Abdominal Wall Reconstruction: The Uncertainty of the Impact of Drain Duration upon Outcomes.

Drains are commonly used after abdominal wall reconstruction (AWR) to prevent seroma formation. Drain management is subjective, and the merits and drawbacks of drains are not well understood. After receiving Institutional Review Board approval, we queried our prospectively maintained surgical database for AWR cases from 2009 to 2012 to ascertain if the number of days postoperatively that drains are left in place impacts the incidence of surgical site complications. Number of drains, drain duration, wound complications, and interval to development of complications were recorded. Wound complications were defined as superficial cellulitis, seroma, hematoma, superficial infection, and deep infection. Among 117 AWRs, we investigated the 64 cases with Centers for Disease Control grade one wound classification. Longest drain duration varied widely (2-171 days postoperatively; mean = 22 days). Cases were divided into four groups based on duration prior to removal of all drains: ≤7 days (n = 18), 8 to 14 days (n = 16), 15 to 28 days (n = 18), or ≥29 days (n = 12). No significant relationship was found between incidence of seroma/hematoma and days postoperatively of last drain removal. Wound complications increased linearly with drain time. Using logistic regression to adjust for obesity (body mass index >35kg/m(2)), drain duration >2 weeks and operative time >220 minutes, only body mass index >35 remained an independent predictor of wound occurrence, P < 0.05. Wound complications occur frequently after AWR. Wound infections occur more commonly among patients with drains in place for more than 2 weeks. Strategies to reduce drain duration require furthermore investigation.

Quality-of-life scores in laparoscopic preperitoneal inguinal hernia repair.

BACKGROUND: Published support exists for using lightweight polypropylene mesh (PPM) to repair inguinal hernias with increased biocompatibility and decreased foreign body reaction and pain. However, quality of life (QOL) has not been assessed. We assess QOL in patients undergoing laparoscopic totally extraperitoneal hernia repair (TEP) with lightweight PPM. METHODS: We performed an IRB-approved study of patients undergoing TEP hernia repair. Demographic information and hernia characteristics were collected perioperatively. Baseline Short Form-36 (SF-36), Carolinas Comfort Scale (CCS), and visual analog scale (VAS) for pain were performed preoperatively, and then after 1, 26, and 52 weeks. RESULTS: Forty-eight patients undergoing TEP with mesh were selected. Average age was 43.2 years (SD = 13.2), and average BMI was 26.1 kg/m(2) (SD = 4.3). Procedures include bilateral hernia, right inguinal hernia, and left inguinal hernia repairs. Mean scores on the CCS(®) and VAS were low during the immediate post-op period and 1 year. SF-36 mean scores for body pain, physical function, and role physical showed decreases at the postoperative survey and then subsequent increases. Pain-associated scores increased during the immediate post-op period. CCS and SF-36 scores demonstrated improvement after 1 year. There was no significant difference in VAS. Bilateral repair patients reported more pain and reduced physical function versus unilateral repairs. Patients with larger mesh reported greater pain scores and reduced physical function scores. CONCLUSIONS: Laparoscopic inguinal hernia repair is associated with initial declines in QOL in the postoperative period. Improvements appear in the long term. General health does not appear to be impacted by laparoscopic TEP. Smaller mesh and unilateral repairs are associated with improved QOL following laparoscopic TEP with PPM. Multiple metrics for QOL are required to reflect patient recovery.

Doxycycline shows dose-dependent changes in hernia repair strength after mesh repair.

BACKGROUND: Ventral hernia is a commonly occurring surgical problem. Our earlier studies have shown that a 30 mg/kg dose of doxycycline can significantly impact the strength of polypropylene (PP) mesh in a rat hernia repair model at 6 and 12 weeks. The objective of the present study was to investigate the dose dependence of doxycycline treatment on hernia repair strengths in rats. STUDY DESIGN: Fifty-six Sprague-Dawley rats underwent hernia repair with either PP mesh (n = 28) or sutures only (primary; n = 28); both groups were further divided into four doxycycline groups of seven animals each: control (0 mg/kg), low (3 mg/kg), medium (10 mg/kg), and high (30 mg/kg). One day before hernia repair surgery, animals received doxycycline doses by gavage and continued receiving daily until euthanasia. After 8 weeks, rats were euthanized and tissue samples from hernia repaired area were collected and analyzed for tensile strength using a tensiometer (Instron, Canton, MA, USA), while MMPs 2, 3, and 9, and collagen type 1 and 3 were analyzed by western blotting. RESULTS: In mesh-repaired animals, medium and high doxycycline dose repaired mesh fascia interface (MFI) showed significant increase in tensile strength when compared to control. In the primary repaired animals, there was no significant difference in MFI tensile strength in any dose group. In medium-dose MFI, there was a significant reduction in MMPs 2, 3, and 9. In this animal group, MFI showed significant increase in collagen 1 and significant reduction in collagen type 3 when compared to control. CONCLUSION: It is possible to improve the strength of mesh-repaired tissue by administering a significantly lower dose of the drug, which has implications for translation of the findings.

Revisional paraesophageal hernia repair outcomes compare favorably to initial operations.

BACKGROUND: Recurrent paraesophageal hernia (PEH) repair is performed for symptomatic recurrent hiatal hernia and/or reflux with little understanding as to outcomes related to perioperative and subjective patient variables. The aim of this study was to understand what differences exist between patients undergoing initial paraesophageal hernia (IPEH) repair and those undergoing redo paraesophageal hernia (RPEH) repair. METHODS: A review of PEH repairs between 2009 and 2013 was performed from a single institution. RPEH patients were identified and analyzed for demographic information, perioperative/intraoperative details, and postoperative outcomes. A similar comparison group of IPEH patients was randomly selected from the same sample as a control. A phone questionnaire was administered to the RPEH group. RESULTS: Among 336 total PEH repairs from 2009 to 2013, 34 RPEH patients were identified. A matched cohort of 76 patients was identified. RPEH and IPEH groups had similar DeMeester score, incidence of Barrett's esophagus, incidence of gastritis, and LOS. Readmission rates (15 vs. 24 %, p = 0.283) and recurrence rate (4 vs. 12 %, p = 0.201) were not statistically different between IPEH and RPEH repairs, respectively. Operative times (163 vs. 209 min, p < 0.001), incidence of Collis gastroplasty (1 vs. 24 %, p < 0.001), and EBL > 10 cc (25 vs. 51 %, p < 0.023) differed between IPEH and RPEH repairs, respectively. Recurrent symptoms included chest pain (37 %), solid dysphagia (42 %), nausea (58 %), vomiting (32 %), bloating (63 %), and hoarseness (21 %). 21 % of patients required ongoing antacid therapy. Patient satisfaction via phone questionnaires demonstrated 88 % of patients were completely satisfied. CONCLUSIONS: Recurrent PEH repair is performed with similar outcomes to IPEH repair with the exception of increased operative time and blood loss. Collis gastroplasty is required more frequently in RPEH patients. Persistent symptoms exist following RPEH repair. Despite recurrent symptomatology, patient satisfaction is high. RPEH repair may be safely performed in patients with recurrent paraesophageal hernias with outcomes similar to IPEH repairs.

Abdominal Wall Reconstruction: A Comparison of Totally Extraperitoneal and Transabdominal Preperitoneal Approaches.

BACKGROUND: Abdominal wall reconstruction for complex ventral and incisional hernias is associated with significant complications. Commonly, the peritoneal cavity is opened and adhesiolysis is performed with the potential for enterotomy. A totally extraperitoneal (TE) approach to abdominal wall reconstruction is feasible in many ventral hernia repairs and can reduce visceral injuries without impacting other outcomes. This study compares outcomes after retro-rectus ventral hernia repairs with TE and transabdominal (TA) preperitoneal approaches. STUDY DESIGN: An IRB-approved review of a prospective hernia database was performed for all ventral hernia repairs between 2009 and 2013. Preoperative patient characteristics, including demographics and comorbidities; operative variables, including surgical technique, operative duration, type/size/location of mesh, concomitant procedures, and incidence of inadvertent injury; and patient outcomes in terms of length of stay, wound and nonwound complications, and readmissions or returns to the operating room were obtained. Groups were compared using t-tests, Mann-Whitney U tests, chi-square tests, and Fisher's exact tests as appropriate. Significance was set at p < .05. RESULTS: One hundred and seventy-five complex abdominal wall reconstructions were performed between 2009 and 2013. Of those, 85 patients underwent hernia repair for CDC grade 1 hernias with retro-rectus mesh placement performed (n = 45 TA, n = 40 TE). Groups did not differ in age, BMI, sex, smoking status, hernia defect size, history of COPD, asthma, hypertension, cancer, or renal failure. More TA patients had diabetes (36% vs. 13%; p = 0.02) and previous hernia repair (73% vs. 45%; p = 0.01) than TE patients. Mesh size was larger in the TE group (625 ± 234 cm(2) vs. 424 ± 214 cm(2); p < .001). There was no difference in enterotomy between TA and TE groups (0% vs. 2%; p = 1.0). However, there was a reduced operative time with TE (170 ± 49 minutes vs. 212 ± 49 minutes; p < .001). CONCLUSIONS: Abdominal wall reconstruction can be performed safely in a TE fashion. The extraperitoneal approach results in shorter operative duration, but had similar complications when compared with TA preperitoneal approach.

Laparoscopic parastomal hernia repair: No different than a laparoscopic ventral hernia repair?

BACKGROUND: Parastomal hernia (PH) is a common complication when a stoma is used. The high incidence (35-50%) and patient longevity have created a situation where patients are being referred for consideration of repair with more frequency. Due to the presence of an ostomy and the increased bacterial contamination of the area, the insertion of a prosthetic material is concerning for complications. Laparoscopic repair of parastomal hernias utilizing a modified Sugarbaker technique has been demonstrated to have excellent outcomes. The purpose of this study is to demonstrate that laparoscopic PH repair has outcomes similar to laparoscopic ventral hernia (LVH) repair without the presence of a stoma. METHODS: After obtaining institutional review board approval, patients with parastomal hernia who underwent laparoscopic repair using Sugarbaker technique between 2009 and 2012 were compared to patients with ventral hernias who underwent LVH repair in a retrospective review, with a match of 1:3. Data collected included demographics, comorbidities, operative time, defect size, and mesh size. Outcomes and complications were compared between the two groups. RESULTS: Twenty patients underwent Sugarbaker repair, and these cases were compared to 60 patients with ventral hernia that received LVH repair. There was no statistically significant difference in age, BMI, smoking status, ASA score, defect size, or mesh size between groups. Operative time was significantly longer in the PH group: 172 ± 35 versus the LVH group: 94 ± 32 min (p < 0.1). Length of stay was longer, 3 days (3-5.5) for PH versus 1 day (1-2.8) for LVH, p < 0.1. The two groups did not differ in terms of wound complications or recurrence, with a median follow-up of 37 days (IQ range 27-518). CONCLUSION: The Sugarbaker technique is as safe as LVH repair with no more complications given the presence of a stoma.

Patient symptoms correlate poorly with objective measures among patients with gastroesophageal reflux disease.

Presentation of gastroesophageal reflux disease (GERD) varies among patients. To attempt to understand the patient's perception of the severity of their reflux symptoms, we developed a questionnaire on which patients rated symptom severity at each office visit. After receiving Institutional Review Board approval, we retrospectively reviewed patient charts of all patients seen by one surgeon for GERD symptoms and/or presence of hiatal hernia (HH) from September 2012 to April 2013. Data from patient questionnaires combined with objective findings from subsequent or prior workup and eventual operative information were recorded. A total of 144 questionnaires were reviewed from 108 patients. Frequencies were calculated for categorical variables. Patients were divided into four categories based on size of the HH on the endoscopic report; 10 patients had no HH, 15 had small HH, 20 had medium HH, and 31 patients had large HH. Size of HH was not available for three patients. Pre- and postoperative questionnaire responses were obtained for 15 patients. A combined reflux score was calculated using the median for each symptom. Patient perception of severity of symptoms does not necessarily predict presence of pathological reflux or HH nor is there a perfect combination of symptoms to predict the presence of pathological reflux or HH based on our sample. The workup of this pathology must be comprehensive, and the confirmation of reflux is imperative when the diagnosis is unclear.

Hypothalamic response to experimental allergic encephalomyelitis: role of substance P.

Adjuvant-induced arthritis (AA) is thought to be a model for experimental chronic stress that has as main features decreased adrenocorticotropin hormone (ACTH) plasma levels and a rise in median eminence content of arginine vasopressin (AVP) due to the activity of substance P. In experimental allergic encephalomyelitis (EAE), another chronic stress model, the role of substance P action is not clear. In this paper we tried to clarify the role of substance P in Lewis rats, which are susceptible to this disease. EAE was induced using myelin basic protein plus complete Freund's adjuvant injected into the hind limbs. One day later injections of an antagonist to substance P (RP 67580), saline, and substance P were administered daily for 12-14 days through a stainless steel cannula into the lateral ventricle of the brain, and then the rats were killed. The rats were divided into groups of controls, sham, diseased controls (no intracerebroventricular injections) and EAE (injected intracerebroventricularly). Plasma was used for the quantification of ACTH and corticosterone but not AVP which was assayed in hypothalamic median eminence extracts. In noninjected diseased rats the plasma levels of ACTH and corticosterone were significantly higher than in noninjected control rats, whereas the AVP concentrations in the median eminence were unchanged. The substance P antagonist did not affect the levels of these hormones in plasma or the median eminence. Substance P decreased the plasma levels of ACTH and corticosterone but did not increase the median eminence content of vasopressin. Administration of the antagonist 30 min before an equivalent dose of substance P increased the plasma levels of the two hormones, but did not change the content of AVP. Based on the lack of response to the antagonist RP 67580 we suggest that the substance P has different roles in EAE and AA at least in the later stages of EAE (after 11 days of immunization).