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Speaker 1 (00:00):
Hi everyone. Welcome to Hernia Talk Live. We are here on another Tuesday on Hernia Talk Tuesday. I’m joining you as Dr. Shirin Towfigh. You know me because all I do is hernia surgery and I love everything about hernias and hernia related topics. Today we will be joined by a lovely guest panelist. Before we go to his introduction, let me just let you know that many of you are here as a Facebook Live on at Dr. Towfigh. You’re also here by Zoom. And I’ll post the remainder of this hour, the recording on my Twitter and Instagram pages at Hernia doc and on YouTube. Shortly today, soon. Today we’ll be joining by Dr. Robert Martindale. Dr. Martindale is a professor and hernia surgeon at O H S U, which is the Oregon Health Sciences University. He is most well known for his work in the hernia field, specifically with the complicated ones. So patients that are dealing with Mesh infections, intestinal fistulas, he’s really one of the first surgeons to talk about how important it is to get the patient’s nutrition optimized so that they can heal these humongous wounds and infections. And what he is also very well known for is the ability to kind of rehabilitate patients to get over the hump of these big hernias. And here you are, Dr. Martindale. Hi. Hey, how are you? Were you in surgery?
Speaker 2 (01:40):
I literally, literally just ran out. Yeah.
Speaker 1 (01:44):
Okay. Well, good timing. I am. You’re a busy man. You’re an important man. Oh, no. Are they? This is why we have you on. It’s so nice to see you.
Speaker 2 (01:52):
Good to see you. How you been?
Speaker 1 (01:54):
I’ve been really, really good. We’ve been doing good hernia talk every week. We’re live on Facebook as a Facebook Live and on Zoom. Great. And we’ve been doing every week since the beginning of the pandemic, kind of in March, April, and so we’ve really loved it. Enjoyed it.
Speaker 2 (02:13):
That’s great. You look good. You look younger. I haven’t seen you for a while. The pandemic’s been good to you.
Speaker 1 (02:19):
It’s the neon lights. Thank you. Yeah,
Speaker 1 (02:23):
That’s very kind of you. Well, so I thought I know a lot about you because I’ve been following your talks and your literature and what you’ve written. We’ve met before, obviously we go to the same society meetings. I’m a big fan of you because surgical and surgical nutrition is a key part of having successful surgery, any surgery. But in particular, these really big complicated operations where the patients have been sick for a while and they’re denature no, they’re under rehabilitated and so on. So I’d like to be able to kind of focus a little bit on what you are most well known for, which is these really complicated hernia operations, but at the same time, making sure patients are appropriately prepared to successfully undergo these operations. Does that sound good?
Speaker 2 (03:16):
Yeah, that sounds great.
Speaker 1 (03:17):
And we have lots of patients already on board asking questions, but I do have some that were submitted ahead of time. And as they provide these questions, I’ll kind of go through and Sure. Read them to you and we can go from there. All right. So basically I already, I would love to have you kind of tell you just briefly the trajectory of your career today. How did you go from being a trainee in surgery to the type of practice you currently have?
Speaker 2 (03:53):
Okay. Well, it’s sort of a circuitous method. I did my PhD while finishing medical school. And so my PhD was in nutrition biochemistry. So that kept my nutrition interest, my metabolism, nutrition interest, which fit very well with nutrition, with the surgery. So when I finished my residency training, I was in the R I did my army payback time, and I truly was a general surgeon, a little bit of everything. And then I got on as chief of general surgery at the Medical College of Georgia where I spent 13 years and I did mostly their esophagus gastric. And of course I created my own hernias with some of that. And so when I moved to Oregon, about 17 years ago, I got here as chief of general surgery. And I looked around and I had a guy doing pure pancreas. Well, I’m not going to go after his business.
Speaker 2 (04:46):
I had two guys doing pancreas. My chairman was doing esophagus. So I said, well, I can’t do a esophagus. I go, what does no one want? And basically nobody wants those big fistulas and big complex hernias. Yes. So I started doing those because I didn’t want to encroach to my partners that I just came over as chief. And it’s been a fruitful career for me. I’ve really enjoyed it. I’ve been able to travel and teach and learn. I learn when I go travel. So it’s been a great career. So the last 15 years, probably 90% of my pr, 85% of my practice is hernia and abdominal wall things.
Speaker 1 (05:23):
Not much has changed. People still don’t want to do fistula.
Speaker 2 (05:26):
Yeah. Know I get ’em from all over the country. I had to get one 10 town now from Washington DC and I last week I do one from Chicago and I did a patient from Venezuela a couple weeks ago
Speaker 1 (05:39):
When I worked at the county, county, LA County, us. It’s the largest county hospital in the nation. And it’s basically patients that don’t have insurance or kind of fall through the cracks. We see those patients and unfortunately we see a lot of complications in that population. So I was official a lady, and I loved it because it was challenging and Oh yeah. Patients were so grateful and a lot of planning their life, but it’s a long process. You can’t just go to surgery and fix them. It’s a long process to get them ready for surgery, get their skin care under control, nutrition, under control, and then oftentimes it’s not one operation, it’s multiple stages of operations. Right. Yeah. Can you tell me a little bit about everyone on this hernia talk liver are patients, so can you describe what we mean by surgical nutrition? They just need to eat a good diet, or what do you mean when you say,
Speaker 2 (06:36):
Yeah,
Speaker 1 (06:37):
Surgical nutrition and optimizing that?
Speaker 2 (06:38):
Yeah. We’ve learned a lot about pre rehabilitation as a big catch word now, and that we see a patient who’s got some issues. Maybe they’re smoking, maybe they’re overweight, maybe they’re not eating much or eating the wrong things. And so we then would say, okay, we’ve got a make a time plan here and say, when do we want to get this surgery? Let’s take for example, my typical guy who’s smoking and maybe he’s 20, 30 pounds overweight, maybe B M I 40 45. Even. We learned the hard weight trying to do hernias with A B M I over 50 body mass index for those, that’s height, weight ratio. And that’s a disaster That has a hundred percent recurrence rate, as you know. Yeah. No matter what you do, you can do the best repair in the world with the best Mesh in the world and you’re still going to have a hundred percent recurrence.
Speaker 2 (07:25):
And we looked at that by looking at our databases, not just our own, we have a almost 7,000 patient database here, prospectively collected plus we added Mike Lee Yangs out of Houston, and we added John Roth out of Scott Roth out of electing Kentucky. So we had about 10,000 hernias, a little over 10,000 hernias. And you look at that, and sure enough, anybody over the BMI over 50 comes back within a year. So we don’t do elective cases with BMI over 50, 40 to 50. We try to get ’em to lose a little bit of weight if we can. We don’t, it’s not AMP mandatory, but we try and no. So usually it’s people under B M I of 40. So we get ’em ready, we get ’em on a high protein diet for about a month before surgery. We try ’em to exercise. If they can walk a block, we try to get ’em up to two blocks for before surgery.
Speaker 2 (08:20):
And we know that eating and then taking a walk gives you better protein deposition in your muscle. So we know that if you eat a protein meal, relatively high protein meal, mixed meal, but protein mainly, and then go on a walk, you take about 20% better protein update by the muscle. So we put ’em on that regimen. Yeah, we put ’em on that regimen. And if they have cirrhotic disease or other sort of frail patients, we also give them 20 grams of protein before they go to bed at night. We know that that helps them, especially the cirrhotic with some liver problems. And of course, we have a lot of hernias in liver patients.
Speaker 1 (09:01):
So when we talk about BMI, it’s a high rate high to weight ratio. So really anyone over 300 pounds pretty much should have some sort of weight loss. Yeah. Before they undergo hernia surgery and
Speaker 2 (09:13):
Yeah.
Speaker 1 (09:14):
Yeah, correct. And then depending on your height in the two 50 range to 300, also weight loss and the 200 to two 50 range depends on how tall you are, because LeBron James probably is over 200 pounds, but we would never tell him to go on a diet. But the point is that the more weight you have, two things happen. Number one is you have a lot of intraabdominal fat probably as well, which makes hernia repair tight and difficult and more like to fail. But you also have other problems like high sugars which affect healing. And also maybe you’re not active as much, which makes you high risk for problems. You may have a lot of skin fat, which adds to your risk for infections. So those are kind of reasons why you’re improving it. And interestingly, but I’d like you to comment on this, overweight, obese, morbidly obese patients are actually not like malnutrition. Actually malnutrition is what,
Speaker 2 (10:20):
Yeah. We know that. We know that 15% of people who are under undergo gastric bypass have at least two nutritional vitamin deficiencies. So we know that eating the wrong things are just as bad as, and I’m not a big advocate of huge amounts of vitamins, but we do patients that have a poor diet, we do give ’em a multivitamin, before surgery. The other thing about the obesity, which we don’t talk too much about is intraabdominal hypertension. We know that constant, if you’ve got extra weight on constant pressure, pushing out 24 hours a day, seven days a week is hard on a new hernia. It doesn’t allow it to heal as much. Also, and also ventilatory capacity, if it’s a very large hernia, when they push it in, we really increase intraabdominal pressure tremendously
Speaker 1 (11:07):
Breathing
Speaker 2 (11:07):
And increase as it pushes up the diaphragm that people don’t breathe as deep and the risk of pneumonia goes up. So there’s so many factors besides weight. And like you said, glucose, a lot of people that are overweight also have glucose trouble and a little bit of diabetes. And the stress of surgery causes that diabetes to raise its ugly head even more. And then once your blood sugar’s over 200, we know between 200- 220, the risk of infection doubles. And between 250 and 300, it triples, and over 300, virtually 70% of those patients will have some skin wound infection over their blood sugar’s over 300.
Speaker 1 (11:45):
And that’s really important because it’s not just a little skin infection because that’s what we’re talking about here, is that skin infection can then just be the tip of the iceberg and you can get a deeper infection. The skin, the muscle, the fascia, the Mesh, the sutures, and then the intestines.
Speaker 2 (12:02):
So yeah, we published some papers in 2015 and 2016 looking, we titled it the vicious cycle, the hernia vicious cycle. And once you get infected, that sets you up and then you get a recurrent one because bacteria, you have little enzymes in ’em that tear up the tissue, the proteases, the protein breakdown enzymes are there and they chew up that tissue and makes them very weak. And now you get another hernia within six months or a year. And then that high risk for infection, if you have one infection, we know that doubles your risk of infection for another infection. Heaven forbid you have synthetic Mesh there, then you know, got trouble. The measures got to come out. And it’s a big problem.
Speaker 1 (12:45):
Big problem. And one of the questions I ask my patients who come in with an incisional hernia, so they’ve had surgery and now they have a hernia from it is, did you have any wound complication or wound infection? Cause that’s a very big predictor of whether they will have a hernia at the same site. Let me ask you this about intestinal of fistula. Can you just quickly explain what of fistula is? And then why do we as hernia surgeons have to kind of know how to handle these? What’s the relation between hernias and intestinal fistulas?
Speaker 2 (13:18):
Yeah. Many of the fistulas arise from a hernia Mesh eroding into the intestine. So an fistula is a abnormal connection between your bowel and your skin. Sort of like a colostomy that somebody gets for cancer or something. They bring out the bowel comes out on the anterior abdominal wall and you put an appliance on there and you collect your stool into that bag. Well, a fistula is like one of those, but not controlled. It just leaks out all the places you don’t want it to leak. And sometimes they’re one, sometimes they’re 10 and sometimes there’s multiple. We got two admissions last night with fistulas, so they’re becoming very, very common as more and more of these meshes, some of the synthetic meshes are put in the wrong layer and eroded into the bowel. And so it’s very common. I average one and a half fistulas per week now.
Speaker 2 (14:13):
Wow. Yeah. So it’s a big problem. So it can either be eroding into the small intestine, which are a little to handle, or the large intestine. The colon almost always then requires a colostomy, at least temporarily until we get everything cleaned up. The Mesh that’s involved in it has to come out of the abdominal wall. And we usually do those in two stages. We then put them back together with just closing cleans up. And then the next day you take ’em back or next six months later you take ’em back and you close it with a good repair.
Speaker 1 (14:45):
Yeah, that’s a problem in that a lot of these, like you mentioned, the risks of intestinal of fistulas is that somehow it’s an issue directly related to the Mesh. So my question to you is, why do you think that is? Is it the Mesh is not correctly designed? Is the patient just at higher risk for getting fistulas, or is the surgical technique at issue or some combination of that?
Speaker 2 (15:14):
Probably all of those. I think the design, we’ve learned a lot about the design of Mesh. And I think the engineers sometimes do great job with their design, but sometimes they really mess up. We know that the ones that have these meshes are put in with two different sheets. One called GoreTex, like the same jacket. You’re making GoreTex jacket. And on top of that you put polypropylene, which is screen door material. We know that all synthetics and the abdominal walls shrink under the natural tissue growth and healing. So if you put two tissues, two synthetic meshes together, one shrinks more than the other one, guess what the one of those gets exposed? And what gets exposed is the polypropylene or send roads into the bowel. The other problem with that was they used, and sometimes they put a plastic ring in there, a plastic ring would break and the plastic is sharp and it would stick a hole in the bell. And I
Speaker 1 (16:17):
Probably, yeah, those Mesh have been recalled.
Speaker 2 (16:19):
They’ve been recalled, but there’s thousands of ’em still out there.
Speaker 1 (16:23):
So do you still people’s see the, do you still see the
Speaker 2 (16:25):
Fall injury ring? I had two last week. No kidding. They were the got perforated.
Speaker 1 (16:30):
Yeah, I had several back in the early two thousands.
Speaker 2 (16:33):
But yeah, they pulled ’em, I think 2009 they quit making the ring. But remember the average time from Mesh going in and having a major complication ends up being about seven years. So these are not things that you can get an infection within 30 days. But so that Mesh luckily is no longer on the market with the plastic ring. And yes, we still have some dual meshes that are combined, but most of our meshes now, we try not to put in the abdominal cavity as the current trend is to do what we call retrorectus, which correct. If you think of the abdominal wall is sort of a sandwich. And there’s one layer, the bowels are down here, there’s a layer on top of that, then there’s muscle, then there’s another layer. So what we do is take the bottom layer close to the bowel and close that and then put the Mesh in there so there’s not Mesh directly at close, approximate to the bowel,
Speaker 1 (17:30):
The Mesh design. And then also the education of the surgeon about the Mesh. I remember I got called into a case because a Mesh had been put in, and then after surgery there was stool coming out of the wound. And it was really early, within two or three days. And that Mesh that you’re talking about, the multi-layered Mesh, the GoreTex part is put to protect the bowel from seeing the polypropylene. But it’s not meant to be cut because if you cut it now the polypropylene is exposed
Speaker 2 (18:02):
To
Speaker 1 (18:02):
The edges. Yeah. So I went in and I looked at the surgeon, I said, did you cut this Mesh? And he said, yeah, because we, yeah, we cut Mesh. And I said, no, no, no. This Mesh is not meant to be cut. And that’s an education issue. So he now had basically a razor sharp edge against bowel and immediately, and those patients have horrible, very lengthy complications. So I assume you have a team, because this is daily wound care plus multiple trips to the operating room plus nutrition. How does your team work with that?
Speaker 2 (18:37):
Yeah, I have a great team. I literally could not work without ’em. I have my clinic team. I have a dietician full-time in the clinic, and I have a physical therapist full-time in the clinic. So every patient gets an individualized diet, an individualized exercise program
Speaker 2 (18:53):
Before they leave the clinic. And a lot of inguinal, little umbilical hernias don’t need that. But unfortunately those go to my partners nowadays and they send fistula my way. So there’s three of us now just doing pure abdominal wall. And it’s been a good group. So I have a very good team. I get in the operating room. We’ve got ostomy wound care nurses that are very good. Two of them are great. We have four, there’s two of them specifically in our team. And so it really takes an effort. We’ve got nurses, dieticians, physical therapists, and in many cases social worker who plans on rehab hospitals and skilled nursing facilities. And a lot of teaching goes on about how to take care of the ostomies, how to take care of the fistula. And a lot of times when people come in, they’re so malnourished and so sick, we takes us three months or six months, or if they come in two months, we can’t go back in their belly. Then they say we have to wait. And time is our friend. We wait at least six months before going back into the belly after some abdominal disaster.
Speaker 1 (19:57):
And that’s a lot of wound care and care to make sure you don’t fall backwards.
Speaker 2 (20:02):
And sometimes intravenous nutrition, they have to have total parental nutrition. That means all intravenous feeding for months.
Speaker 1 (20:09):
So do you also see underweight people because of this problem? And how do you handle underweight and maybe too sick to want to eat?
Speaker 2 (20:19):
Well, we see a lot of my patients have complications from bariatric surgery. They used to be 350 pounds and now they’re 85 pounds. And they come to our surgical nutrition clinic and we make a plan and either link them their one of the limbs of the bowel to give them more absorptive surface or we rearrange it or do something to give them a better absorptive surface. Sometimes in people that have had unfortunate twisting of their and loss of the bell, we have to take the whole thing down and reform the anatomy.
Speaker 1 (20:52):
Yeah. Yeah. That’s really crazy. How often, so you have a very busy practice. Fortunately, most surgeons don’t see that many fistula. Maybe a couple a year at the most. Yeah. Maybe in my practice I see a couple a year. Yeah. I do more kind of growing pain, chronic pain, but I’ll take care of the fistulas. I actually enjoy it. Cause I enjoy wound care and the kind of complexity of reconstructing the abdominal wall. But we don’t really get that many each year. Do you feel that in cases where Mesh is against the small intestine, there’s adhesions? Right? In any surgery you get scar tissue adhesions. What are the chances that will become ally? Like a fraction of a percent.
Speaker 2 (21:45):
Less than 1%? Yeah. Way less than 1%. So Mesh is not terrible. We have to have Mesh. Without Mesh, we’d be doing hernias every too many hernias, because Mesh clearly decreases the risk of hernias recurrent rate. So we really have to have Mesh. It’s just putting it in with the techniques, which we teach all of our residents. No wrinkles in the Mesh. It’s got to be flat, laparoscopic or robotic. Sometimes they put it in the belly. And we usually use a coated Mesh when we put it in the belly. We use a coated Mesh, not like the older ones, but the newer meshes are much more ready for that. And they’re able to be put in very safely. And without Mesh, we would be in bad shape.
Speaker 1 (22:27):
Yeah. They’re softer and better coating. Yeah,
Speaker 2 (22:29):
Softer. More pliable. Yeah. They’re coated. So the bowel won’t stick to ’em and make erosions. And we know now, but we have to put ’em in flat. We make sure we don’t have any wrinkles.
Speaker 1 (22:40):
Yeah, I, I’m a stickler about that. And I have residents that train with me and fellows, and sometimes they question why I’m such a obsessive about it because they go to other surgeons and it’s not as much of a thing they perseverate on. And I explain to them, because I see the patients that can feel the wrinkle or that wrinkle becomes a sharp edge and erode into small intestine and so on. And I always say, it’s fixing your bed. Some people are really good, like doing a perfectly, yeah, beautiful bed fixed when you go to the hotel and other just kind of like, eh. They just throw it over.
Speaker 2 (23:20):
Just cover the bedspread. Just cover it up. Yeah,
Speaker 1 (23:22):
Exactly. That’s how
Speaker 2 (23:24):
I make your
Speaker 1 (23:25):
Bed. Yeah. It’s a different attitude about certain things. How would someone know if they’re about to develop a fistula or if they’re at risk for a fistula or if they have a fistula?
Speaker 2 (23:35):
Well, those inguinal ones that come in 5-7 or 10 years later usually feel the – usually they have a fever, because what’s happened now is if the bowel is eroded, so they get a little abscess and that abscess eventually works its way out. And usually what happens is they get a little redness over the wound and they’ll go, whoa, I wonder what this is. And it’ll open and drains a puss doesn’t look like stool at first. They’ll go, gee. And then they’ll go to the doctor and they, oh, they give ’em some antibiotics and they treat it with some doxycycline or some augmentin. And then it does okay. It goes away for a while. And then about a month later after they stopped antibiotics, it comes back and does again. After about the third time they finally send it in, they say, look, we had a CAT scan. Do a CAT scan. You can see the infected scan fluid.
Speaker 1 (24:24):
Yeah. CT scale would show a little fluid whether it shouldn’t be Or gas bubbles. Yeah. Coming from the intestines that shouldn’t be there. Yeah. Do you normally give antibiotics for your hernia repairs at the time, yeah. Yeah.
Speaker 2 (24:39):
And that’s for our routine. We just give ancef. It’s a very inexpensive, very good one. We give adequate doses. For years until really 2015, we didn’t have good data on what the dosing should be. But now we know that we usually get two grams to everybody if email over 35 gets three grams. Because we know that the volume of distribution changes. And to get adequate tissue levels of antibiotics, we need to give higher doses now than we used to.
Speaker 1 (25:10):
And then with regard to the differences in care that you ta talked to me about, is the way that you approach and prep patients for surgery for abdominal wall hernias different than for the groin? No matter how complex?
Speaker 2 (25:25):
Pretty much the groin hernias can really be a challenge. Ones people that have had five or six or seven prior repairs, those are really a problem. And we would treat those with all the same things. An exercise eating program, dietary program. But most groin hernias, they come in, they’re here for an hour and a half, and they go home, they’re fine. They don’t need anything fancy. I make ’em all quit smoking. Even with groin hernias, I make ’em quit smoking. Cause I think smoking’s an really bad and hard and the abdominal wall.
Speaker 1 (25:57):
So yeah, the
Speaker 2 (25:57):
Nicotine, I only do two or three groin hernias anymore a week, no more than I, in fact, I did four last week in my residents are going, how can we get so many groin hernias, whether we’re all faculty members. So
Speaker 1 (26:12):
I get all, so on that note, you’re one of my contacts up in Oregon for tissue repair. There aren’t that many of us that do tissue repair for the groin. Yeah. What kind of tissue repair do you do for England? I
Speaker 2 (26:24):
Like to do Shouldice. I will occasionally do a McVay. Yeah, it depends. But shouldice is my most common. When I was in the Army, we did lots of tissue repairs. These young, healthy 18 year old kids with Inguinal hernia. And we used to do 5 or 10 every Friday. We did Friday was a hernia day. And we’d do, they all go home the same day. But then when I was leaving the Army, I’d done a lot of research and a lot of money came into the hospital from that research that I couldn’t take with me. So I decided I was going to go to all the places, the tissue repairs. I went to Miami to learn the hernia system, the prolene hernia system. Yeah,
Speaker 1 (27:05):
Gilbert.
Speaker 2 (27:06):
Yeah. I went to New Jersey to learn the patch and plug, and I went up to the Shouldice clinic and spent time at each one of those watching ’em do their hernias. I was going to figure I’m going to get good at this. And I like the Shouldice the best. Yeah. I’ve been back to the Shouldice clinic several times now for visiting professor, and it’s really a pleasure to go there. They do a very nice repair. Now, of course, it’s a modified Shouldice and the old timers, there’ll tell you, oh, we still do the original way.
Speaker 1 (27:37):
Yeah, they’re pretty amazing group over there. They’re excellent what they do. Going back to the fistulas, do you notice more fistulas in the open abdominal wall repairs than in the laparoscopic? Or does it make a difference?
Speaker 2 (27:51):
It doesn’t make a difference really. It seems like laparoscopic in general are smaller hernias. Usually they’re going on with a pretty good wide Mesh. They’re about the same
Speaker 1 (28:02):
Question. But again,
Speaker 2 (28:03):
I don’t want to give the impression that these fist are common. I think that very rare. They’re way less than one per, well, I think the data actually one out of about 600 or former fistula
Speaker 1 (28:16):
Of abdominal wall.
Speaker 2 (28:17):
Abdominal wall. Not the groin. Oh, the groin. I can only remember one or two of my life seeing from a groin. Groin Mesh. Yeah. Very seldom do you have trouble with mashing the groin. So
Speaker 1 (28:27):
There’s about 200, 250,000 abdominal wall hernias done per year. Most
Speaker 2 (28:33):
About three 50 small. Yeah, 350. About 350.
Speaker 1 (28:35):
Most of ’em are small. Of the big ones, a fraction of those. Less than 1% of those will get fistula. It’s a bad problem to have. And you should be going to people like you that are specialists and have an interest in it because it’s, it really overwhelms the system. Otherwise,
Speaker 2 (28:54):
Yeah, I made a mistake or whatever. I’ve given the lecture at the American College of Surgeons about five years ago on a current management of fistula. Yes. And my practice skyrocket. I mean, it was busy with fistulas before that. Obviously I was doing a lot. But after that, it’s become it’s, and they’re
Speaker 1 (29:18):
Like, great, we can send them all to you.
Speaker 2 (29:20):
Yeah. I got friends that’ll say, Bob, I’m sending you a case. I go, yeah, I know it’s a fistula. Right? And they go, yeah. I go, look, you could do this just as well as I can. They go, no, no, we don’t like visuals.
Speaker 1 (29:31):
Question about bariatric patients. Have you seen those who later developed gastroparesis and hernias? Are they related?
Speaker 2 (29:41):
Oh yeah. Gastroparesis. It depends what type of procedure they had. Of course, if they have just a pouch from a gastric bypass, that’s a little less likely. But they get small bowel dismotility commonly in their segment. That’s not being no Condon, no luminal nutrients going through. It’s not uncommon. That’s some of the patients we see in our nutrition clinic used to be 300 pounds and another 80 pounds and can’t gain weight.
Speaker 1 (30:10):
And what do you do for those who can’t gain weight?
Speaker 2 (30:13):
We do a full workup and look at their anatomy. We try to get motility studies done. We scope everything and figure out why are they not. They have bacterial overgrowth to what’s going on, and we many times have to operate on ’em and fix the, either put ’em back in continuity or sometimes, remember when they do gastric bypass a lot, essentially the vagus nerve, which controls emptying the stomach can controls just the small bowel all the way to most of the way through the colon, that if that’s disrupted, they can really mess up their intestinal problems.
Speaker 1 (30:47):
And if it’s not an intestinal absorption issue, it’s more of the appetite issue. Do you give them things to increase their appetite or cannabis?
Speaker 2 (30:54):
Yeah, we do. Those usually don’t cost much lean body tissue weight gain. We usually use prokinetic agents to try to get motility better. And then we use different type of absorptive drinks and things. They can usually get those. The mes and the marijuana derivatives, basically THC derivatives, they get more fat gain than they do muscle gain. We we’re looking for lean by tissue, which is protective.
Speaker 1 (31:24):
So you give them a ProConnect, which means it makes your stomach empty faster so you’re
Speaker 2 (31:28):
More hungry. Yeah. They makes the bowels move along a little bit better. Yeah.
Speaker 1 (31:31):
Well, that’s
Speaker 2 (31:31):
Very interesting. There’s some new ones now that are getting a little bit better.
Speaker 1 (31:37):
Okay. I’d like you to give me a little bit more information about your system with what we call enhanced recovery or pre rehabilitation. I’d love to hear if you have anything to share with the physical therapy that they get as well. But what’s the system they call you? They come and see you in the office? Or do you initiate something long? Do they send all your records to you first? How does the whole process work? Yeah.
Speaker 2 (32:05):
When they usually refer from another surgeon, the thoracic surgeons will have people that are frail or other major surgeon. The orthopod send in a lot of hip replacement, knee replacements that are frail. And the elderly patients come in. So we’ll see them. My dietician will review the records, look at their nutritional status, will send off some baseline labs, and then we design a protocol for every one of ’em. They’re pretty much just individually designed. The average patient gets a month of preoperative high protein diet with an exercise program. And then five days before surgery, they use an immune modulating formula. We use impact advanced recovery, but there’s another one that Abbott makes is very similar. So that’s got fish oils and arginine in it. The arginine is for enhancing the immune system and also vasodilating to new healing tissue. The fish oils in inhibit inflammatory phasix, but they also enhance resolution of inflammation and also decreases on the big belly cases and big chest cases decreases post-op arrhythmia.
Speaker 1 (33:11):
Wow, that’s pretty amazing. And is all that covered by insurance, or how do they pay for
Speaker 2 (33:16):
It is a lot of that. The drink is not too, five days of the drink is not too expensive. They can get that for $24 drop ship from Nestle 30 at the most. So that’s not a big deal. And we can get it paid for by insurance, but we got to write letters and wait and it’s not worth it. Correct. For years, I just paid for it out of my foundation money and just gave it to ’em. I’d always say, Hey, can you spend 30 bucks? Yeah. You got 30 bucks to buy this stuff. And they go, doc, I borrowed money to get my gas money here today. Yeah. I go find, get the head nurse’s office and take the case five days. It’s only five days worth and give it to ’em because we only paid 25 cents a can for this stuff. Oh, 30 cents a can. So it costs us $20, or it costs $15 and it costs them 30 if they go to buy it.
Speaker 1 (34:08):
So
Speaker 2 (34:08):
It’s cheaper to, I know a lot of orthopods, actually, a lot of orthopedic surgeons who use it pre-op for hip and knee replacements, they basically give it to ’em because they’ve shown, we’ve also shown here it’s cost effective for the hospital to give it to ’em. It decreases the infection risk.
Speaker 1 (34:25):
Wow. And where is your foundation? How can we donate money to it to help support
Speaker 2 (34:30):
It? Well, it’s just the OHSU Surgical Nutrition Foundation. Martindale. Yeah.
Speaker 1 (34:36):
Perfect. I’ll add the link to this.
Speaker 2 (34:38):
Okay, great. Thank you. Yeah, you, it’s done pretty well. We’ve been very, very lucky. We’ve had a lot of donors. Bob’s Red Mill, a good plug for him. He gave us a million dollars. Wow. Yeah. He just said, this is good work. I like this nutrition. It’s good for patients here. Basically, here’s a million dollars to use for research projects and healthy eating and
Speaker 1 (35:06):
Going back to the abdominal wall repair. So when you fix the fistula or remove the infected Mesh, first of all, do you agree all infected Mesh should be removed? There’s very little rules for
Speaker 2 (35:17):
Non, yeah. The biologics you can leave in. Biologics don’t rarely need removing. Cause they’ll be fine. The body either grows into them or the bacteria chew it up. Most synthetic infected meshes have to be removed. Now that being said, macroporous meaning real wide Mesh? Yes. Polypropylene, yes. You can probably not sterilize it, but you can probably knock the bacterial counts far enough that you can live with that. And in sick people that have a risky operation, I would just do that. But now, P T F E, the goretex, the like this coats, yeah, that has to come out. No way. You may sterilize it for 10 times, but it’ll keep coming back. Polyester meshes of the three general classes of synthetic meshes. So we have ptfe, which was very popular years ago, and really is very non-popular now. Yes. We don’t, I won’t put it on the shelf. If one of our surgeons, we had a whole bunch of surgeons, if one of ’em wants it, they have to call me and get the approval specifically.
Speaker 1 (36:22):
Good. You’re the hernia. Mesh are me too. Yeah.
Speaker 2 (36:24):
Well, yeah, the
Speaker 1 (36:25):
Inventories
Speaker 2 (36:25):
Are because they asked for these crazy things. They heard about it in the TV and they want to try it. Yes. Agreed. And then polyester, which is kind of fading polyester is really nice. It’s pliable. It rarely causes a fistula because it’s so soft. But the problem is, if that gets infected, it’s a braided polyester and that has to come out because the bacteria hide in those braids. But the polypropylene, the old Mac microports, a very dense, heavy screen dorm, material polypropylene that used to have to come out if it got infected. But the newer ones, the new macro wide meshes, the newer designs, they hold up pretty well. Even the face of infection.
Speaker 1 (37:08):
That’s pretty good. And then once you remove the infected Mesh, if there’s fistula, you fix the bowel. Now you have a big gaping abdominal wall. How do you repair that?
Speaker 2 (37:20):
Yeah, I would use a biological repair. I would use a biologic Mesh then. And there’s some really good ones. The best ones are the porcine, ace, serial dermal matrix there. Several companies make ’em ones a couple better than others. And those was that,
Speaker 1 (37:37):
Have you tried the hybrid Mesh?
Speaker 2 (37:39):
Yeah. Where we’re very lucky people always go when you join this prospective trials. So we’ve tried ’em all, I think.
Speaker 1 (37:46):
Yeah. And what are your thoughts on the hybrid Mesh where it’s mostly
Speaker 2 (37:49):
Biological? Yeah. The problem with the hybrid Mesh is, like you mentioned before, people, if you cut it, you’re now exposing between your biological member membrane. You’ve got synthetics in there, and now you’re exposing the edge of that to bacteria which will crawl in there. And we, we’ve had not very good success with the hybrids.
Speaker 1 (38:09):
Oh, really? Okay. Good to know. Good to know. And then do you see any patients that have Mesh reactions?
Speaker 2 (38:19):
I hate to say it, but a lot of times the Mesh people, the doctors will tell ’em, not again. The doctor will tell, oh, you, your body reacts to the Mesh and that means they got an infection. Yes, I agree. And of course, now I have had a guy, in fact that I just had a guy that works for Intel who can get the world’s literature to fingertips. He brought in some very compelling data that shows he had a Mesh reaction and showed his lab studies and everything. So I mean, he went to rheumatologist and they studied and he definitely had a Mesh reaction.
Speaker 1 (38:54):
But that’s pretty rare. It’s very rare. I have my own share of patients that are truly reacting to the Mesh material. But you’re right. In fact, it’s probably an infection in many patients. And what about this idea of a chronic, some people have not like overt poss or intestinal fistula stool coming out, but they have a chronic low-grade infection, so they’re always kind of sick and have joint pain and headaches. And the Mesh maybe was contaminated at one point and never really, man, the body’s constantly fighting it. Sure. Do you see that?
Speaker 2 (39:30):
Oh yeah. We measure CRPS routinely. Okay. Okay. And the C R P will almost always be elevated if we, that’s a C-reactive protein. It’s a measure of the body’s Rives for the people listening, a measure of the body’s response and tells us what’s going on inflammatory wise. So we measure a ratio of what they call pre albumin, which is your body’s ability to make good visceral proteins and muscle mass versus C R P, which is up when you have inflammatory focus. And that ratio tells us this patient’s got ongoing inflammation.
Speaker 1 (40:03):
Yeah, very true. Very true. And then when you’re prepping your patients, how do you deal with people that are diabetic? Do you tell ’em to endocrinologists to get their blood sugar down to a certain, what we call hemoglobin
Speaker 2 (40:18):
A1c. We routinely will not operate electively with the blood sugar above the of hemoglobin a1c above 7.5. Okay. Used to be eight, but now we say 7.5 and we’d like to see six. So we don’t really bother the endocrinologist much. We have very good diabetic educators that are nurses, nurse practitioners who do diabetes education. And if you’re diabetic, all of ’em go there. Now, most of our obese patients, the BMIs over 40, we draw hemoglobin A1C on those, and many of those will be diabetic. They’ll have a hemoglobin A1C above 7.5 or eight. So those, we get better control. What
Speaker 1 (40:58):
About people with this metabolic syndrome where they’re just got some insulin insufficiency? They don’t have those
Speaker 2 (41:03):
Insulin resistance? Yeah, insulin resistance. Well, classic. They’ve got a metabolic syndrome. Be hypertension, usually pretty big belly. And then that’s more common in Asian patients. Americans usually get metabolic syndrome, BMI of about 40 European and Western United States. But Asians get that metabolic syndrome, the whole thing. Hypertension, everything at about 35.
Speaker 1 (41:29):
And do you treat them the same, or is that not a significant risk for let’s say wound infections?
Speaker 2 (41:34):
Yeah, that we certainly, they’re at risk. It’s not so much hypertension, but the diabetes is at risk. We treat ’em like we would any other diabetic patient.
Speaker 1 (41:44):
And then when you do need to fix these hernias, you’re limited to using biologic Mesh. So biologic Mesh is absorbable, and it is therefore
Speaker 2 (41:55):
Most good biologics. If you don’t have an infection, your body will literally grow in. I think a biologic meshes as the framing of a house. And then your body grows in as a wiring in the plumbing. So it’s collagen structure that your body grows into,
Speaker 1 (42:13):
But it doesn’t have the strength of the structure like synthetic Mesh does. So
Speaker 2 (42:18):
Yeah, that’s true. It’s
Speaker 1 (42:20):
Probably that we don’t bridge it. We don’t do bridging. So do you do as much of an abdominal wall construction to be able to close the whole, and then you add the biologic as the extra?
Speaker 2 (42:35):
Yeah. What we would do is, for example, if they had an infection risk or had four or five comorbidities like diabetes and smoking. Yeah. Say it was emergent operation. We’ll do those and put biologics in a retro rector space, not in the belly, but one layer up. And those biologics usually do very well.
Speaker 1 (42:55):
At the county. We present our experience at the Pacific Coast Surgical Association, and I was young, I was the only one doing it. We were doing a single stage, so I would take out the infected Mesh, repair the hernia, and put in the biologic, and we had a higher recurrence rate than if we did in two stages. So now I do two stages. Two stages, the same hospitalization. So they get everything done infection wise, remove the infected Mesh, clean the tissue, et cetera. Then they get a wound vac put in an open abdomen wound vac, the apthera. Yeah. And they’re on the Fords with the binder, and I try and bring the tissues as close together as possible, change them back in maybe three days, and if it all looks good, I move on to the hernia repair. If it doesn’t look good, they get another three day cycle of the wound back, and then I put the biologic in and they do very well.
Speaker 2 (43:57):
That’s basically our protocol. What
Speaker 1 (43:58):
Do you do?
Speaker 2 (43:59):
Yeah. Yeah. Very, very similar. Usually we’ll go back at four eight to seven two hours with the wound back, so we’ll clean everything out. We’ll do pulse lavage. Yes, that date is a little gray pulse lavage or not, but that means a little spray. It’s like your shower. And so we pulse lavage a tissue and then clean it all up and then give ’em 48 to 72 hours, bring ’em back post lavage again. It looks great. Repair then. Yeah. Sometimes you say, sometimes we say it’s just too dirty, the tissues are bad, let’s come back in months. It’s closing primarily or bridging with a biologic sometimes and come back in six months.
Speaker 1 (44:37):
In those cases, you use a pure biologic or something more like a biological
Speaker 2 (44:41):
For bridging, I use pure biologic because I don’t want that bowel eroding up against that synthetic.
Speaker 1 (44:47):
Yeah, yeah, absolutely. It’s actually a very good biologic dressing to cover.
Speaker 2 (44:52):
Yeah. I still use occasional, if it’s real dirty, I’ll use AlloDerm thick, which is human skin. And that is very resistant to, it grows in fast and you can skin graft it. If the skin breaks down over the top, you can skin graft it very fast.
Speaker 1 (45:08):
Our past experience was always with, I think still remains the most resistant to infections,
Speaker 2 (45:17):
And you can skin graft it in three weeks. It grows in so fast, the body absorbs into that and grows in. Yeah.
Speaker 1 (45:24):
So if you would like to, oh, here we have another question. Is an ultrasound better or a CAT scan looking for these problems? What do you use?
Speaker 2 (45:37):
CAT scan. CAT scan. I’m trained in ultrasound, and it still looks like squiggly lines to me when I’m trying to look at layers of abdominal wall. You can see
Speaker 1 (45:48):
In a
Speaker 2 (45:48):
Good radiologist, yeah, good radiologist can still tell me things, but a CAT scan I can read and I can see what I’m doing. Yeah. I can look at all three dimensions and a,
Speaker 1 (46:00):
I think for any abdominal wall hernia or Mesh question, CT scans the best. But for the groin, in the pelvis, I use MRI because that’s gives you much more details. And then you really need a highly specialized ultrasonographer to get good data, which sounds
Speaker 2 (46:20):
Now they ultrasound in the groin. Okay. Yeah. But it’s still MRI if you’re worried about bones or a sport attorney or something like that.
Speaker 1 (46:29):
Yeah, I agree. Well, were you doing a fun case before you ran over here?
Speaker 2 (46:35):
Yeah, I had a big fistula. The case, yeah.
Speaker 1 (46:37):
Okay. Very good. And your residents probably get excellent training from that because you learn so much from one fistula patient. Oh,
Speaker 2 (46:46):
Yeah. Learn the fluid and left leg balance and everything else. Absorbative capacity and all that sort of thing.
Speaker 1 (46:53):
Yeah. Do you work with plastic surgeons as well, or is it mostly
Speaker 2 (46:56):
Yeah, the third year plastics fellows or second year plastic. A third year now third year residents, which are plastics is two years general on three years of plastics now, or a five year and then plus two. Yes. So either way, they come and spend a couple months with us on general surgery, abdominal wall service. Yeah. And they want to do the fellows, the minimally invasive surgery, want to learn laparoscopic component release. They’ll come over and we’ll teach ’em that, so,
Speaker 1 (47:27):
Okay, very
Speaker 2 (47:28):
Good. Yeah, we have a very big surgical program. In fact, we’re the biggest surgical program in the United States. You’d never suspect that from Portland, but we graduate 13 chiefs a year.
Speaker 1 (47:37):
Oh, wow. Yeah, it used to be
Speaker 2 (47:40):
Baylor,
Speaker 1 (47:40):
Baylor, Texas. Yeah. Yeah.
Speaker 2 (47:42):
And they have 12.
Speaker 1 (47:43):
Yeah. Ooh, you ethibond by one. Yeah, that’s pretty huge. We actually increase a lot at Cedar Sinai. When I first got here 2008, we had four residents, I think up from three. Now we have six. Yeah. So it’s a pretty Are
Speaker 2 (47:56):
They out of UCLA or are they straight at Cedars?
Speaker 1 (47:59):
Straight? Yeah. The department surgery is straight out of Cedars. Yeah. So UCLA’s nearby. That’s where I trained for my residency. Different program, but education wise, sometimes we join forces like for mock orals. Yeah, that’s really fun to do. So the Cedars faculty questioned the UCLA residents and their U slave faculty questioned the Cedars residents. So that’s
Speaker 2 (48:23):
Really fun. Yeah. I was down in Cedars about five year, four or five years ago at Cape Ground Rounds. I like to go to that little restaurant there. Ivy, I think it’s called.
Speaker 1 (48:32):
Yeah, there was Ivy, and then there was another one that I think I, I had lunch with you there. Yeah, they shut that one down, but the Ivy’s still there. Oh. You can sit next to Madonna and the Kardashians at the Ivy, they’re still open. It’s outdoor thing with Covid. It’s still safe. Yeah. I love it. Couple questions about infections. Again, if someone has had a prior wound infection and now they need another hernia pair in the area, do you change how you handle your antibiotic dosing?
Speaker 2 (49:04):
Yeah, I see what the dosing, I see what the antibiotics were. I see what the bacteria was we were dealing with. It was routine staff. I would then, I just Hillsborough Connor, wait something. Okay. Excuse me. Sorry. Yeah, I would say I, I treated them as pretty much the same unless they had unusual bacteria with Mr. S A in the wound. Yeah. I of course then go to Bacom
Speaker 1 (49:35):
Vancomycin. Yeah. Got it. And then when you operate, do you prefer to use the monofilament suture as opposed to berated suture for the same infection or no?
Speaker 2 (49:45):
Yeah, absolutely. I rarely, I use almost all absorbable suture now. I rarely use prolene unless I’m sewing Mesh to Mesh, then I use Prolene.
Speaker 1 (49:55):
Yes.
Speaker 2 (49:55):
Yeah, that’s one. But I use Maxon or PDs, which goes away. And sometimes when they fix the Mesh and those, they hurt a little bit there because they’re pulling through. It’s going through muscle, and they’ll feel a little cramping or get a little cramp. And that’s good because it goes away in about 60 days. I go, don’t worry. Hang in there. It’s going to go away. In the old days, we get a prolene, it hurts. They’ll say, doctor hurts right here. And so then you got to fish out a prolene.
Speaker 1 (50:21):
Have you found any relationship between diastasis recti and any fistula problems?
Speaker 2 (50:29):
No. No. Diastasis, I think if they’re big and there’s no true hernia with the diastasis, I sent it a plastic surgery. Yes, that’s correct. If there’s a hernia with it, if in about 80% of the time they’ll have a small umbilical hernia with it, then I’ll fix those. But I fixed the entire thing because I don’t like, I want to, because the minute you make that hernia tight, it’s going to get a hernia above that, so you have to fix the whole thing. So there’s equal distribution attention along the entire wound.
Speaker 1 (51:00):
That’s absolutely right. So people with diastasis are higher risk for getting an umbilical hernia within that, only because it’s just so thinned out. And diastasis recti actually is quite genetic too. Yeah. I wonder, I don’t know if it’s related to the hernia kind of genetic profile, but because hernias are also genetic, but it seems that the,
Speaker 2 (51:25):
Yeah, we don’t see ’em in people with collagen issues like triple a’s and things, but we do see them in families. Yeah.
Speaker 1 (51:33):
Yeah. Absolutely. All right. Well, everyone’s been very, very thankful. Another question, I’ve had four layers of Mesh, right? Inguinal, I’ve never stopped smoking or drinking at 22. I’m now 58. I’m not overweight. I’ve had recurrent hernias, but every test I have had shows nothing. Well, first of all, before you do, if you do have a recurrent hernia, please, the smoking needs to stop. You’ve already failed hernia before, and the nicotine really affects the way that you heal. And the collagen, any of the comments on someone who may have a hernia recurrence and, oh, sorry. I’ve never smoked and stopped drinking at 22. Oh, good for you. Then. As long as you’re not overweight, what are the risk factors? You look at overweight, diabetes, your
Speaker 2 (52:25):
Weight, diabetes, smoking. Yeah. Those nicotine chronic C O P D, that’s bad for groin. Those are the big ones. And now in that case, he may have a collagen issue. We know that there’s a small percentage of people that do have the abnormal collagen wound dealing. Yes. And if he had four repairs, never smoked, and he’s thin, he’s probably got a collagen issue. Now the question is, what does that mean? Because there’s now 36 types of collagen. So how do we fix that? We don’t, there’s no way. Don’t, you can’t put a gene in that’s going to give better collagen, so we end up just repairing ’em the same. We just are more, we might put a little heavier Mesh and put it a little wider, but we do it the same
Speaker 1 (53:07):
Anyway. We do have to change our technique just slightly to make sure you’re not repeating the same problem. Yeah, more than once. Yeah. Okay. So on that note, everyone’s been very thankful. One participant says, thank you for a very informative session. It just shows how complicated hernias really are and that no one person’s situation Yeah. Is the same. Yeah. Very, very true. All right. I know you have sick patients to go after. I would like to Thank you, Dr. Martindale. Okay. For your time. Always love listening to you and learning.
Speaker 2 (53:38):
Oh, good to see you again. Glad to do
Speaker 1 (53:40):
It. Thank you. And thanks everyone for joining me for Hernia Talk another Tuesday live with your questions. I will post this on YouTube and Facebook, Instagram, and Twitter, so you can all watch it again and share. Thank you, Dr. Martindale. Okay. Thank you. Appreciate it. And I’ll see you later. See you later. Thank you. Okay.
Speaker 2 (54:01):
Bye-bye. Take care. Thanks for asking me. Bye-bye. Bye-bye.
