OC-002 EVALUATION OF GIANT INGUINAL HERNIA REPAIR RESULTS - A RETROSPECTIVE SINGLE INSTITUTION CASE-CONTROL PROPENSITY SCORE MATCHED STUDY

Background

Giant inguinal hernia (GIH), defined as a hernia descending below the inner-thigh midpoint in upright position, is rare. Case reports describe techniques in which the abdominal cavity is prepared and care is taken to prevent abdominal compartment syndrome (ACS). Our aim was to analyze and review our experience with GIH repair.

Methods

Retrospective single-institution, case-control, study included adults who underwent GIH repair between 2014–2021 at an university referral center. Technique included endo-tracheal intubation, head-down positioning, maximal pre-incision reduction of hernia contents, and repair with mesh. Follow-up was conducted in outpatient clinic. Results were compared to a time-based control group.

Results

During the study period, 58 patients underwent an open GIH repair with mesh without abdominal preparation. Control group included 232 patients who underwent open non-giant inguinal hernia repair (control group). Bowel resection was not necessary in any case. The in-hospital and 30-day complication rates were 17.2% and 68.9% in the GIH group, and 8.2% and 27.2%, in the control group (p=0.04, OR=2.3; and p<0.001, OR=5.9, respectively). Ischemic orchitis was common in the GIH group (65.5%) compared to the control group (13.4%) (p<0.001, OR=12.3). ACS, major complications and mortality were not reported. 90-day complication rates were similar. 2 cases of recurrence (0.9%) were observed in the control group.

Conclusions

Our study suggests that GIH repair is safe and feasible, and there is no need for abdominal cavity preparation. Early complications, mainly ischemic orchitis, are more common than control group, but without long-term implications and with a very low recurrence rate.

Does caffeine enhance bowel recovery after elective colorectal resection? A prospective double-blinded randomized clinical trial

BACKGROUND

Postoperative ileus is a common condition following abdominal surgery. Previous studies have shown the positive effects of coffee on gastrointestinal motility. The aim of this study was to assess whether caffeine is the stimulatory agent in coffee that triggers bowel motility and thus may reduce the duration of postoperative ileus.

METHODS

This was a single-centered, prospective, randomized controlled, double-blinded clinical trial. Patients scheduled to undergo elective laparoscopic colectomy between November 2017 and March 2019 were randomly assigned to receive either oral caffeine (100 mg three times daily) or placebo following the procedure. Primary endpoints were time to first flatus and time to first bowel movement. Secondary endpoints were time to tolerate a solid, low-residue diet and length of hospital stay. Registration number: NCT03097900.

RESULTS

Seventy patients were included, [35 males, median age 56 years (range 19-79 years)]. After the exclusion of 12 patients, there were 30 patients in the caffeine group and 28 patients in the placebo group. The first passage of stool in the caffeine group occurred 18 h earlier than in the placebo group (p = 0.012); other endpoints did not reach statistical significance. No caffeine-related adverse events were observed.

CONCLUSION

Caffeine consumption following colectomy is safe, leads to a significantly shorter time to first bowel movement, and may thus potentially lead to a shorter postoperative hospital stay.

Substrate effect on the melting temperature of thin polyethylene films

Strong dependence of the crystal orientation, morphology, and melting temperature (Tm) on the substrate is observed in the semicrystalline polyethylene thin films. The Tm decreases with the film thickness decrease when the film is thinner than a certain critical thickness, and the magnitude of the depression increases with increasing surface interaction. We attribute the large Tm depression to the decrease in the overall free energy on melting, which is caused by the substrate attraction force to the chains that competes against the interchain force which drives the chains to crystallization.

Surface oxidation of polyethylene fiber reinforced polyolefin biomedical composites and its effect on cell attachment

Three different compositions of butene-ethylene copolymer composites reinforced by polyethylene fibers and produced by filament winding are potentially suitable for biomedical applications. This study examines the effect of various processing and finishing conditions and of sterilization on the extent and composition of surface oxidation. An XPS analysis revealed only insignificant differences between the various treatments, while fibroblast cell attachment tests indicated good attachment with no signs of cytotoxity or cell degeneration for any of the materials.

Novel synthetic selectively degradable vascular prostheses: a preliminary implantation study

BACKGROUND

Vascular grafts perform less well than autologous arterial or vein grafts. The purpose of this study was to evaluate the short-term performance of selectively biodegradable filament-wound vascular prostheses, comprising elastomeric poly(ether urethane) (Lycra) scaffolds and flexible, hydrophilic biodegradable coatings.

MATERIALS AND METHODS

Two types of selectively biodegradable vascular grafts were manufactured, comprising a filament-wound Lycra scaffold, subsequently coated with a biodegradable poly(ethylene glycol)/poly(lactic acid) (PELA) block copolymer. The two types of grafts differed in both the overall porosity of the scaffold and the hydrophilicity of the biodegradable constituent. A 60-mm-long and 6-mm-diameter filament-wound and polytetrafluoroethylene (ePTFE) grafts were implanted as interposition prostheses, randomly, at the right- and left-side carotid arteries.

RESULTS

Implantation studies proved the grafts to be patent and pulsatile for periods of up to 3 months. Increasing the scaffold porosity and enhancing the hydrophilicity of the biodegradable component improved both the transmural tissue ingrowth process and the vascularization of the prosthesis wall. Also, a well-adhered peripheral tissue and a thin, uniform intima and endothelial lining were obtained. All ePTFE graft controls, although patent, were rather stiff and nonpulsatile. A thick pseudointima, poorly attached to the prosthesis inner surface, was observed. The compliance of the wet grafts was significantly higher than in the dry state, stemming mainly from the water-plasticizing effect on the biodegradable component. The grafts explanted after a period of 6 weeks exhibited compliance only slightly lower than that of the wet grafts. After 12 weeks, however, the hoop compliance was 20% lower than that prior to implantation. At 100 mm Hg, for example, the original compliance of the wet graft was 2.5%/100 mm Hg decreasing to 2.0%/100 mm Hg after a 3-month implantation. The compliance reduction with implantation is attributed to the ingrowth of the perigraft tissue as revealed by the histological study. A compliance of 2.0%/100 mm Hg is slightly better than that of a standard PTFE graft with an original compliance of 1.6%/100 mm Hg. Yet it is still an order of magnitude smaller than that of a canine carotid artery.

CONCLUSIONS

The improved mechanical properties and enhanced healing of the highly porous filament-wound Lycra scaffold graft coated with hydrophilic biodegradable PELA has the potential of being a highly effective small caliber prosthetic graft.

Elastic response of filament wound arterial prostheses under internal pressure

Filament wound synthetic prostheses have anisotropic material properties and are therefore able to match closely the elastic properties of the replaced host vessels. Highly porous prosthesis walls are required to allow ingrowth of capillar cells from the outer surface of the graft in order to increase endothelium coverage of the luminal surface. The coating of highly porous grafts with biodegradable polymers has been shown to result in a sealed structure at the time of implantation followed by controlled porosity during the healing process. Accordingly, a new manufacturing process for a coated filament wound vascular graft is proposed in this work, which combines high potential porosity with high mechanical compliance. In vitro testing of its mechanical properties shows that the compliance can be controlled by changing the reinforcement angle and the coating material. Whereas the initial compliance of the coated structure expresses a composite material response, the post-degradation compliance reflects the highly compliant response of the filament wound non-woven scaffold. Hence, higher compliance values can be achieved by the proposed technique, compared with those of the commonly used synthetic grafts.

Modelling the anisotropic behaviour of filament wound vascular grafts

The model according to the Law of Laplace, describing the mechanical behaviour of blood vessels and vascular grafts, was applied to filament wound arterial prostheses, which have been manufactured with different winding angles. By varying the winding angle, the anisotropic behaviour of the grafts could be changed and fitted to the anisotropic properties of natural blood vessels. Thus, the Laplace model had to be modified, and answers now to the requirement of responding to the anisotropic behaviour in hoop versus axial direction of the grafts. The experimental data of hoop and axial compliances obtained by biaxial inflation tests could be then correlated to the material properties of the vascular grafts measured by uniaxial tensile loading. It is shown that with the modified Laplace model the changes in the anisotropic behaviour due to different winding angles can be described and predicted. The calculated compliance values derived from the uniaxial tensile tests fitted the experimental data obtained by the biaxial inflation tests, although the calculated hoop compliance values tended to be higher than the experimental data.

Stiffness variability and stress-dependent elastic response of synthetic fibre-reinforced composites for biomedical applications

A major design requirement of biomaterial prostheses is to match their elastic properties with those of the natural host tissue. Composite materials address this requirement because their elastic properties can be altered accurately through composition and directionality parameters, and they can be designed to match closely the elastic properties of the biological tissues, in isocompliance, modulus gradient and anisotropy. This adds to a range of advantages of synthetic composite materials with respect to potential biomedical applications, which draw on their heterogeneity and anisotropy. This paper focuses on the elastic properties of synthetic fibre-reinforced composite materials that pertain to biomedical applications, and demonstrates the range of stiffnesses obtainable through selection of constituents and by choice of angle of reinforcement.

Introducing a selectively biodegradable filament wound arterial prosthesis: a short-term implantation study

This article introduces a new compliant and selectively biodegradable filament wound vascular graft and reports the findings of a short-term implantation study. A basic feature of filament winding is its ability to tailor and better control the mechanical properties of the prosthesis, so that a closer match with the anisotropic properties of native arteries is achieved. The elastomeric vascular grafts comprise poly(ether urethane urea) fibers (Lycra) embedded in a two-component matrix consisting of poly(ether urethane) (Pellethane) and a highly flexible poly(ethylene glycol)/poly(lactic acid) biodegradable segmented copolymer (PELA). Typical tensile modulus values fall in the few megapascals (MPa) range, this being comparable to that of natural arteries. The wound graft exhibits excellent handling and suturability characteristics as well as enhanced burst strength. Furthermore, due to its biodegradable constituent, the prosthesis combines minimal intraoperative blood loss and high healing porosity. The graft displays initially negligible in vitro water permeation, which increases gradually with time. In this short-term study, the prostheses were implanted in the canine carotid, and their biological performance was compared to that of expanded Gore-Tex. The luminal surface of the wound grafts was coated with a thin layer of pseudointima, strongly adhered to the prosthesis surface. Contrasting with the very stiff Gore-Tex grafts, the filament wound prostheses retained their high compliance, being highly pulsatile upon explanation. Histological studies fully corroborated these findings, underscoring the healing properties of these new filament wound vascular prostheses.

Compliance and ultimate strength of composite arterial prostheses

A further stage is reported in a comprehensive project aimed at developing new composites for soft tissue implants. The composite prostheses are made by a filament-winding technique comprising Lycra elastomeric fibres embedded in an elastomeric matrix of mostly Pellethane. New experimental results of compliance of filament-wound tubes and of the ultimate strength are presented and compared with theoretical predictions. It is shown that the functions of these properties in the winding angle are given by common composite material models. The compliance is predicted accurately by the expression based on a transformation of the principal elastic constants, whereby a maximum is expected at a winding angle of around 45 degrees. The ultimate strength is compared with two failure criteria, of which the maximum work criterion gives an excellent fit.

The failure analysis of composite material flight helmets as an aid in aircraft accident investigation

Understanding why a flying helmet fails to maintain its integrity during an accident can contribute to an understanding of the mechanism of injury and even of the accident itself. We performed a post-accident evaluation of failure modes in glass and aramid fibre-reinforced composite helmets. Optical and microscopic (SEM) techniques were employed to identify specific fracture mechanisms. They were correlated with the failure mode. Stress and energy levels were estimated from the damage extent. Damage could be resolved into distinct impact, flexure and compression components. Delamination was identified as a specific mode, dependent upon the matrix material and bonding between the layers. From the energy dissipated in specific fracture mechanisms we calculated the minimum total energy imparted to the helmet-head combination and the major injury vector (MIV) direction and magnitude. The level of protection provided by the helmet can also be estimated.

Utilization of composite laminate theory in the design of synthetic soft tissues for biomedical prostheses

There are several advantages of using composite design considerations for the preparation of biomedical soft tissues. Using a composite laminate design, a wide range for compliance results, proving that the prosthesis compliance can be altered without a concomitant variation of other properties. The trend of compliance as a function of the reinforcement angle is discussed for an angle-ply composite of low compliance constituents, as well as the implications for stress-strain behaviour. Experimental examples pertinent to prosthetic arterial design are presented.

New arterial prostheses by filament winding

A new manufacturing method for vascular grafts, based on a filament winding technique, is unveiled. The concept that pilots this method is presented and analysed in detail alongside the experimental results. A basic feature of filament winding is its ability to produce a two-phase structure built of a continuous fibre-reinforced polymeric matrix, shaped according to the shape of a mandrel. This structure offers a number of advantages over common vascular graft designs, e.g. better control of the mechanical properties and closer match with anisotropic properties of native arteries, and more degrees of design freedom with respect to pore size, biodegradability and biocompatibility. The experimental section offers a range of potential constituent materials, and presents an example of a Lycra fibre/Pellethane matrix prototypical prosthesis.