Absorbable Polyglactin vs. Non-Cross-linked Porcine Biological Mesh for the Surgical Treatment of Infected Incisional Hernia.

BACKGROUND: The use of absorbable meshes during contaminated or infected incisional hernia (IH) repair is associated with high morbidity and recurrence rates. Biological meshes might be more appropriate but have been described in highly heterogeneous series. This study aimed at comparing the efficacy of absorbable vs. biological meshes for the treatment of contaminated or infected IH in a homogeneous series with a standardized technique. METHODS: Data of all patients operated on between 2008 and 2015 for contaminated or infected IH, using an absorbable (A) Vicryl® or a biological (B) Strattice® mesh, were reviewed. Patient characteristics, infectious complication rates, and recurrence-free outcome (RFO) were compared between the two groups. A propensity score methodology was applied to a Cox regression model to deal with unbalanced characteristics between groups. RESULTS: Patient demographics in A (n = 57) and in B (n = 24) were similar except that B patients had larger parietal defects (p < 0.001) and higher Center for Disease Control (CDC) wound class (p = 0.034). Patients in A had statistically significantly more postoperative early (61.4% vs. 33.3%, p = 0.03) and late (31.2% vs. 8.3%, p = 0.046) infectious complications. Six-, 12-, and 36-month RFO rates were 77%, 47%, and 24%, and 96%, 87%, and 82% in A and B, respectively, p < 0.001. Raw multivariable Cox regression analysis found that B (HR = 0.1, 95% CI [0.03-0.34], p < 0.001) was independently associated with prolonged RFO (HR = 0.091, 95% CI [0.045-0.180], p < 0.001). CONCLUSION: Biological meshes seem to be superior to absorbable meshes in patients with contaminated or infected incisional hernia. These results need to be confirmed by prospective randomized trials.

Standard of Open Surgical Repair of Suprapubic Incisional Hernias.

BACKGROUND: Suprapubic incisional hernias (SIH) are a rare wall defect, whose surgical management is challenging because of limited literature. The proximity of the hernia to bone, vascular, nerve, and urinary structures, and the absence of posterior rectus sheath in this location imply adequate technique of surgical repair. We aimed to describe a cohort of female patients operated on for SIH after gynecological surgery using a homogeneous surgical technique and to report surgical outcomes. METHODS: The records of all consecutive patients operated on for SIH in a specialized surgical center between January 2009 and January 2015 were retrospectively reviewed. The same open technique was performed, i.e., using a mesh placed inferiorly in the preperitoneal space of Retzius, with large overlap, and fixed on the Cooper's ligaments, through the muscles superiorly and laterally with strong tension, in a sublay or underlay position. RESULTS: The cohort included 71 female patients. SIH were recurrent in 31% of patients and was related to cesarean in 32 patients (45.1%) and to gynecologic surgery in 39 patients (54.9%). The mesh was totally extraperitoneal in 76.1% of patients. The postoperative mortality rate was null. The rate of specific surgical complications was 29.6%. After a median follow-up of 30.3 months, the recurrence rate was 7%. CONCLUSION: The open approach for SIH repair was safe and efficient. Due to the paucity of adequate scientific studies, this reproducible open method could help moving toward a standardization of SIH surgical management.

Management of large incisional hernias with loss of domain: A prospective series of patients prepared by progressive preoperative pneumoperitoneum.

BACKGROUND: The surgical treatment of giant incisional hernias with loss of domain is challenging due to the possibility of intra-abdominal hypertension after the herniated content is returned to the peritoneal cavity. Progressive preoperative pneumoperitoneum has been described before repair of the hernia, although its efficacy has not been demonstrated clearly. Our aim was to evaluate the efficacy of preoperative progressive pneumoperitoneum in expanding the volume of the peritoneal cavity and the outcomes after surgical treatment of incisional hernias with loss of domain. METHODS: All consecutive patients with incisional hernias with loss of domain undergoing preoperative progressive pneumoperitoneum and operative repair were included in a prospective observational study. All patients had pre- and postoperative progressive pneumoperitoneum computed tomography of the abdomen. Open incisional hernias with loss of domain repair consisted of anatomic reconstruction of the abdominal wall by complete closure of the defect and reinforcement with a sublay synthetic mesh, whenever possible. RESULTS: The cohort was composed of 45 patients (mean age, 60.5 years). Before the preoperative progressive pneumoperitoneum, the mean volume of the herniated content was 38% of the total peritoneal volume. The mean abdominal volume increased by 53% after the preoperative progressive pneumoperitoneum. One patient died during preoperative progressive pneumoperitoneum, but the postoperative mortality was zero, giving a mortality rate of 2% to the treatment using preoperative progressive pneumoperitoneum. Complete reduction of the herniated content intraperitoneally with primary closure of the fascia was achieved in 42 out of 45 patients (94%). Reinforcement by a synthetic mesh was possible in 37 patients (84%). Overall, surgical complications related directly to the operative procedure occured in 48% of cases. The rates of overall and severe morbidity were 75 and 34%, respectively. At a mean follow-up of 18.6 months, the recurrence rate was 8% (3 out of 37 patients) with non-absorbable meshes and 57% (4 out of 7 patients) with absorbable mesh. CONCLUSION: Preoperative progressive pneumoperitoneum increased the volume of the abdominal cavity in patients with incisional hernias with loss of domain, allowing complete reduction of the herniated content and primary fascial closure in 94% of patients, with acceptable overall morbidity.

Definition of giant ventral hernias: Development of standardization through a practice survey.

BACKGROUND: Giant ventral hernias represent a real handicap for patients and constitute a challenge for surgeons. European Hernia Society classification defines all ventral hernia over 10 cm in the same group. However, this group represents different clinical entities with numerous therapeutic possibilities, and no standardized recommendation has been made. The objective of our work was to define consensual criteria that define giant ventral hernias requiring specific management and determine management modalities. METHODS: A national survey consisting of 21 questions was proposed through a secure, anonymous internet interface and on a voluntary basis to all surgeons practising in France involved in care of patients affected by giant ventral hernias. RESULTS: For more than 68% of respondents, loss of domain and a hernia volume greater than 30% of abdominal volume were mandatory to define giant ventral hernias. Pre-operative screening should include abdominal CT scan, functional respiratory exploration, and a cardiology consultation for 98%, 71% and 50% of the respondents respectively. Respiratory and cutaneous preparations were systematically proposed before surgery by 91% and 56% of respondents. Regarding surgical techniques, none has gained the support of the majority of respondents. However, 71% of respondents use a non-resorbable mesh in retro muscular position for more than 70% of their patients treated for giant ventral hernias. CONCLUSION: Giant ventral hernias could be defined as ventral hernia larger than 10 cm with loss of domain. A specific management is advocated.

Efficacy and tolerance of prolonged infliximab treatment of moderate-to-severe forms of hidradenitis suppurativa.

UNLABELLED: Hidradenitis suppurativa (HS) is a chronic suppurative disease impairing patients' quality of life (QOL). The standard treatment remains extensive surgery; medical treatment is often disappointing. OBJECTIVES: Prolonged infliximab efficacy and tolerance in moderate-to-severe forms of HS were evaluated. PATIENTS AND METHODS: This prospective, monocentric, open, interventional study concerned patients with progressive, moderate-to-severe HS ineligible for surgery, or who relapsed after surgery. Infliximab (5 mg/kg) was infused at weeks 0, 2 and 6, and then every 4 weeks. When the response was satisfactory, infusion spacing was attempted. RESULTS: Ten patients were included, 8 treated for 1 year, with a mean of 5 affected sites and 18 years of evolution. The mean initial DLQI was 20/30 (range 9-30). At 1 year, the number of involved sites (P<0.001) and flares (P<0.05) had decreased significantly under infliximab, as did HS severity. QOL improved clearly and rapidly for all patients, with mean DLQI at 6/30 (P<0.001). Tolerance was satisfactory with only 4 minor infections, 1 keratoacanthoma and one rapidly resolving hepatitis. CONCLUSION: This evaluation of prolonged infliximab use in HS after surgical failure showed good efficacy and satisfactory tolerance without therapeutic escape during the first year of treatment.

Beneficial influence of microsatellite instability on gelatinase-tissue inhibitors of metalloproteinase balance in colorectal cancer.

BACKGROUND: Colorectal cancers (CRC) with high level of microsatellite instability (MSI-H) are characterized by lower metastasis propensity and better prognosis than their stable microsatellite (MSS) counterpart. It was hypothesized that the difference in cancer progression might be related to distinct gelatinase-tissue inhibitors of metalloproteinase (TIMPs) balance in MSI-H and MSS sporadic CRC. PATIENTS AND METHODS: Levels of gelatinase-A (MMP-2) and -B (MMP-9), TIMP-1 and -2 and membrane-type matrix metallo-proteinase-1 (MT1-MMP) were compared in tumors and normal mucosa from patients with MSI-H and MSS CRC. RESULTS: Active levels of MMP-2 and -9, normalized to normal mucosa, were lower in MSI-H than MSS CRC. There was a trend for higher levels of TIMP-1 and TIMP-2 within MSI-H tumors compared with MSS tumors (p=0.08 and p=0.15, respectively), while TIMP-2 amounts were significantly higher in adjacent normal tissue (p<0.001) in patients with MSI-H vs. MSS cancers. There was also a trend for lower MT1-MMP activity in MSI-H than in MSS CRC. CONCLUSION: Our data suggest that the distinct invasive and metastatic behaviors of MSI-H and MSS CRC may be related to different patterns of gelatinase secretion and regulation.

[Surgery for inguinal hernia: indications and operative principles]. / Chirurgie des hernies de l'aine: indications et principes opératoires.

During the last century, many surgical techniques have been reported for inguinal hernia repair. The goal of theses methods is to repair or reinforce the posterior wall of inguinal canal. The raphies performed by suturing and closing the inguinal ring may lead to excessive tension resulting in pain and recurrence. The use of prosthetic mesh reinforces the posterior wall and allows tension-free repair whether performed by inguinal route or laparoscopically. No consensus has yet been reached about the best surgical approach to inguinal hernia repair in view of the literature (especially randomised-controlled trials). Mesh repairs are associated with a low recurrence rate. Laparoscopy seems not to be superior to open mesh repair. Therefore, it is not possible to use only a single technique and the surgeon must adjust the choice of repair to each patient.