Philip D. Kondylis

Safety and outcome of use of nonabsorbable mesh for repair of fascial defects in the presence of open bowel.

AbstractPURPOSE: Historically, there has been reluctance to use nonabsorbable synthetic mesh for repair of abdominal-wall defects in an operative field in which the presence of open bowel is accompanied by the potential for contamination. Some believe the risk of wound infection and mesh removal in this setting to be unacceptably high. The purpose of this study was to evaluate the safety and efficacy of nonabsorbable mesh used for hernia repair in the presence of a stoma or at the time of colon resection. METHODS: All patients undergoing elective surgical implantation of mesh with concomitant open bowel from 1987 to 2001 were retrospectively reviewed. Computer database identified all patients undergoing parastomal hernia repair, ventral hernia repair with a stoma present, hernia repair with concomitant bowel resection, and colostomy closure with repair of hernia. No patients so identified were excluded. Follow-up was attained on all patients by chart review and telephone survey. The data was statistically analyzed by chi-squared test using a P value of <0.05 for statistical significance. RESULTS: Twenty-nine patients were identified as having undergone 30 elective hernia repairs using nonabsorbable mesh. The repairs were performed in the presence of a stoma or in conjunction with bowel resection. All patients received bowel preparation. Included were 11 patients undergoing parastomal hernia repair (37 percent), 14 patients undergoing ventral hernia repair in the setting of open bowel (47 percent), and 5 patients in whom mesh repair of ventral and parastomal hernias were performed simultaneously (16 percent). Hernias recurred in 13 patients (43 percent). Overall recurrence for mesh repair at a parastomal site was 63 percent; overall recurrence at an incisional hernia site was 21 percent. The risk of wound complications after mesh placement in the setting of open bowel was assessed. Wound seromas developed after surgery in four patients (13 percent). Seromas were all treated successfully by aspiration. Wound infections occurred after surgery in two patients (7 percent). Wound infection occurred exclusively in sites of parastomal repair representing 2 of 16 (13 percent) of parastomal hernia sites. Infection with fistula necessitated mesh removal in one of these two cases. No chronic sinuses were observed. Incidences of recurrence and wound infection were statistically independent of type of hernia, variety of mesh, or operative approach. CONCLUSION: After bowel preparation, nonabsorbable mesh can be used for elective repair of incisional hernia in the presence of open bowel with an expectation of minor morbidity, minimal risk of infection, and an acceptable rate of recurrence. Nonabsorbable mesh can be used for elective repair of parastomal hernia in a similar setting with a low risk of infection independent of surgical approach. Although safe, local mesh repair of parastomal hernia was, in this study, accompanied by a high rate of recurrence.

The Delorme repair for full-thickness rectal prolapse: a retrospective review

BACKGROUND The purpose of this study was to assess our colorectal surgical training program experience with the Delorme procedure for complete rectal prolapse. METHODS Consecutive patients were identified from a surgical database and evaluated by chart review. RESULTS Seventy-six patients with a mean follow-up period of 3.6 years were included. Outcomes included a recurrence rate of 14.5%, an overall complication rate of 25%, and a surgical site-specific complication rate of 8%. For patients younger than 50 years old (mean age, 36 y; range, 19-49 y), the recurrence rate was 8% with a mean follow-up period of 4.1 years. Their total complication rate was 15%, with no surgery site-specific complications. CONCLUSIONS Our results are consistent with previously published experiences in that most preoperative evacuatory symptoms resolve with repair of the prolapse, and serious complications are uncommon. The observation that recurrence and complication rates may be lower in younger medically fit patients suggests the Delorme repair need not be restricted specifically to older, medically unfit patients.

Neoadjuvant therapy for rectal cancer decreases the number of lymph nodes harvested in operative specimens

BACKGROUND We evaluated the effect of neoadjuvant therapy (NAT) on lymph node harvest in rectal cancer patients undergoing anatomic resection with curative intent. METHODS A prospectively maintained database was retrospectively queried for rectal cancer cases from 1990 to 2010. Demographic data, NAT, and lymph node yield were analyzed. Nonanatomic resections were excluded. RESULTS Five hundred two cases were identified; the mean age was 68 years (range 34-89), and 56% were men. One hundred fifty-one (30%) patients received NAT. Overall, the lymph node yield was diminished in proctectomy specimens after NAT (mean = 9, median = 7) compared with specimens without therapy (mean = 13, median = 10, P = .001). Age was not a significant factor in the lymph node yield (P = .213 and .329). Among patients treated with NAT, younger patients had a significantly lower lymph node yield (P < .0001). CONCLUSIONS A decreased lymph node yield in proctectomy specimens from patients treated with NAT is consistent with prior studies. Younger patients had a greater reduction in lymph node harvest after NAT compared with senior patients.

Limitations of Barium Enema Performed as an Adjunct to Incomplete Colonoscopy

PURPOSEColonoscopy is believed to be inadequate in 4 to 24 percent of procedures. Barium enema often is utilized to complete the examination. In radiology literature, a successful barium enema in this setting requires only that the cecum has been reached. In this study, completion barium enema was assessed for both completeness and quality of proximal visualization.METHODSThe charts of 16,216 patients undergoing colonoscopy at Saint Vincent Health Center from July 1995 to July 2003 were reviewed to identify patients who underwent barium enema within six months of an incomplete colonoscopy. Incomplete colonoscopies were audited for history of previous abdominal/pelvic surgery, level of colon attained, and apparent reasons for failure. Corresponding barium enema reports were evaluated in a similar fashion.RESULTSIn 485 patients (2.9 percent), colonoscopy was incomplete. One hundred eighteen patients underwent barium enema after incomplete colonoscopy. In these patients, sharp angulation (42 percent) or redundancy/looping (31 percent) most often limited endoscopy. Among the barium enema studies, 91 (77 percent) were technically adequate. Twenty-seven studies were suboptimal (poor preparation/intolerance = 7, redundancy = 6, poor filling = 6, stricture/narrowing = 6, severe diverticulosis = 2). Two patients demonstrated additional polyps. There was no correlation between reasons for endoscopic failure and inadequacy of barium enema. Completeness of barium enema was not affected by previous pelvic surgery. Immediate barium enema was no less complete than a delayed study.CONCLUSIONSThe reliability of barium enema after incomplete colonoscopy is less than previously reported.

Male cryptoglandular fistula surgery outcomes: a retrospective analysis

PURPOSE The purpose of this study was to evaluate cryptoglandular fistula surgery outcomes in men with common types of fistulae. METHOD A database review identified study patients. Exclusion criteria included history of previous fistula, previous anorectal surgery, inflammatory bowel disease, pelvic radiation, complex fistula, age <21 years, and absence of follow-up. RESULTS Four hundred twenty-five patients met criteria for review. Mean follow-up was 5.8 years. Concurrent abscess at presentation was strongly associated with poorer outcomes. New-onset seepage is more common with seton treatment (P = 0.01), but seepage resolution occurred less commonly with fistulotomy (P <0.01). CONCLUSIONS Although both treatments are highly successful, men treated with primary fistulotomy are more likely to heal than seton patients. Fistulotomy patients have less early postoperative seepage than seton patients, but when this is present it is less likely to resolve. Presentation with concurrent abscess is strongly associated with poorer outcomes.