Outcomes of Open Retro-Rectus Hernia Repair With Mesh in Obesity Class III

BACKGROUND

Abdominal wall hernias continue to be one of the most common general surgery pathologies. Patients with an elevated body mass index (BMI) are routinely counseled about weight loss before elective repair. However, a definitive BMI "cutoff" has not been established. Here, we report our experience with open retro-rectus hernia repair (ORRHR) with mesh in patients with a BMI over 40 kg/m², and we attempt to determine if a BMI "cutoff" can be established.

METHODS

Data from patients undergoing ORRHR with mesh at Geisinger Medical Center from January 1, 2014, to December 31, 2018, were collected and retrospectively analyzed.

RESULTS

Cohorts were composed of 2 groups, BMI ≥ 40 kg/m² (n = 117) and BMI < 40 kg/m² (n = 90). All patients underwent an elective ORRHR with mesh. Operative time increased significantly as the patient's BMI increased (P ≤ .01). Patients in the higher BMI group had a significantly higher rate of surgical site infections (SSIs) (8.55% vs. 1.1%, P = .018). Higher BMI did not translate to a higher recurrence rate.

CONCLUSIONS

Patients undergoing ORRHR with mesh who had a BMI over 40 kg/m² had an increased risk of SSI and longer operative time, possibly suggesting a potential association other than SSI and BMI. More studies are needed to determine if BMI is indeed correlated with hernia recurrence and if BMI should influence the decision to undergo repair.

Outcomes of Endoscopic and Surgical Pancreatic Necrosectomy: A Single Institution Experience

Pancreatic necrosis can be managed conservatively; however, infection of pancreatic necrosis usually dictates more aggressive management. Our study aimed to assess the outcomes of open pancreatic necrosectomy (OPN) and endoscopic pancreatic necrosectomy (EPN) in a single center. Data from patients undergoing pancreatic necrosectomy at the Geisinger Medical Center from January 1, 2007, to April 25, 2016, were collected and retrospectively analyzed. Cohorts were composed of EPN (n = 22) and OPN (n = 34) groups. The prevalence of preoperative respiratory failure, septic shock, and multiorgan dysfunction syndrome was higher in the OPN group. The OPN group presented with a higher Bedside Index Severity in Acute Pancreatitis score. Postoperative abscess, persistent kidney dysfunction, and death were more frequent in the OPN group. The EPN group had a higher read-mission rate. The results of the univariate analysis for complication and mortality demonstrated that higher mortality and persistent kidney dysfunction were associated with the procedure type, specifically OPN and with a higher Bedside Index Severity in Acute Pancreatitis score. Patients who presented with higher severity of disease underwent an OPN, whereas EPN often was performed successfully in a more benign clinical setting. However, patients with infected necrosis are served best in a tertiary medical facility where multiple treatment modalities are available.

Outcomes of Endoscopic and Surgical Pancreatic Necrosectomy: A Single Institution Experience

Pancreatic necrosis can be managed conservatively; however, infection of pancreatic necrosis usually dictates more aggressive management. Our study aimed to assess the outcomes of open pancreatic necrosectomy (OPN) and endoscopic pancreatic necrosectomy (EPN) in a single center. Data from patients undergoing pancreatic necrosectomy at the Geisinger Medical Center from January 1, 2007, to April 25, 2016, were collected and retrospectively analyzed. Cohorts were composed of EPN (n = 22) and OPN (n = 34) groups. The prevalence of preoperative respiratory failure, septic shock, and multiorgan dysfunction syndrome was higher in the OPN group. The OPN group presented with a higher Bedside Index Severity in Acute Pancreatitis score. Postoperative abscess, persistent kidney dysfunction, and death were more frequent in the OPN group. The EPN group had a higher readmission rate. The results of the univariate analysis for complication and mortality demonstrated that higher mortality and persistent kidney dysfunction were associated with the procedure type, specifically OPN and with a higher Bedside Index Severity in Acute Pancreatitis score. Patients who presented with higher severity of disease underwent an OPN, whereas EPN often was performed successfully in a more benign clinical setting. However, patients with infected necrosis are served best in a tertiary medical facility where multiple treatment modalities are available.

Factors Associated with Failure of Nonoperative Management for Complicated Appendicitis

In recent years, nonoperative management of complicated appendicitis has become more common. Patients managed nonoperatively do well, but there is a paucity of literature on patients who fail nonoperative management. The purpose of this study was to examine the overall failure rate, morbidity associated with failure, and potential predictors of failure in nonop management of appendicitis. This is a descriptive retrospective review of patients from a single hospital system who were diagnosed with advanced appendicitis and underwent nonop management between January 1, 2007, and November of 2017. The data were obtained through review of patient charts from the electronic medical record. Failure was defined as requirement of an operation due to ongoing infection secondary to appendicitis. There were 183 patients initially managed non-operatively, with 70 patients failing nonoperative management. Patients failing nonoperative management experienced longer hospitalization (6.2 vs 2.9 days, P < 0.0001), and more patients in the failure group required admission to the ICU (10.0% vs 1.8%, P = 0.028). Multivariate analysis revealed that longer duration of symptoms reduced the likelihood of failure (odds ratio: 0.77 [0.64–0.92]). In this retrospective review, 38 per cent of patients failed nonop management of appendicitis. Symptom duration could provide insight for clinicians in assessing the role of non-operative management because increasing symptom duration reduced the likelihood of failure.

Factors Associated with Failure of Nonoperative Management for Complicated Appendicitis

In recent years, nonoperative management of complicated appendicitis has become more common. Patients managed nonoperatively do well, but there is a paucity of literature on patients who fail nonoperative management. The purpose of this study was to examine the overall failure rate, morbidity associated with failure, and potential predictors of failure in nonop management of appendicitis. This is a descriptive retrospective review of patients from a single hospital system who were diagnosed with advanced appendicitis and underwent nonop management between January 1, 2007, and November of 2017. The data were obtained through review of patient charts from the electronic medical record. Failure was defined as requirement of an operation due to ongoing infection secondary to appendicitis. There were 183 patients initially managed nonoperatively, with 70 patients failing nonoperative management. Patients failing nonoperative management experienced longer hospitalization (6.2 vs 2.9 days, P < 0.0001), and more patients in the failure group required admission to the ICU (10.0% vs 1.8%, P = 0.028). Multivariate analysis revealed that longer duration of symptoms reduced the likelihood of failure (odds ratio: 0.77 [0.64-0.92]). In this retrospective review, 38 per cent of patients failed nonop management of appendicitis. Symptom duration could provide insight for clinicians in assessing the role of nonoperative management because increasing symptom duration reduced the likelihood of failure.

Management of computed tomography scan detected hemothorax in blunt chest trauma: What computed tomography scan measurements say?

AIM

To investigate the hemothorax size for which tube thoracostomy is necessary.

METHODS

Over a 5-year period, we included all patients who were admitted with blunt chest trauma to our level 1 trauma center. Focus was placed on identifying the hemothorax size requiring tube thoracostomy.

RESULTS

A total number of 274 hemothoraces were studied. All patients with hemothoraces measuring above 3 cm received a chest tube. The 50% predicted probability of tube thoracostomy was 2 cm. Pneumothorax was associated with odds of receiving tube thoracostomy for hemothoraces below 2 cm (Odds Ratio: 4.967, 95%CI: 2.225-11.097, P < 0.0001).

CONCLUSION

All patients with a hemothorax size greater than 3% underwent tube thoracostomy. Prospective studies are warranted to elucidate the clinical outcome of patients with smaller hemothoraces.

Mode of Transport and Clinical Outcome in Rural Trauma: A Helicopter versus Ambulance Comparison

Helicopter Emergency Medical Services (HEMS) is presumably an effective way of patient transport in rural trauma, yet the literature addressing its effectiveness is scarce. In this study, we compared the clinical outcome of rural trauma patients between Ground Emergency Medical Services (GEMS) and HEMS transportation from the beginning of 2006 to the end of 2012. Focus was placed on identifying factors associated with survival to discharge in these patients. Over the seven-year study period, 4492 patients met the inclusion criteria with 2414 patients (54%) being transferred by GEMS and 2078 patients (46%) being transferred by HEMS. In comparison with GEMS, patients transferred by HEMS were younger men who were admitted with a higher mean Injury Severity Score and a lower mean Glasgow Coma Score (all Ps < 0.0001). HEMS patients were more frequently intubated before arrival at the trauma center (32% vs 9%, P < 0.0001) and were more frequently transferred to the operating room from the emergency department (11% vs 5%, P < 0.0001). In multivariate analysis, transfer by HEMS was associated with a significant increase in survival to discharge (odds ratio: 1.57, 95% confidence interval: 1.03–2.40, P = 0.036). Blunt injury, no intubation, and Glasgow Coma Score >8 were also associated with significantly improved odds of survival to discharge (all P < 0.0001). These findings show that although patients transferred by HEMS arrived in less favorable clinical conditions, HEMS transfer was associated with significantly higher odds of survival in rural trauma.

Mode of Transport and Clinical Outcome in Rural Trauma: A Helicopter versus Ambulance Comparison

Helicopter Emergency Medical Services (HEMS) is presumably an effective way of patient transport in rural trauma, yet the literature addressing its effectiveness is scarce. In this study, we compared the clinical outcome of rural trauma patients between Ground Emergency Medical Services (GEMS) and HEMS transportation from the beginning of 2006 to the end of 2012. Focus was placed on identifying factors associated with survival to discharge in these patients. Over the seven-year study period, 4492 patients met the inclusion criteria with 2414 patients (54%) being transferred by GEMS and 2078 patients (46%) being transferred by HEMS. In comparison with GEMS, patients transferred by HEMS were younger men who were admitted with a higher mean Injury Severity Score and a lower mean Glasgow Coma Score (all Ps < 0.0001). HEMS patients were more frequently intubated before arrival at the trauma center (32% vs 9%, P < 0.0001) and were more frequently transferred to the operating room from the emergency department (11% vs 5%, P < 0.0001). In multivariate analysis, transfer by HEMS was associated with a significant increase in survival to discharge (odds ratio: 1.57, 95% confidence interval: 1.03-2.40, P = 0.036). Blunt injury, no intubation, and Glasgow Coma Score >8 were also associated with significantly improved odds of survival to discharge (all P < 0.0001). These findings show that although patients transferred by HEMS arrived in less favorable clinical conditions, HEMS transfer was associated with significantly higher odds of survival in rural trauma.

The Effect of Sarcopenia on Outcomes in Geriatric Blunt Trauma

Elderly patients are at a higher risk of morbidity and mortality after trauma, which is reflected through higher frailty indices. Data collection using existing frailty indices is often not possible because of brain injury, dementia, or inability to communicate with the patient. Sarcopenia is a reliable objective measure for frailty that can be readily assessed in CT imaging. In this study, we aimed to evaluate the effect of sarcopenia on the outcomes of geriatric blunt trauma patients. Left psoas area (LPA) was measured at the level of the third lumbar vertebra on the axial CT images. LPA was normalized for height (LPA mm2/m2) and after stratification by gender, sarcopenia was defined as LPA measurements in the lowest quartile. A total of 1175 patients consisting of 597 males and 578 females were studied. LPAs below 242.6 mm2/m2 in males and below 187.8 mm2/m2 in females were considered to be sarcopenic. We found sarcopenia in 149 males and 145 females. In multivariate analysis, sarcopenia was associated with a higher risk of in-hospital mortality (odds ratio [OR]: 1.61, 95% confidence interval [CI]: 1.01-2.56) and a higher risk of discharge to less favorable destinations (OR: 1.42, 95% CI: 1.05-1.97). Lastly, sarcopenic patients had an increased risk of prolonged hospitalization (hazard ratio: 1.21, 95% CI: 1.04-1.40).

The Effect of Sarcopenia on Outcomes in Geriatric Blunt Trauma

Elderly patients are at a higher risk of morbidity and mortality after trauma, which is reflected through higher frailty indices. Data collection using existing frailty indices is often not possible because of brain injury, dementia, or inability to communicate with the patient. Sarcopenia is a reliable objective measure for frailty that can be readily assessed in CT imaging. In this study, we aimed to evaluate the effect of sarcopenia on the outcomes of geriatric blunt trauma patients. Left psoas area (LPA) was measured at the level of the third lumbar vertebra on the axial CT images. LPA was normalized for height (LPA mm2/m2) and after stratification by gender, sarcopenia was defined as LPA measurements in the lowest quartile. A total of 1175 patients consisting of 597 males and 578 females were studied. LPAs below 242.6 mm2/m2 in males and below 187.8 mm2/m2 in females were considered to be sarcopenic. We found sarcopenia in 149 males and 145 females. In multivariate analysis, sarcopenia was associated with a higher risk of in-hospital mortality (odds ratio [OR]: 1.61, 95% confidence interval [CI]: 1.01–2.56) and a higher risk of discharge to less favorable destinations (OR: 1.42, 95% CI: 1.05–1.97). Lastly, sarcopenic patients had an increased risk of prolonged hospitalization (hazard ratio: 1.21, 95% CI: 1.04–1.40).

In the Modern Era of CT, Do Blunt Trauma Patients with Markers for Blunt Bowel or Mesenteric Injury Still Require Exploratory Laparotomy?

After blunt trauma, certain CT markers, such as free intraperitoneal air, strongly suggest bowel perforation, whereas other markers, including free intraperitoneal fluid without solid organ injury, may be merely suspicious for acute injury. The present study aims to delineate the safety of non-operative management for markers of blunt bowel or mesenteric injury (BBMI) that are suspicious for significant bowel injury after blunt trauma. This was a retrospective review of adult blunt trauma patients with abdominopelvic CT scans on admission to a Level I trauma center between 2012 and 2014. Patients with CT evidence of acute BBMI without solid organ injury were included. The CT markers for BBMI included free intraperitoneal fluid, bowel hematoma, bowel wall thickening, mesenteric edema, hematoma and stranding. Two thousand blunt trauma cases were reviewed, and 94 patients (4.7%) met inclusion criteria. The average Injury Severity Score was 13.6 ± 10.1 and the median hospital stay was four days. The most common finding was free fluid (74 patients, 78.7%). The majority of patients (92, 97.9%) remained asymptomatic or clinically improved without abdominal surgery. After a change in abdominal examination, two patients (2.1%) underwent laparotomy with bowel perforation found in only one patient. Thus, 93 patients did not have a surgically significant injury, indicating that these markers demonstrate 1.1 per cent positive predictive value for bowel perforation. The presence of these markers after blunt trauma does not mandate laparotomy, though it should prompt thorough and continued vigilance toward the abdomen.

In the Modern Era of CT, Do Blunt Trauma Patients with Markers for Blunt Bowel or Mesenteric Injury Still Require Exploratory Laparotomy?

After blunt trauma, certain CT markers, such as free intraperitoneal air, strongly suggest bowel perforation, whereas other markers, including free intraperitoneal fluid without solid organ injury, may be merely suspicious for acute injury. The present study aims to delineate the safety of nonoperative management for markers of blunt bowel or mesenteric injury (BBMI) that are suspicious for significant bowel injury after blunt trauma. This was a retrospective review of adult blunt trauma patients with abdominopelvic CT scans on admission to a Level I trauma center between 2012 and 2014. Patients with CT evidence of acute BBMI without solid organ injury were included. The CT markers for BBMI included free intraperitoneal fluid, bowel hematoma, bowel wall thickening, mesenteric edema, hematoma and stranding. Two thousand blunt trauma cases were reviewed, and 94 patients (4.7%) met inclusion criteria. The average Injury Severity Score was 13.6 ± 10.1 and the median hospital stay was four days. The most common finding was free fluid (74 patients, 78.7%). The majority of patients (92, 97.9%) remained asymptomatic or clinically improved without abdominal surgery. After a change in abdominal examination, two patients (2.1%) underwent laparotomy with bowel perforation found in only one patient. Thus, 93 patients did not have a surgically significant injury, indicating that these markers demonstrate 1.1 per cent positive predictive value for bowel perforation. The presence of these markers after blunt trauma does not mandate laparotomy, though it should prompt thorough and continued vigilance toward the abdomen.

The Effect of Interhospital Transfers on the Outcome of Rural Trauma

Urban areas house the majority of the population in the United States but trauma deaths occur more commonly in rural areas. In this study, we aimed to investigate if direct patient admission to a Level I trauma center improves outcomes in rural trauma. We retrospectively reviewed data in our trauma database from January 2008 to the end of December 2012 to compare the overall outcomes between direct admissions (DAs) and interhospital transfers (IHTs). Of the 6118 patients who met the inclusion criteria, 59.5 per cent were in the DA group and 40.5 per cent in the IHT group. Injury severity score was similar between the two groups but severe traumatic brain injury was more common (P = 0.001) in the DA group. Hospital length of stay, complication rate, and in-hospital mortality were not different between the two groups (all P> 0.2). In multivariate analysis, there was no difference in survival between the two modes of admission (odds ratio, 95% confidence interval: 0.91, 0.69-1.20, P = 0.51). We concluded that rural trauma IHTs had no detrimental impact on the outcome. Prospective studies would better elucidate factors associated with patient outcomes in rural trauma.

The Effect of Interhospital Transfers on the Outcome of Rural Trauma

Urban areas house the majority of the population in the United States but trauma deaths occur more commonly in rural areas. In this study, we aimed to investigate if direct patient admission to a Level I trauma center improves outcomes in rural trauma. We retrospectively reviewed data in our trauma database from January 2008 to the end of December 2012 to compare the overall outcomes between direct admissions (DAs) and interhospital transfers (IHTs). Of the 6118 patients who met the inclusion criteria, 59.5 per cent were in the DA group and 40.5 per cent in the IHT group. Injury severity score was similar between the two groups but severe traumatic brain injury was more common (P = 0.001) in the DA group. Hospital length of stay, complication rate, and in-hospital mortality were not different between the two groups (all P > 0.2). In multivariate analysis, there was no difference in survival between the two modes of admission (odds ratio, 95% confidence interval: 0.91, 0.69–1.20, P = 0.51). We concluded that rural trauma IHTs had no detrimental impact on the outcome. Prospective studies would better elucidate factors associated with patient outcomes in rural trauma.

Changes in rural trauma prehospital times following the Rural Trauma Team Development Course training

BACKGROUND

The majority of the US population live in urban areas, yet more than half of all trauma deaths occur in rural areas. The Rural Trauma Team Development Course (RTTDC) is developed to improve the outcomes of rural trauma and we aimed to study its effect on patient transfer.

METHODS

Trauma referrals 2 years before the RTTDC training were compared with referrals 2 years after the course.

RESULTS

Of the 276 studied patients, 97 were referred before the RTTDC training and 179 patients were referred after the course. Transfer acceptance time was significantly shorter after the RTTDC training (139.2 ± 87.1 vs 110 ± 66.3 min, P = .003). The overall transfer time was also significantly reduced following the RTTDC training (257.4 ± 110.8 vs 219.2 ± 86.5 min, P = .002). Patients receiving pretransfer imaging had a significantly higher transfer time both before and after RTTDC training (all Ps < .01). Mortality was nearly halved (6.2% vs 3.4%) after the RTTDC training.

CONCLUSION

The RTTDC training was associated with reduced transfer acceptance time and reduced transfer time.

Hidradenitis suppurativa complicated by squamous cell carcinoma

Hidradenitis suppurativa (HS) is a chronic inflammatory condition affecting the apocrine glands of the axilla, groin, and perianal region. Although it is a common condition, it is rarely associated with squamous cell carcinoma (SCC). There have been only 41 reports of this uncommon complication of HS in the literature. This study includes two uncommon presentations of HS associated with SCC along with a literature review. The first patient developed diffuse abdominal carcinomatosis from SCC in the anogenital region arising from HS. This is a rare event in patients with perianal SCC, with only one case previously described in the literature. The second patient developed malignant hypercalcemia, an uncommon complication of cutaneous SCC. The current report represents the largest review of the literature of patients with SCC secondary to longstanding HS. A recurrence rate of 48 per cent was observed after "curative" resection. Approximately half of the patients succumbed to their disease, and the grade of carcinoma was the only predictor of mortality. These two new cases underline the importance of close follow-up and aggressive management of patients with HS. Although the development of carcinoma is an uncommon event in HS, the consequences can be devastating with mortality approaching 50 per cent.

Hidradenitis Suppurativa Complicated by Squamous Cell Carcinoma

Hidradenitis suppurativa (HS) is a chronic inflammatory condition affecting the apocrine glands of the axilla, groin, and perianal region. Although it is a common condition, it is rarely associated with squamous cell carcinoma (SCC). There have been only 41 reports of this uncommon complication of HS in the literature. This study includes two uncommon presentations of HS associated with SCC along with a literature review. The first patient developed diffuse abdominal carcinomatosis from SCC in the anogenital region arising from HS. This is a rare event in patients with perianal SCC, with only one case previously described in the literature. The second patient developed malignant hypercalcemia, an uncommon complication of cutaneous SCC. The current report represents the largest review of the literature of patients with SCC secondary to longstanding HS. A recurrence rate of 48 per cent was observed after “curative” resection. Approximately half of the patients succumbed to their disease, and the grade of carcinoma was the only predictor of mortality. These two new cases underline the importance of close follow-up and aggressive management of patients with HS. Although the development of carcinoma is an uncommon event in HS, the consequences can be devastating with mortality approaching 50 per cent.