The INCH-trial: a multicenter randomized controlled trial comparing short- and long-term outcomes of open and laparoscopic surgery for incisional hernia repair

BACKGROUND

Laparoscopic incisional hernia repair is increasingly performed worldwide and expected to be superior to conventional open repair regarding hospital stay and quality of life (QoL). The INCisional Hernia-Trial was designed to test this hypothesis.

METHODS

A multicenter parallel randomized controlled open-label trial with a superiority design was conducted in six hospitals in the Netherlands. Patients with primary or recurrent incisional hernias were randomized by computer-guided block-randomization to undergo either conventional open or laparoscopic repair. Primary endpoint was postoperative length of hospital stay in days. Secondary endpoints included QoL, complications, and recurrences. Patients were followed up for at least 5 years.

RESULTS

Hundred-and-two patients were recruited and randomized. In total, 88 patients underwent surgery and were included in the intention-to-treat analysis (44 in the open group, 44 in the laparoscopic group). Mean age was 59.5 years, gender division was equal, and BMI was 28.8 kg/m. The trial was concluded early for futility after an unplanned interim analysis, which showed that the hypothesis needed to be rejected. There was no difference in primary outcome: length of hospital stay was 3 (range 1-36) days in the open group and 3 (range 1-12) days in the laparoscopic group (p = 0.481). There were no significant between-group differences in QoL questionnaires on the short and long term. Satisfaction was impaired in the open group. Overall recurrence rate was 19%, of which 16% in the open and 23% in the laparoscopic group (p = 0.25) at a mean follow-up of 6.6 years.

CONCLUSIONS

In a randomized controlled trial, short- and long-term outcomes after laparoscopic incisional hernia repair were not superior to open surgery. The persisting high recurrence rates, reduced QoL, and suboptimal satisfaction warrant the need for patient's expectation management in the preoperative process and individualized surgical management.

TRIAL REGISTRATION

Netherlands Trial Register NTR2808.

O21 EVALUATION OF THE TREATMENT OF PARASTOMAL HERNIA IN THE NETHERLANDS: A NATIONAL SURVEY

Aim

The incidence of a parastomal hernia (PSH) is approximately 40% two years after stoma construction and can even increase to 50% after a longer period. The European Hernia Society (EHS) published a guideline showing that the evidence for treatment of a PSH is of low quality. Due to the lack of evidence, a survey was conducted to provide insight into the Dutch approach.

Material and Methods

A survey was sent to 104 surgeons in the Netherlands representing their surgical department. The survey was developed by three hernia surgeons and a physiotherapist specialized in abdominal wall pathology.

Results

The survey was completed by 103 surgeons (99%) from 75 hospitals. 75% of the respondents perform a laparoscopic Sugarbaker for the treatment of PSH after colostomy, ileostomy or Bricker deviation. Most respondents (75%) replied that they never use a prophylactic mesh to prevent for the occurrence of PSH, although more than half of them do wish to introduce this.

Conclusions

Authors believe that the implementation of minimally invasive surgery and the systematic review performed by Hansson et al. in 2012, shifted the treatment strategy for PSH towards the use of a laparoscopic Sugarbaker. Nevertheless, little is known about the results of this treatment. Although there is a high level of evidence for the use of prophylactic mesh placement in reducing the incidence of PSH development, this has not been implemented in daily practice for colorectal and/or hernia surgeons. Authors aim for registration of PSH repair to evaluate the outcomes in terms of recurrence, pain and quality of life.

P147 REHABILITATION AFTER VENTRAL HERNIA SURGERY IN THE NETHERLANDS: A SURVEY

Aim

After any type of musculoskeletal surgery, post-operative rehabilitation with advices on weight baring and physical therapy is normal practice. Rehabilitation protocols lead to early mobilization and shorter hospitalization. Although ventral hernia repair (VHR) is musculotendinous surgery with tremendous impact on muscle strength and coordination, standardized and evidenced rehabilitation protocols for VHR are lacking. This survey aims to provide insight into the rehabilitation protocols after VHR, commonly used in the Netherlands.

Material and Methods

Hernia-surgeons in all Dutch hospitals were addressed in May 2021 by an electronic survey. Three cases were presented; non-complex (2 cm, primary umbilical repair), moderate-complex (8 cm, Rives-Stoppa) and complex (13 cm, myofascial release). Use of abdominal binders, advice on physical strain and referral for physical therapy were surveyed.

Results

75 of 75 (100%) Dutch hospitals responded. In order of increasing hernia complexity an abdominal binder was prescribed in respectively 10%, 74% and 92% with various duration. Reduced physical strain was advised in 73%, 90% and 91%, mainly with a duration of 4-6 weeks (40%, 58% and 70%). Patients were referred for physical therapy after discharge in 4%, 15% and 41%.

Conclusions

This study describes the practice of rehabilitation after VHR in the Netherlands. Although abdominal binder prescription and physical strain advices increases with hernia complexity, there is no uniformity in duration. Physical therapy was advised only in a minority of the VHR patients, even after complex reconstructions. Lack of standardized rehabilitation protocols after VHR underlines the need for guidelines.

Developing a literature-based systems map of determinants of dietary intake in low-income groups

Background

Inequalities in obesity and related non-communicable diseases pertain in part to less healthy dietary intake in disadvantaged groups. Examining determinants of intake as a complex adaptive system - i.e. interconnected determinants exerting non-linear influence on outcomes - honours the complexity of dietary choices, behaviours and intake, and could inform policies. This study used literature to map the complex system underlying dietary intake in low-income groups, to identify system structure and goals perpetuating poorer dietary outcomes.

Methods

A systematic umbrella literature review examined determinants of dietary outcomes in children, adolescents and adults. Inclusion criteria were: • Low-income sample; analysis by income (Non-)systematic review of quantitative/qualitative, observational/intervention studiesHigher/upper-middle-income countriesExposures: individual, sociocultural, physical, political determinants/correlates; effect modifiers

Excluded outcomes were: breastfeeding, alcohol and neophobia.

Using causal loop diagramming, extracted data on determinants, associations and interpretation were embedded in a systems map of mechanisms driving dietary intake. System structure (e.g. sub-systems) and goals (e.g. feedback loops) were analysed.

Results

A systems map of hypothesised mechanisms driving dietary intake in low-income groups was developed from 43 reviews and expert consensus. The system comprised sub-systems: 1) accessibility, 2) household resources, 3) financial constraints, 4) health/biology, 5) knowledge, attitudes and beliefs, 6) sociocultural influences. Identified sub-system goals could undermine healthy intake opportunities, e.g. energy-dense food choices for cost-efficiency, heightened exposure to energy-dense foods determining preferences.

Conclusions

The literature-based systems map articulates the systemic basis of poorer dietary outcomes in low-income groups. Understanding system structure and goals will inform equitable policy.

Key messages

Dietary intake in low-income groups is driven by a complex system of mechanisms which may perpetuate poorer dietary outcomes. Existing literature was synthesised as a systems map; identification of structures and goals of the system can inform health equity policies.

Acute biliary pancreatitis masking haemobilia due to a false aneurysm of the right hepatic artery after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is a commonly performed surgical procedure. The postoperative course is often uncomplicated; however, complications like infection, biliary leakage, and bleeding and bile duct injury can occur. Here we report on a patient with common bile duct obstruction and haemobilia due to a false aneurysm of the right hepatic artery after laparoscopic cholecystectomy, masked by biliary pancreatitis, complicated by an infarction of the liver after embolisation. The aetiology of upper gastrointestinal bleeding greatly varies. This case is an uncommon case of gastrointestinal bleeding due to a false aneurysm of the right hepatic artery, which was successfully treated.

Controversies in laparoscopic ventral hernia repair

The introduction of laparoscopy as a surgical technique provided a method which allows for preventing major abdominal wall incisions and improving recovery of the patient after surgery. In abdominal wall surgery, laparoscopic ventral hernia repair has proven to be at least as safe as open repair. However, the technique of laparoscopic ventral hernia repair has not been standardized. Despite all the research that has been conducted and all the articles that have been published, there still seems to be a lack of consensus about the best method to repair a ventral hernia. The aim of this paper is to review knowledge on incisional hernias and discuss several controversies regarding the laparoscopic management of ventral hernias. A review of the literature was undertaken, and a search identified twenty records: six RCTs on incisional hernias, five RCTs on ventral hernias, and nine reviews or meta-analyses. Interpretation of the scientific data was difficult because the outcomes in literature were often based on pooled data of primary ventral hernias and incisional ventral hernias. Controversy remains regarding the optimal laparoscopic management of ventral hernias in terms of selection of patients for laparoscopic repair, optimal technique, outcomes and cost-efficacy. Lack of evidence allows persisting controversies in laparoscopic ventral hernia repair. RCTs and registries are necessary to document efficacy, morbidity, quality of life and costs during a sufficient period of time to provide clinicians with the evidence required to make the right choice for the best surgical technique.

Economic values of growth and feed efficiency for fish farming in recirculating aquaculture system with density and nitrogen output limitations: a case study with African catfish (Clarias gariepinus)

In fish farming, economic values (EV) of breeding goal traits are lacking, even though they are key parameters when defining selection objectives. The aim of this study was to develop a bioeconomic model to estimate EV of 2 traits representing production performances in fish farming: the thermal growth coefficient (TGC) and the feed conversion ratio (FCR). This approach was applied to a farm producing African catfish (Clarias gariepinus) in a recirculating aquaculture system (RAS). In the RAS, 2 factors could limit production level: the nitrogen treatment capacity of the biofilter or the fish density in rearing tanks at harvest. Profit calculation includes revenue from fish sales, cost of juveniles, cost of feed, cost of waste water treatment, and fixed costs. In the reference scenario, profit was modeled to zero. EV were calculated as the difference in profit per kilogram of fish between the current population mean for both traits (µt) and the next generation of selective breeding (µt+Δt) for either TGC or FCR. EV of TGC and FCR were calculated for three generations of hypothetical selection on either TGC or FCR (respectively 6.8% and 7.6% improvement per generation). The results show that changes in TGC and FCR can affect both the number of fish that can be stocked (number of batches per year and number of fish per batch) and the factor limiting production. The EV of TGC and FCR vary and depend on the limiting factors. When dissolved NH3-N is the limiting factor for both µt and µt+Δt, increasing TGC decreases the number of fish that can be stocked but increases the number of batches that can be grown. As a result, profit remains constant and EVTGC is zero. Increasing FCR, however, increases the number of fish stocked and the ratio of fish produced per kilogram of feed consumed ("economic efficiency"). The EVFCR is 0.14 €/kg of fish, and profit per kilogram of fish increases by about 10%. When density is the limiting factor for both µt and µt+Δt, the number of fish stocked per batch is fixed; therefore, extra profit is obtained by increasing either TGC, which increases the annual number of batches, or by decreasing FCR, which decreases annual feed consumption. EVTGC is 0.03 €/kg of fish and EVFCR is 0.05-0.06 €/kg of fish. These results emphasize the importance of calculating economic values in the right context to develop efficient future breeding programs in aquaculture.

Controversies in laparoscopic ventral hernia repair

BACKGROUND

The introduction of laparoscopy as a surgical technique provided a method preventing major abdominal wall incisions and improving recovery of the patient after surgery. In abdominal wall surgery laparoscopic ventral hernia repair has proven to be at least as save as open repair. However, the technique of laparoscopic ventral hernia repair has not been standardized. Despite all the research that has been conducted and all the articles that were published, there still seems to be absence of consensus about the best method to repair a ventral hernia.

AIM

To review knowledge on incisional hernias and discuss several controversies regarding the laparoscopic management of ventral hernias.

METHODS

A review of the literature was undertaken.

RESULTS

A search identified twenty records: six RCTs on incisional hernias, five RCTs on ventral hernias and nine reviews or meta-analyses. Interpretation of the scientific data is difficult because the outcomes in literature are often based on pooled data of primary ventral hernias and incisional ventral hernias. Controversy remains regarding the optimal laparoscopic management of ventral hernias in terms of selection of patients for laparoscopic repair, optimal technique, outcomes and cost-efficacy.

CONCLUSION

Lack of evidence allows persisting controversies in laparoscopic ventral hernia repair. RCTs and registries are necessary to document efficacy, morbidity, quality of life and costs during a sufficient period of time to provide clinicians with the evidence required to make the right choice for the best surgical technique.

The INCH-Trial: a multicentre randomized controlled trial comparing the efficacy of conventional open surgery and laparoscopic surgery for incisional hernia repair

BACKGROUND

Annually approximately 100.000 patients undergo a laparotomy in the Netherlands. About 15,000 of these patients will develop an incisional hernia. Both open and laparoscopic surgical repair have been proven to be safe. However, the most effective treatment of incisional hernias remains unclear. This study, the 'INCH-trial', comparing cost-effectiveness of open and laparoscopic incisional hernia repair, is therefore needed.

METHODS/DESIGN

A randomized multi-center clinical trial comparing cost-effectiveness of open and laparoscopic repair of incisional hernias. Patients with a symptomatic incisional hernia, eligible for laparoscopic and open incisional hernia repair. Only surgeons, experienced in both open and laparoscopic incisional hernia repair, will participate in the INCH trial. During incisional hernia repair, a mesh is placed under or on top of the fascia, with a minimal overlap of 5 cm. Primary endpoint is length of hospital stay after an incisional hernia repair. Secondary endpoints are time to full recovery within three months after index surgery, post-operative complications, recurrences, mortality and quality of life.Our hypothesis is that laparoscopic incisional hernia repair comes with a significant shorter hospital stay compared to open incisional hernia repair. A difference of two days is considered significant. One-hunderd-and-thirty-five patients are enrolled in each treatment arm. The economic evaluation will be performed from a societal perspective. Primary outcomes are costs per patient related to time-to-recovery and quality of life.The main goal of the trial is to establish whether laparoscopic incisional hernia repair is superior to conventional open incisional hernia repair in terms of cost-effectiveness. This is measured through length of hospital stay and quality of life. Secondary endpoints are re-operation rate due to post-operative complications or recurrences, mortality and quality of life.

DISCUSSION

The difference in time to full recovery between the two treatment strategies is thought to be in favor of laparoscopic incisional hernia repair. Laparoscopic incisional hernia repair is therefore expected to be a more cost-effective approach.

TRIAL REGISTRATION

Netherlands Trial register: NTR2808.

Fish welfare assurance system: initial steps to set up an effective tool to safeguard and monitor farmed fish welfare at a company level

The objective was to take a first step in the development of a process-oriented quality assurance (QA) system for monitoring and safeguarding of fish welfare at a company level. A process-oriented approach is focused on preventing hazards and involves establishment of critical steps in a process that requires careful control. The seven principles of the Hazard Analysis Critical Control Points (HACCP) concept were used as a framework to establish the QA system. HACCP is an internationally agreed approach for management of food safety, which was adapted for the purpose of safeguarding and monitoring the welfare of farmed fish. As the main focus of this QA system is farmed fish welfare assurance at a company level, it was named Fish Welfare Assurance System (FWAS). In this paper we present the initial steps of setting up FWAS for on growing of sea bass (Dicentrarchus labrax), carp (Cyprinus carpio) and European eel (Anguilla anguilla). Four major hazards were selected, which were fish species dependent. Critical Control Points (CCPs) that need to be controlled to minimize or avoid the four hazards are presented. For FWAS, monitoring of CCPs at a farm level is essential. For monitoring purposes, Operational Welfare Indicators (OWIs) are needed to establish whether critical biotic, abiotic, managerial and environmental factors are controlled. For the OWIs we present critical limits/target values. A critical limit is the maximum or minimum value to which a factor must be controlled at a critical control point to prevent, eliminate or reduce a hazard to an acceptable level. For managerial factors target levels are more appropriate than critical limits. Regarding the international trade of farmed fish products, we propose that FWAS needs to be standardized in aquaculture chains. For this standardization a consensus on the concept of fish welfare, methods to assess welfare objectively and knowledge on the needs of farmed fish are required.

Proficiency studies on the determination of paralytic shellfish poisoning toxins in shellfish

Paralytic shellfish poisoning toxins are produced by dinoflagellates. Shellfish filtering these unicellular algae will accumulate the toxins and pose a health risk when consumed by man. In the European Union, paralytic shellfish poisoning toxins in bivalve molluscs are regulated at a maximum content of 80 microg/100 g (91/492/EEC). The current reference method in the European Union is the mouse bioassay, but alternative methods including the liquid chromatography methodology are preferred for ethical reasons. Analyses of suspected shellfish batches revealed, however, unacceptable differences in results reported by a small group of Dutch laboratories all using liquid chromatography methods with precolumn derivatization, followed by fluorescence detection. Therefore, a series of proficiency studies were undertaken among these laboratories. In the first three studies, participants were more or less allowed their own choice of method execution details. This approach yielded unsatisfactory results. A fourth study was then initiated in which a standardized method was mandatory. Two types of test material were used in the fourth study: lyophilized Cardium tuberculatum material containing saxitoxin (STX) and decarbamoyl-saxitoxin (dc-STX), and lyophilized mussel material containing dc-STX. The latter material was investigated in an interlaboratory study involving 15 participants and was considered as the reference material. Among the four laboratories, coefficients of variation (ANOVA) for C. tuberculatum material were 10% (n = 11) and 9% (n = 12) for STX and dc-STX, respectively, and for the reference material was 8% (n = 12) for dc-STX. The joint efforts showed that variability in analysis results between laboratories that all apply more or less the same method can be drastically improved if the methodology is rigorously standardized.

Histone deacetylase inhibitors arrest polyglutamine-dependent neurodegeneration in Drosophila

Proteins with expanded polyglutamine repeats cause Huntington's disease and other neurodegenerative diseases. Transcriptional dysregulation and loss of function of transcriptional co-activator proteins have been implicated in the pathogenesis of these diseases. Huntington's disease is caused by expansion of a repeated sequence of the amino acid glutamine in the abnormal protein huntingtin (Htt). Here we show that the polyglutamine-containing domain of Htt, Htt exon 1 protein (Httex1p), directly binds the acetyltransferase domains of two distinct proteins: CREB-binding protein (CBP) and p300/CBP-associated factor (P/CAF). In cell-free assays, Httex1p also inhibits the acetyltransferase activity of at least three enzymes: p300, P/CAF and CBP. Expression of Httex1p in cultured cells reduces the level of the acetylated histones H3 and H4, and this reduction can be reversed by administering inhibitors of histone deacetylase (HDAC). In vivo, HDAC inhibitors arrest ongoing progressive neuronal degeneration induced by polyglutamine repeat expansion, and they reduce lethality in two Drosophila models of polyglutamine disease. These findings raise the possibility that therapy with HDAC inhibitors may slow or prevent the progressive neurodegeneration seen in Huntington's disease and other polyglutamine-repeat diseases, even after the onset of symptoms.

Absence of a PDX-1 mutation and normal gastroduodenal immunohistology in a child with pancreatic agenesis

Pancreatic agenesis is a rare condition, of which only a limited number of cases have been described. One recent paper reported a homozygous mutation in the pancreatic duodenal homeobox gene 1 (PDX-1) in a child with pancreatic agenesis. We report a 6-year-old boy with pancreatic agenesis, treated medically, without abnormalities in the PDX-1 gene coding sequence and with normal gastroduodenal endocrine cell distribution. Genes other than PDX-1 also appear to be involved in human pancreatic agenesis.

[The detection of melanoma metastases in sentinel nodes by polymerase chain reaction]

OBJECTIVE

To investigate the possibility of detecting melanoma metastases using molecular biological techniques in patients with a primary malignant melanoma.

DESIGN

Descriptive.

SETTING

Reinier de Graaf Gasthuis Hospital Delft and diagnostic centre SSDZ Delft, the Netherlands.

METHODS

A melanoma specific tyrosinase mRNA was amplified using the reverse transcriptase polymerase chain reaction (RT-PCR) technique.

RESULTS

A total of 23 sentinel nodes derived from 9 patients were examined. In 14 sentinel nodes metastases were found using RT-PCR. In microscopic slides stained with haematoxylin and eosin (HE) melanoma metastases were found in 2 sentinel nodes of 2 patients. With immunohistochemistry melanoma metastases were found in the same 2 sentinel nodes.

CONCLUSION

It is possible to detect melanoma metastases in sentinel nodes using molecular biological techniques.

Dirithromycin versus amoxiclav in the treatment of acute exacerbations of chronic bronchitis

A total of 334 patients with acute exacerbation of chronic bronchitis were treated with either dirithromycin for 5 days (n = 169) or amoxiclav for 7-10 days (n = 165) in an open randomized trial. The efficacy and tolerability of the two drugs were compared. There was no statistically significant difference in outcome between the two treatment arms. Clinical success (cure or improvement) was obtained in 94.5% and 93.1% of patients treated with dirithromycin and amoxiclav, respectively. Adverse events (mostly gastrointestinal) occurred in both groups, but led to discontinuation of treatment (in only seven patients). We conclude that the two drugs are equally efficacious and safe.

Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. A controlled randomized videotaped intervention study

BACKGROUND

Many patients with asthma or chronic obstructive pulmonary disease use their medication inhalers incorrectly. General practitioners, pharmacists and other health care providers do not always have the opportunity to instruct patients in correct inhaler technique.

OBJECTIVE

To find out whether the inhaler technique and respiratory symptoms of patients can be improved after instruction by practice assistants.

METHODS

Single blind, randomized intervention study in which 48 patients who had been using a dry powder inhaler for at least one month took part. Their inhaler technique was videotaped on two visits with a two-week interval between visits. The inhaler technique on the videos was subsequently scored by two experts on nine criteria. At both visits the patients completed a questionnaire about their respiratory symptoms. After the first video, 25 patients were randomly chosen to receive instruction from one of six practice assistants who had followed a one evening course about inhaler instruction, and who had been issued an instruction-set.

RESULTS

The patients who received instruction had a significantly greater reduction in number of mistakes at the second visit than the patients who did not (P = 0.01). The instructed patients also reported less dyspnoea at the second visit (P = 0.03). No effect of instruction was found on wheezing, cough and sputum production.

CONCLUSION

The inhaler technique of patients can be improved significantly by the instruction of patients by trained practice assistants, possibly resulting in less dyspnoea.

Bacteraemia in patients presenting with fever

In three studies, in Ghana and Kenya, blood from 639 patients admitted with fever was cultured. Standard treatments were antimalarials (54-100%) and antibiotics (39-90%). According to the criteria in use, however, only 10-31% had malaria alone; of those who received antibiotics, 66% were diagnosed with malaria, gastrointestinal infections, post-operative recuperations, circulatory problems, central nervous system disorders or FUO, and did not need antibiotics at the first encounter. For those with wounds and abscesses (8%), generalised antibiotic treatment can also be questioned. Bacteraemia was found in 71 (11.3%) patients; in the HIV patients, however, 5 (23%) of 22 had bacteraemia. This is a minimum incidence, since culture techniques were not optimal for the isolation of fastidious microorganisms. The most prevalent organisms isolated were Salmonella, Klebsiella/Enterobacter and S. aureus. Resistance (intrinsic and extrinsic) in the Gram- bacteria was high: 31-100% were resistant to amoxycillin, 0-80% to cotrimoxazole, 15-95% to chloramphenicol and 9-15% to gentamicin. The need for cultures and sensitivity tests for patients with prolonged or undiagnosed fever is stressed. Specific treatment should be given only when infections, whether malarial or bacterial, have been positively diagnosed.

Acute suppurative thyroiditis complicating second allogeneic transplant for juvenile CMML

We describe here a 3-year-old boy with juvenile chronic myelomonocytic leukemia and monosomy 7 who underwent a second HLA matched bone marrow transplant from his sister. He developed hypothyroidism due to acute suppurative thyroiditis in the recovery phase of BMT. This is an extremely rare complication of BMT.