Evolving concepts in ventral hernia repair and physical therapy: prehabilitation, rehabilitation, and analogies to tendon reconstruction.

PURPOSE: The abdominal wall and musculoskeletal tendons share many anatomic, physiologic, and functional characteristics. This review aims to highlight these similar characteristics and to present a rationale why the treatment principles of successful musculoskeletal tendon reconstruction, including principles of surgical technique and physical therapy, can be used in the treatment of complex abdominal wall reconstruction or ventral hernia repair. METHODS: The MEDLINE/PubMed database was used to identify published literature relevant to the purpose of this review. CONCLUSIONS: There are several anatomical and functional similarities between the linea alba and musculoskeletal tendons. Because of this reason, many of the surgical principles for musculoskeletal tendon repair and ventral hernia repair overlap. Distribution of tension is the main driving principle for both procedures. Suture material and configuration are chosen to maximize tension distribution among the tissue edges, as seen in the standard of care multistrand repairs for musculoskeletal tendons, as well as in the small bites for laparotomy technique described in the STITCH trial. Physical therapy is also one of the mainstays of tendon repair, but surprisingly, is not routine in ventral hernia repair. The evidence surrounding physical therapy prehabilitation and rehabilitation protocols in other disciplines is significant. This review challenges the fact that these protocols are not routinely implemented for ventral hernia repair, and presents the rationale and feasibility for the routine practice of physical therapy in ventral hernia repair.

What is the fate of the cholecystostomy tube following percutaneous cholecystostomy?

INTRODUCTION: Cholecystectomy is the preferred treatment for acute cholecystitis with percutaneous cholecystostomy (PC) considered an alternative therapy in severely debilitated patients. The aim of this study was to evaluate the efficacy and outcomes of PC at a tertiary referral center. METHODS: We retrospectively reviewed all patients that had undergone PC from 2000 to 2014. Data collected included baseline demographics, comorbidities, details of PC placement and management, and post-procedure outcomes. The Charlson comorbidity index (CCI) was calculated for all patients at the time of PC. RESULTS: Four hundred and twenty-four patients underwent PC placement from 2000 to 2014, and a total of 380 patients had long-term data available for review. Within this cohort, 223 (58.7 %) of the patients were male. The mean age at the time of PC placement was 65.3 ± 14.2 years of age, and the mean CCI was 3.2 ± 2.1 for all patients. One hundred and twenty-five (32.9 %) patients went on to have a cholecystectomy following PC placement. Comparison of patients who underwent PC followed by surgical intervention revealed that they were significantly younger (p = 0.0054) and had a lower CCI (p < 0.0001) compared to those who underwent PC alone. CONCLUSIONS: PC placement appears to be a viable, long-term alternative to cholecystectomy for the management of biliary disease in high-risk patients. Old and frail patients benefit the most, and in this cohort PC may be the definitive treatment.

Improved quality of life following total pancreatectomy and auto-islet transplantation for chronic pancreatitis.

BACKGROUND: Total pancreatectomy (TP) with auto-islet transplant (AIT) is an extreme treatment for chronic pancreatitis, and we reviewed our experience to assess the impact on quality of life (QOL). METHODS: A prospective cohort study from 2007 through 2010 with pre- and postoperative assessments of the Depression Anxiety Stress Scale, Pain Disability Index, and visual analogue pain scale was performed. RESULTS: Twenty patients underwent TP-AIT with a median follow-up of 12 months (6.75-24 months). All patients reported moderate (45 %) to severe (55 %) pain prior to surgery. TP-AIT resulted in significant decreases in abdominal pain (p < 0.001), 80 % reporting no or mild pain. Despite pain improvement, only 30 % discontinued narcotics. Improvements in all PDI QOL domains improved from 79 to 90 % (p = 0.002), with greatest improvements seen in those without prior pancreatic surgery, younger patients, and in those with higher levels of preoperative pain. Patients were less affected by depression and anxiety prior to surgery, but 60 and 70 % did show improvement in depression and anxiety, respectively (p = 0.033). Sixteen patients (80 %) required exogenous insulin at last follow-up (mean total dose of insulin 11.6 U/day). CONCLUSIONS: TP-AIT significantly improves pain and QOL measures in appropriately selected patients with CP.