Necessary duration of follow-up to assess complications of mesh in hernia surgery: a time-lapse study based on 460 explants.

PURPOSE: Risk of complications following hernia repair is the key parameter to assess risk/benefit ratio of a technique. As mesh devices are permanent, their risks are life-long. Too many reports in the past assessed mesh safety prematurely after short follow-ups. We aimed to explore what length of follow up would reveal the full extent of complications. METHODS: Time lapses between implantation and excision were analyzed in 460 cases of meshes excised for complications after hernia repair. Patterns of percentage growth and time lapses at 50th and 95th percentiles were used to compare groups of different hernia type, age, gender and reason for excision. RESULTS: The 50th and 95th case percentiles in the dataset were at 3.75 and 15.0 years between mesh implantation and excision. For hernia types, the longest time lapses were for groin hernias (4.0 and 16.11 years at 50th and 95th percentiles). The shortest were for umbilical hernias (2.16 and 9.68 years). Males had later excisions than females (4.11 and 16.1 vs. 2.47 and 9.79 years). Younger patients (< 45 y.o.) had later excisions than older patients (4.12 and 17.68 vs. 3.37 and 10.0 years). Out of all subgroups, the longest time lapses were for groin hernias in younger males (4.77 and 18.89 years) and for mesh erosion into organs (4.67 and 17.0 years). CONCLUSIONS: Follow-up of more than 15 years is needed to fully assess complications after mesh hernia repair. Especially longer periods are needed to detect mesh erosion into organs and complications in younger males. Presently, short observations and lack of reporting standard in the literature prohibit accurate assessment of complication risks. We propose to use cumulative incidence for standardized risk reporting (y% risk at x years). This will show time-dependent patterns and allow comparisons between different techniques and studies of variable duration. Standardization will also help to predict long-term risks beyond shorter (practical) follow-ups and facilitate real-time monitoring during surveillance.

A mechanism of mesh-related post-herniorrhaphy neuralgia.

PURPOSE: The objective is to compare nerve densities in explanted polypropylene meshes in patients with or without chronic pain. Pain has supplanted recurrences as a complication of hernia surgery. The increased incidence of pain mirrors a parallel increase in the use of polypropylene meshes. Neither triple neurectomy nor careful nerve preservation has brought relief. Perhaps because we have forgotten that nerves, in response to some evolutionary mechanism, tend to regenerate, undergo changes imposed by prosthetic elements and architecture, mimicking entrapment and compartment syndromes. METHODS: A total of 33 hernia meshes have been analyzed: 17 excised due to severe pain, two for combined pain and recurrence, 14 sampled during revision for recurrence without pain. Each mesh had standardized sampling for histology and the nerves were highlighted by S100 stain. Nerve densities were assessed within the mesh spaces and in tissue outside the mesh. RESULTS: The density of nerves present in the standardized mesh samples of patients complaining of pain was much more elevated than in the mesh of those patients who had a recurrence but no pain. The difference was statistically significant (p < 0.001). Excluding two patients who had both pain and recurrence, the difference was even more marked (p < 0.0001). CONCLUSIONS: Re-innervation and neo-innervation are known to take place following hernia repairs in indigenous tissue as well as through polypropylene meshes. However, when pain is an overriding issue dictating mesh explant, the degree of mesh innervation is significantly higher when compared to mesh excised for recurrence. That increase has been confirmed statistically.

Localized duodenal lymphoma masquerading as a duodenal ulcer.

A 64-year-old woman presented with atypical abdominal pain, weight loss, melena and hematemesis. Reactivation of a peptic ulcer was diagnosed and she was treated with antacids and cimetidine. When her symptoms recurred 4 months later, a perforated duodenal ulcer was noted on roentgenograms. At laparotomy this proved to be a perforated, localized lymphoma of the duodenum. This case highlights an important consideration in the management of duodenal ulcers. Patients who present with a previously diagnosed peptic ulcer, who demonstrate atypical symptoms and remain refractory to treatment should undergo endoscopic examination and biopsy to rule out an occult localized duodenal lymphoma.

Failure of LeVeen shunting in refractory ascites--a view from the other side.

We have reviewed our experience with 11 patients treated with LeVeen peritoneovenous shunts during a 22-month period from March, 1976, through December, 1977, to assess long-term results and shunt patency. Nine patients had follow-up studies to assess shunt patency at a mean of 26 months. After insertion of the shunt, the mean weight loss was 7.9 kg at hospital discharge. At 26-month follow-up evaluation, six patients had minimal ascites (responders), whereas five had massive ascites (nonresponders). Of the six responders, three patients with nonfunctioning shunts lost an average of 15.8 kg of ascites, three whereas with patent shunts lost an average of 15.0 kg. Eight of 11 patients (73%) required revision or replacement of the shunt because of malfunction; clotting was the most common cause of failure. We conclude that the role and effectiveness of LeVeen peritoneovenous shunts remain questionable. They may cause diuresis, maintain it, or not be responsible for it all. Clinical reports that cite their effectiveness should document patency of these shunts.

Maintenance of home hyperalimentation in patients with high-output jejunostomies.

We studied four patients with high-output end jejunostomies (greater than 3,000 mL/day) who were receiving home hyperalimentation. With knowledge of urine and stoma output, standard total parenteral nutrition fluid was infused and titrated according to individual needs, first during the hospital stay and then on follow-up office visits. Mean daily stoma output for the group was 3,556 mL/day. With oral fluid intake restricted to 1,500 mL/day, average daily stoma output dropped to 2,892 mL. The mean daily volume of nutrient fluid required to achieve stabel biochemistries and weight was 3,550 mL. Daily caloric requirements ranged from 23 kcal/kg to 44 kcal/kg, with a mean of 32.5 kcal/kg. Amino acid requirements averaged 1.6 g/kg. With 65 patient months of continuous overnight catheter infusion, there have been no serious metabolic derangements or deaths. The program of home hyperalimentation can maintain a satisfactory metabolic state in patients with high-output jejunostomies.