Do various mesh placement techniques affect the outcome in totally extraperitoneal hernia repair? What is the role of the surgeon?

BACKGROUND: Various modifications of mesh placement are currently used in total extraperitoneal (TEP) groin hernia repair. The aim of this study was to compare three different variants of mesh placement with respect to rate of complications and clinical outcome. METHODS: A series of 397 consecutive patients with a total of 534 preperitoneal groin hernia TEP repairs performed by four surgeons at a single institution between 1999 and 2003 were retrospectively analyzed. The mean follow-up was 19.7 +/- 7.5 months. A single-mesh technique was used in cases of hernial orifice <1.5 cm. Larger hernial defects were closed either in a double-mesh or a modified double-mesh placement technique. The three placement techniques were compared with respect to hospital stay, operative time, early and late complications, return-to-work time, and recurrence rate. RESULTS: The modified double-mesh technique was associated with the longest hospital stay, the longest operative time, the slowest return to work, and significantly higher rates of early (5.6% vs. 4.6% vs. 2.9%) and late (19.1% vs. 11.3% vs. 7.9%) postoperative complications, when compared to double-and single-mesh placement. Overall recurrence rate was 1.3% after a mean follow-up of 19.7 months. The larger the experience of a surgeon with his preferred technique, the shorter the operative time and hospital stay were. CONCLUSIONS: Mesh placement techniques appeared to have a direct impact on clinical outcome and hospital stay. The modified double-mesh technique showed the worst postoperative results, independent of the surgeon's experience. Which mesh placement technique is most appropriate for complex hernias remains to be answered by further randomized, controlled trials.

Experimental comparison of monofile light and heavy polypropylene meshes: less weight does not mean less biological response.

BACKGROUND: Mesh implantation is a standard procedure in hernia repair. It provides low recurrence rate but increases complication rate due to foreign-body reaction induced by alloplastic materials in surrounding tissues. It is believed that biocompatibility of meshes may be improved by reducing their weight per meter squared (m2) and altering the implant structure. AIM: The aim of this study was to evaluate the effect of weight and structure as determinants of mesh biocompatibility. METHOD: Thirty-six Wistar rats were studied. In 12 animals, conventional polypropylene (heavy) meshes (HM) were implanted; in other 12, material-reduced (light) microporous polypropylene meshes (LM); and the remaining 12 served as a sham-operated control group. Meshes were explanted after 21 and 90 days (6 animals per group). All samples were examined by light and electron microscopies. Integration of meshes in surrounding tissue, inflammatory response, fibrotic reactions, and structural changes were recorded. Quantification of the inflammatory response was achieved by CD-68 marking of macrophages and counting their number per surface unit. RESULTS: After 21 days, there was no significant difference in thickness of surrounding connective tissue between meshes in all groups studied. After 90 days, thickness of connective tissue decreased in both groups, and fibrotic reaction in the mesh bed was significantly less in the HM group. Total amount of macrophages per millimeter squared (mm2) decreased with time in HM and LM samples but was significantly lower in the HM group on day 21 (43.5%) and day 90 (46.7%). CONCLUSION: This study found worse biocompatibility of LM compared with HM. Thus, the amount of implanted mesh was not the main determinant of biocompatibility (expressed as successful incorporation and diminished foreign-body reaction) but the size of the pores.

Central perineal hernia mimicking rectocele: a case report.

BACKGROUND: A perineal hernia is a very rare clinical finding. Three forms are distinguished: anterior, posterior, and central. Diagnosis of the last one is difficult, and sometimes, it is falsely named a posterior rectocele. AIM: This work presents a successfully treated case of central perineal hernia and makes a brief summary of existent literature on the problem. PRESENTATION OF THE CASE: We report of a 67-year-old female patient with a symptomatic central pelvic floor hernia. After radiological confirmation of the diagnosis, a transperitoneal approach was chosen to reposition the protruded segment of the small bowel. The hernial orifice was closed by extraperitoneal implantation of a polypropylene mesh. DISCUSSION: In the present case, the use of a laparoscopic technique seemed unsuitable due to the extension of the findings. For the repair of perineal hernia, we followed the principles of the "tension-free" concept. If there are no signs of a pelvic floor infection and if the mesh can be implanted totally extraperitoneally, we recommend the use of nonabsorbable alloplastic material (polypropylene) for reinforcement of the pelvic floor as a suitable technique for the repair of large perineal hernias.

Early enteral gut feeding with conditionally indispensable pharmaconutrients is metabolically safe and is well tolerated in postoperative cancer patients--a pilot study.

BACKGROUND & AIMS: Postoperative early enteral gut feeding with conditionally indispensable pharmaconutrients can contribute to minimize trauma-induced gut damage. Aim of this pilot study was the evaluation of metabolic effects and gastrointestinal tolerance of a new enteral supplement. METHODS: In a prospective open clinical trial, 20 cancer patients received the test supplement containing glutamine (as dipeptides), antioxidative (pro-)vitamins (C, E, beta-carotene), maltodextrine, tributyrine, sodium, zinc, and selenium within 2-3 h after elective gastrointestinal surgery continuously via jejunostomy tube for 3 postoperative days (500 ml/day). From postoperative day 3-5, additional enteral nutrition (1500 kcal/6270 kJ/day) was given. Metabolic effects (substrate monitoring, hematology, liver/kidney parameters) and tolerance (nausea, vomiting, flatulence, constipation, diarrhea) was assessed through the study. RESULTS: Gastrointestinal tolerance of the supplement was excellent: no adverse events related to the product were documented. Significantly increased mean plasma levels (day 3 vs. day 1) of vitamin C (13.0 +/- 7.3 vs. 62.8 +/- 29.7 micromol/l), vitamin E (13.5 +/- 6.6 vs. 20.8 +/- 9.2 micromol/l), zinc (5.6 +/- 1.9 vs. 8.6 +/- 2.3 micromol/l) and selenium (35.0 +/- 19.6 vs. 42.9 +/- 0.9 microg/l) as well as enhanced plasma glutamine levels (429.6 +/- 90.6 vs. 530 +/- 200.1 micromol/l) reflected an effective absorption of substrates supplied. Adverse effects on organ functions and hematology were not observed. CONCLUSIONS: Early postoperative gut feeding with the newly developed enteral supplement shows no adverse effects, is well tolerated in cancer patients and provides a novel method to deliver conditionally indispensable pharmaconutrients.

Intravenous glucagon-like peptide 1 normalizes blood glucose after major surgery in patients with type 2 diabetes.

OBJECTIVE: Hyperglycemia is a major risk factor for a poor outcome after major surgery in patients with type 2 diabetes. Intensive insulin treatment aiming at normoglycemia can markedly improve the survival of critically ill patients, but the broad clinical application is limited by its practicability and the risk of hypoglycemia. Therefore, the glucose-lowering effect of the incretin hormone glucagon-like peptide 1 (GLP-1) was investigated in patients with type 2 diabetes after major surgery. DESIGN: Randomised clinical study. SETTING: A surgical unit of a university hospital. PATIENTS AND MEASUREMENTS: Eight patients with type 2 diabetes (five men, three women; age, 49+/-15 yrs; body mass index, 28+/-3 kg/m; glycosylated hemoglobin, 8.0%+/-1.9%), who had undergone major surgical procedures, were studied between the second and the eighth postoperative day with the intravenous administration of GLP-1 (1.2 pmol x kg x min) and placebo over 8 hrs, each administered in randomized order in the fasting state. C-reactive protein concentrations of 4.9+/-4.2 mg/dL indicated a systemic inflammation. Blood was drawn in 30-min intervals for glucose (glucose oxidase), insulin, C-peptide, glucagon, and GLP-1 (specific immunoassays). Statistics were done with repeated-measures analysis of variance and Duncan's post hoc tests. MAIN RESULTS: During the intravenous infusion of GLP-1, plasma glucose concentrations were significantly lowered, reaching the normoglycemic fasting glucose range within 150 mins, but they remained elevated during placebo infusion (p <.001). The GLP-1 infusion led to a significant increase of insulin secretion (p <.001 for insulin and C-peptide) and a suppression of glucagon secretion (p =.041). No hypoglycemic events were recorded during the experiments. CONCLUSIONS: As far as can be concluded on the basis of our data with the infusion of GLP-1 over 8 hrs in eight patients, GLP-1 can be used to reduce glucose concentrations in patients with type 2 diabetes after major surgery.