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Abdominal hernia is a protruding weakness in the abdominal wall. It affects abdominal strength and life quality and can lead to complications due to intestinal entrapment. Autologous full-thickness skin graft (FTSG) has recently become an alternative material for reinforcement in the surgical repair of large abdominal hernias instead of synthetic mesh. FTSG eventually integrates with the abdominal wall, but the long-term fate of the graft itself is not fully understood. This has implications as to how these grafts should be optimally used and handled intraoperatively. This study investigates the remodeling of FTSG in either the onlay or the intraperitoneal position 8 weeks after FTSG transplantation in an experimental mouse model. There was a significant presence of fibroblasts, indicated by vimentin and S100A4 staining, but there were significant variations among animals as to how much of the graft had been remodeled into dense connective tissue. This correlated significantly with the proportion of vimentin-positive cells in the dense connective tissue. We also found that collagen hybridizing peptide staining intensity, a marker of active remodeling, was significantly associated with the proportion of S100A4-positive cells in the dense connective tissue of the FTSG.

Background and aims: Parastomal hernia (PSH) is a common complication after the creation of a colostomy, with a prevalence of approximately 50%. Despite the high frequency, little is known how PSH affects the cost of colostomy care. The hypothesis in this study was that PSH increases the cost of colostomy care compared with not having a PSH.

Methods: Two groups with (N = 61) and without (n = 147) PSH were compared regarding costs of stoma appliances and visits. The population from a large randomized trial comparing construction of colostomy with or without prophylactic mesh (STOMAMESH) was used and cross-matched with health economic data from the National Pharmaceutical Register, 1 year after initial surgery.

Results: Patients with and without a PSH were similar in basic demographic data. No difference in cost of stoma appliances (with PSH 2668.3 EUR versus no PSH 2724.5 EUR, p = 0.938) or number of visits to a stoma therapist (p = 0.987) was seen, regardless of the presence or not of a PSH.

Conclusions: PSH appears not to affect costs due to colostomy appliances or the need to visit a stoma therapist, in the first year. The lesson to be learnt is that PSHs are not a driver for costs. Other factors may be determinants of the cost of a colostomy, including manufacturers' price and persuasion, means of procurement, and presence of guidelines.

Background: Suturing of the hernia aperture in laparoscopic ventral hernia repair has increased during the past decade. The primary aim of this is to restore the anatomy of the abdominal wall. Closure of the aperture, however, may cause additional tension in the abdominal wall which could increase postoperative pain. The aim of this study was to investigate whether suturing of the hernia aperture affects postoperative pain and hernia-site complications, including seroma, infection, pseudohernia, and mesh migration, 3 months after repair.

Methods: Some 192 patients with a midline hernia between 2 and 8 cm in transverse diameter were included in a randomized controlled double-blinded multicentre study. Patients were randomized to mesh repair with (intervention) or without (control) suturing of the hernia aperture before mesh placement. Patients completed the Ventral Hernia Pain Questionnaire before and 3 months after surgery. Abdominal wall pain and hernia-site complications were assessed 3 months after surgery.

Results: Ninety-seven patients were randomized to the intervention group and 95 to the control group. Among all patients, median age and BMI was 56 years and 31 kg/m2 respectively. Overall pain experienced decreased by 3 months after operation (P < 0.001). There was no difference between groups regarding hernia-site complications or pain experienced during the past week (13 versus 23 patients; P = 0.111). Seroma and pseudohernia occurred in 13 and 11 patients in the intervention and control groups respectively (P = 0.975 and P = 0.977).

Conclusion: Restoration of the abdominal wall anatomy by suturing the hernia aperture before mesh placement does not increase the risk of hernia-site complication or pain 3 months after surgery. This implies that fascial suturing of the aperture can be justified if there are potential long-term benefits such as lower recurrence and/or complication rates.

Registration number: ISRCTN51495042 (http://www.controlled-trials.com).

Background: Ultrasound-guided nerve block can be used for perioperative analgesia and can potentially improve the course of recovery. Although iliohypogastric-ilioinguinal nerve block has been successfully used for inguinal hernia surgery, the poor blocking effect of intraoperative traction reflex remains a major drawback of this technique. The main objective of this study was to investigate the feasibility of single-point ultrasound-guided iliohypogastric-ilioinguinal-genitofemoral nerve (GFN) blockage for open anterior inguinal hernia repair in older adults. Methods: A total of 40 older adult patients [categorized as American Society of Anesthesiologists (ASA) I–III, body mass index (BMI) ≤28 kg/m2, age ≥60 years] undergoing open anterior inguinal hernia repair (the Lichtenstein technique) from June 2018 to December 2019 were recruited and randomly separated into an iliohypogastric-ilioinguinal nerve block group (group A; n=20) and an iliohypogastric-ilioinguinal-GFN block group (group B; n=20). The numerical rating scale (NRS) score in the post-anesthesia care unit (PACU) was the primary endpoint. Moreover, the following secondary indicators were recorded: the NRS score at 4 and 12 h after surgery and the duration of the nerve block; the total consumption of anesthetics; the occurrence of perioperative complications; and the mean arterial pressure (MAP), heart rate (HR), and respiration rate (RR), and oxygen saturation (SpO2) at baseline (T0), before skin incision (T1), 1 min after skin incision (T2), after dissection of the hernial sac (T3), at mesh placement (T4), and at the end of surgery (T5). Results: Patients in Group B had lower NRS scores in the PACU (0.9±0.7 vs. 2.1±0.9), at 4 hours post-operation (1.9±1 vs. 2.7±0.7), lower intraoperative traction response scores (0.6±0.8 vs. 1.7±1.2), and fewer postoperative complication scores (0.1±0.3 vs. 0.8±0.9) compared to group A (P<0.05). In addition, the MAP in group A was significantly higher than that in group B (P<0.01) at T2 (89.3±6.7 vs. 83.8±4.9), T3 (92.4±6.9 vs. 86.6±4.8), and T4 (87.8±5.2 vs. 83.1±4.6). The HR in group A was also higher than that in group B (P<0.05) at T2 (73.3±8.4 vs. 68.4±5.4) and T3 (77.0±14.7 vs. 68.7±6.9). Finally, compared to group B, group A showed a higher consumption of sufentanil (5.5±3.9 vs. 2.4±2.8) and lidocaine (3.4±2.3 vs. 1.0±2.0) (P<0.05). Conclusions: Performing an ultrasound-guided iliohypogastric-ilioinguinal-GFN block through a single puncture point is a feasible clinical approach. This strategy provides appropriate intraoperative and postoperative analgesia in older adult patients undergoing open anterior inguinal hernia repair and significantly reduces postoperative complications and thus has the potential to emerge as a novel analgesic option for inguinal hernia surgery.

Background and Objectives: Disparities between tumors arising via different sporadic carcinogenetic pathways have not been studied systematically. This retrospective multicenter cohort study evaluated the differences in the risk for non-colorectal malignancy between sporadic colorectal cancer (CRC) patients from different DNA mismatch repair status.

Methods: A retrospective European multicenter cohort study including in total of 1706 CRC patients treated between 1996 and 2019 in three different countries. The proficiency (pMMR) or deficiency (dMMR) of mismatch repair was determined by immunohistochemistry. Cases were analyzed for tumor BRAFV600E mutation, and BRAF mutated tumors were further analyzed for hypermethylation status in the promoter region of MLH1 to distinguish between sporadic and hereditary cases. Swedish and Finish patients were matched with their respective National Cancer Registries. For the Czech cohort, thorough scrutiny of medical files was performed to identify any non-colorectal malignancy within 20 years before or after the diagnosis of CRC. Poisson regression analysis was performed to identify the incidence rates of non-colorectal malignancies. For validation purposes, standardized incidence ratios were calculated for the Swedish cases adjusted for age, year, and sex.

Results: Of the 1706 CRC patients included in the analysis, 819 were female [48%], median age at surgery was 67 years [interquartile range: 60–75], and sporadic dMMR was found in 188 patients (11%). Patients with sporadic dMMR CRC had a higher incidence rate ratio (IRR) for non-colorectal malignancy before and after diagnosis compared to patients with a pMMR tumor, in both uni- (IRR = 2.49, 95% confidence interval [CI] = 1.89–3.31, p = 0.003) and multivariable analysis (IRR = 2.24, 95% CI = 1.67–3.01, p = 0.004). This association applied whether or not the non-colorectal tumor developed before or after the diagnosis of CRC in both uni- (IRR = 1.91, 95% CI = 1.28–2.98, p = 0.004), (IRR = 2.45, 95% CI = 1.72–3.49, p = 0.004) and multivariable analysis (IRR = 1.67,95% CI = 1.05–2.65, p = 0.029), (IRR = 2.35, 95% CI = 1.63–3.42, p = 0.005), respectively.

Conclusion: In this retrospective European multicenter cohort study, patients with sporadic dMMR CRC had a higher risk for non-colorectal malignancy than those with pMMR CRC. These findings indicate the need for further studies to establish the need for and design of surveillance strategies for patients with dMMR CRC.

The systemic inflammatory response (SIR), defined as elevated levels of circulating C-reactive protein (CRP), is an important predictor of impaired survival in colorectal cancer. The aim of this study was to explore the prognostic role of SIR and its association with tumour mismatch repair status and the immune response. Immune activity profiles of mononuclear cells isolated from CRC tissues and blood in the U-CAN exploration cohort (n = 69), were analysed by flow cytometry. In the U-CAN validation cohort (n = 257), T-helper cells (T-bet⁺), cytotoxic T cells (CD8⁺), regulatory T cells (FoxP3⁺), B cells (CD20⁺), and macrophages (CD68⁺) were analysed by multispectral imaging. Microsatellite instability was determined using five mononucleotide-repeat microsatellite markers. Patients with high CRP levels (> 10 mg/l) were significantly more often diagnosed with high-grade tumours and tumours exhibiting microsatellite instability. However, some patients with high CRP levels were found to have microsatellite-stable tumours. Furthermore, high CRP levels were associated with specific tumour immune traits including an augmented macrophage response and were significantly linked to poorer cancer-specific survival, particularly in patients with microsatellite-stable tumours. In conclusion, our findings suggest an interplay between SIR and mismatch repair status in CRC prognosis which needs to be further explored.

The aim of this study was to investigate if Low Anterior Resection Syndrome (LARS) score contributed with complementary information to Wexner score when assessing fecal incontinence (FI). The hypothesis was that LARS score would be likely to provide complementary information to Wexner score in the assessment of FI regardless of etiology. LARS score has been used as a complement to traditional scoring systems to assess bowel dysfunction, targeting FI among patients after radical cystectomy, in women with endometriosis, and in colorectal cancer patients. Wexner score as a single tool does not address the complexity of FI and urgency, a disabling symptom. A retrospective cohort study at a surgical outpatient clinic included patients diagnosed with FI who answered LARS and Wexner scores questionnaires at their first visit to the clinic between 1st January 2015 and 31st December 2018. Kendall’s tau, Spearman rank correlation, Cohen’s kappa, and scatterplots were analyzed for participants and specific subgroups to assess any correlation and agreement between answers to the two scoring systems. One hundred nineteen patients met the inclusion criteria, one hundred eight women and eleven men. Kendall’s tau ranged from 0.32 to 0.39, indicating lack of correlation. Correlation coefficients using Spearman rank ranged from 0.36 to 0.55, i.e., only fair to moderate correlation. Kappa was 0.21–0.28, i.e., only slight to fair agreement. Distribution of LARS and Wexner scores in the scatterplot showed wide variability and lack of agreement. Combined use of both the Wexner and LARS scores provided complimentary information, and thus a more complete mapping of FI as well as taking all entities in consideration.

Purpose: Sarcopenia and myosteatosis, quantified via computed tomography (CT), are associated with poor colorectal cancer outcomes. These body composition estimates can be influenced by physical exercise. We explored the correlation between pre-diagnostic physical exercise, body composition close to diagnosis, and the combined prognosis impact of these factors.

Methods: We studied 519 stage I–III colorectal cancer (CRC) cases diagnosed 2000–2016 with pre-diagnostic self-reported recreational physical exercise data collected in the prospective, population-based Northern Sweden Health and Disease Study, and CT-estimated skeletal muscle index (SMI) or skeletal muscle density (SMD). Risk estimates were calculated by multivariable logistic regression and Cox proportional hazards models.

Results: No association was seen between low pre-diagnostic physical exercise and sarcopenia/myosteatosis in the multivariable model adjusted for age, sex, educational level, tumor stage, and tumor location. In multivariable Cox regression models, the combination of low pre-diagnostic physical exercise and either sarcopenia or myosteatosis at the time of diagnosis was associated with cancer-specific mortality compared to the reference group of high physical exercise combined with no sarcopenia/myosteatosis (adjusted HR 1.94 95% CI 1.00–3.76 for sarcopenia and adjusted HR 2.39 95% CI 1.16–4.94 for myosteatosis).

Conclusions: The combined presence of low pre-diagnostic physical exercise and sarcopenia or myosteatosis was associated with increased CRC-specific mortality. Despite the positive effect on prognosis, physical exercise did not alter body composition estimates at diagnosis, which could indicate attenuation from other factors.

The repair of complex ventral hernias, such as giant incisional or parastomal hernia, is associated with a high risk for complications and recurrence. Some serious complications are related to implantation of synthetic mesh as reinforcement material. Autologous full-thickness skin graft (FTSG) as reinforcement material in the repair of these complex hernias may offer a safe alternative. This is a review of the history of FTSG use in hernia surgery and the experiences of our research group regarding its application over the last decade. The results of FTSG used in the repair of giant ventral hernias are promising, and this method may already be recommended in selected cases. We have also conducted a translational chain of preclinical studies, based on a murine model, to gain a greater understanding of the behaviour of FTSG implanted in various positions in the abdominal wall. The use of intraperitoneal FTSG as reinforcement material in parastomal hernia repair is currently being evaluated in a randomised, controlled, multicentre study.

Low anterior resection for rectal cancer often includes a diverting loop-ileostomy to avoid the severe consequences of anastomotic leakage. Reversal of the stoma is often delayed, which can incur health-care costs on different levels. The aim is to, on population basis, determine stoma-related costs, and to investigate habitual and socioeconomic factors associated to the level of cost. Multi-register design with data from the Swedish Rectal Cancer Registry, the National Prescribed Drug Register, Statistics Sweden and cost-administrative data from the National Board of Health and Welfare. Data was gathered for 3564 patients with rectal cancer surgery 2007 to 2013, for 3 years following the surgery. Factors influencing the cost of inpatient care and stoma-related consumables were assessed with linear regression analyses. All monthly costs were higher for females (consumables P <.001 and in-patient care P =.031). Post-secondary education (P =.003) and younger age (P =.020) was associated with a higher cost for consumables while suffering a surgical complication was associated with increased cost for inpatient care (P <.001). Patients who had their stoma longer had lower monthly costs (consumables P <.001 and in-patient care P <.001). Female gender, longer duration of stoma, young age, and higher education are associated with higher costs for the care of a diverting stoma after rectal cancer surgery. This study does not allow for analyses of causality but the results together with deepened analyses of underlying reasons form a proper basis for decisions in health care planning and allocation of resources. These findings may have implications on the debate of equal care for all.