Validation of a radiographic model for the assessment of mesh migration.

BACKGROUND: The natural history of laparoscopically placed mesh remains uncharacterized. Mesh migration is not infrequently discovered at reoperation and implicated as a cause of hernia recurrence, and it has also been associated with more serious complications, such as enteric and bladder erosion and fistula formation. To date, there is no noninvasive method by which to reliably assess the in-vivo behavior of laparoscopically placed mesh. In this study, we devised and validated a safe and noninvasive model, utilizing computed radiography (CR), for measuring postoperative mesh migration that may be applied to the clinical setting. METHODS: The anatomical structures of the inguinal region were recreated using a skeletal male pelvic model. A sheet of commercially available surgical mesh, marked with three 5mm surgical clips at its medial and superior corners, was moved along the inguinal ligament wire for various random distances. The mesh displacement was measured from the model, and a CR film was obtained. The corresponding mesh displacement was then measured on the CR using two different calibration methods (calibration disk and clip measurement). RESULTS: A total of 60 measurements were made and recorded. There were no statistically significant differences between the true (as measured from the model) and CR-measured distances of mesh migration. In comparing the two methods, only method 1 (calibration disk) showed a tendency towards a significant difference when lateral or superior displacement was measured, but correlation remained excellent (r(2) = 0.99). All other measurements showed no significant difference and excellent correlation (r(2) > 0.96). Pearson's correlation coefficients showed no significant inter-rater variability using either of these methods. CONCLUSION: Our CR model reliably provides a noninvasive means to characterize mesh movement in the postoperative clinical setting. This should provide an instrument to facilitate future clinical evaluation of mesh migration in human trials.

Does platelet administration affect mortality in elderly head-injured patients taking antiplatelet medications?

A significant portion of patients sustaining traumatic brain injury (TBI) take antiplatelet medications (aspirin or clopidogrel), which have been associated with increased morbidity and mortality. In an attempt to alleviate the risk of increased bleeding, platelet transfusion has become standard practice in some institutions. This study was designed to determine if platelet transfusion reduces mortality in patients with TBI on antiplatelet medications. Databases from two Level I trauma centers were reviewed. Patients with TBI 50 years of age or older with documented preinjury use of clopidogrel or aspirin were included in our cohort. Patients who received platelet transfusions were compared with those who did not to assess outcome differences between them. Demographics and other patient characteristics abstracted included Injury Severity Score, Glasgow Coma Scale, hospital length of stay, and warfarin use. Three hundred twenty-eight patients comprised the study group. Of these patients, 166 received platelet transfusion and 162 patients did not. Patients who received platelets had a mortality rate of 17.5 per cent (29 of 166), whereas those who did not receive platelets had a mortality rate of 16.7 per cent (27 of 162) (P = 0.85). Transfusion of platelets in patients with TBI using antiplatelet therapy did not reduce mortality.

Gastrointestinal staple line reinforcement.

Gastrointestinal resections and anastomoses are commonly performed using stapling devices in a wide range of open and laparoscopic procedures. Whether they are hand-sewn or stapled, anastomoses have an associated leak rate that can impart significant morbidity or mortality to a procedure. In addition, bleeding from staple lines can cause additional complications. Staple line reinforcement is one intervention that has been postulated to reduce both the leak rate and associated bleeding risk. This can be accomplished with either material applied exogenously to the staple line, as in an engineered absorbable biomaterial, or it may use a material - either absorbable or nonabsorbable - that is incorporated into the staple line. A number of reinforcements are currently available but all add time and cost to the procedures in which they are used. However, preventing the complications associated with leak and hemorrhage from staple lines may justify the added cost of these devices. A review of the available published literature was performed to review the current data pertaining to the reinforcement of living tissue and anastomoses with these various reinforcements available to surgeons.

Increased burst pressure in gastrointestinal staple-lines using reinforcement with a bioprosthetic material.

BACKGROUND: Leakage at an anastomosis is a major and often catastrophic complication of gastrointestinal (GI) surgery. Staple-line reinforcement with one of the several materials commercially available has been utilized to reduce the incidence of this complication. The bioprosthetic material, small intestinal submucosa (SIS, Surgisis((R)); Cook, Inc., Bloomington, IN) has found widespread applications in surgery. However, its ability to improve the durability of staple-lines in GI surgery in terms of burst pressure has not been documented. We hypothesized that SIS reinforcement of staple-lines in healthy living GI tissue would increase durability, as determined by leak rates at increased intraluminal pressures, compared to unreinforced staple-lines. METHODS: Two healthy Yorkshire-Cross pigs were subjected to midline laparotomy and underwent small intestinal division (n=28) with GIA stapling devices. Half of the staple-lines were reinforced with SIS. The staple-lines were then exposed to increased intraluminal pressures by means of a constant-rate dye solution infusion, until staple-lines exhibited visible leakage of the dye solution. The intraluminal pressure was recorded at the time of visible leakage. RESULTS: Staple-lines reinforced with SIS had significantly better durability as determined by analysis of variance and Kaplan-Meier survival calculations, with respect to leak rate as a function of intraluminal pressure (P<0.003). The mean burst pressure of the unreinforced staple-lines was 53 mmHg, while those staple-lines reinforced with SIS had a mean burst pressure of 83 mmHg. CONCLUSION: Reinforcement of stapled GI anastomoses with SIS significantly increases anastomotic burst pressure. These findings suggest a role for this material in GI surgery.

Evaluation of endoscopic full-thickness plication on anti-reflux valve competency.

BACKGROUND: We sought to investigate the efficacy of endoscopically created, full-thickness plications on the competency of the anti-reflux barrier when placed at different positions on the stomach adjacent to the gastroesophageal junction. METHODS: Explanted human cadaver stomachs and esophagi were used. An endoscopic plication system (Plicator, NDO Surgical, Mansfield, Massachusetts) was then fitted over a pediatric gastroscope and passed through the esophagus into the stomach. A full-thickness plication implant was then deployed at 1 of 3 positions (fundus, anterior, and between the anterior and the lesser curvature) on the explanted stomach within 1 cm of the gastroesophageal junction. Intragastric pressure was measured before and after plication at the time of visible reflux from the esophagus (reflux threshold) using a water-perfused manometer. RESULTS: Five explanted stomachs were used. The mean reflux threshold before plication (baseline) was 1.7 mm Hg. A single plication at each position resulted universally in a significantly increased reflux threshold over the baseline value (p < 0.006). The greatest reflux threshold was observed when plication was performed on the anterior wall of the stomach, although this reflux pressure did not achieve statistical significance over the other 2 positions. A second plication performed adjacent to the initial plication at the fundus (n = 2) and anterior (n = 2) positions did increase reflux threshold; however, this increase also failed to achieve statistical significance. CONCLUSIONS: These results suggest that an endoscopic, full-thickness plication system can inhibit gastroesophageal reflux effectively in an explanted stomach model. Although anterior plication resulted in the greatest intragastric pressure at reflux, it was not significantly different from intragastric pressure recorded at the other plication positions. A second plication adjacent to the first showed incremental effect, but larger studies are warranted to understand its clinical significance.

Recurrence of primary breast lymphoma in contralateral breast: case report and review of the literature.

Lymphoma presenting as a breast mass is rare, although well documented. Although recurrence rates can reach approximately 50%, recurrence in the contralateral breast is rare. We report a case of recurrent primary breast lymphoma (PBL), which was discovered on screening mammography after a 5-year disease-free interval from initial diagnosis.

Ecthyma gangrenosum in a patient with toxic epidermal necrolysis.

Toxic epidermal necrolysis and Stevens-Johnson syndrome are a spectrum of disease characterized by a delayed hypersensitivity reaction that involves the skin and mucous membranes and typically is associated with either recent upper respiratory infection or with certain medications. Ecthyma gangrenosum is a rare necrotizing vasculitis that most commonly affects immunocompromised and burn patients and is often a sequela of Pseudomonas aeruginosa bacteremia. The cutaneous lesions of ecthyma gangrenosum are characterized by an erythematous halo surrounding a dark gray or black nodule. P. aeruginosa preferentially invades the venules, resulting in secondary thrombosis of the arterioles, tissue edema, and separation of the epidermis. Management of ecthyma gangrenosum includes systemic treatment with antipseudomonal antibiotics and débridment of the lesions, as well as improving the patient's immune status if possible. We present a case of a patient admitted to the burn unit for toxic epidermal necrolysis who developed pseudomonal bacteremia with ecthyma gangrenosum.

Functional comparison of staple line reinforcements in lung resection.

PURPOSE: Staple line reinforcement with bovine pericardium and expanded polytetrafluoroethylene during lung resections has shown reduction in air leak incidence and duration. Small intestinal submucosa and polyglycolic acid-trimethylene carbonate, have been introduced as new reinforcements for nonpulmonary staple lines. We hypothesize that reinforcement of staple lines in lungs with commercially available materials will decrease staple line leak at increased pressures. DESCRIPTION: We evaluated 8 staple lines per reinforcement material (4 groups) and a control group (n = 40) in healthy living pigs. After resections (up to four per animal), the lungs were tested sequentially using hand ventilation to increasing pressures (5-75 cm H2O). The occurrence of pressure at which leaks was recorded. EVALUATION: All reinforced staple lines exhibited higher mean leak threshold when compared with the controls; however only small intestinal submucosa achieved significance when compared with the controls. CONCLUSIONS: Commercially available reinforcements allow pulmonary staple lines to tolerate higher intrabronchial pressures without demonstrating air leak. In addition, reinforcement with small intestinal submucosa imparts a significant advantage to the other reinforcements in terms of pulmonary staple line leak rate.

Functional assessment of a new staple line reinforcement in lung resection.

BACKGROUND: A major complication of lung resection is prolonged leaking at the staple line. Staple-line reinforcement is performed routinely during these procedures using bovine pericardium (peri-strips) and expanded polytetrafluorethylene. Both materials have been shown previously to increase staple-line durability and reduce the overall incidence of prolonged air leaking after lung resection, specifically in lung volume-reduction surgery. Small intestinal submucosa (SIS) has had many applications in human tissues consequent to its absorption and healing profile, which are well documented in human and animal models. However, it had not been studied in reinforcement of pulmonary staple lines. MATERIALS AND METHODS: We hypothesized that SIS reinforcement of staple lines in healthy lung tissue would increase durability, as determined by leak rates at increased airway pressures as compared to nonreinforced staple lines. Eight healthy juvenile Yorkshire-cross pigs were subjected to bilateral apical lung resections; one side was reinforced with SIS. The lungs were then inflated to sequentially increase intrabronchial pressures (5-75 cm H2O) for 60-second intervals while the chest was filled with saline under direct visualization monitoring for air leak. RESULTS: Staple lines reinforced with porcine small intestinal submucosa had significantly better durability as determined by Kaplan-Meier survival calculations with respect to leak rate as a function of pressure. CONCLUSION: Reinforcement of staple lines with SIS allows pulmonary staple lines to tolerate significantly higher intrabronchial pressures without demonstrating air leak at the staple line.