B L Pratt

Carolinas Medical Center University, Charlotte, North Carolina, United States

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Publications (13)23.56 Total impact

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    ABSTRACT: Because herniorrhaphy failure and complication rates appear proportional to the number of previous repairs, multiply recurrent hernias (MRH) represent a formidable challenge. We sought to determine the safety and efficacy of open preperitoneal retrofascial mesh repair of MRH. We conducted a retrospective review of consecutive patients undergoing an open preperitoneal retrofascial mesh repair of multiply (two or more) recurrent hernias at a tertiary care referral center. From January 2001 to May 2005, 128 patients underwent surgical repair of an MRH; 32 of these underwent an open preperitoneal repair. The average body mass index was 39.1 +/- 8.4 kg/m2 (range 28.9 to 61.0 kg/m2). All patients had significant comorbidities; 18.8% were smokers. The number of previous herniorrhaphies was 3.6 (range 2 to 24). Polypropylene mesh was used in all patients, including lightweight polypropylene in 10 (31.2%) patients. The average mesh size was 937 +/- 531 cm2 (range 225 to 1,800 cm2). There were no major intraoperative complications. Wound infection occurred in 4 patients (12.5%, all smokers), requiring partial mesh excision in 1 patient. Univariate analysis revealed smoking as the only predictor of wound or mesh-related morbidity (p = 0.0004). At a mean followup of 28.1 months (range 8 to 60 months), there has been 1 recurrence (3.1%) in the patient requiring partial mesh removal. Open preperitoneal retrofascial mesh repair resulted in an effective herniorrhaphy with low perioperative morbidity in patients with MRH. Smoking cessation appears to be important in minimizing infectious complications. Given the technical challenge, surgical care of patients with MRH may be best provided in referral centers with interest and expertise in complex hernia repairs.
    Journal of the American College of Surgeons 10/2006; 203(3):283-9. · 4.50 Impact Factor
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    ABSTRACT: The development of intra-abdominal adhesions, bowel obstruction, and enterocutaneous fistulas are potentially severe complications related to the intraperitoneal placement of prosthetic biomaterials. The purpose of this study was to determine the natural history of adhesion formation to polypropylene mesh and two types of polytetrafluoroethylene (ePTFE) mesh when placed intraperitoneally in a rabbit model that simulates laparoscopic ventral hernia repair. Thirty New Zealand white rabbits were used for this study. A 10-cm midline incision was performed for intra-abdominal access and a 2 cm x 2 cm piece of mesh (n = 60) was sewn to an intact peritoneum on each side of the midline. Two types of ePTFE mesh (Dual Mesh and modified Dual Mesh, W.L. Gore & Assoc., Flagstaff, AZ) and polypropylene mesh were compared. The rate of adhesion formation was evaluated by direct visualization using microlaparoscopy (2-mm endoscope/trocar) at 7 days, 3 weeks, 9 weeks, and 16 weeks after mesh implantation. Adhesions to the prosthetic mesh were scored for extent (%) using the Modified Diamond Scale (0 = 0%, 1 <or= 25%, 2 = 25-50%, 3 > 50%). At necropsy the mesh was excised en bloc with the anterior abdominal wall for histological evaluation of mesothelial layer growth. The mean adhesion score for the polypropylene mesh was significantly greater (P < 0.05) than Dual Mesh at 9 weeks and 16 weeks and modified Dual Mesh at 7 days, 9 weeks, and 16 weeks. Fifty-five percent (n = 11) of the polypropylene mesh had adhesions to small intestine or omentum at necropsy compared to 30% (n = 6) of the Dual Mesh and 20% (n = 4) of the modified Dual Mesh. There was a significantly greater percentage (P < 0.003) of ePTFE mesh mesothelialized at explant (modified Dual Mesh 44.2%; Dual Mesh 55.8%) compared to the polypropylene mesh (12.9%). Serial microlaparoscopic evaluation of intraperitoneally implanted polypropylene mesh and ePTFE mesh in a rabbit model revealed a progression of adhesions to polypropylene mesh over a 16 week period. The pore size of mesh is critical in the development and maintenance of abdominal adhesions and tissue ingrowth. The macroporous polypropylene mesh promoted adhesion formation, while the microporous nature of the visceral side of the ePTFE served as a barrier to adhesions.
    Journal of Surgical Research 10/2003; 114(2):126-32. · 2.02 Impact Factor
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    ABSTRACT: Laparoscopic suturing is required to develop competency in advanced laparoscopy. Manuals detailing laparoscopic suturing were give to 17 Surgery residents. One week later they performed a suture on a training model. Time (s), accuracy (mm), and knot strength (lb) were recorded. The residents were blindly randomized to intervention (n = 9) and control (n = 8) groups. The intervention residents attended a 60-min course with lecture, video, and individual proctoring. Two weeks later they performed a stitch with standard laparoscopic instruments and a stitch with a suturing assist device. Statistical analysis included a Wilcoxon rank-sum test. The intervention residents decreased their suturing time from the first to the second stitich (732.4-257.6s), the control and residents decreased their time from 500.2 s to 421.8 s. The time required to perform the second stitch showed no significant difference between the two groups (p = 0.46), but the difference in reduced time between the first and second stitch was significant (p = 0.001). Using the suturing assist device for the third suture, the intervention and control groups both decreased their times significantly. The control residents performed almost as quickly as the intervention residents with the suturing; device (p = 0.11). Accuracy and knot strength were not different in any test. Residents can improve suturing skill with a short didactic course and individual proctoring. A suturing assist device decreases time required by inexperienced surgeons to device perform an intracorporeal tie.
    Surgical Endoscopy 01/2003; 16(12):1729-31. · 3.43 Impact Factor
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    ABSTRACT: The purpose of this study was to investigate the effects of early adhesiolysis on long-term adhesion formation after the intraperitoneal implantation of polypropylene (PP) mesh and expanded polytetrafluoroethylene (ePTFE) mesh in a rabbit model. Through a small midline laparotomy a 2 x 2-cm piece of mesh (n = 80) was sewn to an intact peritoneum on each side of a midline incision in 40 New Zealand White rabbits. Two types of ePTFE mesh [Dual Mesh (Dual) and modified Dual Mesh (C-Type), W.L. Gore and Associates, Flagstaff, AZ] and PP mesh (Marlex, C.R. Bard, Murray Hill, NJ) were compared. In 10 rabbits (n = 20) a laparoscopic adhesiolysis (LapA) was performed at one week. Mesh adhesions were scored using a modified Diamond scale (0, 0%; 1, 1-25%; 2, 26-50%; and 3, > 50%) at 1, 3, 9, and 16 weeks by serial microlaparoscopic (2 mm) examinations. After recording the final adhesion score at 16 weeks the prosthetic biomaterials were excised en bloc with the anterior abdominal wall for histologic evaluation of mesothelial layer growth (%) on the visceral surface of the mesh. Statistical differences (P value < 0.05) were measured by chi-square and Wilcoxon signed rank tests. There were no statistical differences in mean adhesion scores at adhesiolysis at 7 days. The mean adhesion scores in the groups undergoing laparoscopic adhesiolysis was statistically less (P < 0.05) for PP and both ePTFE meshes at 3-, 9-, and 16-week intervals compared with those not undergoing adhesiolysis. The percentage of mesothelialization on the visceral surface of the mesh was not statistically different between the adhesiolysis and control groups for any of the prosthetic biomaterials. Laparoscopic adhesiolysis at one week minimizes subsequent adhesion formation to PP and ePTFE mesh over a 4-month follow-up. Adhesion formation within the first 7 days after mesh implantation appears to determine the long-term adhesion score. Eliminating adhesions to mesh by mechanical or other means during this critical time may control adhesions to the mesh and subsequent mesh-related complications.
    The American surgeon 12/2002; 68(11):936-40; discussion 941. · 0.92 Impact Factor
  • The American surgeon 08/2002; 68(7):652. · 0.92 Impact Factor
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    ABSTRACT: Gastric stromal tumors are rare neoplasms that may be benign or malignant. Given that malignant gastric stromal tumors rarely involve lymph nodes and require excision with negative margins, they appear amendable to laparoscopic excision. There are few reports of laparoscopic resection, and no comparisons have been done between laparoscopic and open surgery. This study compares the relative efficacy of the two approaches. Between May 1994 and December 2000, 33 patients underwent 35 operations for gastric stromal tumors. Laparoscopic resections were performed in 21 patients; open resections were done in 12 patients. The medical records of the patients were reviewed retrospectively with regard to operating time, blood loss, length of stay, and clinical course. Patient demographics, tumor characteristics (mean tumor size, benign vs malignant), and presenting symptoms were similar for both groups. In the laparoscopic group, 15 wedge resections; three partial gastrectomies, and three transgastric needlescopic enucleations were performed. In the open group, six wedge resections, four antrectomies, and two partial proximal gastrectomies were performed. There were no significant differences in mean operative time (169 vs 160 min), mean estimated blood loss (106 vs 129 cc), or perioperative complication rate (9.5% vs 8.3%) between the laparoscopic and open groups, respectively. The mean length of stay was significantly less (p<0.05) in the laparoscopic group (3.8 vs 6.2 days). Average follow-up was 1.5 years. One patient in each group has died due to metastatic disease. There have been no trocar site recurrences. Laparoscopic resection of gastric stromal tumors is safe and appropriate. Tumor size, operating time, and estimated blood loss were equivalent to the open approach, and there was a statistically shorter hospital stay in the laparoscopic group.
    Surgical Endoscopy 05/2002; 16(5):803-7. · 3.43 Impact Factor
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    ABSTRACT: The extent of lateral spread of tissue injury is important in the success of a primary anastomosis. We compared the injury produced by the Laparo-sonic Coagulation Shears and the Ligasure system. Ureters were harvested from domestic farm pigs and ligated with the Laparo-sonic (N = 13) or Ligasure (N = 9) system. The tissues were then fixed, stained, and examined by two pathologists without knowledge of the type of treatment. The mean length of thermal damage from the Ligasure was 2.11 mm (range 1.0-4.0 mm) whereas it was 1.92 (range 0.5-4.25 mm) from the Laparo-sonic system. The difference is not statistically significant. Debridement of as much as 5 mm of each cut end produced by the Laparo-sonic or Ligasure system may be beneficial in reducing stricture and leak.
    Journal of Laparoendoscopic & Advanced Surgical Techniques 03/2002; 12(1):61-3. · 1.07 Impact Factor
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    ABSTRACT: The development of practice guidelines is an effective way to provide consistent and cost-effective patient care. Despite much progress in developing practice guidelines for various other clinical problems data documenting the efficacy of these guidelines are lacking. The purpose of this study was to compare usage patterns and cost effectiveness of a stress ulcer prophylaxis guideline in a trauma intensive care unit. The trauma intensive care unit team was observed for a 50-day period. Immediately after this period a stress ulcer prophylaxis guideline was implemented, and the team was again observed for a 50-day period. All information was recorded prospectively. The trauma intensive care unit team was blind to the existence of the study. The days of appropriate use of prophylaxis (ulcer prophylaxis prescribed per the practice guidelines) and inappropriate use (use other than per the practice guidelines) in each study phase and the resulting costs were calculated as the primary measurement of outcome. Forty-six patients were studied. The use of practice guidelines in the period after the guideline was implemented of the study reduced overall stress ulcer prophylaxis by 17 per cent (P = 0.04). The appropriate prophylaxis was not significantly different when comparing the two periods of study; however, inappropriate use of prophylaxis (and associated charges) was statistically significantly less frequent after implementation of the practice guidelines. No patients developed clinically important gastrointestinal bleeding. The estimated annual savings of $102,895 in patient charges and $11,333 in actual drug costs in our trauma intensive care unit were due to the implementation of stress ulcer prophylaxis guidelines. We conclude that use of practice guidelines can significantly reduce patient charges without compromising patient care.
    The American surgeon 03/2002; 68(2):146-50. · 0.92 Impact Factor
  • Problems in General Surgery 01/2002; 19(4):73-83.
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    ABSTRACT: Advancements in laparoscopic surgery are often dictated by the limitations of technical instrumentation. Energy sources other than electrosurgery have become popular with the promise of quick and effective vascular control. With their success surgeons have begun using these on structures other than blood vessels with little or no data establishing their efficacy or safety. This study evaluates alternative energy sources in sealing ductal structures for possible use in liver or gallbladder surgery. After elective cholecystectomy cystic ducts (n = 45) were resealed ex vivo with surgical clips (n = 14), ultrasonic coagulating shears (n = 16), or electrothermal bipolar vessel sealer (n = 15), and bursting pressures were measured. Nineteen additional human cystic ducts were randomized to seal by ultrasonic coagulating shears (n = 9) or electrothermal bipolar vessel sealer (n = 10) and fixed in 10 per cent buffered formalin for histologic evaluation of thermal spread (mm). After this nine adult pigs were randomized to laparoscopic ligation and transection of the common bile duct using surgical clips (n = 3), ultrasonic coagulating shears (n = 3), or electrothermal bipolar vessel sealer (n = 3). The animals underwent necropsy for assessment of seal integrity on the sixth postoperative day. In the ex vivo study the mean cystic duct bursting pressure was 621 mm Hg with surgical clips and 482 mm Hg with the electrothermal bipolar vessel sealer (P = 0.39). The mean cystic duct bursting pressure after ultrasonic coagulating shears was 278 mm Hg, which was statistically less than surgical clips (P = 0.007) and electrothermal bipolar vessel sealer (P = 0.02). The mean thermal spread was 3.5 mm for ultrasonic coagulating shears and 13.4 mm for electrothermal bipolar vessel sealer (P = 0.0002). All animals undergoing ligation and transection of the common bile duct with ultrasonic coagulating shears and electrothermal bipolar vessel sealer developed bile peritonitis by postoperative day 6 as a result of seal leak. All animals undergoing surgical clip ligation and transection of the common bile duct maintained seal integrity. The mean common bile duct pressure above the surgical clip was 12 mm Hg (range 10-14). In conclusion the acute ex vivo study demonstrated a significant difference in the cystic duct bursting pressure between surgical clips and ultrasonic coagulating shears and between electrothermal bipolar vessel sealer and ultrasonic coagulating shears. The ultrasonic coagulating shears and electrothermal bipolar vessel sealer failed to maintain seal integrity in the in vivo animal study. Given the failure of the ultrasonic coagulating shears and electrothermal bipolar vessel sealer in the animal model these energy sources should not be used for transection of the cystic duct or major hepatic ducts during hepatobiliary surgery.
    The American surgeon 10/2001; 67(9):901-6. · 0.92 Impact Factor
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    ABSTRACT: An electrothermal bipolar vessel sealer (EBVS; Ligasure, Valleylab, Boulder, CO, USA) was developed as an alternative to suture ligatures, hemoclips, staplers, and ultrasonic coagulators for ligating vessels and tissue bundles. The EBVS seals vessels up to 7 mm in diameter by denaturing collagen and elastin within the vessel wall and surrounding connective tissue. This study is the first to determine the clinical efficacy and safety of this instrument and delineate its potential timesavings in both experimental (animal) and clinical scenarios. A prospective review of the author's clinical experience with the EBVS in laparoscopic and open operations from October 1998 to March 2000 was performed. In addition, five Yorkshire domestic pigs underwent 150-cm small intestine resections (n = 10) using the EBVS (n = 5) and suture ligatures (n = 5). Measurements included time to complete intestinal resection, the number of applications per minute for each method, and the presence of postapplication bleeding. Statistical analysis was performed using Student's t-test. The EBVS was used in 98 cases (46 laparoscopic and 52 open) with a mean of 43 applications (range, 10-150 applications) per case. The operations included 53 colon and/or small bowel resections (54.1%), 24 fundoplications (24.5%), 12 gastric resections (12.2%), 3 splenectomies, 2 pancreatectomies, 1 adrenalectomy, 1 bilateral salpingo-oopherectomy, 1 pancreatic cyst-jejunostomy, and 1 vagotomy with gastrojejunostomy. In all these cases, the EBVS was intended to be the only means of vessel ligation. An alternative ligation technique was required for bleeding in only 13 (0.3%) of more than 4,200 applications of the EBVS. No postoperative hemorrhagic complications occurred. There was an estimated mean reduction in operative time of 39 min per open procedure, and a mean prolongation in operative time of 8 min per laparoscopic procedure when the EBVS was used in lieu of suture ligatures, hemoclips, staplers, or ultrasonic coagulators. In the animal model, the mean time for completion of the intestinal resection was 251.9 s for the EBVS and 702.0 s for ligatures (p < 0.001). The mean number of applications per minute was 7.6 for the EBVS and 1.8 for ligatures (p < 0.001). No postapplication bleeding was seen. Initial clinical results from the use of EBVS in laparoscopic and open procedures demonstrate it to be safe and effective, reducing operative time in open procedures. Suture ligatures, ties, hemoclips, and other ligating techniques were used rarely (0.3%) after an application of the EBVS. In an experimental animal model, the EBVS was significantly faster and more efficient (more applications per minute) than ligatures for intestinal resection.
    Surgical Endoscopy 09/2001; 15(8):799-801. · 3.43 Impact Factor
  • B L Pratt, F L Greene
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    ABSTRACT: Although diagnostic laparoscopy has been used by surgeons and gastroenterologists since the early 1900s, today's surgical oncologists have been relatively slow to embrace this technology. Together with the fervor and benefits afforded by laparoscopic therapeutic interventions in the management of patients with benign disease and the diagnostic usefulness in blunt trauma and abdominal pain, awareness has been rekindled regarding the advantages of laparoscopy for the staging of abdominal malignancy. As surgeons begin to realize that extirpative procedures are doomed to failure in curing patients with diffuse abdominal metastases disclosed on laparoscopic assessment, palliative measures, such as stent placement, ablative procedures, balloon dilatation, intraluminal high-dose radiation, and laser techniques will be used commonly by surgical endoscopists and gastroenterologists. Similarly, it is hoped that the use of systemic chemotherapy will achieve better specificity in cell destruction in patients identified laparoscopically to have uncontained disease in the abdominal cavity. The sensitivity of sonography combined with laparoscopy has been shown to approach that of celiotomy in the evaluation of solid organs, thereby avoiding unnecessary laparotomy and its associated morbidities. Using sonography as a complement to laparoscopy will extend the usefulness of both techniques. The application of laparoscopy and the advent of miniaturized laparoscopic instrumentation (Fig. 7), both diagnostic and therapeutic, in the management of patients with abdominal malignancy will be limited only by the creativity and expertise of physicians and instrument makers.
    Surgical Clinics of North America 09/2000; 80(4):1111-26. · 2.02 Impact Factor
  • G A Answini, B L Pratt, F L Greene
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    ABSTRACT: Accurate cancer diagnosis and staging are crucial to the determination of an efficacious treatment plan for localized and advanced malignancy. The physician must differentiate patients with potentially resectable, localized disease from those with advanced and/or distant disease. The diagnostic and staging modalities currently available are expensive and often inaccurate. This can result in the nonoperative management of potentially resectable malignancies or, more commonly, in an underestimation of the preoperative cancer stage with intraoperative evidence of advanced/metastatic disease. The combination of laparoscopy and laparoscopic ultrasonography can be used to help diagnose and stage malignancies and select patients for either curative or palliative procedures.
    Seminars in Laparoscopic Surgery 07/2000; 7(2):68-77.