Charles F. Bellows

Abdominal wall reconstruction using biological tissue grafts: present status and future opportunities

Surgeons often encounter the challenge of treating acquired abdominal wall defects following abdominal surgery. The current standard of practice is to repair most defects using permanent synthetic mesh material. Mesh augments the strength of the weakened abdominal wall fascia and enables the hernia repair to be performed in a tension-free manner. However, there is a risk of acute and/or chronic infection, fistula formation and chronic abdominal wall pain with the use of permanent mesh materials, which can lead to more complex operations. As a means to avoid such problems, surgeons are turning increasingly to the use of xenogenic and allogenic materials for the repair of abdominal wall defects. Their rapid evolution and introduction into the clinical operating room is leading to a new era in abdominal wall reconstruction. There are promising, albeit limited, clinical data with short-term follow-up for only a few of the many biological tissue grafts that are being promoted currently for the repair of abdominal hernias. Additional clinical studies are required to better understand the long-term efficacy and limitations of these materials.

Proximal splenic angioembolization does not improve outcomes in treating blunt splenic injuries compared with splenectomy: a cohort analysis.

BACKGROUNDnAlthough splenic angioembolization (SAE) has been introduced and adopted in many trauma centers, the appropriate selection for and utility of SAE in trauma patients remains under debate. This study examined the outcomes of proximal SAE as part of a management algorithm for adult traumatic splenic injury compared with splenectomy.nnnMETHODSnA retrospective cohort analysis was performed on all hemodynamically stable (HDS) blunt trauma patients with isolated splenic injury and computed tomographic (CT) evidence of active contrast extravasation that presented to a level 1 Trauma Center over a period of 5 years. The cohorts were defined by two separate 30 month periods and included 78 patients seen before (group I) and 76 patients seen after (group II) the introduction of an institutional SAE protocol. Demographics, splenic injury grade, and outcomes of the two groups were compared using Students t test, or chi2 test. Analysis was by intention-to-treat.nnnRESULTSnSix hundred eighty-two patients with blunt splenic injury were identified; 154 patients (29%) were HDS with CT evidence of active contrast extravasation. Group I (n = 78) was treated with splenectomy and group II (n = 76) was treated with proximal SAE. There was no difference in age (33 +/- 14 vs. 37 +/- 17 years), Injury Severity Score (31 +/- 13 vs. 29 +/- 11), or mortality (18% vs. 15%) between the two groups. However, the incidence of Adult Respiratory Distress Syndrome (ARDS) was 4-fold higher in those patients that underwent proximal SAE compared with those that underwent splenectomy (22% vs. 5%, p = 0.002). Twenty two patients failed nonoperative management (NOM) after SAE. This failure appeared to be directly related to the grade of splenic organ injury (grade I and II: 0%; grade III: 24%; grade IV: 53%; and grade V: 100%).nnnCONCLUSIONnIntroduction of proximal SAE in NOM of HDS splenic trauma patients with active extravasation did not alter mortality rates at a Level 1 Trauma Center. Increased incidence of ARDS and association of failure of NOM with higher splenic organ injury score identify areas for cautionary application of proximal SAE in the more severely injured trauma patient population. Better patient selection guidelines for proximal SAE are needed. Without these guidelines, outcomes from SAE will still lack transparency.

More than 150 consecutive open umbilical hernia repairs in a major Veterans Administration Medical Center

BACKGROUNDnThe purpose of this study was to determine the rate of surgical site infection for open elective umbilical hernia repairs and to identify the factors related to an increased risk of infection and/or recurrence.nnnMETHODSnA retrospective analysis of 152 open elective umbilical hernia repairs between 2003 and 2007 was performed.nnnRESULTSnOverall, 19% of repairs became infected. Both high ASA classification (P = .01) and mesh repair (P = .01) significantly predicted wound infection, whereas age >60 years, body mass index >30, smoking, immunosuppression, diabetes, and hernia size did not. Only 2 of 17 infected mesh repairs required removal of the mesh. The recurrence rate was 1.5% for mesh and 9.2% for suture repairs.nnnCONCLUSIONSnUmbilical hernia repair is associated with a high rate of infection, and most superficial mesh infections can be treated with antibiotics alone. In addition, mesh repair of umbilical hernias decreased the rate of recurrence but increased the risk of infection compared with suture repairs.

Microbiology of infected acellular dermal matrix (AlloDerm) in patients requiring complex abdominal closure after emergency surgery.

BACKGROUNDnAcellular dermal matrix (AlloDerm) has recently been introduced as an option for complex abdominal closure for patients with loss of abdominal wall domain secondary to intra-abdominal sepsis or necrotizing fasciitis. AlloDerm has been touted as a promoter of neovascularization and collagen deposition. Currently, the rate of AlloDerm infection in contaminated cases is unknown. Our objective was to determine if the organisms cultured during source control would infect AlloDerm.nnnMETHODSnThe medical records of patients who required complex abdominal closure with AlloDerm in a tertiary-care hospital were reviewed from January to December, 2005. For each patient demographic, the reason for urgent surgery, American Society of Anesthesiologists (ASA) class, Acute Physiology and Chronic Health Evaluation (APACHE) II score, serum albumin concentration, culture results of purulent fluid obtained during surgery, and culture results of biopsies of infected-appearing AlloDerm (change of color, delayed granulation, odor) were collected. Data are presented as mean +/- standard error of the mean.nnnRESULTSnSeventeen patients required the use of AlloDerm for tension-free closure of the abdominal wall after surgery for source control in necrotizing fasciitis (13%) or intra-abdominal sepsis (87%). The mean age was 61 +/- 2 years; 73% of the patients were Caucasian, the remainder being African American. The mean APACHE II score was 23.7 +/- 2.0, and the median ASA class was 3. The mean preoperative albumin concentration was 2.27 +/- 0.26 g/dL. Most (76%) of the patients had a wound vacuum-assisted closure system placed over the AlloDerm. Four patients (24%) were noted to have an infection of the AlloDerm graft at 24 +/- 10 days postoperatively. The cultures obtained at operation and from infected AlloDerm show similar organisms (Pseudomonas in two, Escherichia coli and methicillin-resistant Staphylococcus aureus in one each). Infected AlloDerm was coated with silver sulfadiazene and moistened dressings, and all four patients had complete resolution of the AlloDerm infection with an adequate bed of granulation tissue, allowing skin grafting.nnnCONCLUSIONnPatients with contaminated abdomens who require complex closure with AlloDerm are at risk of developing infection of their graft material with organisms similar to those present at the time of surgery. Once culture results are obtained, topical antimicrobials with activity against the cultured organisms may be employed as part of the AlloDerm dressings to prevent infection and promote healing.

Laparoscopic splenectomy: present status and future perspective.

Laparoscopic splenectomy has become widely accepted as the approach of choice for the surgical treatment of benign and malignant hematologic diseases. Advances in technology have led to better outcomes for the procedure, and have allowed surgeons to apply the technique to disease processes that were at one time felt to be contraindications to laparoscopic splenectomy. However, challenges still remain. There is a steep learning curve associated with the procedure. The development of cost-effective laparoscopic simulators to target the skills required for laparoscopic splenectomy and other laparoscopic procedures is essential. The advent of devices which isolate and seal the large blood vessels that surround the spleen have reduced intra-operative bleeding and minimized conversions to open splenectomy. Improvements in optics and instrumentation, as well as robotic technology, will continue to define the frontier of minimally invasive surgery, and further facilitate the acceptance of laparoscopic splenectomy for the treatment of benign and malignant hematologic diseases.

CASE REPORT: Adenocarcinoma Within a Diverticulum: A Common Tumor Arising in an Uncommon Location

A 63-year-old man presented with burning, and the passage of flatus with urination. A cystoscopic evaluation revealed some irregularity of the dome of the bladder. However, the patient was lost to follow-up. Five months later, he represented with dull, intermittent lower abdominal pain. He admitted to decreasing caliber of stools, diarrhea, occasional hematochezia, and weight loss (20 lb/y). Physical examination was noncontributory. His carcinembryonic antigen level was 1.3 ng/ml. A barium enema revealed a narrowing of the distal sigmoid colon as well as a fistula tract connected to the bladder. An abdominal computed tomographic scan showed diverticula, bladder and sigmoid wall thickening, and no liver lesions. At laparotomy, a large rectosigmoid mass with a significant inflammatory reaction around it was discovered at 20 cm from the anal verge. The mass was adherent to the bladder. A sigmoid colectomy with end-to-end anastomosis and partial cystectomy was performed. Macroscopic examination of the resected specimen showed many diverticula and a large fistulous opening on the serosal surface. On opening the bowel, a large fungating necrotic mass was present surrounding the stoma of an enlarged distended diverticulum. The tumor grew along the diverticular wall and appeared to be continuous with the fistulous opening on the serosal surface. The rest of the colonic mucosal surface had numerous diverticular openings but was otherwise grossly unremarkable. Microscopic examination revealed a moderately differentiated adenocarcinoma growing along the wall of a single diverticulum. The tumor had perforated the diverticulum, extensively spread onto the serosal surface, and formed a fistulous connection with the bladder. The mucosal lining of diverticulum was nearly completely replaced by tumor with extensive ulceration. Tumor involved the submucosa, but normal mucosa was observed at the stoma. Severe acute and chronic inflammation was noted in the diverticular wall with abscess formation surrounding this area. Tumor also involved the fistulous tract on the serosal surface of the bladder, but it did not appear to involve the muscular wall of the bladder itself. Resection margins and fourteen sampled lymph nodes were free of tumor. The remaining diverticula showed severe diverticulitis.

Two Unusual Cases of Adult Intussusception

Adult intussusception is very rare. We report 2 unusual cases, a 58-year-old man with a transverse colo-colonic intussusception caused by a malignant sessile polyp that also had an asymptomatic synchronous neoplasm of the kidney, and an 18-year-old female with an ileocecolic intussusception caused by acute appendicitis. This report stresses the point that intussusception in adults may represent an underlying malignancy. The age of the patient and the anatomic location of the intussusception provide significant input as to the etiology and hence the most appropriate surgical procedure.

Bariatric Aftercare and Outcomes in the Medicaid Population Following Sleeve Gastrectomy

Background: Medicaid patients tend to have poor access to care and suffer from more obesity and obesity-related co-morbidities compared to their privately insured counterparts. The impact of Medicaid status on outcomes after laparoscopic sleeve gastrectomy (LSG) is unknown. The aim of this study was to identify factors that influence outcomes following LSG in the adult Medicaid population of Louisiana with particular focus on adherence to bariatric aftercare attendance and access to care. Methods: A retrospective review of 63 Medicaid patients undergoing LSG was performed. Demographic data, access to care, weight, co-morbidities morbidity, and mortality were analyzed. Changes in weight and obesity-related co-morbidities were analyzed for patients with ≥12 months of follow-up. Regression analyses were used for estimating the relationships among variables. Results: The majority of patients were female and non-Caucasian. The mean age was 38.6 years. Morbidity was 16% and mortality was 0%. The average distance traveled to clinic was 71.9 miles. Within the first year only 10% of the patients attended all post-operative clinic visits. A multiple logistic model showed that the only predictor of clinic attendance was increased age. At a mean follow-up of 17.7 months, the mean percent excess body weight loss was 47.2%. Greater pre-surgical weight was the only variable associated with suboptimal weight loss. Improvement or resolution of all major co-morbidities was seen in 65% of patients. Conclusion: Medicaid patients had a poor attendance at bariatric surgery follow up appointments. Since long-term follow-up is critical, we needed to develop strategies that will optimize follow-up in this patient population.

A Simple and Safe Minimally Invasive Technique for Laparoscopic Gastrostomy

Described is a 2-port laparoscopic technique for the placement of a gastric feeding tube in patients who may not be candidates for endoscopic PEG tube insertion.