1
|
Biswas S, Pilkington JJ, Stathakis P, Jamdar S, Harwood R, Paajanen H, Sheen AJ. The Sheen Paajanen grOin Recommended Treatment 'SPoRT' score for groin pain. Hernia 2023; 27:1085-1093. [PMID: 37093340 DOI: 10.1007/s10029-023-02771-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/12/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Evaluating groin pain still evades many clinicians at times as they have difficulty determining the cause of pain when no true hernia exists. This study's aim was to evaluate a simple and novel scoring system which is reproducible, to help determine whether conservative measures or surgery is recommended for the management of groin pain attributable to inguinal disruption. MATERIAL & METHODS A retrospective analysis of all patients from 2018 to 2020 that underwent surgery or conservative management for inguinal disruption with at least a 1-year follow-up were evaluated. The scoring system is based on MRI and ultrasound imaging as well as clinical findings, with scores given from - 2 to + 2 based on the defined findings listed. A maximum total of four points scored for each assessment was used. Sensitivity and specificity analysis was conducted for each potential score cut off point. RESULTS A total of 172 patients were evaluated with 33 patients (19%) undergoing conservative management and 139 patients (81%) undergoing surgery. The median SPoRT score for the surgery group was 2.0 (1.0, 3.0), and - 1.0 (- 3.0, 0.0) in the physiotherapy group which was a significant difference (p < 0.001). An optimal cut off of ≤ 0 for physio and ≥ 1 for surgery was established, yielding a sensitivity of 90.9% (95% CI 75.7%-98.1%), a specificity of 89.2% (95% CI 82.8%-93.8%) and an area under the curve (AUC) of 0.936 (95% CI 0.874-0.997). DISCUSSION SPoRT score of ≤ 0 can recommend a patient should undergo conservative measures or physiotherapy as a mainstay of treatment with a score of ≥ 1 recommending surgery. Further validation of the score is necessary.
Collapse
Affiliation(s)
- S Biswas
- Department of Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - J J Pilkington
- Department of Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - P Stathakis
- Department of Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - S Jamdar
- Department of Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - R Harwood
- Department of Medical Statistics, Manchester University NHS Foundation Trust, Manchester, UK
| | - H Paajanen
- Department of Surgery, University of Eastern Finland and Mikkeli Central Hospital, Mikkeli, Finland
| | - A J Sheen
- Department of Surgery, Manchester University NHS Foundation Trust, Manchester, UK.
- Manchester Academic Health Science Centre (MAHSC), Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| |
Collapse
|
2
|
Nanayakkara KDL, Viswanath NG, Wilson M, Mahawar K, Baig S, Rosenberg J, Rosen M, Sheen AJ, Goodman E, Prabhu A, Madhok B. An international survey of 1014 hernia surgeons: outcome of GLACIER (global practice of inguinal hernia repair) study. Hernia 2023; 27:1235-1243. [PMID: 37310493 DOI: 10.1007/s10029-023-02818-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 06/04/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION The practice of inguinal hernia repair varies internationally. The global practice of inguinal hernia repair study (GLACIER) aimed to capture these variations in open, laparoscopic, and robotic inguinal hernia repair. METHODS A questionnaire-based survey was created on a web-based platform, and the link was shared on various social media platforms, personal e-mail network of authors, and e-mails to members of the endorsed organisations, which include British Hernia Society (BHS), The Upper Gastrointestinal Surgical Society (TUGSS), and Abdominal Core Health Quality Collaborative (ACHQC). RESULTS A total of 1014 surgeons from 81 countries completed the survey. Open and laparoscopic approaches were preferred by 43% and 47% of participants, respectively. Transabdominal pre-peritoneal repair (TAPP) was the favoured minimally invasive approach. Bilateral and recurrent hernia following previous open repair were the most common indications for a minimally invasive procedure. Ninety-eight percent of the surgeons preferred repair with a mesh, and synthetic monofilament lightweight mesh with large pores was the most common choice. Lichtenstein repair was the most favoured open mesh repair technique (90%), while Shouldice repair was the favoured non-mesh repair technique. The risk of chronic groin pain was quoted as 5% after open repair and 1% after minimally invasive repair. Only 10% of surgeons preferred to perform an open repair using local anaesthesia. CONCLUSION This survey identified similarities and variations in practice internationally and some discrepancies in inguinal hernia repair compared to best practice guidelines, such as low rates of repair using local anaesthesia and the use of lightweight mesh for minimally invasive repair. It also identifies several key areas for future research, such as incidence, risk factors, and management of chronic groin pain after hernia surgery and the clinical and cost-effectiveness of robotic hernia surgery.
Collapse
Affiliation(s)
- K D L Nanayakkara
- Royal Derby Hospital, University Hospital Derby and Burton NHS Trust, Derby, UK.
| | - N G Viswanath
- Royal Derby Hospital, University Hospital Derby and Burton NHS Trust, Derby, UK
| | - M Wilson
- Forth Valley NHS Trust, Larbert, UK
| | - K Mahawar
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - S Baig
- Belle Vue Hospital, Kolkata, India
| | - J Rosenberg
- Department of Surgery, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M Rosen
- Cleveland Clinic, Cleveland, USA
| | - A J Sheen
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - A Prabhu
- Cleveland Clinic, Cleveland, USA
| | - B Madhok
- Royal Derby Hospital, University Hospital Derby and Burton NHS Trust, Derby, UK
| |
Collapse
|
3
|
Bandyopadhyay S, Sheen AJ, Iqbal A. P-116 UNUSUAL VISCERAL CONTENT IN PARASTOMAL HERNIAS - A REVIEW OF LITERATURE. Br J Surg 2022. [DOI: 10.1093/bjs/znac308.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Parastomal hernias remain the most common complication of an ileostomy or colostomy - It is estimated that upto 50 percent of patients with a stoma will develop one. They may be classified as Interstitial, Subcutaneous, Intrastomal or Peristomal. The most common contents of Parastomal Hernias are bowel and omentum.However, other visceras have been reported as a content of a parastomal hernia. This presentation is aimed at a literature review of such surprise surgical situations that are challenging to the surgeons.
Presence of gallbladder in a parastomal hernia has been reported by multiple authors - there is reported incidence of incarceration or acute inflammation of the gallbladder. Cholecystectomy t the time of parastomal hernia repair has been reported though some patients have been treated non-operatively as well.
Similarly, there have been multiple reports of stomach beong the contents of parastomal hernias - there have been patients presenting with gastric outlet obstruction who have been found to have the stomach being a content of their parastomal herniation.
This presentation reviews the available literature and presents the challenges and oprions that a surgeon may face when treating similar patients.
Collapse
Affiliation(s)
- S Bandyopadhyay
- HPB Surgery, Manchester Royal Infirmary , Manchester , United Kingdom
| | - A J Sheen
- HPB Surgery, Manchester Royal Infirmary , Manchester , United Kingdom
| | - A Iqbal
- HPB Surgery, Manchester Royal Infirmary , Manchester , United Kingdom
| |
Collapse
|
4
|
Pilkington J, Wilkinson F, Pritchett J, Fullwood C, Sheen AJ. OC-087 PAIN AND INFLAMMATORY SIGNALLING IN TACKOMESH TRIAL PARTICIPANTS FOLLOWING ELECTIVE LAPAROSCOPIC INCISIONAL HERNIA REPAIR WITH INTRAPERITONEAL ONLAY MESH (IPOM) AND SPIRAL-TACK MESH FIXATION. Br J Surg 2022. [DOI: 10.1093/bjs/znac308.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Background
The aim of this study was to investigate for links between reported pain and inflammation within a sub-cohort of patients undergoing the IPOM plus repair through the measurement of serum/plasma levels of established inflammatory biomarkers in trial participants across 1-year follow up.
Methods
22 patients (12 Protack™ and 10 Reliatack™) within the TACKoMesh randomised controlled trial underwent serial blood sampling as part of their follow up. A panel of pro- and anti-inflammatory biomarkers were assayed using Luminex multiplex assays and ELISAs. Circulating biomarker concentrations were described and compared in the context of clinical and patient reported outcome data that was obtained within the trial.
Results
An increase in the serum concentration of pro- (IL-6 and CRP) and anti- (IL-10) inflammatory biomarkers was seen following IPOM plus repair. Serum IL-6 and CRP were significantly raised compared to baseline at post-operative Days 1, 6 and 30 (p < 0.05). Markers of onward signalling (Cortisol and TNF-alpha) and tissue repair (PDGF-AA and VEGF) showed a trend towards an elevation at similar timepoints (notably at post-op Day 6) but were not significantly different from baseline levels. There were no observed correlations between inflammatory signal and reported pain, treatment allocation within the trial, burden of implanted prosthetic material, or hernia recurrence.
Discussion
This study demonstrates the novel finding of a pro-inflammatory signal at post-operative Day 30 following the IPOM plus repair.
Collapse
Affiliation(s)
- J Pilkington
- Department of Surgery, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - F Wilkinson
- Centre for Bioscience, Manchester Metropolitan University , Manchester , United Kingdom
| | - J Pritchett
- Centre for Bioscience, Manchester Metropolitan University , Manchester , United Kingdom
| | - C Fullwood
- Medical Statistics, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - A J Sheen
- Department of Surgery, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| |
Collapse
|
5
|
Bandyopadhyay S, Iqbal A, Sheen AJ. P-115 HYBRID REPAIR OF RECURRENT COMPLEX GROIN HERNIA - CHALLENGES AND LESSONS LEARNT. Br J Surg 2022. [DOI: 10.1093/bjs/znac308.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
A 45 year old lady presented with a recurrent swelling over the right groin that had gradually turned tense and tender over the last 48 hours. Having undergone an urgent right femoral hernia repair in 2002, she underwent an inguinal hernioplasty in 2004 and amesh repair of a recurrent inguinal hernia in 2008. She developed a third recurrence that slowly increased in size and needed an urgent repair. At assessment, she was found to have a large complete recurrent irreducible right inguinal hernia containing loops of bowel.
At laparoscopy, multiple loops of bowel and omentum were reduced from a large multiloculated hernial sac. In view of the large sac which had incorporated the previously placed meshes in the wall, a decision was made to abandon laparoscopic approach. The myopectineal orifice was approached through a groin incision and the hernial sac with it's locules, including a prevascular component, was defined. The posterior sheath was defined and the rigt rectus muscle, displaced by the hernia, was repositioned. The dissection was carried upto the Space of Bogros to ensure that no component of the hernia was missed out. After completing a formal herniotomy, a sandwich prosthesis, created by stitching a biomesh and a polypropylene mesh, was utilised for hernia repair.
The patient had an uneventful recovery.
The presentation is aimed at discussing the challenges of repairing a complex recurrent hernia, the possible pitfalls and lessons learnt.
Collapse
Affiliation(s)
- S Bandyopadhyay
- HPB Surgery, Manchester Royal Infirmary , Manchester , United Kingdom
| | - A Iqbal
- HPB Surgery, Manchester Royal Infirmary , Manchester , United Kingdom
| | - A J Sheen
- HPB Surgery, Manchester Royal Infirmary , Manchester , United Kingdom
| |
Collapse
|
6
|
Iqbal A, Kaul A, Sheen AJ. P-083 AMYANDS HERNIA WITH RENAL CELL CARCINOMA - A RARE CASE PRESENTATION. Br J Surg 2022. [DOI: 10.1093/bjs/znac308.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
47 year old gentleman presented to the emergency department with 2 days history of lower abdominal pain and right inguinal swelling which has increased in size during the same duration, he also had one episode of vomiting, bloating and constipation since 2 days. Investigations revealed an inflamed appendix within the right inguinal hernia along with a left renal lesion. The patient underwent emergency open primary repair of inguinal hernia with appendicectomy. Followed up with urology as an outpatient regarding renal lesion and with MDT discussion the patient was subjected for a partial nephrectomy.
Collapse
Affiliation(s)
- A Iqbal
- Hepato pancreato biliary surgery , Manchester royal Infirmary , Manchester, United Kingdom
| | - A Kaul
- Hepato pancreato biliary surgery , Manchester royal Infirmary , Manchester, United Kingdom
| | - A J Sheen
- Hepato pancreato biliary surgery , Manchester royal Infirmary , Manchester, United Kingdom
| |
Collapse
|
7
|
Pilkington J, Wilkinson F, Pritchett J, Fullwood C, Sheen AJ. OC-088 CAN PROCOLLAGEN I AND PROCOLLAGEN III SERVE AS PREDICTIVE BIOMARKERS FOR INCISIONAL HERNIA RECURRENCE? Br J Surg 2022. [DOI: 10.1093/bjs/znac308.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Background
The aim of this study was to determine the temporal evolution of extracellular matrix (ECM) remodelling and collagen biomarkers and their influence on incisional hernia recurrence after the IPOM plus repair.
Methods
A sub-cohort of patients (n=25) undergoing laparoscopic incisional hernia repair within the TACKoMesh randomised controlled trial were bled at serial timepoints up to 1-year following surgery. Serum/plasma concentration of biomarkers (Procollagen I, Procollagen III, Fibronectin, TGF-beta, MMP-2, MMP-9, TIMP-1, and TIMP-2) were quantified using ELISA and Luminex multiplex techniques. Data were described and compared between groups that developed and remained free from recurrence using R statistical software.
Results
Procollagen I was reduced relative to baseline on post-op Day 1 but increased at Days 6 and 30 (p<0.05). Procollagen III showed an elevation at Day 30. Lower levels of Procollagen I were detected at Day 0, Day 1 and Day 6 (p<0.05) and higher levels of Procollagen III at Day 0, Day 1, Day 6 and Day 30 (p<0.05) in patients with a recurrence.
Fibronectin was reduced at Day 1 and 6 (p<0.05) whilst TGF-β was increased at Day 30 (p<0.05). MMP-2 and its inhibitor TIMP-2 were reduced at post-operative Day 1 (p<0.05). MMP-9 was persistently higher than baseline (p<0.05) at all timepoints. TIMP-1 was elevated at post-op Days 6 and 30. No differences were found in the circulating concentrations of these biomarkers to predict a recurrence.
Conclusion
In patients that developed incisional hernia recurrence, low levels of Procollagen I and high levels of Procollagen III were detected.
Collapse
Affiliation(s)
- J Pilkington
- Department of Surgery, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - F Wilkinson
- Centre for Bioscience, Manchester Metropolitan University , Manchester , United Kingdom
| | - J Pritchett
- Centre for Bioscience, Manchester Metropolitan University , Manchester , United Kingdom
| | - C Fullwood
- Medical Statistics, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - A J Sheen
- Department of Surgery, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| |
Collapse
|
8
|
Dave M, Pilkington J, Fullwood C, Sheen AJ. P-112 PRE-OPERATIVE PAIN AND REDUCED QUALITY OF LIFE SCORES IN PATIENTS THAT REPORT PERSISTENT PAIN AT 365 DAYS FOLLOWING LAPAROSCOPIC INCISIONAL HERNIA REPAIR. Br J Surg 2022. [DOI: 10.1093/bjs/znac308.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Background
The use of patient reported outcome measures (PROMs) for incisional hernia has been established. This study aims to explore relationships between persistent pain at Day365 post laparoscopic-IPOM repair and other clinical and patient-reported data for patients within the TACKoMESH randomised trial.
Methods
Clinical, operative and PROMs data were collected pre-operatively and at four post-operative time points up to one year. Pain scores were measured using a visual analogue scale (VAS). Quality of life (QoL) data were measured using the short-form 36 (SF-36) and Carolina Comfort Score (CCS). Patients reporting pain ‘at rest’ at Day365 were compared with those reporting no pain. Statistical analysis was undertaken in R studio.
Results
54/63 trial participants attended followed up at Day365; 36 were male, and mean age was 59.1.
10 patients reported persistent pain at Day365 ranging from 1–9 on VAS. Patients were found to have reported higher pre-operative pain scores ‘at rest’ (5 [2–7] vs 0 [0–3] p=0.0181) and ‘on activity’ (8.5 [5–10] vs 4 [2–8] p=0.0181). They reported lower QoL scores in every domain on the SF-36, with significantly lower score for social function (50 [31–50] vs 75 [63–100] p=0.006).
Those reporting persistent pain at Day365 were more likely to have developed hernia recurrence (4 vs 3 p=0.0171). There were no significant differences in baseline characteristics, operative variables, and other complication rates between the groups.
Conclusion
Patients that report persistent pain at Day365 following laparoscopic-IPOM repair are more likely to have reported higher pain and lower QoL scores at pre-operative assessment.
Collapse
Affiliation(s)
- M Dave
- Department of Academic Hernia Surgery, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - J Pilkington
- Department of Academic Hernia Surgery, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - C Fullwood
- Research and Innovation, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - A J Sheen
- Department of Academic Hernia Surgery, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| |
Collapse
|
9
|
Pilkington J, Wilkinson F, Pritchett J, Fullwood C, Sheen AJ. OC-086 COMPARISON OF MESH-FIXATION TECHNIQUES IN LAPAROSCOPIC REPAIR OF INCISIONAL HERNIA, RELIATACK™ V PROTACK™ (TACKOMESH) NCT 03434301. Br J Surg 2022. [DOI: 10.1093/bjs/znac308.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Background
A study examining post-op pain, comparing permanent versus absorbable tack fixation devices, Protack™ versus Reliatack™, in IPOM plus repair.
Methods
TACKoMesh is a single-centre double-blind RCT conducted from 2017–2020 with 1-year follow up. Patients were randomised to either Protack™ (titanium tacks) or Reliatack™ (an articulating-arm with dissolvable tacks). Primary outcome was reported pain on activity at Day30. Secondary outcomes include recurrence and quality of life measures (SF-36 & Carolina Comfort Score).
Results
67 patients randomised: 36 with Protack™, 27 with Reliatack™, with 4 conversions. No significant difference in reported pain ‘on activity’ (post-operative Day 1, 6, 30 and 365). There was significantly reduced pain ‘at rest’ on Day1 with Reliatack™ (Protack™ 6 [4 to 9] vs Reliatack™ 4 [3 to 5], p = 0.020) and reduced pain at all other points with Reliatack™.
Operation (p = 0.001) & mesh-fixation (p = 0.001) times were longer, with more knots (p = 0.001) & tacks (p = 0.001) used with Reliatack™.
Entire cohort hernia recurrence, seroma formation, SSI & Clavien-Dindo Grade III-V complication were 8/63 (12.7%), 33/63 (52.4%), 7/63 (11.1%), and 12/63 (19.1%) respectively. There were no significant differences in these outcomes between the treatment groups. CCS showed improvement from post-op Day30 to 365. SF36 showed a reduction in baseline scores at post-op Day30.
Conclusion
There is no difference in reported pain ‘on activity’ following elective IPOM plus hernia repair when choosing either Protack™ or Reliatack™. There is a trend towards improved post-op pain ‘at rest’ with Reliatack™.
Collapse
Affiliation(s)
- J Pilkington
- Department of Surgery, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - F Wilkinson
- Centre for Bioscience, Manchester Metropolitan University , Manchester , United Kingdom
| | - J Pritchett
- Centre for Bioscience, Manchester Metropolitan University , Manchester , United Kingdom
| | - C Fullwood
- Medical Statistics, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - A J Sheen
- Department of Surgery, Manchester University NHS Foundation Trust , Manchester , United Kingdom
| |
Collapse
|
10
|
Burns E, Aliar A, Baltatzis M, O'keeffe N, Sheen AJ. V-021 REPORT OF AN ACQUIRED INTERCOSTAL HERNIA REPAIR USING A BILAYER MESH. Br J Surg 2022. [DOI: 10.1093/bjs/znac308.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Aim
A 53-year-old male underwent a T10/11 discectomy with partial removal of the right T9 rib. 10 years later, he developed an acquired painful intercostal hernia, worsened by leaning against the defect. CT imaging demonstrated an 8cm hernial defect containing the posterior lobe (segment VII) of the liver with a loss of integrity of the diaphragm.
Methods
Open surgical repair though the original incision was undertaken, with the patient in the left lateral position. The hernia was entirely reducible in this position.
Results
The liver was replaced into the peritoneal cavity, the hernial sac and the weakness at the postero-lateral edge of the diaphragm were then identified. The edges of the hernial sac were dissected off the ribs. An intraperitoneal mesh (SymbotexTM; Medtronic, Lyon) was cut to size, placed, and fixed to the undersurface of the ribs, with a 5cm overlap obtained medially and laterally. Care was taken to avoid damaging the neurovascular bundle and breach of the pleural cavity was not observed.
A bridging mesh was then used to reinforce the repair (VersatexTM; Medtronic, Lyon) with fixation to the ribs using ethibond sutures and cyanoacrylate glue (Glubran®; Viareggio). The repair was checked by Valsalva manoeuver prior to wound closure.
Post operative pain control was achieved using intercostal nerve block and patient-controlled analgesia. A post-operative chest x-ray did not demonstrate a pneumothorax. The patient was discharged on postoperative day 2.
Discussion
The patient experienced no serious postoperative sequelae and was pain free with no hernia at 30 days post-surgery.
Collapse
Affiliation(s)
- E Burns
- Department of Surgery, Manchester University NHS Foundation NHS Trust , Manchester , United Kingdom
| | - A Aliar
- Department of Cardiovascular Surgery, Manchester University NHS Foundation NHS Trust , Manchester , United Kingdom
| | - M Baltatzis
- Department of Surgery , Salford Royal NHS Foundation, Manchester , United Kingdom
| | - N O'keeffe
- Department of Anaesthesia, Manchester University NHS Foundation NHS Trust , Manchester , United Kingdom
| | - A J Sheen
- Department of Surgery, Manchester University NHS Foundation NHS Trust , Manchester , United Kingdom
| |
Collapse
|
11
|
Pilkington JJ, Davies TW, Schaff O, Alexander MY, Pritchett J, Wilkinson FL, Sheen AJ. Systemic biomarkers currently implicated in the formation of abdominal wall hernia: A systematic review of the literature. Am J Surg 2020; 222:56-66. [PMID: 33189313 DOI: 10.1016/j.amjsurg.2020.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Surgery to the abdominal wall is ubiquitous worldwide and hernia treatment is challenging and expensive, posing a critical need to tailor treatment to individual patient risk-factors. In this systematic review, we consider specific systemic factors with potential as biomarkers of hernia formation. METHODS A healthcare database-assisted search, following PRISMA guidelines, identified journal articles for inclusion and analysis. RESULTS 14 biomarker studies were selected, comparing hernia patients and hernia-free controls, focusing on markers of extracellular matrix (ECM) remodelling and collagen turnover. Matrix metalloproteinase-2 was increased in patients with inguinal hernia. Markers of type IV collagen synthesis were increased in patients with abdominal wall hernia; while markers of fibrillar collagen synthesis were reduced. Additional other ECM signalling proteins differ significantly within published studies. CONCLUSION We identify a lack of high-quality evidence of systemic biomarkers in tailoring treatment strategies relative to patient-specific risks, but recognise the potential held within biomarker-based diagnostic studies to improve management of hernia pathogeneses.
Collapse
Affiliation(s)
- J J Pilkington
- Centre for Bioscience, Manchester Metropolitan University, John Dalton Building, Chester Street, Manchester, UK; Department of Academic Hernia Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - T W Davies
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK; UCLH NIHR Biomedical Research Centre, Institute of Sport and Exercise Health, University College London Centre for Altitude Space and Extreme Environment Medicine, London, UK
| | - O Schaff
- Trust Library Services, Manchester University NHS Foundation Trust, Manchester, UK
| | - M Y Alexander
- Centre for Bioscience, Manchester Metropolitan University, John Dalton Building, Chester Street, Manchester, UK
| | - J Pritchett
- Centre for Bioscience, Manchester Metropolitan University, John Dalton Building, Chester Street, Manchester, UK
| | - F L Wilkinson
- Centre for Bioscience, Manchester Metropolitan University, John Dalton Building, Chester Street, Manchester, UK
| | - A J Sheen
- Centre for Bioscience, Manchester Metropolitan University, John Dalton Building, Chester Street, Manchester, UK; Department of Academic Hernia Surgery, Manchester University NHS Foundation Trust, Manchester, UK.
| |
Collapse
|
12
|
Pilkington JJ, Obeidallah R, Baltatzis M, Fullwood C, Jamdar S, Sheen AJ. Totally extraperitoneal repair for the 'sportsman's groin' via 'the Manchester Groin Repair': a comparison of elite versus amateur athletes. Surg Endosc 2020; 35:4371-4379. [PMID: 32909207 DOI: 10.1007/s00464-020-07930-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Surgery has a recognised role in the treatment of 'sportsman's groin'. This study hypothesises that elite athletes have a superior advantage in both pre- and post-op rehabilitation and therefore will present and resume sporting activities quicker. METHODS A retrospective analysis on a secure database of athletes presenting with groin pain that underwent surgery for 'inguinal disruption'. All data were explored via appropriate descriptive statistics and comparisons made between elite and amateur athletes. RESULTS All patients were male (n = 144). The median age 33 years (range 14-72). The median return to sporting activity was 4.5 weeks (range 2.0-16.0) with one amateur athlete being unable to return to sporting activity. Using the mean of both sides, a comparison of VAS pain scores at pre-operative and 1 month post-operative time points showed a significant reduction (p < 0.001). Comparing 'elite' versus 'amateur' athletes, significant differences were seen in patient age (median 26 vs 40 years; p < 0.001), lead time to clinic presentation (median 62.0 vs 111.5 days; p = 0.004), and time to return to sporting activity (4 vs 5 weeks; p = 0.019). Additional MRI findings within the groin girdle were found in 89 patients (66.4%) and 34 patients (23.6%) had an MRI finding within the adductor tendon. CONCLUSION The Manchester Groin Rrepair is an effective surgical management for 'inguinal disruption'. Elite athletes present quicker and return to sport sooner. Given the prevalence of other findings, a multidisciplinary approach to the 'sportsman's groin' is required.
Collapse
Affiliation(s)
- J J Pilkington
- Department of Academic Hernia Surgery, Manchester University NHS Foundation Trust, Manchester, UK.,Centre for Bioscience, Manchester Metropolitan University, Manchester, UK
| | - R Obeidallah
- Department of Academic Hernia Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - M Baltatzis
- Department of Academic Hernia Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - C Fullwood
- Research & Innovation, Manchester University NHS Foundation Trust, Manchester, UK.,Centre for Biostatistics, Manchester University, Manchester, UK
| | - S Jamdar
- Department of Academic Hernia Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - A J Sheen
- Department of Academic Hernia Surgery, Manchester University NHS Foundation Trust, Manchester, UK. .,Centre for Bioscience, Manchester Metropolitan University, Manchester, UK. .,Fortius Clinic, 17 Fitzhardinge street, London, UK.
| |
Collapse
|
13
|
Köckerling F, Sheen AJ, Berrevoet F, Campanelli G, Cuccurullo D, Fortelny R, Friis-Andersen H, Gillion JF, Gorjanc J, Kopelman D, Lopez-Cano M, Morales-Conde S, Österberg J, Reinpold W, Simmermacher RKJ, Smietanski M, Weyhe D, Simons MP. The reality of general surgery training and increased complexity of abdominal wall hernia surgery. Hernia 2019; 23:1081-1091. [PMID: 31754953 PMCID: PMC6938469 DOI: 10.1007/s10029-019-02062-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 09/27/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature. METHODS A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated. RESULTS All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures. CONCLUSION A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.
Collapse
Affiliation(s)
- F Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany.
| | - A J Sheen
- Department of Surgery, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK
| | - F Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Universitair Ziekenhuis Gent, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - G Campanelli
- General and Day Surgery Unit, Center of Research and High Specialization for the Pathologies of Abdominal Wall and Surgical Treatment and Repair of Abdominal Hernia, Milano Hernia Center, Instituto Clinico Sant'Ambrogio, University of Insurbria, Milan, Italy
| | - D Cuccurullo
- Department of General, Laparoscopic and Robotic Surgery, Chief Week Surgery Departmental Unit, A.O. dei Colli Monaldi Hospital Naples, Naples, Italy
| | - R Fortelny
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, 1160, Vienna, Austria
- Medical Faculty of Sigmund Freud University, 1020, Vienna, Austria
| | - H Friis-Andersen
- Surgical Department, Horsens Regional Hospital, Aarhus University, Sundvey 30, 8700, Horsens, Denmark
| | - J F Gillion
- Unité de Chirurgie Viscérale, Hôpital Privé d'Antony, 1, Rue Velpeau, 92160, Antony, France
| | - J Gorjanc
- Department of Surgery, Krankenhaus der Barmherzigen Brüder, Spitalgasse 26, 9300, St. Veit an der Glan, Austria
| | - D Kopelman
- Department of Surgery Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - M Lopez-Cano
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - S Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, University Hospital Virgen del Rocío, Av. Manuel Siurot, s/n, 41013, Seville, Spain
| | - J Österberg
- Department of Surgery, Mora Hospital, 79285, Mora, Sweden
| | - W Reinpold
- Wilhelmsburger Krankenhaus Gross-Sand, Gross-Sand 3, 21107, Hamburg, Germany
| | - R K J Simmermacher
- Department of Surgery, University Medical Center Utrecht, Heidelbergglaan 100, Utrecht, The Netherlands
| | - M Smietanski
- Department of General Surgery and Hernia Centre, Hospital in Puck, Medical University of Gdansk, Gdansk, Poland
| | - D Weyhe
- School of Medicine and Health Sciences, University Hospital for Visceral Surgery, Pius Hospital Oldenburg, Medical Campus University of Oldenburg, Georgstr. 12, 26121, Oldenburg, Germany
| | - M P Simons
- Department of Surgery, OLVG Hospital, Amsterdam, The Netherlands
| |
Collapse
|
14
|
Sheen AJ, Montgomery A, Simon T, Ilves I, Paajanen H. Randomized clinical trial of open suture repair versus totally extraperitoneal repair for treatment of sportsman's hernia. Br J Surg 2019; 106:837-844. [DOI: 10.1002/bjs.11226] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/22/2019] [Accepted: 04/04/2019] [Indexed: 12/31/2022]
Abstract
Abstract
Background
Sportsman's hernia/athletic pubalgia is a recognized cause of chronic groin pain in athletes. Both open and laparoscopic surgical repairs have been described for treatment, but there are no comparative studies. The hypothesis here was that relief of pain would be achieved earlier in patients treated with open minimal suture repair than totally extraperitoneal repair.
Methods
A randomized multicentre trial in four European countries was conducted to compare open minimal suture repair with totally extraperitoneal repair. The primary endpoint was complete relief of pain (visual analogue scale (VAS) score 20 or less on a scale from 0 to 100 mm) at 1 month. Secondary endpoints included complications, time to return to sporting activity, and number of patients returning to sport within 1 year.
Results
A total of 65 athletes (92 per cent men) with a median age of 29 years were enrolled (31 open repair, 34 totally extraperitoneal repair). By 4 weeks after surgery, median preoperative VAS scores had dropped from 70–80 to 10–20 in both groups (P < 0·001). Relief of pain (VAS score 20 or less) during sports activity 4 weeks after surgery was achieved in 14 of 31 patients after open repair and 24 of 34 after totally extraperitoneal repair (P = 0·047). Return to full sporting activity was achieved by 16 and 18 patients respectively after 1 month (P = 0·992), and by 25 versus 31 after 3 months (P = 0·408).
Conclusion
Totally extraperitoneal repair was less painful than open repair in the first month, but otherwise both procedures were similarly effective in treating chronic pain due to sportsman's hernia. Registration number: NCT02297711 ( http://www.clinical.trials.gov).
Collapse
Affiliation(s)
- A J Sheen
- Department of Surgery, Manchester University Foundation Trust, Manchester, UK
- Centre of Biomedicine Manchester Metropolitan University, Manchester, UK
- Fortius Clinic, London, UK
| | - A Montgomery
- Department of Surgery, Institution for Clinical Science, Lund University, Skåne University Hospital, Malmö, Sweden
| | - T Simon
- Department of General Surgery, GRN-Klinik Sinsheim, Heidelberg University Hospital, Heidelberg, Germany
| | - I Ilves
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - H Paajanen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| |
Collapse
|
15
|
Köckerling F, Sheen AJ, Berrevoet F, Campanelli G, Cuccurullo D, Fortelny R, Friis-Andersen H, Gillion JF, Gorjanc J, Kopelman D, Lopez-Cano M, Morales-Conde S, Österberg J, Reinpold W, Simmermacher RKJ, Smietanski M, Weyhe D, Simons MP. Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project. Hernia 2019; 23:185-203. [PMID: 30671899 PMCID: PMC6456484 DOI: 10.1007/s10029-018-1873-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 12/11/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist hernia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems. METHODS The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group-Hernia Accreditation and Certification of Centers and Surgeons-Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries. RESULTS The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accredited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for education and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group suggests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center. CONCLUSION Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems.
Collapse
Affiliation(s)
- F Köckerling
- Department of Surgery, Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany.
| | - A J Sheen
- Associate Clinical Head of Division (Surgery), Manchester University NHS Foundation Trust, Manchester, UK
| | - F Berrevoet
- General and HPB Surgery and Liver Transplantations, Pancreas and Abdominal Wall Specialist, Universitair Ziekenhuis Gent, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - G Campanelli
- General and Day Surgery Unit, Center of Research and High Specialization for the Pathologies of Abdominal Wall and Surgical Treatment and Repair of Abdominal Hernia, Milano Hernia Center, Instituto Clinico Sant'Ambrogio, University of Insurbria, Milan, Italy
| | - D Cuccurullo
- Chief Week Surgery Departmental Unit, Department of General, Laparoscopic and Robotic Surgery, A.O. Dei Colli Monaldi Hospital Naples, Naples, Italy
| | - R Fortelny
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, 1160, Vienna, Austria
| | - H Friis-Andersen
- Surgical Department, Horsens Regional Hospital, Horsens, Denmark
| | - J F Gillion
- Unité de Chirurgie Viscérale, Hôpital Privé d'Antony, 1, Rue Velpeau, 92160, Antony, France
| | - J Gorjanc
- Department of Surgery, Krankenhaus der Barmherzigen Brüder, Spitalgasse 26, 9300, St. Veit an der Glan, Austria
| | - D Kopelman
- Department of Surgery Emek Medical Center, Afula and the Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - M Lopez-Cano
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - S Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, University Hospital Virgen del Rocío, Av. Manuel Siurot, s/n, 41013, Seville, Spain
| | - J Österberg
- Department of Surgery, Mora Hospital, 79285, Mora, Sweden
| | - W Reinpold
- Wilhelmsburger Krankenhaus Gross-Sand, Gross-Sand 3, 21107, Hamburg, Germany
| | - R K J Simmermacher
- Department of Surgery, University Medical Center Utrecht, Heidelbergglaan 100, Utrecht, The Netherlands
| | - M Smietanski
- Department of General Surgery and Hernia Centre, Hospital in Puck, Medical University of Gdansk, Gdańsk, Poland
| | - D Weyhe
- School of Medicine and Health Sciences, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Georgstrasse 12, 26121, Oldenburg, Germany
| | - M P Simons
- Department of Surgery, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| |
Collapse
|
16
|
Junejo MA, Mason JM, Sheen AJ, Bryan A, Moore J, Foster P, Atkinson D, Parker MJ, Siriwardena AK. Cardiopulmonary exercise testing for preoperative risk assessment before pancreaticoduodenectomy for cancer. Ann Surg Oncol 2014; 21:1929-36. [PMID: 24477709 DOI: 10.1245/s10434-014-3493-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Pancreaticoduodenectomy is the standard of care for tumors confined to the head of pancreas and can be undertaken with low operative mortality. The procedure has a high morbidity, particularly in older patient populations with preexisting comorbidities. This study evaluated the role of cardiopulmonary exercise testing to predict postoperative morbidity and outcome in high-risk patients undergoing pancreaticoduodenectomy. METHODS In a prospective cohort of consecutive patients undergoing pancreaticoduodenectomy, those aged over 65 years (or younger with comorbidity) were categorized as high risk and underwent preoperative assessment by cardiopulmonary exercise testing (CPET) according to a predefined protocol. Data were collected on functional status, postoperative complications, and survival. RESULTS A total of 143 patients underwent preoperative assessment, 50 of whom were deemed to be at low risk for surgery per study protocol. Of 93 high-risk patients, 64 proceeded to surgery after preoperative CPET. Neither anaerobic threshold (AT) nor maximal oxygen consumption ([Formula: see text] O 2 MAX) predicted patient mortality or morbidity. However, ventilatory equivalent of carbon dioxide ([Formula: see text] E/[Formula: see text] CO 2) at AT was a predictive marker of postoperative mortality, with an area under the curve (AUC) of 0.84 (95 % confidence interval [CI] 0.63-1.00, p = 0.020); a threshold of 41 was 75 % sensitive and 95 % specific (positive predictive value 50 %, negative predictive value 98 %). Above this threshold, raised [Formula: see text] E/[Formula: see text] CO 2 predicted poor long-term survival (hazard ratio 2.05, 95 % CI 1.09-3.86, p = 0.026). CONCLUSIONS CPET is a useful adjunctive test for predicting postoperative outcome in patients being assessed for pancreaticoduodenectomy. Raised CPET-derived [Formula: see text] E/[Formula: see text] CO 2 predicts early postoperative death and poor long-term survival.
Collapse
Affiliation(s)
- M A Junejo
- Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Jegatheeswaran S, Satyadas T, Sheen AJ, Treasure T, Siriwardena AK. Thoracic surgical management of colorectal lung metastases: a questionnaire survey of members of the Society for Cardiothoracic Surgery in Great Britain and Ireland. Ann R Coll Surg Engl 2013; 95:140-3. [PMID: 23484998 PMCID: PMC4098581 DOI: 10.1308/003588413x13511609956336] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Distant metastases to liver and lung are not uncommon in colorectal cancer. Resection of metastases is accepted widely as the standard of care. However, there is no firm evidence base for this. This questionnaire survey was carried out to assess the current practice preferences of cardiothoracic surgeons in Great Britain and Ireland. METHODS An online questionnaire survey was emailed to cardiothoracic surgeons in Great Britain and Ireland. The survey was live for 12 weeks. Responses were collated with SurveyMonkey(®). RESULTS Overall, there were 75 respondents. The majority (83%) indicated thoracic surgery as a specialist interest. Almost all (99%) used thoracic computed tomography (CT) for staging; 70% added liver CT and 51% added pelvic CT. Fluorodeoxy-glucose positron emission tomography was used by 86%. The most frequent indication for pulmonary resection (97%) was solitary lung metastasis without extrathoracic disease. Video assisted thoracoscopic surgery (VATS) was used by 85%. In addition, thoracotomy was used by 96%. A third (33%) used radiofrequency ablation. Synchronous liver and lung resection was contraindicated for 83% of respondents. Over three-quarters (77%) thought that scientific equipoise exists presently for lung resection for colorectal lung metastases but only 21% supported a moratorium on this type of surgery until further evidence becomes available. CONCLUSIONS The results confirm that the majority of respondents use conventional cross-sectional imaging and either VATS or formal thoracotomy for resection. The results emphasise the continuing need for formal randomised trials to provide evidence of any survival benefit from pulmonary metastasectomy for colorectal lung metastases.
Collapse
Affiliation(s)
- S Jegatheeswaran
- Central Manchester University Hospitals NHS Foundation Trust, UK
| | | | | | | | | |
Collapse
|
18
|
Junejo MA, Mason JM, Sheen AJ, Moore J, Foster P, Atkinson D, Parker MJ, Siriwardena AK. Cardiopulmonary exercise testing for preoperative risk assessment before hepatic resection. Br J Surg 2012; 99:1097-104. [PMID: 22696424 DOI: 10.1002/bjs.8773] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Contemporary liver surgery practice must accurately assess operative risk in increasingly elderly populations with greater co-morbidity. This study evaluated preoperative cardiopulmonary exercise testing (CPET) in high-risk patients undergoing hepatic resection. METHODS In a prospective cohort referred for liver resection, patients aged over 65 years (or younger with co-morbidity) were evaluated by preoperative CPET. Data were collected prospectively on functional status, postoperative complications and survival. RESULTS Two hundred and four patients were assessed for hepatic resection, of whom 108 had preoperative CPET. An anaerobic threshold (AT) of 9·9 ml O(2) per kg per min predicted in-hospital death and subsequent survival. Below this value, AT was 100 per cent sensitive and 76 per cent specific for in-hospital mortality, with a positive predictive value (PPV) of 19 per cent and a negative predictive value (NPV) of 100 per cent: no deaths occurred above the threshold. Age and respiratory efficiency in the elimination of carbon dioxide (VE/VCO(2)) at AT were statistically significant predictors of postoperative complications. Receiver operating characteristic (ROC) curve analysis showed that a threshold of 34·5 for VE/VCO(2) at AT provided a specificity of 84 per cent and a sensitivity of 47 per cent, with a PPV of 76 (95 per cent confidence interval (c.i.) 58 to 88) per cent and a NPV of 60 (48 to 72) per cent for postoperative complications. Long-term survival of those with an AT of less than 9·9 ml O(2) per kg per min was significantly worse than that of patients with a higher AT (hazard ratio for mortality 1·81, 95 per cent c.i. 1·04 to 3·17; P = 0·036). CONCLUSION CPET provides a useful prognostic adjunct in the preoperative assessment of patients undergoing hepatic resection.
Collapse
Affiliation(s)
- M A Junejo
- National Institute for Health Research Manchester Biomedical Research Centre and Regional Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Sheen AJ, Satyadas T, Siriwardena AK. Letter 2: Randomized clinical trial of routine on-table cholangiography during laparoscopic cholecystectomy ( Br J Surg 2011; 98: 362–367). Br J Surg 2011; 98:887; author reply 887-8. [DOI: 10.1002/bjs.7553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
20
|
Owen RP, Sheen AJ. Letter 3: Systematic review and meta-analysis of preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery (Br J Surg 2010; 97: 1614-1620). Br J Surg 2011; 98:462; author reply 462. [PMID: 21254036 DOI: 10.1002/bjs.7447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
21
|
Jamdar S, Jegatheeswaran S, Bandara A, Sheen AJ, Siriwardena AK. Impact of portal vein embolization on long-term survival of patients with primarily unresectable colorectal liver metastases (Br J Surg 2010; 97: 240–250). Br J Surg 2010; 97:958; author reply 958. [DOI: 10.1002/bjs.7138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Abstract
The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.
Collapse
Affiliation(s)
- S Jamdar
- Regional Hepatobiliary Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK
| | - S Jegatheeswaran
- Regional Hepatobiliary Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK
| | - A Bandara
- Regional Hepatobiliary Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK
| | - A J Sheen
- Regional Hepatobiliary Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK
| | - A K Siriwardena
- Regional Hepatobiliary Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK
| |
Collapse
|
22
|
Petras P, Kontostolis V, Sheen AJ, Siriwardena AK. Randomized clinical trial of efficacy and costs of three dissection devices in liver resection (Br J Surg 2009; 96: 593-601). Br J Surg 2009; 96:1223; author reply 1223. [PMID: 19787756 DOI: 10.1002/bjs.6846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
23
|
Abstract
INTRODUCTION The aim of this study is to determine whether there are any clinical or biochemical predictors of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy. METHODS A prospective database of nearly 1000 laparoscopic cholecystectomies performed under the care of a single surgeon with a standardised technique between 1999 and 2006, was analysed. Clinical presentation, ultrasound and immediate preoperative biochemical results as well as the operative cholangiogram findings were reviewed. Routine cholangiography was attempted in most patients and the primary outcome variable was the detection of bile duct stones. The data was analysed using chi-squared test for categorical variables. The significant variables on univariate analysis were further characterised to identify the independent predictors of bile duct stones using a logistic regression model (significance p < 0.05). RESULTS A total of 757 of 988 patients (77%) underwent cholangiography. Male-to-female ratio was 1 : 3 with a median age of 54 years (range: 17-93). Ten per cent of patients had bile duct stones identified on cholangiography. On univariate analysis, jaundice (p = 0.019), cholangitis (p < 0.001), alanine transaminase > 100 (p = 0.024), alkaline phosphatase (ALP) > 350 (p < 0.001) and CBD > 10 mm (p = 0.01) were significant markers for predicting bile duct stones. Bilirubin > 30 (x2 normal) was found not to be significant (p = 0.145). On a logistic regression model, ALP > 350 and/or cholangitis were found to be independent predictive factors of CBD stones (odds ratio 6.1). CONCLUSIONS If a policy of routine intra-operative cholangiography is not adopted, a history of cholangitis or a raised ALP immediately preoperatively should lead to a high suspicion of CBD stones.
Collapse
Affiliation(s)
- A J Sheen
- Department of Hepatobiliary Surgery, St James University Hospital, Leeds, UK
| | | | | | | | | |
Collapse
|
24
|
Sheen AJ, Siriwardana HPP, Siriwardena AK. Authors' reply: Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer ( Br J Surg 2006; 93: 662 –673). Br J Surg 2006. [DOI: 10.1002/bjs.5612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- A J Sheen
- Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - H P P Siriwardana
- Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - A K Siriwardena
- Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| |
Collapse
|
25
|
Sheen AJ, Sherlock DJ, Irlam J, Hawkins RE, Gilham DE. T lymphocytes isolated from patients with advanced colorectal cancer are suitable for gene immunotherapy approaches. Br J Cancer 2003; 88:1119-27. [PMID: 12671714 PMCID: PMC2376387 DOI: 10.1038/sj.bjc.6600857] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Despite improvements in treatment, the 5-year survival for metastatic colorectal cancer remains poor. Novel approaches such as gene immunotherapy are being investigated to improve treatment. Retroviral gene transfer methods have been shown to transduce primary human T lymphocytes effectively resulting in the expression of therapeutic genes. However, a number of defects have been identified in T lymphocytes isolated from patients bearing tumour, which may have critical implications for the development of gene-targeted T cells as an anticancer therapy. To address this issue, primary T lymphocytes were isolated from patients with advanced colorectal cancer and tested for their ability to be transduced and to express subsequently a chimeric immune receptor consisting of a single-chain antibody fragment antigen-binding moiety specific for carcinoembryonic antigen (CEA) fused to the T cell receptor (TCR) CD3zeta chain. In 10 out of 10 patients, T lymphocytes were transduced, expanded in the absence of selection and tested for functional activity against CEA-expressing tumour cells. In each case, functional-specific cytotoxic activity was observed. Negligible activity was found in control cultures. This study highlights the feasibility of patient-derived T lymphocytes as a source of immune cells for autologous gene immunotherapy approaches.
Collapse
Affiliation(s)
- A J Sheen
- Cancer Research UK Department of Medical Oncology, Paterson Institute for Cancer Research, Christie Hospital NHS Trust, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK
- Department of Surgery, North Manchester Healthcare NHS Trust, Manchester M8 5RB, UK
| | - D J Sherlock
- Department of Surgery, North Manchester Healthcare NHS Trust, Manchester M8 5RB, UK
| | - J Irlam
- Cancer Research UK Department of Medical Oncology, Paterson Institute for Cancer Research, Christie Hospital NHS Trust, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK
| | - R E Hawkins
- Cancer Research UK Department of Medical Oncology, Paterson Institute for Cancer Research, Christie Hospital NHS Trust, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK
- Cancer Research UK Department of Medical Oncology, Paterson Institute for Cancer Research, Christie Hospital NHS Trust, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK. E-mail:
| | - D E Gilham
- Cancer Research UK Department of Medical Oncology, Paterson Institute for Cancer Research, Christie Hospital NHS Trust, University of Manchester, Wilmslow Road, Manchester M20 4BX, UK
| |
Collapse
|
26
|
Abstract
BACKGROUND This paper reports a 7-year experience of cryoablation for colorectal and non-colorectal liver metastases. METHODS A retrospective review was undertaken of patients treated in two adjacent UK centres in the north-west of England. RESULTS Over a 7-year period (1993-2000), 57 patients underwent cryotherapy for malignant hepatic tumours (41 colorectal, 16 non-colorectal). In the patients with colorectal metastases, preoperative carcinoembryonic antigen (CEA) levels fell significantly, from a mean of 444.1 to 6.22 micro g/l (P = 0.002). One patient died, two developed cryoshock and six had cardiorespiratory complications. All patients with colorectal metastases subsequently received 5-fluorouracil-based chemotherapy. The remaining 16 patients with non-colorectal tumours (seven neuroendocrine metastases, five hepatocellular carcinomas, three sarcomas, one cholangiocarcinoma) all received cryotherapy alone, with no major complications. The median survival for patients with non-colorectal metastases was 37 months, compared with 22 months for those with colorectal metastases (P = 0.005). CONCLUSION Hepatic cryotherapy is effective and safe, as demonstrated by the significant reduction in postoperative CEA concentration and the low risk of complications. However, this initial short-term success was not reflected in 5-year survival rates. Cryotherapy for non-colorectal metastases had a greater long-term survival benefit and is a useful means of controlling symptoms.
Collapse
Affiliation(s)
- A J Sheen
- Department of Surgery, North Manchester Healthcare NHS Trust, Manchester, UK
| | | | | |
Collapse
|
27
|
Woodcock A, Sheen AJ, James NK, Wilkinson B, Hofman D, Bullus S, Butterfield H. Letters. J Wound Care 1998; 7:438. [PMID: 27957882 DOI: 10.12968/jowc.1998.7.9.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
USE OF MEPITEL IN SKIN CRAFT DONOR SITES USE OF MEPITEL ON PUNCH CRAFT SITES EPIDERMOLYSIS BULLOSA.
Collapse
Affiliation(s)
| | - A J Sheen
- Department of Plastics Surgery, Lister Hospital, Stevenage
| | - N K James
- Department of Plastics Surgery, Lister Hospital, Stevenage
| | - B Wilkinson
- Department of Plastics Surgery, Lister Hospital, Stevenage
| | | | - Sue Bullus
- Wound Healing Institute, The Churchill, Oxford
| | | |
Collapse
|
28
|
Abstract
COMMUNITY GUIDELINES ON PRESSURE AREA CARE NECROTISING FASCIITIS INTERNET SOURCES MEPITEL: A 'STICKY' SUBJECT.
Collapse
Affiliation(s)
| | - T Shipperley
- Wound Care Specialist Nurse, South Downs Health Trust, Brighton
| | - Ann Lies
- Senior Pharmacy Technician, Gloucester Drug Information Service
| | | | - A J Sheen
- Department of Plastics Surgery, Lister Hospital, Stevenage, UK
| | - N K James
- Department of Plastics Surgery, Lister Hospital, Stevenage, UK
| | - B Wilkinson
- Department of Plastics Surgery, Lister Hospital, Stevenage, UK
| |
Collapse
|
29
|
Sheen AJ, James NK, Wilkinson B. Mepitel: a 'sticky' subject. J Wound Care 1998; 7:429. [PMID: 9832753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
|