D'Amore L

Double synchronous occluding tumors of the large bowel: A report of three cases

The development of acute large bowel obstruction secondary to colorectal cancer is very common and, while right hemicolectomy with a primary anastomosis is the accepted procedure for right-sided obstructing tumors, the different strategies performed for left-sided tumors, including staged procedures, Hartmanns procedure, and resection with anastomosis, remain a subject of controversy. We present herein the case reports of three patients who developed two synchronous occlusive tumors of the large bowel. Complete exploration of the entire colon is highly recommended to assess the most feasible therapeutic option in such cases, as the second occlusive tumor, often hidden within the bowel segments, can cause failure of limited resection or intestinal decompression.

Transduodenal sphincterotomy in laparoscopic era.

Abstract. Indications for transduodenal sphincterotomy have been reduced in recent years, mainly because of the development of endoscopic sphincterotomy and laparoscopic procedures. Endoscopic treatment is effective, but it is necessary to carefully evaluate its indications because the incidence of early and late complications is not negligible. Laparoscopic procedures require advanced and expensive technologies and considerable laparoscopic experience. Transduodenal sphincterotomy is safe and effective, if correctly performed. Some risk factors appear to be related to the incidence of complications that do not significantly differ from those following endoscopic sphincterotomy. Transduodenal sphincterotomy may be still indicated in selected cases, and for this reason it should be considered an essential part of the knowledge of a general surgeon.

Comment on: Biologic mesh in ventral hernia repair: Outcomes, recurrence, and charge analysis

To the Editors: The article by Huntington et al is of great interest because it provides stimulating arguments concerning the use of biologic mesh in difficult abdominal wall reconstruction (AWR). Recently, we have commented on the article by Majumder et al, which was also published in Surgery and suggested that selection of the proper implant is crucial. Results of the Huntington et al study confirm this statement. In fact, in 223 AWRs performed with non–cross-linked biologic mesh, at a mean follow-up of 18.2 months, recurrence rate was significantly lower (P < .001) in the Strattice group (14.7%) when compared to another porcine acellular dermal matrix, such as Xenmatrix (59.1%), and to human acellular dermis Alloderm (35.0%), Allomax (34.8 %), and FlexHD (37.1%). Fascial bridging repair was performed in a minority of cases (8.8%) in the Strattice group when compared to the other groups (P < .0001). In our opinion, this could partially explain the better results of Strattice mesh because bridging technique with biologic mesh is unsatisfactory and should be avoided when possible. Nevertheless, we agree with the authors that Strattice performs better than the other non–cross-linked meshes. Our experience with biologics (49 AWRs) mainly concerns the use of porcine cross-linked acellular dermal matrix, Permacol and CollaMend, because these implants are both easily commercially available in Europe. From the beginning of our experience, we restricted the indications to the use of biologics to cleancontaminated or contaminated operative fields. The overall recurrence rate was actually 8.2%, with a median follow-up longer than 59.3 months. Our results were significantly better in the Permacol group than in the CollaMend group, with a recurrence rate of 2.8% and 23%, respectively. This confirms that not all biologics are equal also in the cross-linked subgroup. After all, could Strattice and Permacol be considered the “leaders” of biologic implants, in the non–crossand cross-linked groups, respectively? Could both be used in all AWRs at risk of infection, or rather would specific indications to the use of one or another be needed? Controlled randomized trials are necessary to answer this question. As a matter of fact, contrary to that reported by Huntington et al, no study has ever compared Strattice and Permacol. The repair of infected and contaminated hernias study, cited by Huntington, is a prospective trial of single-stage AWR with the use of biologic non–cross-linked porcine tissue matrix (Strattice). Only one retrospective study exists comparing Permacol versus Alloderm, with a recurrence rate that was significantly higher in the Alloderm group (47% and 32%, respectively). Different techniques were performed in this study with bridging repair in more than 50% of cases thus limiting results. In the search for the best mesh to be used in AWR, we believe that it is time to perform a controlled randomized trial comparing long-term outcomes of Strattice versus Permacol. As Huntington et al assert, a study like this would collect 60 patients in each mesh group to have a study 80% power at 5% level, and we agree with them. Furthermore, in our opinion, this study should use some selection criteria, such as patient demographic and comorbidity not significantly being different in the 2 groups, following the same indication for biologics (clean-contaminated or contaminated field), using the same technique of repair (retrorectus placement of the implant), and having a follow-up not shorter than 5 years. This study could be difficult to realize even at a dedicated hernia referral center. Could a multicenter collected study be helpful to overcome this criticism and get to a final clinical decision?