Yuri W. Novitsky

Comparison of generic versus specific quality-of-life scales for mesh hernia repairs.

BACKGROUNDnWith the use of mesh shown to considerably reduce recurrence rates for hernia repair and the subsequent improvement in clinical outcomes, focus has now been placed on quality-of-life outcomes in patients undergoing these repairs, specifically, as they relate to the mesh prosthesis. Traditionally, quality of life after hernia surgery, like many other medical conditions, has been tested using the generic SF-36 survey. The SF-36 quality-of-life survey, although well studied and validated, may not be ideal for patients undergoing hernia repairs. We propose a new quality-of-life survey, the Carolinas Comfort Scale (CCS), pertaining specifically to patients undergoing hernia repair with mesh; our goal was to test the validity and reliability of this survey.nnnSTUDY DESIGNnThe CCS questionnaire was mailed to 1,048 patients to assess its acceptability, responsiveness, and psychometric properties. The survey sample included patients who were at least 6 months out after hernia repair with mesh. Patients were asked to fill out the CCS and the generic SF-36 questionnaires, four questions comparing the two surveys, and their overall satisfaction relating to their hernia repair and mesh.nnnRESULTSnThe reliability of the CCS was confirmed by Cronbachs alpha coefficient (0.97). Test-retest validity was supported by the correlation found between two different administrations of the CCS; both Spearmans correlation coefficient and the kappa coefficient were important for each question of the CCS. Assessment of its discriminant validity showed that both the mean and median scores for satisfied patients were considerably lower than those for dissatisfied patients. Concurrent validity was demonstrated by the marked correlations found between the CCS and SF-36 questionnaire scales. When comparing the two surveys, 72% of patients preferred the CCS questionnaire, 80% believed it was easier to understand, 66% thought it was more reflective of their condition, and 69% said they would rather fill it out over the SF-36.nnnCONCLUSIONSnThe CCS better assesses quality of life and satisfaction of patients who have undergone surgical hernia repair than the generic SF-36.

Laparoscopic parastomal hernia repair using a nonslit mesh technique

BackgroundThe management of parastomal hernia is associated with high morbidity and recurrence rates (20–70%). This study investigated a novel laparoscopic approach and evaluated its outcomes.MethodsA consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence.ResultsA total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m2 underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm2, and the mean size of the mesh was 365 cm2. There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2–38 months), 4% (1/25) of the patients experienced recurrence.ConclusionOn the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands.

In vitro infectability of prosthetic mesh by methicillin-resistant Staphylococcus aureus

Although mesh use is important for effective herniorrhaphy in adults, prosthetic infections can cause serious morbidity. Bacterial adherence to the mesh is a known precursor to prosthetic infection. We compared the ability of common mesh prosthetics to resist bacterial adherence. The meshes studied included polypropylene (Marlex®), expanded polytetrafluoroethylene (PTFE) with and without silver chlorhexidine coating (DualMesh Plus® and Dualmesh®) composite meshes (Composix E/X®, Proceed™, and Parietex Composite®) and lightweight polypropylene meshes (TiMesh®, Ultrapro®, and Vypro®). Fifteen samples of each mesh type were individually inoculated with a suspension of 108 methicillin-resistant Staphylococcus aureus (MRSA) in tryptic soy broth. After incubation at 37°C for 1xa0h, the mesh pieces were then removed and serially washed. The colony-forming units (CFU) of MRSA present in the initial inoculum, at the end of the 1-h warm-water bath (broth count), and the pooled washes (wash count), were determined using serial dilutions and spot plating. The bacteria not accounted for in the broth or wash counts were considered adhered to the mesh. Samples of each mesh type were also analyzed using scanning electron microscopy (SEM). Data are presented as the mean percentage adherence with ANOVA and Tukey’s test used to determine significance (P<0.05). The DualMesh Plus® mesh had no detectable MRSA in the broth or the pooled wash samples. Dualmesh® had less adherence compared with Marlex®, Proceed™, and Vypro® (P<0.05). Conversely, Vypro® had a statistically higher adherence (96%, P<0.05) as compared to TiMesh®, Ultrapro®, Composix E/X®, and Parietex Composite®. SEM confirmed bacterial adherence to all the mesh types except DualMesh Plus®. The ability of a biomaterial to resist infection has an important clinical significance. DualMesh Plus®, due to its antimicrobial coating, is the only mesh type of the nine tested that demonstrated a bactericidal property. Standard PTFE (Dualmesh®) also had less bacterial adherence. Vypro® demonstrated an increase in bacterial adherence; this was possibly due to the multifilament polyglactin 910 weaved within the prolene component of the mesh.

Prospective histologic evaluation of intra-abdominal prosthetics four months after implantation in a rabbit model

BackgroundPlacement of an intraperitoneal prosthetic is required for laparoscopic ventral hernia repair. The biocompatibility of these prosthetics determines the host’s inflammatory response, scar plate formation, tissue ingrowth, and subsequent mesh performance, including prosthetic compliance and prevention of hernia recurrence. We evaluated the host response to intraperitoneal placement of several prosthetics currently used in clinical practice.MethodsA 4-cm × 4-cm piece of mesh was implanted on intact peritoneum in New Zealand white rabbits. The mesh types included expanded polytetrafluoroethylene (ePTFE) (DualMesh®), ePTFE and polypropylene (Composix®, heavyweight polypropylene), polypropylene and oxidized regenerated cellulose (Proceed®, midweight polypropylene), and polypropylene (Marlex®, heavyweight polypropylene). At four months, standard hematoxylin and eosin and Milligan’s trichrome stains of the mesh-tissue interaction were analyzed by three observers blinded to the mesh types. Each specimen was evaluated for scar plate formation, inflammatory response, and tissue ingrowth. Each of these three categories was graded on a standard scale of 1–4 (1 = normal tissue and 4 = severe inflammatory response). The scores were analyzed using Wilcoxon rank sum test with p < 0.05 as significant.ResultsTen samples of each mesh type were evaluated. There was no difference in tissue incorporation between the groups. The mean scar plate formation was greater in the heavyweight polypropylene meshes than for DualMesh (p = 0.04). With Proceed, the reduction in scar plate formation compared with that for Composix and Marlex approached statistical significance (p = 0.07). The mean number of inflammatory cells was greater around the ePTFE when compared with the midweight polypropylene (p = 0.02) but equal to the other meshes.ConclusionsThe four prosthetic materials evaluated in this study demonstrate comparable host biocompatibility as evidenced by the tissue ingrowth. Scar plate formation around DualMesh was significantly less than that around Composix and Marlex. Interestingly, more inflammatory cells were noted surrounding the DualMesh which was equal to that of the heavyweight meshes. Proceed, a midweight polypropylene mesh, has the potential for improved patient tolerance compared to heavyweight polypropylene meshes based on its favorable histologic findings.

Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair

Introduction: Chronic groin pain is the most common long-term complication after open inguinal hernia repair. Traditional surgical management of the associated neuralgia consists of injection therapy followed by groin exploration, mesh removal, and nerve transection. The resultant hernia defect may be difficult to repair from an anterior approach. We evaluate the outcomes of a combined laparoscopic and open approach for the treatment of chronic groin pain following open inguinal herniorrhaphy. Methods: All patients who underwent groin exploration for chronic neuralgia after a prior open inguinal hernia repair were prospectively analyzed. Patient demographics, type of prior hernia repair, and prior nonoperative therapies were recorded. The operation consisted of a standard three trocar laparoscopic transabdominal preperitoneal hernia repair, followed by groin exploration, mesh removal, and nerve transection. Outcome measures included recurrent groin pain, numbness, hernia recurrence, and complications. Results: Twelve patients (11 male and 1 female) with a mean age of 41xa0years (range 29–51) underwent combined laparoscopic and open treatment for chronic groin pain. Ten patients complained of unilateral neuralgia, one patient had bilateral complaints, and one patient complained of orchalgia. All patients failed at least two attempted percutaneous nerve blocks. Prior repairs included Lichtenstein (n=9), McVay (n=1), plug and patch (n=1), and Shouldice (n=1). There were no intraoperative complications or wound infections. With a minimum of 6xa0weeks follow up, all patients were significantly improved. One patient complained of intermittent minor discomfort that required no further therapy. Two patients had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure. Conclusions: A combined laparoscopic and open approach for postherniorrhaphy groin pain results in good to excellent patient satisfaction with no perioperative morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after prior open hernia repair.

Immunohistochemical analysis of host reaction to heavyweight-, reduced-weight-, and expanded polytetrafluoroethylene (ePTFE)-based meshes after short- and long-term intraabdominal implantations

BackgroundProsthetic meshes induce a variety of inflammatory changes in the host, which may lead to excessive scarring with detrimental clinical consequences, especially in the long term. This study aimed to characterize the degree of short- and long-term inflammatory changes induced by common prosthetic meshes.MethodsTwenty 4xa0×xa04-cm samples each of expanded polytetrafluoroethylene (ePTFE), heavyweight polypropylene (hPP), ePTFE/heavyweight polypropylene (ePTFE/hPP), and reduced-weight polypropylene/regenerated cellulose (rPP) were implanted intraperitoneally in 40 rabbits for 4 or 12xa0months. After explantation, samples of mesh/tissue complex were analyzed for the degrees of cellular apoptosis (enzyme-linked immunoassay [ELISA]) and cellular turnover (mouse monoclonal antibody).ResultsIn the short term, the degree of apoptosis in the hPP mesh was significantly higher than in the ePTFE and rPP groups. Similarly, it was higher in the ePTFE/hPP group than in either the ePTFE or the rPP group. The amount of Ki-67-positive cells was significantly higher in the hPP group than in the ePTFE or rPP group. The cell turnover in the ePTFE/hPP group was similar to that in the hPP group, but significantly higher than in either the ePTFE or the rPP group. The rPP group, in turn, had a higher Ki-67 score than the ePTFE group. In the long term, both the degree of apoptosis and Ki-67 positivity were significantly lower in the rPP and ePTFE groups than in either the ePTFE/hPP or the hPP group. A significant decrease in Ki-67 scores between the short and long-term groups was found only in the rPP group.ConclusionIn the short term, heavyweight polypropylene-based meshes were associated with significantly higher cell proliferation and death. A significantly higher degree of apoptosis and cell turnover were associated with heavyweight polypropylene-based meshes even 1xa0year after implantation, indicating ongoing inflammation and scar remodeling. On the other hand, ePTFE and reduced-weight polypropylene meshes were associated with nearly physiologic levels of inflammatory markers. Overall, an exaggerated and persistent host foreign body response to heavyweight polypropylene-based meshes indicates poor biocompatibility, with potential detrimental clinical sequela.

Laparoscopic Heller myotomy for achalasia in 101 patients: can successful symptomatic outcomes be predicted?

We aimed to evaluate the clinical outcomes of patients undergoing laparoscopic esophageal myotomy for achalasia and identify the factors that might predict postoperative dysphagia or symptomatic reflux. A retrospective analysis of all patients undergoing laparoscopic Heller myotomy from January 1997 to June 2004 was performed. Postoperative frequency and severity of reflux, dysphagia, chest pain, and regurgitation were evaluated using a standardized telephone interview. Forty-eight males and 53 females, with an average age of 45 years, underwent laparoscopic Heller myotomy during the study period. Prior to presentation, 65% of patients had undergone pneumatic dilatation (52%) and/or Botox injection (28%). The mean lower esophageal sphincter pressure was 44 mmHg. A Toupet fundoplication was performed in 89 patients, and 12 patients had no fundoplication. There were no intraoperative complications and 10 minor postoperative complications. During an average follow-up of 34 months (range 2-90), 15% of patients had a weekly dysphagia, and 16% had subjective reflux. Only an older age predicted higher incidence of postoperative dysphagia. No factors were identified to predict postoperative symptomatic reflux. Eighty-one percent of patients rated their outcome as excellent, 14% good, 4% fair, and 1% poor. Ninety-nine percent of patients would choose surgery over other treatment options again. Laparoscopic anterior esophageal myotomy is a safe and effective treatment for achalasia. Improvement in dysphagia can be expected in more than 95% of patients. Younger patients tended to have better improvement of dysphagia. Predicting the patients at higher risk for postoperative reflux remains elusive at this time.

Optional Vena Cava Filters for Patients with High Thromboembolic Risk: Questions to be Answered

The use of vena cava filters has increased rapidly over the past few years to more than 140,000 filters inserted worldwide in 2003. Continued improvements in filter design have increased the safety of intravascular caval filtration. Although there are many factors attributed to this increase, the most significant contributing factor has been the development of optional vena cava filters. That is, filters that can be left as a permanent device or can be removed endovascularly at a later date. Three filters are approved for removal in the United States, the Günther Tulip, the OptEase, and the Recovery. Recent reports have demonstrated the safety and feasibility of these devices in appropriate patients, but a number of questions have arisen regarding their use.

Laparoscopic Ventral Hernia Repair

With an advent of minimally invasive surgery, the use of laparoscopy for ventral hernia repairs has become standard. Laparoscopic ventral hernia repair is associated with decreased perioperative pain, reduced hospital stay, and faster recovery. The mesh is placed as an intra-peritoneal underlay with wide coverage of the hernia defect. Minimal wound morbidity appears to be its biggest advantage over most open repairs. Numerous studies demonstrate that laparoscopic ventral hernia repair is an effective and safe approach to the abdominal wall hernia. Appropriate patient selection, safe abdominal access, adhesiolysis, precise mesh positioning, and fixation are key factors that ensure a safe and effective laparoscopic repair of most ventral defects. In this chapter, we will describe our perioperative patient selection and management, detail our operative techniques, and address potential pitfalls, contraindications, and complications of the traditional laparoscopic ventral hernia repair.

Do the risks of emergent colectomy justify nonoperative management strategies for recurrent diverticulitis

BACKGROUNDnThe nonoperative approach to recurrent and even multiple recurrent diverticulitis has recently been advocated. This approach, however, may result in more frequent acute attacks requiring emergent colectomy. Our aim was to compare the colectomy outcomes for diverticulitis in the elective and acute settings.nnnMETHODSnAll patients with diverticulitis undergoing elective (EL) and emergent (EM) colectomy selected from the 2001 to 2002 Nationwide Inpatient Sample Database were analyzed and compared.nnnRESULTSnFive thousand ninety-seven (27.1% emergent) colectomy cases were analyzed. EL patients had a significantly reduced length of stay (7.5 vs 13.3 days) and total hospital charges (