Laparoscopic repair of anterior abdominal wall herniation using composite mesh

.ETTERS TO THE EDITORM SURVIVAL IN CARCINOMA OF THE CERVICAL ESOPHAGUS To

the

Editor:

I would like to make a few comments on the article by Kelley et al regarding survival in carcinoma of the cervical esophagus.’ The authors have concluded that there was a trend towards improved survival in patients treated with surgical resection. Although they did mention staging the patient according to AJCC, different stage groupings have not been assigned to different treatment modalities. Hence, we do not know whether the surgical series had more curable cases as usually is the case. Moreover, the radiation dose mentioned is 50 Gy, which is a suboptimum dose whether given with or without chemotherapy. Conclusions by the authors are, at the best, misleading. Anwar Ahmad, MD St . Joseph, Michigan 1. Kelley DJ, Wolf R, Shaha AR, et al. Impact of clinical pathologic parameters of patient survival in carcinoma of the cervical esophagus. Am J Surg. 1995;170:427-431. The

Reply:

We appreciate the comments and perspective of Dr. Ahmad. He correctly points out that the AJCC staging system is inadequate in that pathologic staging is only available on surgical resection specimens. Until such time that MRI or possibly ultrasound can accurately stage patients with carcinoma of the cervical esophagus, comparisons between surgical and nonsurgical treatments will remain difficult. Based on clinical staging, the patients who were considered surgically resectable and elected nonsurgical treatment, primarily because of an unwillingness to undergo total laryngectomy, were comparable to those who elected surgical resection. There is no evidence from a review of the data that the patients treated with surgery were more curable than ehose treated with chemotherapy and/or radiation. The dosage of 50 Gy represents the mean of all patients treated with radiotherapy in the report, in542

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Medica,

Inc.

eluding patients who were unable to complete a full course of treatment. The conclusions presented in the paper were based on a statistical analysis of data collected retrospectively on a cohort of patients with an uncommon neoplasm. Few institutions have a series of patients large enough to evaluate the efficacy of different treatments. It must be pointed out that the surgical management of carcinoma of the cervical esophagus becomes much more complex because of the need for total laryngectomy. Surgical reconstruction either by gastric pull-up or jejunal interposition is not without significant morbidity. However, until such time that a prospective randomized trial of surgical resection versus radiation and/or chemotherapy as treatment for patients with carcinoma of the cervical esophagus is completed, treatment choices for these patients will depend on published reports of the results of various treatment modalities. Our intention was not to mislead but to simply report our experience in an effort to improve our understanding of this unusual and often fatal disease. Jatin I’. Shah, MD Daniel Kelley, MD Memorial Sloan-Kettering Cancer Center New York, New York

LAPAROSCOPIC REPAIR OF ANTERIOR ABDOMINAL WALL HERNIATION USING COMPOSITE MESH To the Editor: We read the article entitled “A Technique for Laparoscopic Repair of Herniation of the Anterior Abdominal Wall Using a Composite Mesh Prosthesis” by Barie et al with interest (Am J Surg. 1995;170:62-63). The authors advocate the use of a composite mesh prosthesis made of a sheet of woven polyester fiber (Mersilene) coupled with a sheet of polyglactin 910 (Vicryl) for the intraperitoneal repair of anterior abdominal wall hernias. This composite was originally described in 1983 by Loury and Chevrel of the University of Paris.’ In 1992, Trivellini and Danelli, from the Uni-

versity of Milan, introduced it to American surgical literature.2 The concept was based on the hypothesis that while the polyglactin layer is absorbed, a layer of mesothelium would cover the Mersilene mesh and act as a physical barrier to prevent biomaterial-related intestinal adhesions and intestinal fistula resulting from the migration of the Mersilene into the lumen of the bowel. In 1993, while introducing an experimental composite mesh with the selective property of incorporation to the abdominal wall without adhering to the intestines, we pointed out that the intended purpose of composites as described by Barie et al could not be substantiated by our ra’bbit model experimentatiom3 In fact, one of our laboratory animals died of bowel obstruction as a result of intestinal adhesions to the composite. More importantly, a report by Soler and Stoppa, based on their animal experimentation as well as clinical studies, indicated that the Mersilene/Vicry1 composite resulted in intestinal fistulization in both rat ,models and human subjects.4 Notwit.hstanding the hazards of such combination of biomaterials, manufacturers have been quick to jump onto the bandwagon of composite making and market their own version of a combined prosthesis in Europe. During the XVII Congress of Groupe de Recherche Europeen sur la Paroi Abdominale held in Palermo, Italy, in June 1995, th,is new product was discussed and its placement in direct contact with the intestines was criticized. Most probaibly, marketing of similar prostheses will1 soon begin in the United States, and as a result, surgeons must be aware of these possible consequences. Therefore, we feel that the Journal’s readership should be made aware of the potential complications of the absorbable/nonabsorbable composites. Park: K. Amid, MD Lichtenstein Hernia Institute Los Angeles, California 1. Louty JN, Chevrel JP. Traitement des eventrations. Utilisation simultanee du treillis de polyglactine 910 et de dacron presse. Med 72. 19’83;34:2116. 0002-961 O/96/$1 PII SOOO2-9610(96)00096-1

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1LETTERS TO THE EDITOR

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2. Trivelline G, Danelli PG. Use if two prostheses in the surgical repair of recurrent hernias. Postgr Gen Surg. 1992;4:135-138. 3. Amid PK, Shulman AG, Lichtenstein IL. An experimental evaluation of a new composite mesh with the selective property of incorporation to the abdominal wall without adhering to the intestines. J Biomed Mater Res. 1994;28:373-375. 4. Soler N, Verhaeghe P, Essomba A, Sevestre H, Stoppa R. Treatment of postoperative incisional hernias by composite prosthesis (polyester-polyglactin 910). Clinical and experimental study. Ann Chir. 1993;47:598-608.

ANAMOLOUS ANATOMY

BILIARY

To the Editor: We read the article by Meyers and colleagues with interest.’ Injury to a low insertion of an anomalous branch of the right hepatic duct below the hepatic duct confluence is a well described pattern of bile duct injury,’ and their reinforcement of the principle that safe laparoscopic cholecystectomy demands meticulous dissection of Calot’s triangle is laudable. However, their description of the anomalous biliary anatomy is confusing. Repeated reference is made to injury of the “VII-VIII duct” or “VII-VIII segment” based upon its “anteroposterior and superior appearance” during contrast studies. Even accepting differences in the nomenclature of the sectoral and segmental hepatic anatomy employed by American and European authors,3x4 hepatic segments VII and VIII remain separate entities and belong to the posterior (ie, segments VI and VII) and anterior (ie, segments V and VIII) “sectors” respectively of the right liver. A common segment “VII-VIII” duct system would be a rarity, and it is assumed the authors are referring in their article to right anterior or posterior sectoral duct injuries (“Bismuth type V injuries”). Timothy G. John, MBBCh, FRCS(Ed) 0. James Garden, BSc, MBChB, MD, FRCS (Ed and Glas) University of Edinburgh Edinburgh, Scotland 1. Meyers WC, Peterseim DS, Pappas TN, et al. Low insertion of hepatic segmental duct VII-VIII is an important cause

of major biliary injury or misdiagnosis. Am JSurg. 1996;171:187-191. 2. Bismuth H. Post-operative strictures of the bile duct. In: Blumgart LH, ed. The Biliary Tract. Clinical Surgery fnternational, ~015. Edinburgh: Churchill Livingstone, 1982:209-218. 3. Couinaud C. Le Foie: kfudes Anatomiques et Chirurgicales. Paris: Masson, 1957. 4. Soyer P. Segmental anatomy of the liver: utility of nomenclature accepted worldwide. AJR. 1993;161:572-573. The Reply: As we listed in the article, we were also surprised to find that the “dome” segments VII-VIII had a common trunk. This was different from previously reported anatomic dissections, which makes me think there are inaccuracies in the older literature. CTcholangiograms and 3-dimensional computer reproductions confirmed these findings. It is certainly possible that this is an extremely unusual group of patients and this anatomical arrangement is rare! However, this would be exceedingly circumstantial, considering more than one patient had this anatomy. William C. Meyers, MD University of Massachusetts Worcester, Massachwe tts

SHORT TUBES

VERSUS

LONG

To the Editor: Dr. Fleshner and his co-authors are to be congratulated for their prospective randomized study, “A Prospective, Randomized Treatment of Short Versus Long Tubes in Adhesive Small-Bowel Obstruction.” (Am J Surg. 1995;170:366-370), showing superior results with long tube decompression in properly selected patients with small bowel obstruction. They found 75% success with the long tube versus 51% for the short tube. I am sure you will agree that when a long tube fails to pass beyond the stomach it must be considered a short tube. In their report 3 of the 27 long tubes remained in the stomach and 18 of the remaining 24 were successful, equals 75%. Of the three that failed to pass, two required operation so their 28 patients with the short tube becomes 31 with 16 successes, equals 51%.

The results are in accord with our 12-year cohort study in which 32139 patients with small bowel obstruction were successfully decompressed, equals 82%. Whereas they used a Cantor Tube with frequent fluoroscopic manipulations we can place the long tube into the jejunum endoscopically in 20 minutes. In addition we have developed an improved tube (Cook, Inc.) designed for immediate placement endoscopically or fluoroscopically into the small bowel. Despite their ambivalent and apparently misleading conclusion., Fleshner et al stated, “the success of n.onoperative therapy was influenced by long tube “location as only 6 of the 24 patients (25%) in whom the tube passed into the small bowel required operation.” There can be no doubt that the success of the long tube depends on its ability to reach and decompress the small bowel as so well stated by Wolfson’s study in 1985 from the same institution. George F. Gowen, MD Philadelphia, .Pennsyluania 1. Gowen GF, DeLaurentis DA, Stefan MM. Immediate endoscopic placement of long intestinal tube in partial small bowel obstruction. Surg G:yneco/ Obsf. 1987; 165:456-58. 2. Wolfson P, Bauer J, Gelernt JM, Kreel I, Aufses A. Use of the long tube in the management of patients with small bowel obstruction dlue to adhesions. Arch Surg. 1985;120:1001-1006. 3. Gowen GF. Long tube decompression is successful in 80% of patients with adhesive small bowel obstruction. Submitted for publication. The Reply: My colleagues and I thank Dr. Gowen for his comments, and appreciate the opportunity to respond. He and I have discussed the management of adhesive obstruction on many occasions over the years, and I know that he too favors the initial use of attempted tube decompression in the majority of cases. The tube that he has developed which can be manipulated endoscopically into the small bowel represents an advantage over the conventional tubes now in Icommon use which must be manipulated under fluoroscopic control. We would certainly ag:ree with his comment that if a long tube does not pass beyond the pylorus, then it must be considered the same :as a nasogas-

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