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Late infection after mesh-plug inguinal hernioplasty
LETTERS TO THE EDITOR INFLAMMATORY RESPONSE TO OPEN TENSION-FREE INGUINAL HERNIOPLASTY VERSUS CONVENTIONAL REPAIR To the Editor: We read with great interest the article written by Gu¨rleyik et al.1 We have some concerns about the study they carried out. The study was not randomized. The first 16 patients were treated with tension-free and the following patients with conventional repairs. Randomization improves the chance that the probabilities obtained from statistical tests will be valid.2 The mean values were given in Tables I and II. It was not obvious whether the values following the mean were standard deviation (SD) or standard error of mean (SEM). Also, there was no need to use two different measures of dispersion (SD or SEM and range) at the same time. The authors reported that cytokine response increases with age and magnitude of the procedure. Comparing pediatric patients in group 1, with no reinforcement of posterior wall, with the adult patients in groups 2 and 3 showed the reported significant differences in mean serum IL-6 levels, which is easy to understand. Group 4 (control) consisted of 10 healthy adult volunteers without any operation. The control subjects should be chosen to match individual cases for certain characteristics, such as age and gender.2 Although age ranges were similar in adult groups, the gender of the patients in group 4 was not given. If the control group was simply used to measure the reference ranges of IL-6 and C-reactive protein (CRP) in the sample population, those healthy volunteers would seem to be cooperative colleagues in the authors’ clinic, at the mean age of 53.9 ⫾ 15.6 years. Turkey may have a smaller mean age value. The mean CRP value in group 4 was measured 7.5 ⫾ 4 (2–14) mg/L. If the data following the mean value were reflecting the SD, then the normal range (mean ⫾ 2 SD) would be between ⫺0.5 and 15.5 mg/L. Whether SD or SEM, a normal distribution cannot be assumed, since a negative value for 76
© 2000 by Excerpta Medica, Inc. All rights reserved.
CRP is not possible.2 It was also written that the reference range of the laboratory was between 0 and 6 mg/L, which is lower than the values found in group 4. The serum levels of IL-6 and CRP did not seem to be precisely or sensitively measured. We believe that randomizing the patients, performing the same type of conventional operation, and leaving groups 1 and 4 out of the study would give more significant results. Mehmet Ku¨rt¸at Bozkurt, MD Division of General Surgery Isparta State Hospital Fatih Ag˘alar, MD Argun Akc¸akanat, MD Department of General Surgery Suleyman Demirel University School of Medicine Isparta, Turkey 1. Gu¨rleyik E, Gu¨rleyik G, C¸etinkaya F, U¨nalmis¸er S. The inflammatory response to open tension-free inguinal hernioplasty versus conventional repairs. Am J Surg. 1998;175:179 –182. 2. Campbell MJ, Machin D. Medical Statistics. A Commonsense Approach. West Sussex, England: John Wiley & Sons; 1993.
The Reply: We thank Dr. Bozkurt et al for their interest on our manuscript. As mentioned in the manuscript, we had planned prospectively to take the first 16 consecutive patients with indirect inguinal hernia for tension-free and the following 20 patients for conventional repairs. The presence of inguinal hernia was the only factor for selection of these 36 patients for the surgical treatment of their disease. We did not use further selection criteria for forming our two groups. We do not believe that this selection affects the validity of statistical analysis of our results. The data were statistically analyzed using a computer program. Results were presented as mean and standard deviation. The range of our measurements was also presented for each variable in the two tables. Serum Il-6 measurement is not a routine test. A control group consisting of 10 healthy adult men was formed for determining the normal reference value. We disagree with Dr. Bozkurt et al about the mean age of this group. We were easily able to find
10 healthy adult men with a mean age of 54 years. We do not understand why they have some doubt about the mean age of this control group. The serum levels of Il-6 and C-reactive protein were sensitively measured with precise methods described in the Patients and Methods section, by a specialist who is a coauthor of our manuscript. All the measured values were written in a computer program, and analyzed for statistical significance. Dr. Bozkurt et al have suggested performing the same type of conventional operation. In our study, we chose to perform the three most common types of inguinal hernia operations for conventional repair group. As proposed by Dr. Bozkurt et al, similar studies could also be carried out performing only a single type of conventional operation. Dr. Bozkurt et al have also proposed that we leave groups 1 and 4 out of the study. We do not agree with them. In this study, we also tried to determine the effect of posterior wall repair on the stress response. A group of hernia repairs without reinforcement of the posterior wall was needed for the comparison. Pediatric hernia patients (group 1) offered the only possibility to form such a group for this purpose. We appreciate the opportunity to respond to this critique. Emin Gu¨rleyik, MD Istanbul, Turkey
LATE INFECTION AFTER MESH-PLUG INGUINAL HERNIOPLASTY To the Editor: We read with interest the article by Mann et al (Am J Surg. 1998;176:12– 14) about late-onset deep prosthetic infection following mesh repair of inguinal hernia. We report here a case of late onset prosthetic infection after mesh-plug inguinal hernioplasty1 and our treatment of this complication. A 47-year-old man had a right-sided direct inguinal hernia. We performed inguinal hernioplasty using mesh and a plug in July 1998. He was discharged from our hospital 7 days later without any wound infection. He presented again complaining of right in0002-9610/00/$–see front matter PII S0002-9610(99)00249-4
LETTERS TO THE EDITOR
guinal wound pain after 3 months. A postoperative abscess was detected under the inguinal scar by high-resolution, real-time, hand-held ultrasonography (US). This was apparently caused by late-onset deep prosthetic infection. The wound was opened and drainage was established. Then he was given oral antibiotics for 5 days. We could not cure this complication, despite drainage for 82 days. Therefore, we removed both the sinus and the infected mesh-plug. His infection was cured by this treatment. Previous reported cases of late-onset deep infection after mesh hernioplasty appear to have been simply treated by drainage and antibiotics.2 Our experience suggests that surgical intervention is necessary to cure this complication. In addition, US allows easier diagnosis of such infections. Takuya Hatada, MD Hiromitsu Ishii, MD Shigetoshi Ichii, MD Hiroshi Ashida, MD Takehira Yamamura, MD Second Department of Surgery Hyogo College of Medicine Hyogo, Japan 1. Rutkow IR, Robbins AW. “Tensionfree” inguinal herniorrhaphy: a preliminary report on the “mesh plug” technique. Surgery. 1993;114:3– 8. 2. Gilbert AI, Felton LL. Infection in inguinal hernia repair considering biomaterials and antibiotics. Surg Gynecol Obstet. 1993;177:126 –130.
The Reply: The curious clinical phenomenon of infection surrounding a prosthetic device needs more study. There are some fundamental differences vis-avis infection that involves prostheses and a dominant theme is their extremely late appearance and their extreme clinical indolence. There are rare examples where the transfer of fresh vascularized muscle to a site can control an infection. In general, the principles here of removal of the prosthesis must be followed. This whole problem represents an increasingly frequent issue in the practice of surgery and basic research in this field needs to continue to receive appropriate attention.1 The Editor 1. Henke PK, Bergamini TM, Rose SM, Richardson JD. Prosthetic vascular
graft infection. Am Surg. 1998;64:39 – 46.
RECONSTRUCTION OF THE HEPATIC AND PORTAL VEINS USING A PATCH FROM THE RIGHT OVARIAN VEIN To the Editor: Dr. Kubota et al1 recently described a technique to reconstruct the hepatic and portal veins, after resection in hepatectomy, using a patch graft created from the right ovarian vein. This technique was used in 2 patients. The ovarian vein was resected, divided longitudinally into two equal parts that were sutured together to provide a patch measuring 2.5 ⫻ 2.0 cm. The authors consider a vein invasion of 3 cm to be the limit for resection; this appears to be related to graft size. They do not report evaluation of patency in these 2 cases. Although this technique has the advantage of using autologous tissue, it has the disadvantage of being time consuming and requiring more extensive dissection, and it is limited to small resections because of the small size patch. We have described a technique2 utilizing a bovine pericardial xenograft that is readily available and is not limited by the amount of venous invasion because it can be tailored to any given size, and it is applicable to both women and men. Furthermore, we have made tubular grafts with this material to replace the superior vena cava in the experimental model.3 The patency of this graft has been excellent both clinically and experimentally.2,3 This patch has been reported to have the longest patency in a survivor of colon carcinoma with hepatic metastases involving the IVC after its resection.2,4 On enhanced computerized tomography, the patch was indistinguishable from the native vessel. Pericardial patches have been extensively utilized for years in multiple intracardiac repairs in high- and low-pressure chambers with excellent results. In view of the above data, a pericardial bovine xenograft deserves strong consideration in these situations. The technique described by Kubota et al has a definite value when a pericardial patch is not available and the in-
volvement of either the IVC or portal vein is limited. Valves are usually present in these veins, and it may be advisable to remove them if found. The ovarian vein has a significantly thinner wall than the IVC and the possibility of aneurysmal dilatation should be kept in mind. Further collective data are needed prior to formulation of guidelines. Carlos Del Campo, MD Fullerton, California 1. Kubota K, Makuuchi M, Sugawara Y, et al. Reconstruction of the hepatic and portal veins using a patch graft from the right ovarian vein. Am J Surg. 1998;176:295–297. 2. Del Campo C, Konok GP. Use of a pericardial xenograft patch in repair of resected retrohepatic vena cava. Can J Surg. 1994;37:59 – 61. 3. Miyazaki M, Ito H, Nakagawa K, et al. Aggressive surgical resection for hepatic metastases involving the inferior vena cava. Am J Surg. 1999;177:294 – 298. 4. Del Campo C, Love J, Bowes F. Prosthetic replacement of the superior vena cava with a custom made pericardial graft: an experimental study. Can J Surg. 1992;35:305–309.
The Reply: We appreciate the kind comments of Dr. Del Campo regarding our article “Reconstruction of the hepatic and portal veins using a patch graft from the right ovarian vein” (Am J Surg. 1998;176:295–297). We have employed this type of patch graft in 2 patients. The patency of the reconstructed veins was confirmed by Doppler ultrasound or computed tomographic scan 10 and 6 months after surgery, respectively, suggesting that our technique guarantees long-term patency. We cannot agree completely that our technique has the disadvantages of being time consuming, requiring more extensive dissection, and being indicated only for small resections. Although it takes about 15 minutes to harvest the right ovarian vein following hepatectomy, it is not a time-consuming procedure in pancreatoduodenectomy. In both situations, vein harvest can be accomplished easily without any postoperative morbidity. Plasty of the right ovarian vein can be performed by residents on the back table. It is true that the indica-
THE AMERICAN JOURNAL OF SURGERY® VOLUME 179 JANUARY 2000
77
© 2000 by Excerpta Medica, Inc. All rights reserved.
CRP is not possible.2 It was also written that the reference range of the laboratory was between 0 and 6 mg/L, which is lower than the values found in group 4. The serum levels of IL-6 and CRP did not seem to be precisely or sensitively measured. We believe that randomizing the patients, performing the same type of conventional operation, and leaving groups 1 and 4 out of the study would give more significant results. Mehmet Ku¨rt¸at Bozkurt, MD Division of General Surgery Isparta State Hospital Fatih Ag˘alar, MD Argun Akc¸akanat, MD Department of General Surgery Suleyman Demirel University School of Medicine Isparta, Turkey 1. Gu¨rleyik E, Gu¨rleyik G, C¸etinkaya F, U¨nalmis¸er S. The inflammatory response to open tension-free inguinal hernioplasty versus conventional repairs. Am J Surg. 1998;175:179 –182. 2. Campbell MJ, Machin D. Medical Statistics. A Commonsense Approach. West Sussex, England: John Wiley & Sons; 1993.
The Reply: We thank Dr. Bozkurt et al for their interest on our manuscript. As mentioned in the manuscript, we had planned prospectively to take the first 16 consecutive patients with indirect inguinal hernia for tension-free and the following 20 patients for conventional repairs. The presence of inguinal hernia was the only factor for selection of these 36 patients for the surgical treatment of their disease. We did not use further selection criteria for forming our two groups. We do not believe that this selection affects the validity of statistical analysis of our results. The data were statistically analyzed using a computer program. Results were presented as mean and standard deviation. The range of our measurements was also presented for each variable in the two tables. Serum Il-6 measurement is not a routine test. A control group consisting of 10 healthy adult men was formed for determining the normal reference value. We disagree with Dr. Bozkurt et al about the mean age of this group. We were easily able to find
10 healthy adult men with a mean age of 54 years. We do not understand why they have some doubt about the mean age of this control group. The serum levels of Il-6 and C-reactive protein were sensitively measured with precise methods described in the Patients and Methods section, by a specialist who is a coauthor of our manuscript. All the measured values were written in a computer program, and analyzed for statistical significance. Dr. Bozkurt et al have suggested performing the same type of conventional operation. In our study, we chose to perform the three most common types of inguinal hernia operations for conventional repair group. As proposed by Dr. Bozkurt et al, similar studies could also be carried out performing only a single type of conventional operation. Dr. Bozkurt et al have also proposed that we leave groups 1 and 4 out of the study. We do not agree with them. In this study, we also tried to determine the effect of posterior wall repair on the stress response. A group of hernia repairs without reinforcement of the posterior wall was needed for the comparison. Pediatric hernia patients (group 1) offered the only possibility to form such a group for this purpose. We appreciate the opportunity to respond to this critique. Emin Gu¨rleyik, MD Istanbul, Turkey
LATE INFECTION AFTER MESH-PLUG INGUINAL HERNIOPLASTY To the Editor: We read with interest the article by Mann et al (Am J Surg. 1998;176:12– 14) about late-onset deep prosthetic infection following mesh repair of inguinal hernia. We report here a case of late onset prosthetic infection after mesh-plug inguinal hernioplasty1 and our treatment of this complication. A 47-year-old man had a right-sided direct inguinal hernia. We performed inguinal hernioplasty using mesh and a plug in July 1998. He was discharged from our hospital 7 days later without any wound infection. He presented again complaining of right in0002-9610/00/$–see front matter PII S0002-9610(99)00249-4
LETTERS TO THE EDITOR
guinal wound pain after 3 months. A postoperative abscess was detected under the inguinal scar by high-resolution, real-time, hand-held ultrasonography (US). This was apparently caused by late-onset deep prosthetic infection. The wound was opened and drainage was established. Then he was given oral antibiotics for 5 days. We could not cure this complication, despite drainage for 82 days. Therefore, we removed both the sinus and the infected mesh-plug. His infection was cured by this treatment. Previous reported cases of late-onset deep infection after mesh hernioplasty appear to have been simply treated by drainage and antibiotics.2 Our experience suggests that surgical intervention is necessary to cure this complication. In addition, US allows easier diagnosis of such infections. Takuya Hatada, MD Hiromitsu Ishii, MD Shigetoshi Ichii, MD Hiroshi Ashida, MD Takehira Yamamura, MD Second Department of Surgery Hyogo College of Medicine Hyogo, Japan 1. Rutkow IR, Robbins AW. “Tensionfree” inguinal herniorrhaphy: a preliminary report on the “mesh plug” technique. Surgery. 1993;114:3– 8. 2. Gilbert AI, Felton LL. Infection in inguinal hernia repair considering biomaterials and antibiotics. Surg Gynecol Obstet. 1993;177:126 –130.
The Reply: The curious clinical phenomenon of infection surrounding a prosthetic device needs more study. There are some fundamental differences vis-avis infection that involves prostheses and a dominant theme is their extremely late appearance and their extreme clinical indolence. There are rare examples where the transfer of fresh vascularized muscle to a site can control an infection. In general, the principles here of removal of the prosthesis must be followed. This whole problem represents an increasingly frequent issue in the practice of surgery and basic research in this field needs to continue to receive appropriate attention.1 The Editor 1. Henke PK, Bergamini TM, Rose SM, Richardson JD. Prosthetic vascular
graft infection. Am Surg. 1998;64:39 – 46.
RECONSTRUCTION OF THE HEPATIC AND PORTAL VEINS USING A PATCH FROM THE RIGHT OVARIAN VEIN To the Editor: Dr. Kubota et al1 recently described a technique to reconstruct the hepatic and portal veins, after resection in hepatectomy, using a patch graft created from the right ovarian vein. This technique was used in 2 patients. The ovarian vein was resected, divided longitudinally into two equal parts that were sutured together to provide a patch measuring 2.5 ⫻ 2.0 cm. The authors consider a vein invasion of 3 cm to be the limit for resection; this appears to be related to graft size. They do not report evaluation of patency in these 2 cases. Although this technique has the advantage of using autologous tissue, it has the disadvantage of being time consuming and requiring more extensive dissection, and it is limited to small resections because of the small size patch. We have described a technique2 utilizing a bovine pericardial xenograft that is readily available and is not limited by the amount of venous invasion because it can be tailored to any given size, and it is applicable to both women and men. Furthermore, we have made tubular grafts with this material to replace the superior vena cava in the experimental model.3 The patency of this graft has been excellent both clinically and experimentally.2,3 This patch has been reported to have the longest patency in a survivor of colon carcinoma with hepatic metastases involving the IVC after its resection.2,4 On enhanced computerized tomography, the patch was indistinguishable from the native vessel. Pericardial patches have been extensively utilized for years in multiple intracardiac repairs in high- and low-pressure chambers with excellent results. In view of the above data, a pericardial bovine xenograft deserves strong consideration in these situations. The technique described by Kubota et al has a definite value when a pericardial patch is not available and the in-
volvement of either the IVC or portal vein is limited. Valves are usually present in these veins, and it may be advisable to remove them if found. The ovarian vein has a significantly thinner wall than the IVC and the possibility of aneurysmal dilatation should be kept in mind. Further collective data are needed prior to formulation of guidelines. Carlos Del Campo, MD Fullerton, California 1. Kubota K, Makuuchi M, Sugawara Y, et al. Reconstruction of the hepatic and portal veins using a patch graft from the right ovarian vein. Am J Surg. 1998;176:295–297. 2. Del Campo C, Konok GP. Use of a pericardial xenograft patch in repair of resected retrohepatic vena cava. Can J Surg. 1994;37:59 – 61. 3. Miyazaki M, Ito H, Nakagawa K, et al. Aggressive surgical resection for hepatic metastases involving the inferior vena cava. Am J Surg. 1999;177:294 – 298. 4. Del Campo C, Love J, Bowes F. Prosthetic replacement of the superior vena cava with a custom made pericardial graft: an experimental study. Can J Surg. 1992;35:305–309.
The Reply: We appreciate the kind comments of Dr. Del Campo regarding our article “Reconstruction of the hepatic and portal veins using a patch graft from the right ovarian vein” (Am J Surg. 1998;176:295–297). We have employed this type of patch graft in 2 patients. The patency of the reconstructed veins was confirmed by Doppler ultrasound or computed tomographic scan 10 and 6 months after surgery, respectively, suggesting that our technique guarantees long-term patency. We cannot agree completely that our technique has the disadvantages of being time consuming, requiring more extensive dissection, and being indicated only for small resections. Although it takes about 15 minutes to harvest the right ovarian vein following hepatectomy, it is not a time-consuming procedure in pancreatoduodenectomy. In both situations, vein harvest can be accomplished easily without any postoperative morbidity. Plasty of the right ovarian vein can be performed by residents on the back table. It is true that the indica-
THE AMERICAN JOURNAL OF SURGERY® VOLUME 179 JANUARY 2000
77