Lessons learned from 227 biological meshes used for the surgical treatment of ventral abdominal defects

PURPOSE

The advantages of biological meshes for ventral hernia repair are still under debate. Given the high financial cost, the proper indications for biological meshes should be clarified to restrict their use to properly selected patients.

METHODS

A retrospective database was instituted to register all cases of abdominal wall defect treated with biological meshes from 1/2010 to 3/2016.

RESULTS

A total of 227 patients (mean age: 64 years) whose ventral abdominal defects were reconstructed with a biological mesh were included in the study. Patients were divided according to the 2010 four-level surgical-site complication risk grading system proposed by the Ventral Hernia Working Group (VHWG): Grade 1 (G1, 12 cases), Grade 2 (G2, 68 cases), Grade 3 (G3, 112 cases), and Grade 4 (G4, 35 cases). The surgical site complication rate was higher in patients with one or more risk factors (33.6% vs 19% in patients with no risk factors) (P = 0.68). Statistically significant risk factors associated with the onset of one or more postoperative surgical site complications included: diabetes, coronary artery disease, immunosuppression, and obesity. Recurrence was more common in patients with surgical site complications and mainly associated with infection (38.9%) and wound necrosis (44.4%), and in cases of inlay positioning of the mesh (36%).

CONCLUSIONS

Due to their high costs, biological mesh should not be used in G1 patients. In infected fields (G4), they should only be used if no other surgical solution is feasible. There is a clear need to prospectively evaluate the performance of biological meshes.

Intestinal leiomyosarcoma and gastroparesis associated with von Recklinghausen's disease

The rare association between intestinal leiomyosarcoma, von Recklinghausen's disease (type-1 neurofibromatosis) and gastroparesis is described. A 20-year-old male, diagnosed 12 years earlier as having pelvic von Recklinghausen's disease, presented with nausea and vomiting. A gastric scintigraphy demonstrated an extremely slow gastric emptying time in the absence of obvious causes for gastroparesis. A small ileal leiomyosarcoma was later found and removed by surgery. The latter was followed by a marked improvement in the clinical condition of the patient.

[Difficult digestive hemorrhage: angiodysplasia]

The authors report 7 cases of ileal and colonic angiodysplasia observed over a 3 year period (1992-1994). After a review of literature concerning etiology, pathology, diagnosis, and treatment emphasize the use of angiography for preoperatory diagnosis an intraoperatory localization of the lesion when this one is localized in the ileum. After review of usefull therapies, they stress the role of surgery as the most used therapy and only really complete.

[Colonic anastomoses. Methods compared]

The authors used Bar-Valtrac for 18 months to perform colic anastomoses. To weigh up the effectiveness of this method they compare manual, Stapler and Bar-Valtrac anastomoses performed in this period. They examined 169 anastomoses in the same number of patients being careful of complications, post-operative canalizing, periods in hospital. It is clear that Bar-Valtrac is a good alternative to the stapler and to manual anastomoses because it is done in a way that doesn't determine anastomotic foreign body reactions and consequently reduces stenotic complications. The limit of this method is the great difficulty in performing low and very low colo-rectal anastomoses. Actually, to perform low and very low anastomoses, the authors prefer to use the Stapler that offers higher probabilities of recovery without complications and higher speed of carrying out.

[Digestive hemorrhage due to an unusual cause: duodenal varices]

The paper reports a case of digestive hemorrhage due to duodenal varices in a cirrhotic patient. The authors emphasise the extreme rarity and severity of this pathology and, in accordance with the literature, underline the difficulty of selecting the correct approach.