How-we-do-it: the repair of postoperative ventral hernias after a Mercedes abdominal incision.

PURPOSE: To describe the abdominal wall reconstruction technique with an Ultrapro mesh and outcome for the repair of postoperative ventral hernias after the use of a Mercedes incision during the initial abdominal operation. METHOD: A retrospective review of all the patients undergoing elective postoperative ventral hernia repair between 2013 and 2019. The cohort of these patients that had an initial Mercedes incision was used for this study. RESULTS: Fourteen patients met the criteria for this study. Thirteen of the patients were transplant patients (10 liver transplant and 3 combined pancreas and kidney transplant), and one patient was after a hepatectomy. Fifty-seven percent of these hernias were multiple defects. All the patients underwent the same repair of a modified Rives-Stoppa, transversus abdominis release, and a bilateral transverse plication. A partially absorbable Ultrapro mesh was used for all the patients, with two of the patients needing an additional Symbotex mesh in order to bridge a portion of the posterior fascia. There were 6 minor early postoperative complications (hematoma, superficial wound infection, and seroma) that did not require reoperation. Two patients were readmitted for observation of a wound hematoma, and two patients (14.2%) had recurrence during the follow-up period. The average length of hospitalization was 5.6 days. CONCLUSION: This technique, with the use of an Ultrapro mesh, was found to be safe and effective for the repair of a postoperative ventral hernia due to an initial Mercedes incision.

Number of evaluated lymph nodes and positive lymph nodes, lymph node ratio, and log odds evaluation in early-stage pancreatic ductal adenocarcinoma: numerology or valid indicators of patient outcome?

BACKGROUND: We evaluated the prognostic significance and universal validity of the total number of evaluated lymph nodes (ELN), number of positive lymph nodes (PLN), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) in a relatively large and homogenous cohort of surgically treated pancreatic ductal adenocarcinoma (PDAC) patients. METHODS: Prospectively accrued data were retrospectively analyzed for 282 PDAC patients who had pancreaticoduodenectomy (PD) at our institution. Long-term survival was analyzed according to the ELN, PLN, LNR, and LODDS. RESULTS: Of these patients, 168 patients (59.5 %) had LN metastasis (N1). Mean ELN and PLN were 13.5 and 1.6, respectively. LN positivity correlated with a greater number of evaluated lymph nodes; positive lymph nodes were identified in 61.4 % of the patients with ELN ≥ 13 compared with 44.9 % of the patients with ELN < 13 (p = 0.014). Median overall survival (OS) and 5-year OS rate were higher in N0 than in N1 patients, 22.4 vs. 18.7 months and 35 vs. 11 %, respectively (p = 0.008). Mean LNR was 0.12; 91 patients (54.1 %) had LNR < 0.3. Among the N1 patients, median OS was comparable in those with LNR ≥ 0.3 vs. LNR < 0.3 (16.7 vs. 14.1 months, p = 0.950). Neither LODDS nor various ELN and PLN cutoff values provided more discriminative information within the group of N1 patients. CONCLUSIONS: Our data confirms that lymph node positivity strongly reflects PDAC biology and thus patient outcome. While a higher number of evaluated lymph nodes may provide a more accurate nodal staging, it does not have any prognostic value among N1 patients. Similarly, PLN, LNR, and LODDS had limited prognostic relevance.

C-reactive protein as a marker of complicated diverticulitis in patients on anti-inflammatory medications.

BACKGROUND: Diverticulitis is a common indication for surgical emergency room admission, often leading to abdominal computed tomography (CT) scanning for both diagnosis and staging. C-reactive protein (CRP) has been identified as a useful biomarker of inflammation. Aspirin and corticosteroids are known to down-regulate CRP production. In this study, we evaluated the usefulness of CRP as a biomarker for complicated diverticulitis and specifically in patients on anti-inflammatory medications: aspirin and corticosteroids. METHODS: We analyzed the medical records of patients diagnosed at one medical center during a two-year period, with left-sided diverticulitis, according to clinical data and CT scan. Disease severity was assessed by the Hinchey score using the radiological findings detected by CT. RESULTS: A total of 295 patients were included in the study. Two hundred and forty-three (82 %) were classified with uncomplicated (Hinchey 1a) and 52 (18 %) with complicated disease (Hinchey > 1a). Mean CRP levels were 133.5 and 63.5 mg/ml for those with complicated and uncomplicated disease, respectively (p < 0.001), and 139 and 60 mg/ml, respectively (p < 0.001) in the subgroup of patients taking aspirin (n = 61). For 14 patients on corticosteroid treatment, the difference in mean CRP levels for complicated and uncomplicated disease was not statistically significant. CRP > 90 mg/ml had 88 % sensitivity and 75 % specificity for complicated disease. CONCLUSIONS: The CRP level distinguished between complicated and uncomplicated disease among left-sided diverticulitis patients including those taking aspirin, but not among those on corticosteroid treatment.