Obesity is a major risk factor for perioperative morbidity, especially for patients undergoing complex incisional hernia repair. The feasibility and effectiveness of medical weight loss programs prior to complex abdominal wall reconstruction have not been well characterized. Here, we report our experience collaborating with a medical weight loss specialist utilizing a protein sparing modified fast in order to optimize weight loss prior to complex abdominal wall reconstruction. Morbidly obese patients (body mass index (BMI) > 35 kg/m(2)) evaluated by our medical weight loss specialist prior to complex ventral hernia repair were identified within our prospective database. Our primary outcome measure was the amount of weight lost prior to surgical intervention. Our secondary outcome measure was to determine the maintenance of weight loss during long-term follow-up after the surgical intervention. A total of 25 patients with a BMI > 35 kg/m(2) were evaluated by our medical weight loss specialist prior to undergoing a planned incisional hernia repair. The mean weight of the patients preoperatively was 128 kg ± 25 (range 96-205 kg) (mean ± standard deviation), and the mean BMI was 49 kg/m(2) ± 10 (range 36-85). After completion of the preoperative modified protein sparing fast, the mean preoperative weight loss of the group was 24 kg ± 21 (range 2-80 kg). The overall change in BMI for the group prior to surgery was 9 kg/m(2) ± 8 (0.6 to 33). The percentage of excess BMI loss and total BMI loss preoperatively was 37 % ± 23 (2 to 83) and 18 % ± 12 (1 to 43), respectively. Of the 24 patients that initially lost weight in the program preoperatively, 22 (88 %) successfully maintained their weight loss for the entire study period for an average of 18 months. Collaboration with a medical weight loss specialist and a surgeon with a structured approach using a modified protein sparing fast can successfully result in meaningful weight loss prior to complex abdominal wall reconstruction. The majority of patients in this study were able to maintain their weight loss during long-term follow-up. Utilization of a protein sparing modified fast in collaboration with a medical weight loss specialist is a valuable resource for guiding weight loss in patients with morbid obesity prior to elective complex surgical procedures.
Background Infection remains a dreaded complication after implantation of surgical prosthetics, particularly after hernia repair with synthetic mesh. We previously demonstrated the ability of a newly developed polymer to provide controlled release of an antibiotic in a linear fashion over 45 days. We subsequently showed that coating mesh with the drug-releasing polymer prevented a Staphylococcus aureus (SA) infection in vivo. In order to broaden the applicability of this technology, the polymer was synthesized as isolated “microspheres” and loaded with vancomycin (VM) before conducting a non-inferiority analysis. Materials and Methods Seventy-three mice underwent creation of a dorsal subcutaneous pocket that was inoculated with 104 CFU of green fluorescent protein (GFP)-labeled SA (105 CFU/ml). Multifilament polyester mesh (7*7mm) was placed into the pocket and the skin was closed. Mesh was either placed alone (n=16), coated with VM-loaded polymer (n=20), placed next to VM-loaded microspheres (n=20) or unloaded microspheres (n=10), or flushed with VM solution (n=7). Quantitative tissue/mesh cultures were performed at 2 and 4-weeks. Mice with open wounds and explanted mesh were excluded. Results Twenty-two of twenty-three (96%) tissue-mesh samples from mesh alone or empty miscrospheres were positive for GFP-labeled SA at two and four-weeks. Six of seven (86%) samples from the VM flush group were positive for GFP SA at 4 weeks. Thirty-eight of thirty-eight (100%) VM-loaded pCD-coated mesh or VM-loaded microspheres were negative for GFP SA at two and four weeks. Conclusion Slow affinity based drug-releasing polymers in the form of microspheres are able to adequately clear a bacterial burden of SA and prevent mesh infection.
Among patients with critical limb ischemia and noncompressible ankle brachial index results, the prevalence of occlusive tibial and pedal arch disease is very high. Toe brachial index <0.7 is more sensitive in diagnosing occluded and significantly stenotic tibial artery disease in these patients compared with ankle pulse volume recording.
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