A decade of ventral incisional hernia repairs with biologic acellular dermal matrix: what have we learned?

BACKGROUND: Innovative types of biologic mesh have provided new alternatives to ventral incisional hernia repair, especially in the face of contamination. The authors studied the experience and outcomes of patients who underwent repair of a ventral incisional hernia with biologic mesh. METHODS: Online database and detailed reference searches were conducted. Studies chosen for review had a sample size of at least 40 patients, level IV evidence at most, and a Methodological Index for Nonrandomized Studies index of at least 10. Indications for use of biologic mesh, type of mesh, patient comorbidities, and surgical techniques were also noted. RESULTS: Eight studies fulfilled the search criteria and included 635 patients using AlloDerm, Surgisis, and Strattice biologic tissue matrices. In one study, indications and surgical techniques were standardized, and follow-up was prospective. In the other seven studies, indications, surgical techniques, and follow-up were assessed retrospectively. The mean patient age, when reported, was 55.7 years. Body mass index ranged from 30 to 35 kg/m2 in 44 percent of the reported patients. In seven of the eight studies [565 patients (89 percent)], the mean follow-up was 25.8 months and the mean hernia recurrence rate was 21 percent. Complication rate exceeded 20 percent in most studies. CONCLUSIONS: Biologic tissue matrices are mostly used in contaminated fields, which has allowed for a one-stage repair with no or little subsequent mesh removal. Ventral incisional hernia repair with these matrices continues to be plagued by a high recurrence rate and complications. Prospective randomized trials are needed to properly direct practice in the use of these meshes and evaluate their ultimate value.

Medical and surgical treatment of obesity.

The prevalence of obesity has reached epidemic proportions. Conceptualization of obesity as a chronic disease facilitates greater understanding its treatment. The NIH Consensus Conference on Gastrointestinal Surgery for Severe Obesity provides a framework by which to manage the severely obese--specifically providing medical versus surgical recommendations which are based on scientific and outcomes data. Medical treatments of obesity include primary prevention, dietary intervention, increased physical activity, behavior modification, and pharmacotherapy. Surgical treatment for obesity is based on the extensive neural-hormonal effects of weight loss surgery on metabolism, and as such is better termed Metabolic Surgery. Surgery is not limited to the procedure itself, it also necessitates thorough preoperative evaluation, risk assessment, and counseling. The most common metabolic surgical procedures include Roux-en-Y gastric bypass, adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion. Surgical outcomes for metabolic surgery are well studied and demonstrate superior long-term weight loss compared to medical management in cases of severe obesity.

Patients with Cushing's syndrome are care-intensive even in the era of laparoscopic adrenalectomy.

We report outcomes from laparoscopic adrenalectomy (LA) comparing patients with Cushing's syndrome with those with other adrenal pathology with respect to length of stay (LOS), overall complications, and financial implications. We conducted a retrospective review of 80 continuous patients (103 glands) undergoing LA. The clinical diagnoses were: hypercortisolism (Cushing' syndrome; n=33), hyperaldosteronism (Conn's syndrome; n=20), phaeochromocytoma (n=16), and neoplasm (others; n=11). Advanced care in the intermediate or intensive care unit was necessary in 27 patients, most frequently in our Cushing's population (16 of 33 [48%]). Six patients sustained major complications, including death in two patients; seven patients sustained minor complications. LOS was longer for patients with Cushing's syndrome (mean, 5.5 vs. 3.3 days; P = 0.024). Financially, patients with Cushing's syndrome had statistically higher total hospital (P = 0.009), advanced care (P = 0.002), and anesthetic costs (P = 0.005). LA in patients with Cushing's syndrome is associated with longer hospitalizations, more frequent major complications, and higher advanced care requirements, especially for patients undergoing bilateral adrenalectomy. Minor complications were infrequent and median LOS was brief regardless of diagnosis. Patients with Cushing's syndrome had higher costs for overall hospital charges, advanced care, and anesthesia.