Practice patterns in complex ventral hernia repair and place of biological grafts: a national survey among French digestive academic surgeons.

BACKGROUND: Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications. METHODS: A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals. RESULTS: Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%). CONCLUSIONS: Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications.

The implantable cardioverter-defibrillator: postcode prescribing in the UK 1998-2002.

OBJECTIVE: To determine the rate of implantable cardioverter-defibrillator (ICD) implantation across the UK during the period 1998 to 2002. DESIGN: Observational self reporting with cross checking. SETTING: All ICD implanting centres coordinated by the National Pacemaker and ICD Database. PATIENTS: Every patient receiving an ICD in the UK from 1998 to 2002. MAIN OUTCOME MEASURES: Date of implantation and postcode of each ICD recipient during the study period. RESULTS: ICD implantation increased in the UK in the five year period studied but fell far short of the European average and national targets. Implantation rates varied greatly by region. CONCLUSIONS: The low rate of ICD implantation in the UK and the disparity between regions require further study to determine the barriers to this evidence based treatment.

Morphologic Study of Homograft Valves before and after Cryopreservation and after Short-Term Implantation in Patients.

Cryopreserved heart valve homografts have been implanted in patients for the past 15 years, but controversies still exist on the survival of donor cells, matrix maintenance, and possible rejection by the host. Therefore a full morphologic study (histology, immunohistochemistry, transmission electron microscopy, and cuprolinic blue-TEM for glycosaminoglycans [GAG]) of short-term implanted uninfected grafts was done using unimplanted valves as the reference. Unimplanted tissues consisted of 5 fresh and 11 cryopreserved valves. Eight implants were recovered at reoperation [4] or autopsy [4], 4 from the right and 4 from the left ventricular outflow tract. The implantation time was 2 hours to 30 days. For unimplanted valves we found a partial preservation of the endothelium, the presence of dendritic Langerhans cells (Lc) and macrophages, and no significant damage to fibroblasts, collagen framework, and GAG pattern, except when the tissues had been ischemic for a long time. Explanted cusps exhibited (i) early disappearance of endothelium and Lc; (ii) nonspecific low-grade inflammatory cell infiltration, mostly of monocytoid type; (iii) viable degree of devitalization of fibroblasts with persistence of viable cells in some areas in most cusps; and (iv) fair preservation of collagen framework and GAGs. It is likely that, in view of the good graft preservation at implantation, humoral rejection is responsible for the earlier destruction of the endothelium and dendritic cells and the delayed devitalization of the fibroblasts and that preservation of the collagen framework and other intercellular matrix components (glycosaminoglycans) should guarantee longterm graft function.