Introduction: Nissen fundoplication is the golden standard for surgical treatment of gastroesophageal reflux disease (GERD). Numerous studies report excellent short-term results. However, data ...regarding long-term quality of life are lacking. The aim of this study is to investigate the long-term quality of life after Nissen fundoplication in patients with GERD and to compare this with the short-term results.
Patients and Methods: We retrospectively analysed all patients who underwent laparoscopic Nissen fundoplication for GERD between January 2004 and January 2016. All patients received a validated GERD-Health-Related Quality of Life questionnaire by mail to assess post-operative quality of life. Maximum quality of life is represented by a score of 75. Secondary outcome measures were complications and recurrence rate.
Results: One hundred and seventy-five (77.1%) of the 227 operated patients returned the questionnaire. The median follow-up was 3.7 (0.1-10.3) years. Mean age was 51.6 (range 15-85) and 72 patients were male. We report an excellent quality of life with a median total score of 70 (range 2-75). Re-operation rate was 13.6% (23/169); the re-operation was due to recurrent reflux in 12 patients and due to persistent dysphagia in 11 patients. 91.3% of the re-operations were performed within the first 5 years after surgery. Mortality rate was zero.
Conclusion: We report a large series of single-centre, single-surgeon laparoscopic Nissen fundoplication. Despite the re-operation rate of 13.6%, we found excellent long-term symptomatic outcome. There was no difference between short- and long-term results.
Purpose
Complex ventral hernia repair (CVHR) encompasses patient optimization, primary fascial closure (PFC), mesh reinforcement and component separation technique (CST), if needed. High rates of ...complications after CST are still reported. Prehabilitation by managing pre-operative modifiable risk factors, like abdominal wall compliance, possibly reduces these rates. Compliance can be modified by intramuscular injection of Botulinum in the lateral abdominal wall muscles (LAWM). Paralysis leads to elongation of these muscles, which may facilitate PFC and/or prevent CST. Evidence to use Botulinum in hernia patients is scarce and fragmented. An update of evidence for the effect of Botulinum is presented.
Methods
A multi-database search was conducted for Botulinum studies in ventral hernia patients. A systematic review was performed to describe its primary effect on compliance (LAWM elongation) and secondary effects like PFC ± CST rate, complications and recurrence.
Results
14 studies were included (377 patients) with a HDW of median 12 (10–15) cm. A typical intervention consisted of 200–300 U Botulinum in 3 points per hemi-abdomen under US guidance, > 2 weeks pre-operatively and evaluated by CT just before the operation. The primary effect was a median LAWM elongation of 4.0 cm per side without complications of the injection (four studies, 107 patients). The median PFC rate was 100%, CST rate 38%, wound-related complications 19%, medical complications 18% and recurrence 0% (14 studies).
Conclusion
Botulinum safely elongates the abdominal wall muscles, but the level of evidence available remains low. Any patient in whom PFC is expected to be difficult, could be a candidate for prehabilitation with Botulinum.
Obesity in children and adolescents is an increasing problem associated with multiple co-morbidities including metabolic and endocrine changes, cardiovascular abnormalities, and impaired quality of ...life. Combined lifestyle interventions are the current standard treatment for severe obesity in children. However, the medium- and long-term results of these interventions are relatively poor. Bariatric surgery shows substantial weight loss and health improvement in adults and retrospective studies in adolescents show similar outcomes. However, well-designed prospective studies in this young age group are rare. Our objectives are to determine whether combining surgery with lifestyle interventions in severely obese adolescents leads to a significant additional weight reduction compared to lifestyle interventions solely, and to assess its effect on obesity-associated co-morbidities in a prospective randomized controlled setting.
Patients aged 14-16 years with sex- and age-adjusted BMI > 40 kg/m
(or > 35 kg/m
with comorbidity) and failure to achieve weight reduction > 5% during at least one year of combined lifestyle interventions are included in this trial. Randomization determines whether laparoscopic adjustable gastric banding will be added to combined lifestyle intervention throughout the trial period. Sixty children will be included in this trial. Follow-up visits are planned at 6 months, 1,2 and 3 years. Primary endpoints are percentage of total weight loss, and change of BMI. Secondary endpoints include body composition, pubertal development, metabolic and endocrine changes, inflammatory status, cardiovascular abnormalities, non-alcoholic steatohepatitis, quality of life and changes in behaviour.
This randomized controlled trial is designed to provide important information about the safety and efficacy of laparoscopic adjustable gastric banding treatment in severely obese adolescents with unsuccessful combined lifestyle interventions. The reversibility of this surgical procedure forms a strong argument to decide for gastric banding over other surgical procedures, since bariatric surgery in adolescents is still in its infancy.
The BASIC trial is registered in the register of ClinicalTrials.gov since July 2010, Identifier: NCT01172899.
Aim
Low anterior resection syndrome (LARS) severely affects the quality of life (QoL) of patients after surgery for rectal cancer. There are very few studies that have investigated LARS‐like symptoms ...and their effect on QoL after colon cancer surgery. The aim of this study was to investigate the prevalence of functional abdominal complaints and related QoL after colon cancer surgery compared with patients with similar complaints after rectal cancer surgery.
Method
All patients who underwent colorectal cancer resections between January 2008 and December 2015, and who were free of colostomy for at least 1 year, were eligible (n = 2136). Bowel function was assessed by the LARS score, QoL by the EORTC QLQ‐C30 and QLQ‐CR29 questionnaires. QoL was compared between the LARS score categories and tumour height categories.
Results
A total of 1495 patients (70.0%) were included in the analyses, of whom 1145 had a colonic and 350 a rectal tumour. Symptoms of LARS were observed in 55% after rectal cancer resection compared with 21% after colon cancer resection. Female gender (OR 1.88, CI 1.392–2.528) and a previous diverting stoma (OR 1.84, CI 1.14–2.97) were independently associated with a higher prevalence of LARS after colon cancer surgery. Patients with LARS after colon cancer surgery performed significantly worse in most QoL domains.
Conclusion
The results of this study highlight the presence of LARS‐like symptoms after surgery for colonic cancer. Patients suffering from major LARS‐like symptoms after colon resection reported the same debilitating effect on their QoL as patients with major LARS after rectal resection. This should be addressed by colorectal cancer specialists in order to adequately inform patients.
Laparoscopic surgery is associated with reduced surgical trauma, and therefore with a less acute phase response, as compared with open surgery. Impairment of the immune system may enhance surgical ...infections, port-site metastases, and sepsis. The objectives of this review was to assess immunologic consequences of benign laparoscopic surgery and to highlight controversial aspects.
A literature search on stress response to nonmalignant laparoscopic and open surgery was conducted using the MEDLINE and Cochrane databases. Cross-references from the reference list of major articles on the subject were used, as well as manuscripts published between 1993 and 2002.
Local (i.e., peritoneal) immune function is affected by carbon dioxide pneumoperitoneum. The production of tumor necrosis factor and the phagocytotic capacity of peritoneal macrophages are less lowered. The systemic stress response, as determined by delayed-type hypersensitivity response and leukocyte antigen expression on lymphocytes, shows a preservation of immune function after laparoscopic surgery, as compared with conventional surgery.
Intraperitoneal carbon dioxide insufflation attenuates peritoneal immunity, but laparoscopic surgery is associated with a lower systemic stress response than open surgery.
Background and Aims
To assess safety of the Exilis™ gastric electrical stimulation (GES) system and to investigate whether the settings can be adjusted for comfortable chronic use in subjects with ...morbid obesity. Gastric emptying and motility and meal intake were evaluated.
Method
In a multicenter, phase 1, open prospective cohort study, 20 morbidly obese subjects (17 female, mean BMI of 40.8 ± 0.7 kg/m
2
) were implanted with the Exilis™ system. Amplitude of the Exilis™ system was individually set during titration visits. Subjects underwent two blinded baseline test days (GES ON vs. OFF), after which long-term, monthly follow-up continued for up to 52 weeks.
Results
The procedure was safe, and electrical stimulation was well tolerated and comfortable in all subjects. No significant differences in gastric emptying halftime (203 ± 16 vs. 212 ± 14 min,
p
> 0.05), food intake (713 ± 68 vs. 799 ± 69 kcal,
p
> 0.05), insulin AUC (2448 ± 347 vs. 2186 ± 204,
p
> 0.05), and glucose AUC (41 ± 2 vs.41 ± 2,
p
> 0.05) were found between GES ON and OFF. At week 4, 13, and 26, a significant (
p
< 0.01) reduction in weight loss was observed but not at week 52. At this time point, the mean excess weight loss (EWL) was 14.2 ± 4.5%.
Conclusion
Gastric electrical stimulation with the Exilis™ system can be considered as safe. No significant effect on food intake, gastric emptying, or gastric motility was observed. The reduction in weight loss with Exilis™ GES was significant but short lasting. Further electrophysiological research is needed to gain more insight in optimal stimulation parameters and lead localization.
Background
The Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) is an open procedure in which the mesh is placed in the preperitoneal space and is therefore associated with less chronic ...post-operative inguinal pain. TREPP is primarily performed under general or spinal anesthesia, however, it is also possible to perform under sedation and local anesthesia with potentially advantages. This retrospective feasibility pilot study investigates the safety and efficiency of TREPP under local anesthesia in the outpatient clinic in comparison with Lichtenstein.
Methods
Between 2019 and 2022, all patients who underwent an elective inguinal hernia repair under local anesthesia in the outpatient clinic operation theatre were assessed. 34 patients in the TREPP group and 213 patients in the Lichtenstein group were included. Outcomes were complications, operating time, theatre time, and early inguinal hernia recurrence within 8 weeks and 6 months post-operatively.
Results
No significant differences in complications such as wound infection, hematoma, seroma, urine retention and early recurrence between TREPP and Lichtenstein were found. Post-operative pain at 8 weeks was not significantly higher after Lichtenstein (8.8% vs. 18.8%,
P =
0.22). Operating time (21.0 (IQR: 16.0-27.3) minutes vs. 39.0 (IQR: 31.5–45.0) minutes,
P
< 0.001) and theatre time (37.5 (IQR: 30.8–42.5) minutes vs. 54.0 (IQR: 46.0–62.0) minutes,
P
< 0.001) was significantly shorter for TREPP.
Conclusion
This pilot study showed that TREPP appears to be feasible to perform safely under local anesthesia with comparable complication rates and substantially shorter operation time than Lichtenstein. These results justify further research with a larger study population and a longer period of follow up in order to provide firm conclusions.
Incisional hernias after laparotomy are associated with significant morbidity and increased costs. Recent research on prevention of incisional hernia formation suggests that a laparotomy closure ...technique using a slowly absorbable monofilament suture with small fascial steps and bites in a continuous, single layer with a suture length to wound length (SL/WL) ratio of at least 4:1 is effective in lowering morbidity. Little is known about application of this evidence in daily practice. Therefore, a survey was performed among Dutch surgeons.
All members of the Dutch Surgical Society were invited to participate in a 24-question online survey on techniques and materials used for abdominal wall closure after midline laparotomy. Subgroup analysis was performed based on surgical subspecialty, type of hospital and experience.
Response rate was 26% (402 respondents), representing 97% of all Dutch surgical departments. More than 90% of participants closed the abdominal wall in a single mass layer, using a slowly absorbable monofilament running suture The SL/WL ratio of >4:1 is practiced by only 35% of participants and preferred suture size was variable among participants. Risk factors for incisional hernia development were generally identified correctly but more than half of the participants were unaware of the incidence and time of occurrence of incisional hernia. Subgroup analysis found that gastrointestinal and oncologic surgeons preferred smaller diameter sutures and higher suture-length to wound-length ratios. Trauma, vascular and pediatric surgeons had lower estimates of incidence of incisional hernia than other subspecialties. Surgeons employed in academic hospitals were more likely to use small fascial steps and smaller suture sizes than their colleagues in non-academic hospitals. Correct estimates of incisional hernia incidence decreased when surgeons perform less than 10 laparotomies annually.
Implementation of the latest evidence regarding closure techniques of the abdominal wall is not widespread. Only 35% of surgeons close the abdominal fascia using a suture length to wound length ratio of 4:1, which is recommended based on the latest evidence. Surgical trainees, gastrointestinal and oncological surgeons are most familiar with the recommended technique and use it in their daily practice. Efforts should be directed at improving spreading of this technique.
•Little is known about implementation of best-evidence closure strategies after laparotomy.•A survey among Dutch surgeons was performed.•Techniques and materials used are widely variable.•Current best evidence is not widely adopted.•Efforts should be directed to improve this.
Purpose
Laparoscopic intraperitoneal onlay mesh in hernia repair can result in adhesions leading to intestinal obstruction and fistulation. The aim of this systematic review is to compare the effects ...of mesh coatings reducing the tissue-to-mesh adhesion in animal studies.
Methods
Pubmed and Embase were systematically searched. Animal experiments comparing intraperitoneally placed meshes with coatings were eligible for inclusion. Only studies with comparable follow-up, measurements, and species were included for data pooling and subsequent meta-analysis.
Results
A total of 131 articles met inclusion criteria, with four studies integrated into one comparison and five studies integrated into another comparison. Compared to uncoated polypropylene (PP) mesh, PP mesh coated with hyaluronic acid/carboxymethyl cellulose (HA/CMC) showed significantly reduced adhesion formation at follow-up of 4 weeks measured with adhesion score of extent (random effects model, mean difference,− 0.96, 95% CI − 1.32 to − 0.61,
P
< 0.001, I
2
= 23%; fixed effects model, mean difference,− 0.94, 95% CI − 1.25 to − 0.63,
P
< 0.001,
I
2
= 23%). Compared to PP mesh, polyester mesh coated with collagen (PC mesh) showed no significant difference at follow-up of 4 weeks regarding percentage of adhesion-area on a mesh, using random effects model (mean difference − 11.69, 95% CI − 44.14 to 20.76,
P
= 0.48,
I
2
= 92%). However, this result differed using fixed effects model (mean difference − 25.55, 95% CI − 33.70 to − 7.40,
P
< 0.001,
I
2
= 92%).
Conclusion
HA/CMC coating reduces adhesion formation to PP mesh effectively at a follow-up of 4 weeks, while the anti-adhesive properties of PC mesh are inclusive comparing all study data.
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