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So Good morning, everyone. Today we will do another Dorner club, this time on the speech trial. So a stitch tile is a trial about small bites versus large bites for the closure of abdominal midline incisions, Um, essentially a bit of background. That running technique with the long lasting monofilament suture material reduces the incidence of incisional hernia compared with interrupted future technique. And this has been proposed as a guideline for from the European Hernia Society and by getting it right together the first time, um so a running technique compared to the interrupted futures and with the long lasting monofilament future. So this has been known and proven. But what hasn't been proven is whether the large bites or small bites are necessary for this running technique. So Incisional hernia is a complication of any abdominal operation and has an incidence of 10 to 38%. So, as I said, running technique has been proven to be uh, superior to the interrupted stitches technique. And in 2014, the group of people from Stitch Trial performed a literature search to identify randomized control trial that compare small bites versus large bites, and only one study was found at that time, it was performed in a single center, and it showed that the small tissue by to decrease the incidence of intentional harness. So they set out to compare the common conventional large bites future technique with the small bites technique for the facial closure of Midland operatory me incisions. So, uh, if they call it stitch tile and the clothes procedure or anterior rectus, she's so who were eligible to participate 18 year old or older, and they were scheduled to undergo an elective abdominal surgery through a midline incision. It was prospective multi center double blind, the first study support that's been double blind, um, as in from the previous journal clubs to its randomized control trial at surgical and gynaecological departments in 10 hospitals. So it's also multi center in the New Zealand's. So, whatever the exclusion criteria's, they excluded people with the history of incisional hernia or fascial decisions. After Midland Lap Rotary, they excluded those who had abdominal surgery through a midline incision. Within the past three months, they excluded those who were pregnant or those who participated in another interventional trial. They randomly assigned, uh, patient's 1 to 1 while computer generates a randomization sequence, which is pretty random and what's also important. Patient's and study investigators were masked to group allocation, so they were blamed IT treatment. So there were two groups. One group had small bites, uh, for the closure, the other ones large bites. So those who had the small bites, what were they doing? So they were ought to place at least twice as many stitches as the incision lengthen centimeter. Using the 20 PDS plus to buy Ethicon with a 31 millimeter needle, they had to do the tissue bites of five millimeters and the inter future space to maintain or five millimeters, too. Um so in all cases, in both small and large bites, the stitch incorporated in upon neurosis only, um was used, and what was trying to be avoided is including inclusion of fetal or muscle while closing with fascia. So in the large bites, uh, the teacher bites of at least one centimeter were taking with the in the future space of one centimeter. And the tissue, uh, suture material was PDS plus to buy Ethicon a double up one with the 48 millimeter needle in both groups The situation was started on both ends of the incision and moved towards the center, where they have an overlap of at least two centimeters in both cranial and coral futures. So and for both future technique, they aimed for the future lens to wound length Thracian to be 4 to 1. So they stand there diced everything apart from the technique itself. The primary outcomes, the occurrence of incisional hernia during the follow up at one month or at one year. So we will take the latest one money or follow up and the second day outcomes. So again, black are those who have been reported in the study and then red are those who that were reported in the protocol but not mentioned in the study. So short term post operative complications burst abdomen, cardiac events, length of hospital stay, health related quality of life and in the project all, they also mentioned cost of activism and pain scoring statistics they perform, they calculate your power, and they identified that the sample size of 576 patient is needed. They analyze the differences between the group of the participants, Um, and they assessed the subgroup side effects by test of interactions, so they kind of perform. You try to be as unbiased as possible by assessing the subgroups from the patient's, but without fairness. The statistics wasn't very clear regarding confidence, intervals and all that other things. So between October 2009 and March 2012, they performed the study. So they found 560 patient that were randomly assigned. So it's only under powered by 2.8% which is very small. They had to drop out in both groups, so in the small bites, the dropout rate was 2.8% in the large bites, 2.5% and reasons for dropouts were stated. Um, maybe lost to follow up, but we always say lost to follow up so they can. They were pretty good, and overall 97% completed to follow up and were included in the primary analysis, which is a good result too. This were the baseline characteristics of participants and it's been pretty balanced between the groups, apart from maybe COPD patient's, which was slightly disinterred. But otherwise everything is pretty much okay. They also included a say classification, which is actually important pre morbid conditions corticosteroid use, which is important for the healing. So I think they are pretty. Couldn't baseline characteristics, so we can put some risk of buys, a low risk for organization and low risk from deviation from intended intervention. But they follow the protocol. Pretty Mayes. They just didn't report to outcomes, which I mean could be important, but especially the cost effectiveness. So the results were as follows. Out of 545 Patient's assessments in the follow up were done by clinical and radiological examination in 338 radiological examination only in 76 physical examination only in 131. So at one year year, post operatively 57 or 21% had incisional hernia in the large bites, and 35 or 13% had incisional hernia in the small bites. So the size of the hornet effect didn't differ significantly between the groups, and the time of facial closure was pretty similar slightly longer in the small white group by four minute. So in the secondary outcomes, there were no significant difference between the groups in the post operative complications and adverse events and there was no significant difference in length of state and quality of life, so it's all worst pretty similar. Interestingly, for example, the burst abdomen in the large bite group only happen to to patient's in a small bite grouping for patient's. But again, it's not the most significant, so missing outcome data. I think it's a low risk because they pretty much reported everything. Um, measurement of the outcome is also again low risk because also importantly, the assessors were blinded so they don't didn't know when trying to identify. The incisional hernias Assessor didn't know whether the person or in the small bites or the large white group, which is important, and the selection of the reported results is a low risk. So overall, all of the risk of bias have been low for me. So discussion what this study has proven is that this huge legal, the fashion after abdominal midline incision with continuous small bites technique reduces the incidence of the incisional hernia as compared with the futuristic with the conventional large bite technique. So it's also been proven to be a safe technique in view of the lowly incidence of burst abdomen and I mean additional closure time was only four more minutes. They also used the imaging in order to identify, uh, to identify incisional hernias, as stated by the European Hernia Society guidelines, However, not every participant had in imaging 131 participants, which is one thieves might be like one C yeah, one of these. They didn't have any imaging done, and they also standardize the technique for the closure. So they standardize the materials. Usual material, the target number of speeches and the overall technique. The limitations. So, as I said in some patient's radiological imaging, was not done so and the reasons for that we're either because the patient's for visits home or because of some other logistical difficulties. So another limitation is the longer the follow up, the higher chances of incisional hernia to occur. So maybe a longer follow up was needed for these patient's and results don't differentiate between the effect of the smaller bites or the use of different future material. So the only used one future material one needle standardise, so we don't know what will happen with another future material. And again, some of the discussion points what will happen during the emergency laparotomy, Um, for example, for prediabetic abdomen, when everything is just so inflamed and messy and it will be impossible to clothes using only faster, for example. Yeah, And then what will happen if the fascia is not intact? What if there are some holes and just breaking down? Um, what if the people have such an inflamed tissue that it's really difficult to teach? And also they did do? They did do some baseline characteristics for comorbidities, but they didn't actually do the analysis, and they didn't take into the account. The tissue laxity. So overall, that's it. Thank you very much.