Accelerated healing of complex open pilonidal wounds using MatriStem extracellular matrix xenograft: nine cases.

Complex open pilonidal wounds represent a challenging wound healing problem. Nine cases of complex open pilonidal wounds are described. Each of them was treated at the time of primary wide excision with placement of xenograft extracellular matrix material derived from urinary bladder (MatriStem, ACell Corporation). The patients left the xenograft material and dressings intact and returned to our clinic at weekly intervals for inspection of the wounds. All of the cases of complex open pilonidal wounds healed without infection and without requiring re-operation. The average time to healing in this series was 7 weeks. Treatment of complex open pilonidal wounds with MatriStem extracellular matrix derived from urinary bladder in this fashion results in favorable wound healing of complex open pilonidal wounds.

Long-term durability and comfort of laparoscopic ventral hernia repair.

BACKGROUND: Repair of ventral hernias, including primary ventral hernias and incisional ventral hernias, is performed in the United States 90,000 times per year. Open or traditional ventral hernia repairs involve the significant morbidity and expense of a laparotomy and a significant risk of recurrent herniation. Laparoscopic ventral hernia repair (LVHR) may offer a less-invasive alternative with shorter length of hospital stay, fewer cardiopulmonary complications, and low recurrence rates. METHODS: 225 patients underwent laparoscopic ventral hernia repairs in which carboxymethylcellulose-sodium hyaluronate coating (Sepramesh, Davol, Providence, RI) was used primarily. All cases were included prospectively from the study period of 2002 through 2009. Patient characteristics were recorded, and follow-up analysis was performed over a period of 42 mo following surgery. Recurrence, reoperations, and all complications were recorded. Mesh awareness and mesh-related pain were assessed using the hernia-specific Carolinas Comfort Scale (CCS) instrument, completed by 72 patients. RESULTS: Over 42 mo of follow-up, 2 ventral hernias have recurred, and no long-term bowel erosion or fistulization has occurred. Little or no mesh-related symptoms were reported, and mean scores for mesh awareness and mesh pain were 3.6 and 3.2, respectively, on a scale from 0 - 40 (lower scores signify less pain or awareness). Two serious early complications occurred related to intestinal ileus and metal tacks producing intestinal perforation, and this led to a change in the tacking devices used. CONCLUSIONS: LVHR with carboxymethylcellulose-sodium hyaluronate coating (Sepramesh) is safe and effective. Complications are rare, the repair is durable, and long-term results are good with rare recurrences, low awareness of mesh, and little pain. Technical lessons include use of at least one transfascial suture and the avoidance of metal tacks for fixation.

Outpatient weight loss surgery: initiating a gastric bypass and gastric banding ambulatory weight loss surgery center.

BACKGROUND: Ambulatory surgery or outpatient surgery is becoming increasingly common. In 2002, 63% of all operations performed in the United States were ambulatory procedures. Bariatric procedures performed in the United States have increased from 16,200 in 1992 to approximately 205,000 in 2007. In 2002, our center began offering laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures on an outpatient basis for select candidates at an ambulatory surgery center (ASC). We subsequently added laparoscopic adjustable gastric band procedures (LAGB) in 2005. METHODS: Between 2002 and 2008, 248 LRYGB and LAGB patients were carefully selected for ASC surgery by the bariatric surgeon and medical director. Extensive preoperative education was mandatory for all surgical candidates. RESULTS: Since 2002, we have performed 248 bariatric cases at the ASC, including 38 LRYGB and 210 LAGB procedures. In this overall experience, 5 patients (2%) required readmission within 30 days of surgery, and 98.6% of LAGB patients were discharged the same day; 62% were discharged after a 4-hour to 6-hour stay in the ASC. All LRYGB patients remained in the ASC overnight and were discharge within 24 hours of their procedure. Weight loss results have been excellent. CONCLUSION: LAGB surgery can be safely performed in an ASC setting in most patients. LRYGB can be performed safely in the ASC setting with careful scrutiny and cautious selection of patient candidates.

Seven cases of gastric perforation in Roux-en-Y gastric bypass patients: what lessons can we learn?

BACKGROUND: Patients undergoing Roux-en-Y gastric bypass for the resolution of morbid obesity have significant medical sequelae related to their weight. One of the most common comorbid conditions is joint pain requiring the use of non-steroidal anti-inflammatory medications (NSAIDs). In addition to NSAIDs, patients may engage in behaviors such as smoking and alcohol misuse that increase the risk of long-term postoperative complications to include gastric perforation. METHODS: Data on 1,690 patients undergoing gastric bypass surgery were collected prospectively and reviewed retrospectively. RESULTS: We identified seven patients who presented to an emergency room and subsequently required emergent surgical intervention for repair of gastric perforation. Six of the seven cases involved use or abuse of NSAIDs. CONCLUSION: Important characteristics were identified including the use of NSAIDs, alcohol use, and non-compliance with routine long-term postoperative follow-up. Identifying those patients at high risk may decrease the incidence of this potentially life-threatening complication.