Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

173 Long Term Analysis of The Evolution of Practice and Results of Abdominal Wall Reconstruction by A Single Surgeon

Background

It is estimated that at least 12-15% of abdominal operations lead to incisional hernias, and Worldwide, evidence shows high rates of recurrence after surgical repair ranging from 12.7% in the Danish hernia registry to 23% in the Swedish registry.

Method

This is a retrospective analysis of the practice of a single surgeon at a tertiary centre. An electronic database provided all hernia surgeries done by the surgeon. A total of 185 patients with complete data were included who had open hernia repair. Electronic patient records were analysed to collect the data.

Results

185 patients, with a median age of 57 years (IQR 68 – 49), and BMI of 31.14 (IQR 36.02 – 27.52), had a hernia recurrence rate of 15.6% (29/185). More than 80% of the cases were complex hernias with a European Hernia classification of M3 and/ or W3, with dense intestinal adhesions and multiple previous repairs. Variability in techniques and mesh evolved over this period, from anterior component separation to transversus abdominis release to achieve closure of the abdomen. Polypropylene meshes were used for non-contaminated or less complex cases. The use of biologics in the early years has been superseded by biosynthetic.

Conclusions

The creation of the abdominal wall unit and subsequent MDT at this centre resulted in a rise of total procedures, complexity of cases and patients with significant co-morbidities. Specialised abdominal wall surgeons are associated with better results when performing complex abdominal wall reconstructions.

Patients newly diagnosed with ulcerative colitis receive earlier treatment in surgical clinics

AIM

The diagnosis and treatment of ulcerative colitis (UC) is traditionally the realm of gastroenterologists. However, the symptoms of UC overlap with those of bowel cancer and patients may be initially referred to colorectal surgery clinics. The aims of this study were to define which specialty most frequently diagnoses UC and to determine if there were differences in management between the two specialities.

METHOD

The demographics, presenting symptoms and clinical management of patients with newly diagnosed UC were determined and compared by speciality clinic of initial referral. Histopathology reports and clinic letters were reviewed to identify patients newly diagnosed with UC at a large university teaching hospital from January 2007 to January 2012.

RESULTS

Patients were more commonly referred to colorectal surgeons (74 vs 41 patients) than gastroenterologists. Patients referred to gastroenterology were younger (36.0 vs 59.6 years, P < 0.01) but there were no significant differences in gender, presenting symptoms or disease extent. Rigid sigmoidoscopy ± biopsy was more commonly performed in colorectal clinic (93.2 vs 31.7%, P < 0.01). There was a significantly shorter delay in starting disease-specific treatment for those patients referred initially to colorectal surgery (13.8 vs 33.6 days, P = 0.01). Performing rigid sigmoidoscopy in clinic was associated with starting disease-specific treatment at this visit.

CONCLUSION

Patients with first presentation UC are more commonly seen in colorectal surgery clinics where rigid sigmoidoscopy is more frequently undertaken, allowing earlier commencement of UC treatment.

Identification of serum biomarkers for colon cancer by proteomic analysis

Colorectal cancer (CRC) is often diagnosed at a late stage with concomitant poor prognosis. Early detection greatly improves prognosis; however, the invasive, unpleasant and inconvenient nature of current diagnostic procedures limits their applicability. No serum-based test is currently of sufficient sensitivity or specificity for widespread use. In the best currently available blood test, carcinoembryonic antigen exhibits low sensitivity and specificity particularly in the setting of early disease. Hence, there is great need for new biomarkers for early detection of CRC. We have used surface-enhanced laser desorbtion/ionisation (SELDI) to investigate the serum proteome of 62 CRC patients and 31 noncancer subjects. We have identified proteins (complement C3a des-arg, α1-antitrypsin and transferrin) with diagnostic potential. Artificial neural networks trained using only the intensities of the SELDI peaks corresponding to identified proteins were able to classify the patients used in this study with 95% sensitivity and 91% specificity.

Structure-activity relationships for DT-diaphorase reduction of hypoxic cell directed agents: indoloquinones and diaziridinyl benzoquinones

The flavoenzyme DT-diaphorase has the potential either to bioactivate or to detoxify different bioreductive cytotoxins. Elucidation of structural features governing the ability to act as a substrate for DT-diaphorase should facilitate rational optimization or elimination of this reductive pathway for a particular class of bioreductive drug. We have examined structure-activity relationships governing both the cytotoxicity and the DT-diaphorase mediated reduction of two groups of bioreductive alkylating agents: (1) Indoloquinones related to EO9 [3-hydroxy-methyl-5-aziridinyl-1-methyl-2-(1H-indole-4,7-dione)prop-beta - en-alpha-ol]; and (2) derivatives of diaziridinyl benzoquinone or diaziquone [2,5-bis(carboethoxyamino)-3,6-diaziridinyl-1,4-benzoquinone]. The rat U.K. 256 Walker tumor cell line and the human HT29 colon carcinoma line were studied because of their high DT-diaphorase content. Enzyme activity was measured spectrophotometrically by dicoumarol inhibitable cytochrome c reduction in the presence of drug, and aerobic cytotoxicity was assessed by the MTT assay. EO9 acted as a good substrate for both enzyme preparations and was highly potent in each cell line, especially in Walker tumor cells (ID50 0.039 nM). AZQ was also reduced efficiently and gave an ID50 of 6 nM in the Walker tumor line. Slight modifications in structure resulted in large variations in both DT-diaphorase metabolism and toxicity for both types of agent. There was a clear tendency for the most efficiently reduced analogues to exhibit greater cytotoxic potency. Inclusion of an aziridine moiety in the structure appears to be desirable, but not essential, for both rapid reduction and cytotoxicity. There was no evidence of active site-directed enzyme inhibition.