onlay polypropylene mesh hernioplasty.

Results

Between January 2013 and May 2022, 44 consecutive patients with LIH+MIH underwent surgery. A median (range) LIH defect surface was 90 (20–270) cm2. During mean follow up of 14 months postoperative complications occured in seven (15,9%) patients: seroma in three, hematoma in two, mesh infection and hernia recurrence in one.

Conclusion

Our original method can be one of the good solutions for simultaneous treatment of LIH and MIH.

The combination of the three modifications of the component separation technique in the management of complex subcostal abdominal wall hernia

PURPOSE

The purpose of this study is to present a concept combining three modifications of the component separation technique (CST) in one procedure as an original solution for the management of complex subcostal abdominal wall hernia.

METHODS

Between January 2010 and January 2020, seven patients presenting at the high-volume academic center with complex subcostal hernia underwent surgery in which three modifications of CST were combined into one procedure. Major complex subcostal hernia was defined by either width or length of the defect being greater than 10 cm. The following were the stages of the operative technique: (a) the "method of wide myofascial release" at the side of the hernia defect; (b) "open-book variation" of the component separation technique at the opposite side of the hernia defect; (c) a modified component separation technique for closure of midline abdominal wall hernias in the presence of enterostomies; (d) suturing of the myofascial flaps to each other to cover the defect; and (e) repair augmentation with an absorbable mesh in the onlay position.

RESULTS

The median length and width of the complex subcostal hernias were 15 cm (10-19) and 15 cm (8-24), respectively. The overall morbidity rate was 57.1% (wound infection occurred in three patients, seroma in two patients, and skin necrosis in one patient). There was no hernia recurrence during the median follow-up period of 19 months.

CONCLUSION

The operative technique integrating three modifications of CST in one procedure with onlay absorbable mesh reinforcement is a feasible solution for the management of complex subcostal abdominal wall hernia.

Liver resection versus transarterial chemoembolization for huge hepatocellular carcinoma: a propensity score matched analysis

To date, it is unclear which treatment modality, liver resection (LR) or transarterial chemoembolization (TACE) is the more appropriate for patients with huge (≥ 10 cm) hepatocellular carcinoma (HCC). The study aim was to compare, using propensity score matching, short- and long-term outcomes of patients with huge HCC who underwent potentially curative LR or TACE. Patients with huge HCC who had been managed at the Clinical Center by curative-intent LR or by palliative TACE between November 2001 and December 2018 were retrospectively identified. The morbidity and mortality rates and overall survival were compared between the groups before and after the propensity score matching. Independent predictors of long-term survival were determined by multivariate analysis. A total of 103 patients with huge HCC were included; 68 were assigned to the LR group and 35 to the TACE group. The overall morbidity rate was higher in the LR group than in the TACE group before matching (64.7% vs. 37.1%, p = 0.012), while there was no difference after matching (60% vs. 30%, p = 0.055). The major morbidity and 30-days mortality were similar between the groups before and after matching. The LR group was associated with longer overall survival than the TACE group before matching (p = 0.032) and after matching (p = 0.023). Total bilirubin and TACE treatment were independent prognostic factors associated with long-term survival. In patients with huge HCC, liver resection provides better long-term survival than TACE and should be considered as the initial treatment whenever possible.

Orbital and ocular adnexal Mucosa-Associated Lymphoid Tissue (MALT) lymphomas: a single-center 10-year experience

Orbital and ocular andexal Mucosa-Associated Lymphoid Tissue Lymphoma (MALT) or ocular adnexal MALT lymphoma (OAML) is the most common of all eye non-Hodgkin lymphomas. Autoimmune inflammatory disorders and chronic infections are important etiological factors and CD5 and CD43 (sialophorin) tumor markers are significant negative prognostic factors. Disease signs and symptoms can occur a long time before diagnosis. Varieties of treatment options are available. The aim of this retrospective analysis was to compare the efficiency of different treatment options and to investigate disease outcome. Twenty OAML patients, diagnosed in the Clinic of Hematology, Clinical Centre of Serbia, between 2003 and 2013, were enrolled. In most cases, OAML developed in the eighth decade with greater incidence in the male population. Median age was 67.5 years. The median period between the appearance of local signs and symptoms and diagnosis was 7 months. The dominant sign at presentation was swelling of involved tissue (40%). The most common was orbital involvement (55%). All patients had localized disease. Observed laboratory parameters on presentation showed low disease activity. Sialophorin prognostic significance was not registered. Our patients were initially treated differently but there was no significant difference in progression-free survival (PFS) due to initial treatment option (p = 0.2957). Median PFS was 22 months (3-89), and 5-year PFS was 60%. Median overall survival (OS) was 43 months (1-105) and 5-year OS 95%. Eight patients (40%) relapsed and one patient died due to non-hematological complications. In our experience, most modern induction treatment options appear to result in the same, favorable outcome.

Mixed phenotype acute leukemia of T/myeloid type with a prominent cellular heterogeneity and unique karyotypic aberration 45,XY, dic(11;17)

INTRODUCTION

A 26-yr-old male patient with mixed phenotype acute leukemia of T/myeloid type with prominent leukemic cell heterogeneity, and the presence of a so far unreported karyotype aberration in this type of acute leukemia 45,XY, dic(11;17)(11qter→11p11.2::17p11.2→17qter) is presented.

METHODS

Flow immunocytometry was performed by direct multicolor immunofluorescent technique on bone marrow aspirates. Cytogenetic analyses were performed using G-banding method by direct preparation of unstimulated bone marrow cells and following 24 hours of culture in RPMI 1540 culture medium with 25% fetal calf serum at 37°C RESULTS: The flow immunocytometry of bone marrow nucleated cells revealed the existance of three distinct blast cell populations with overlapping immunophenotypes. Predominant blast cell population had an early myeloid phenotype and aberrant expression of CD7 antigen (HLA-DR(+), CD34(+), anti-MPO(+), CD117(+), CD33(+), CD13(+), CD7(+low), cyCD3(-), TdT(-)). The other two blast cell populations, smaller in cell diameter and less sizable in cell proportion, both shared the T-lymphoid features. The patient was treated with ADE protocol (etoposide, cytarabine and doxorubicine). A complete remission was achieved and lasted 5 months.

CONCLUSION

A case of MPAL with complex biological features, 45,XY, dic(11;17)(11qter→11p11.2::17p11.2→17qter) karyotype and an aggressive, therapy-resistant clinical course, is presented.

Frequency of BCR-ABL fusion transcripts in Serbian patients with chronic myeloid leukemia

PURPOSE

The aim of this study was to analyze the occurrence of the most frequent BCR-ABL transcript variants (b3a2, b2a2 and e1a2) in Serbian patients with chronic myeloid leukemia (CML) and compare it with the occurrence reported in other populations.

METHODS

We analyzed peripheral blood and bone marrow samples of 136 Serbian patients with CML by RT-PCR and cytogenetic methods.

RESULTS

In 100 patients (73.5%) the b3a2 and in 34 (25%) the b2a2 forms of BCR-ABL were detected. One (0.75%) patient was BCR-ABL negative, but in lymphoblastic transformation he expressed the e1a2 [corrected] transcript of BCR-ABL. One (0.75%) patient displayed both b2a2 and b3a2 forms of BCR-ABL. Analysis of this group according to karyotype showed b3a2 predominance (79%) in patients with classic t(9;22); b2a2 was found in 20% and both b2a2 and b3a2 forms in 1%. In variant translocations b3a2 in 65% and b2a2 in 35% of the patients were detected. In contrast, the subgroup with normal karyotype expressed slight predominance of the b2a2 form (50%); b3a2 was found in 43% of the patients and one patient (7%) displayed e1a2.

CONCLUSION

Predominance of the b3a2 form in Serbian patients with CML is in concordance with other relevant investigations, conducted mostly on Caucasian ethnic groups, but in contrast to the study performed on the Mestizo ethnic group in Ecuador. Slight predominance of the b2a2 form was also noticed among the patients with normal karyotype.

New approach of the treatment of von Willebrand’s disease during pregnancy

AIM

The aim of the study was to analyze the effectiveness of the application of DDAVP (desmopressin) and Hemate P with cryoprecipitate pre- and postpartum in patients with von Willebrand disease.

METHODS

We monitored 32 patients with von Willebrand disease during the study period 1993-2003. DDAVP was applied in the 36th/37th week of gestation and cryoprecipitate and fresh frozen plasma were applied 1 day before and 3 days after delivery. DDAVP treatment continued for 4 weeks. Factor VIII (Hemate P) at the day of delivery

RESULTS

No complications occurred in the studied population.

CONCLUSION

Precipitation of DDAVP, Hemate P, and cryoprecipitate may help in the treatment of pregnant women with von Willebrand disease.

Interrelationships between body composition and energy expenditure in cancer malnutrition. The role of bioimpedance assessment

AIM

The aim of the experience was a case-control evaluation of the role of biological impedance assessment (BIA) for estimating resting energy expenditure (REE) instead of indirect calorimetry (IC) in cancer patients.

METHODS

Thirteen patients with gastric cancer (GK) were studied vs 18 control (C) patients. GK patients were depleted in fat free mass (FFM) (33+/-3 vs 44+/-5 kg; p<0.0001) and in body cell mass (BCM), (19+/-1 vs 26+/-3 kg; p<0.0001).

RESULTS

The REE, calculated with the Harris-Benedict formula (REE-HB) was higher in C than in GK (1,443+/-149 vs 1,196+/-109 Kcal/day; p<0.0001) despite that, when evaluated by means of Indirect Calorimetry (REE-IC), it showed similar values in both groups (1,456+/-157 vs 1,353+/-210 Kcal/day; p=NS; C vs GK), a remarkable decrease of BCM in GK notwithstanding. The REE-IC/actual weight ratio was 21+/-2 Kcal/kg/day in C and 25+/-3 Kcal/kg/day in GK (p<0.005) and the REE-IC/BCM ratio was 55+/-4 Kcal/kg/day in C, and 68+/-8 Kcal/kg/day, in GK (p<0.0001), with a significant correlation between BCM and REE-IC in controls vs GK.

CONCLUSIONS

The group of gastric malnourished cancer patients showed an increase in REE-IC in comparison with REE-HB; the increase in REE-IC was not related to the size of the remaining BCM; it is impossible to get a satisfying linear regression function expressing REE in terms of body composition measures obtained by means of BIA instead of indirect calorimetry; the IC is more appropriate to evaluate REE in cancer malnourished patients because in the present experience the Harris-Benedict formula underestimates this parameter by more than 10% (11.06%).

In vitro sensitivity of hematopoietic progenitors to tiazofurin in refractory acute myeloid leukemia and in the blast crisis of chronic myeloid leukemia

The effect of Tiazofurin (TR) on the in vitro growth of bone marrow (BM) and peripheral blood (PB) leukemic progenitors was investigated in 29 patients. Nineteen of the patients were suffering the blast crisis of chronic myeloid leukemia (bcCML) and ten patients refractory acute myeloid leukemia (AML). PB and BM mononuclear cells were cultured in methylcellulose alone or with concentrations of TR ranging between 10 and 200 microM. TR produced a dose dependent inhibition of colony forming unit (CFU)-blast growth in all the samples tested from BM and PB. The most effective concentrations of TR used were 150 and 200 microM, while concentrations of less than 50 microM TR were not adequate for 50% inhibition of cell growth (IC50). Differences were found in the response of CFU-blasts to TR related to the type of underlying leukemia. Inhibition of CFU-blast growth was more pronounced in bcCML than in AML in both the BM and PB samples. The concentration of TR required to induce IC50 in bcCML was 50 microM, while the same effect in AML required a concentration of 150 microM. Analysis of the control samples also revealed that CFU-blasts from bcCML produced smaller numbers of colonies, though these differences were not statistically significant. It has therefore been demonstrated that TR has strong in vitro anti-leukemic activity, more pronounced in bcCML than in refractory AML. We thus feel this study gives further rationale for the clinical application of TR, and would strongly support this.

A syntaxin 7 homologue is present in Dictyostelium discoideum endosomes and controls their homotypic fusion

Endo-phagocytic activity is prominent in Dictyostelium discoideum and makes it a good model organism to study the molecular organization of membrane traffic in this pathway. We have identified a syntaxin 7 homologue (26% identity and 54% similarity to human syntaxin 7) in Dictyostelium cDNA and genomic data banks. In addition to the Habc and H3 helices and the C-terminal transmembrane domain characteristic of syntaxins, this protein contains a repetitive N-terminal extension of 68 amino acids. We first showed that Dictyostelium syntaxin 7 was able to form a complex with N-ethylmaleimide-sensitive fusion protein and alpha- and gamma-soluble N-ethylmaleimide-sensitive fusion protein attachment protein. Its intracellular localization was then studied by cell fractionation techniques and magnetic purification of the endocytic compartments. Most of D. discoideum syntaxin 7 is contained in endosomes. Finally, an in vitro endosome homotypic fusion assay (Laurent, O., Bruckert, F., Adessi, C., and Satre, M. (1998) J. Biol. Chem. 273, 793-799) was used to study a possible role for syntaxin 7 in this process. Purified anti-syntaxin 7 antibodies and a recombinant soluble fragment of syntaxin 7 both strongly inhibited fusion activity, indicating that this protein was necessary for endosome-endosome fusion. These results demonstrate the importance of this syntaxin 7 homologue in the early phases of Dictyostelium endo-phagocytic pathway.

The determination of spontaneous megakaryocyte colony formation is an unequivocal test for discrimination between essential thrombocythaemia and reactive thrombocytosis

Spontaneous colony formation from bone marrow megakaryocyte progenitors (BMsCFU-Mk) was studied in 24 patients with essential thrombocythaemia (ET), 20 patients with reactive thrombocytosis (RT), 20 patients with polycthaemia rubra vera with thrombocytosis (PRVtr), 16 patients with chronic myeloid leukaemia with thrombocytosis (CMLtr) and 18 normal control subjects (C). The culture medium which was used in the methylcellulose assay in vitro contained 30% of plasma from a single patient with hereditary haemochromatosis. Remarkable BMsCFU-Mk growth was recorded in all patients with ET but in none with RT or in C. BMs-CFU-Mk were present in 11/20 patients with PRVtr and 7/16 patients with CMLtr. Spontaneous bone marrow erythroid progenitors (BMsBFU-E) were also determined in these patients. BMsBFU-E were found in 21/24 patients with ET and none in the patients with RT and C. All patients with PRVtr and one patient with CMLtr showed BMsBFU-E. We conclude that our implementation of the in vitro methylcellulose assay allows the BMsCFU-Mk to be used as an unequivocal test for discrimination between ET and RT which has not been shown in previously published studies. In addition, we present evidence that in 10 patients BMsCFU-Mk and/or BMsBFU-E growth in the test persisted after long-lasting haematological remission.