P056 RETROSPECTIVE ANALYSIS OF LONG-TERM INCIDENCE, RISK FACTORS AND SURGICAL REPAIR OF VENTRAL INCISIONAL HERNIAS AFTER LIVER TRANSPLANTATION

Aim “Assess risk factors and incidence of ventral incisional hernia (VIH) following liver transplantation (LT).” Material and Methods “Retrospective analysis of clinical or radiological signs of VIH during a systematic ten year follow up after liver transplantation. Descriptive statistics and a binary logistic regression analysis were performed to identify possible risk factors.” Results “Between 01/2007-12/2017, 708 LT were performed in 660 patients at our institution. Following LT, 122 patients (18.5%) had a VIH as identified per clinical examination. Further to this, 85 patients (12.9%) had CT findings consistent with VIH adding to a total of 207 (31.4%) patients with VIH after LT. Male gender (p < 0.001), BMI (p < 0.001), age at LT (p < 0.001), alcohol induced cirrhosis (p = 0.032) and reoperation after 180 days following LT (p = 0.007) were identified as risk factors in a multivariate analysis. An incisional hernia repair was performed in 76 patients (11.5%) at 22.9 months (median, 5.7-101.5). Laparoscopic IPOM repair was performed in 46 (60.5%) patients and 30 patients had an open hernia repair including 26 (34.2%) with mesh augmentation and 4 (5.3%) with primary closure. Five patients (6.6%) needed a reoperation for postoperative complications related to hernia repair. Recurrent VIH occurred in 12 (15.8%) patients. In 131 patients, no hernia repair was performed because of only mild clinical symptoms, patient preference and/or poor general condition.” Conclusions “The incidence and burden of incisional hernia following LT is significant. Many cases of VIH are clinically mild but radiomorphologically manifest.”

P104 POSTOPERATIVE OUTCOME AND COMPLICATIONS AFTER STOMA REVERSAL SURGERY WITH CICATRIAL HERNIA HERNIA PROPHYLAXIS BY MESH AUGMENTATION IN SUBLAY TECHNIQUE USING GORE® BIO A® MESH

Aim At the surgery hospital of Klinikum Mittelbaden in Baden-Baden (Prof. Dr. Dieter Berger) stoma reversal surgery was performed on 127 patients in the time from Nov. 15, 2010 to Mar. 11, 2015. All 127 patients were treated with a resorbable synthetic mesh (GORE® BIO-A® mesh) in sublay technique to close abdominal wall incisions. Primary wound closure was carried out in all cases. In order to evaluate the rate of postoperative hernias, which literature reports to be over 30 percent and a common complication, all 127 patients were included in a prospective study. Material and Methods In total, 104 of the included patients (n = 127) took part in the follow-up examinations. 72 patients underwent clinical examinations and imaging diagnostics, 21 were surveyed on the telephone whenever their presentation at a follow-up exam was impossible, whereas 11 patients deceased during the follow-up period. These cases were analyzed on the basis of the previous examinations which had been part of the respective health records. The follow-up examination took place after a median time span of 87 weeks (8 -218 weeks). Results The total herniation rate of 7.7 percent (n = 8/104) in the examined patient population was thus much lower than described in the literature. Conclusions According to our own prospective analysis, we were able to register a very low herniation rate compared to the literature when the resorbable synthetic mesh (GORE® BIO-A®) was applied in sublay technique for stoma reversal. One disadvantage could lie in the increased perioperative wound infection rate. 5/8 hernias were observed after the occurrence of perioperative wound infections.

791 RECURRENT HIATAL HERNIA A HIGH PREDICTOR OF PATHOLOGIC REFLUX AND NEED FOR REINTERVENTION

Anti-reflux surgery (ARS) has been postulated to have high failure rates, which may approach 50% depending upon hiatal hernia size. Most failures are thought to be related to wrap disruption or hiatal hernia recurrence. Recently, diaphragmatic mesh augmentation has been shown to reduce hiatal hernia recurrence. We aimed to determine factors that influence recurrence based on vigilant imaging and diagnostic pH studies, and the need for surgical reintervention. Methods A prospectively maintained database of all patients undergoing index robotic ARS (including Hill, Nissen, Toupet, and Linx procedures) with Phasix ST ® mesh was queried. Between December 2016 and July 2020, 134 patients were identified of which 92 met inclusion criteria for post-operative barium esophagram performed at routine intervals (6, 12, or 24-months) or for recurrent symptoms. Median follow-up time was 11.4 months. Clinical characteristics, manometry, pH studies, as well as surgical approach was evaluated. Radiographic recurrences were then associated with endoscopic confirmation and rates of surgical re-intervention. Results Radiographic recurrence >2 cm was noted in 9 (9.8%) patients, of which 44% were symptomatic, compared to 36% of those without radiographic recurrence (p = 0.620). Endoscopy confirmed recurrence in 67% of patients with radiographic recurrence versus 0% without (p = 0.001). When all radiographic recurrences, including those <2 cm, were evaluated, 17 (18%) were identified, of which 53% of patients were symptomatic. Endoscopic and pH studies confirmed recurrences in 75% and 71% of these patients, respectively. Overall reintervention rates were 23% in the setting of any radiographic recurrence versus 1.3% without (p = 0.001). Conclusion Recurrence rates following robotic ARS and hiatal hernia repair with mesh augmentation appear low with nearly 1-year follow-up. Prior to surgical reintervention, endoscopic and pH studies are warranted to confirm symptomatic recurrence. Recurrent hiatal hernias, including those <2 cm, can lead to abnormal pH studies that merit reintervention at rates higher than those without evidence of recurrence. Longer term follow-up is required to optimally delineate true recurrence patterns.

Midline incisional hernia prophylaxis using synthetic mesh in an emergency or urgent gastrointestinal tract surgery: a protocol for multicentre randomised clinical trial

IntroductionBetween 5% and 30% of abdominal incisions eventually result in incisional hernias (IHs) that can lead to severe complications and impaired quality of life. Unfortunately, IH repair is often unsuccessful; therefore, hernia prophylaxis is an important issue. The efficacy of mesh augmentation has been proven for hernia prophylaxis in high-risk patients, but no randomised clinical trial has evaluated prophylactic mesh placement in emergency/urgent gastrointestinal operations.Methods and analysisA multicentre, prospective randomised, open and patient–assessor blinded endpoint design will be conducted. A total of 470 patients will be enrolled and randomly allocated to retrorectus mesh augmentation with lightweight polypropylene mesh or primary suture closure. The primary outcome is IH occurrence within 24 months of follow-up, while other clinical outcomes are secondary endpoints. A cost-effectiveness analysis will be conducted from the societal and provider perspectives.Ethics and disseminationEthics approval was obtained from Ramathibodi Hospital (MURA2020/1478) and Vajira Hospital (COA164/2563). The protocol is on the process of submission to the local ethics committee of the other study sites. Results will be submitted for publication in a peer-reviewed journal.Trial registration numberTCTR20200924002.

Abdominal incision defect following AAA-surgery (AIDA): 2-year results of prophylactic onlay-mesh augmentation in a multicentre, double-blind, randomised controlled trial

The reported incidence of incisional hernia following repair of abdominal aortic aneurysm (AAA) via midline laparotomy is up to 69%. This prospective, multicenter, double-blind, randomised controlled trial was conducted at eleven hospitals in Germany. Patients aged 18 years or older undergoing elective AAA-repair via midline incision were randomly assigned using a computer-generated randomisation sequence to one of three groups for fascial closure: with long-term absorbable suture (MonoPlus®, group I), long-term absorbable suture and onlay mesh reinforcement (group II) or extra long-term absorbable suture (MonoMax®, group III). The primary endpoint was the incidence of incisional hernia within 24 months of follow-up, analysed by intention to treat. Physicians conducting the postoperative visits and the patients were blinded. Between February 2011 and July 2013, 104 patients (69.8 ± 7.7 years) were randomised, 99 of them received a study intervention. The rate of incisional hernia within 24 months was not significantly reduced with onlay mesh augmentation compared to primary suture (p = 0.290). Furthermore, the rate of incisional hernia did not differ significantly between fascial closure with slow and extra long-term absorbable suture (p = 0.111). Serious adverse events related to study intervention occurred in five patients (5.1%) from treatment groups II and III. Wound healing disorders were more frequently seen after onlay mesh implantation on the day of discharge (p = 0.010) and three (p = 0.009) and six (p = 0.023) months postoperatively. The existing evidence on prophylactic mesh augmentation in patients undergoing AAA-repair via midline laparotomy probably needs critical review. As the implementation of new RCTs is considered difficult due to the increasing number of endovascular AAA treated, registry studies could help to collect and evaluate data in cases of open AAA-repair. Comparisons between prophylactic mesh implantation and the small bite technique are also required. Trial registration: ClinicalTrials.gov Identifier: NCT01353443. Funding Sources: Aesculap AG, Tuttlingen, Germany.

Arthroscopic Superior Capsular Reconstruction for Older Patients With Irreparable Rotator Cuff Tears: A Comparative Study With Younger Patients

Background: Arthroscopic superior capsular reconstruction (ASCR) is a method for treating irreparable chronic rotator cuff tears. However, the extent to which ASCR can be performed with regard to the patient’s age has yet to be determined. Purpose: To compare the surgical outcomes of ASCR for the treatment of irreparable rotator cuff tears (IRCTs) in patients aged <65 years versus patients aged ≥65 years. Study Design: Cohort study; Level of evidence, 3. Methods: Of 105 patients with IRCTs who underwent ASCR between March 2013 and June 2020, 73 patients were enrolled in this study based on the selection criteria. Polypropylene mesh augmentation to the graft was used in 18 of 36 patients in the younger adults group (age, <65 years) and 20 of 37 patients in the older adults group (age, ≥65 years). The clinical and radiological outcomes were evaluated preoperatively and at the final clinical follow-up. The graft integrity status was evaluated using serial magnetic resonance imaging and set as the primary endpoint. Furthermore, subgroup analysis was performed based on age group and graft type. Results: The mean age of the patients was 59.2 ± 3.8 years in the younger adults group and 70.5 ± 4.1 years in the older adults group. Both groups showed improvement based on the clinical and radiological outcomes at the final follow-up. The mean American Shoulder and Elbow Surgeons scores improved from 52.3 ± 15.4 to 77.3 ± 13.5 in the younger adults group ( P < .001) and from 45.7 ± 16.1 to 76.6 ± 11.4 in the older adults group ( P < .001). The mean visual analog scale for pain scores improved from 5.5 ± 1.2 to 2.1 ± 0.9 in the younger adults group ( P < .001) and from 5.5 ± 1.4 to 2.1 ± 1.2 in the older adults group ( P < .001). The graft healing rate was significantly higher in the younger adults group (81%) than in the older adults group (65%) ( P = .049). Subgroup analysis showed that after mesh augmentation, the healing rate in the younger adults group (84%) was similar to that in the older adults group (85%) ( P = .299). Conclusion: ASCR resulted in a favorable surgical outcome for both younger and older adult patients with IRCT. The younger patients had lower graft failure rates and superior surgical outcomes. In older patients, ASCR using polypropylene mesh augmentation may reduce graft failure and result in surgical outcomes similar to those in younger patients.