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Wilson HH, Augenstein VA, Colavita PD, Davis BR, Heniford BT, Kercher KW, Kasten KR. Disparate potential for readmission prevention exists among inpatient and outpatient procedures in a minimally invasive surgery practice. Surgery 2024; 175:847-855. [PMID: 37770342 DOI: 10.1016/j.surg.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/26/2023] [Accepted: 07/08/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Administrators have focused on decreasing postoperative readmissions for cost reduction without fully understanding their preventability. This study describes the development and implementation of a surgeon-led readmission review process that assessed preventability. METHODS A gastrointestinal surgical group at a tertiary referral hospital developed and implemented a template to analyze inpatient and outpatient readmissions. Monthly stakeholder assessments reviewed and categorized readmissions as potentially preventable or not preventable. Continuous variables were examined by the Student's t test and reported as means and standard deviations. Categorical variables were examined by the Pearson χ2 statistic and Fisher's exact test. RESULTS There were 61 readmission events after 849 inpatient operations (7.2%) and 16 after 856 outpatient operations (1.9%), the latter of which were all classified as potentially preventable. Colorectal procedures represented 65.6% of readmissions despite being only 37.2% of all cases. The majority (67.2%) of readmission events were not preventable. Compared to the not-preventable group, the potentially preventable group experienced more dehydration (30.0% vs 9.8%, P = .045) and ileostomy creation (78.6% vs 33.3%, P = .017). The potential for outpatient management to prevent readmission was significantly higher in the potentially preventable group (40.0% vs 0.0%, P < .001), as was premature discharge prevention (35.0% vs 0.0%, P < .001). CONCLUSION The use of the standardized template developed for analyzing readmission events after inpatient and outpatient procedures identified a disparate potential for readmission prevention. This finding suggests that a singular focus on readmission reduction is misguided, with further work needed to evaluate and implement appropriate quality-based strategies.
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Polcz M, Ku D, Scarola GT, Colavita PD. Using impedance planimetry to define the end of a peroral endoscopic myotomy. Surg Endosc 2024; 38:400-406. [PMID: 37814168 DOI: 10.1007/s00464-023-10427-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/31/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic option for management of achalasia. Adequate distal myotomy is necessary for relief of symptoms, but when too long may also increase risk of reflux. The objective of this study is to evaluate clinical outcomes after POEM and final length of gastric myotomy using impedance planimetry (EndoFLIP). METHODS A retrospective review of 34 consecutive patients undergoing POEM with EndoFLIP were included. EndoFLIP measurements, including esophagogastric junction distensibility index (DI), minimum diameter (Dmin), and cross-sectional area (CSA) were recorded at 30- and 40-mL balloon-fill pre- and post- myotomy. The myotomy was considered complete when DI ≥ 3.4 mm2/mmHg. Postoperative Eckardt score (ES) was determined at initial postoperative visit and most recent follow-up. Linear and logistic regression were used to evaluate the association between gastric myotomy length and post-myotomy EndoFLIP measurements on postoperative ES and GERD. Wilcoxon rank-sum test was used to compare gastric myotomy lengths and EndoFLIP parameters in relation to clinical success and development of GERD, and paired t-test to compare EndoFLIP measurements and ES pre- and post-myotomy. RESULTS Final length of gastric myotomy measured 1 cm in 1 (2.9%), 1.5 cm in 11 (32.4%), 2.0 cm in 19 (55.9%), and 2.5 cm in 3 (8.8%) patients. Mean preoperative ES was 6.6 ± 2.2. All patients achieved ES < 3 postoperatively, which was maintained in 88.5% of patients at a median of 7.5 months of follow-up. Gastric myotomy length and post-myotomy EndoFLIP values were not associated with postoperative Eckardt scores or GERD. DISCUSSION Early and late symptom relief was achieved in 100 and 88.5% of patients, respectively, at a gastric myotomy length of 1-2.5 cm. Using EndoFLIP to define a completed myotomy at DI of 3.4 mm2/mmHg yielded variable lengths of gastric myotomy.
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Affiliation(s)
- Monica Polcz
- Department of General Surgery, Atrium Health, Carolinas Medical Center, 1025 Morehead Medical Dr #300, Charlotte, NC, 28204, USA
| | - Dau Ku
- Department of General Surgery, Atrium Health, Carolinas Medical Center, 1025 Morehead Medical Dr #300, Charlotte, NC, 28204, USA
| | - Gregory T Scarola
- Department of General Surgery, Atrium Health, Carolinas Medical Center, 1025 Morehead Medical Dr #300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Department of General Surgery, Atrium Health, Carolinas Medical Center, 1025 Morehead Medical Dr #300, Charlotte, NC, 28204, USA.
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Wilson HH, Rose M, Ku D, Scarola GT, Augenstein VA, Colavita PD, Heniford BT. Prospective, international analysis of quality of life outcomes in recurrent versus primary ventral hernia repairs. Am J Surg 2023; 226:803-807. [PMID: 37407392 DOI: 10.1016/j.amjsurg.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Quality of life (QOL) has become a key outcome measure following ventral hernia repair (VHR), but recurrent and primary VHR have not been compared in this context previously. METHODS The International Hernia Mesh Registry (2008-2019) was used to identify patients with QOL data scored by the Carolinas Comfort Scale preoperatively and postoperatively at 1 year. RESULTS Repairs were performed in 227 recurrent and 1,122 primary VHs. Recurrent patients had a higher BMI, larger defects, and were more likely to have preoperative pain, but other comorbidities were equal. Recurrence rates at 1 year were equivalent. Recurrent patients had a greater improvement in pain (-6.3 ± 10.2 vs -4.3 ± 8.3,p = 0.002) and movement limitation (-5.5 ± 10.0 vs -3.2 ± 7.2,p < 0.001) compared to primary patients, but they had increased postoperative mesh sensation (4.6 ± 7.7 vs 2.7 ± 5.5,p < 0.001). CONCLUSIONS Recurrent VHRs led to improved pain and movement limitation, but increased mesh sensation. These findings may be useful for preoperative counseling in the elective setting.
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Affiliation(s)
- Hadley H Wilson
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Mikayla Rose
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dau Ku
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Gregory T Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Wilson HH, Ayuso SA, Rose M, Ku D, Scarola GT, Augenstein VA, Colavita PD, Heniford BT. Defining surgical risk in octogenarians undergoing paraesophageal hernia repair. Surg Endosc 2023; 37:8644-8654. [PMID: 37495845 DOI: 10.1007/s00464-023-10270-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND With an aging population, the utility of surgery in elderly patients, particularly octogenarians, is of increasing interest. The goal of this study was to analyze outcomes of octogenarians versus non-octogenarians undergoing paraesophageal hernia repair (PEHR). METHODS The Nationwide Readmission Database was queried for patients > 18 years old who underwent PEHR from 2016 to 2018. Exclusion criteria included a diagnosis of gastrointestinal malignancy or a concurrent bariatric procedure. Patients ≥ 80 were compared to those 18-79 years old using standard statistical methods, and subgroup analyses of elective and non-elective PEHRs were performed. RESULTS From 2016 to 2018, 46,450 patients were identified with 5425 (11.7%) octogenarians and 41,025 (88.3%) non-octogenarians. Octogenarians were more likely to have a non-elective operation (46.3% vs 18.2%, p < 0.001), and those undergoing non-elective PEHR had a higher mortality (5.5% vs 1.2%, p < 0.001). Outcomes were improved with elective PEHR, but octogenarians still had higher mortality (1.3% vs 0.2%, p < 0.001), longer LOS (3[2, 5] vs 2[1, 3] days, p < 0.001), and higher readmission rates within 30 days (11.1% vs 6.5%, p < 0.001) compared to non-octogenarian elective patients. Multivariable logistic regression showed that being an octogenarian was not independently predictive of mortality (odds ratio (OR) 1.373[95% confidence interval 0.962-1.959], p = 0.081), but a non-elective operation was (OR 3.180[2.492-4.057], p < 0.001). Being an octogenarian was a risk factor for readmission within 30 days (OR 1.512[1.348-1.697], p < 0.001). CONCLUSIONS Octogenarians represented a substantial proportion of patients undergoing PEHR and were more likely to undergo a non-elective operation. Being an octogenarian was not an independent predictor of perioperative mortality, but a non-elective operation was. Octogenarians' morbidity and mortality was reduced in elective procedures but was still higher than non-octogenarians. Elective PEHR in octogenarians is reasonable but should involve a thorough risk-benefit analysis.
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Affiliation(s)
- Hadley H Wilson
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Sullivan A Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Mikayla Rose
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Dau Ku
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Gregory T Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA.
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Sacco JM, Ayuso SA, Salvino MJ, Scarola GT, Ku D, Tawkaliyar R, Brown K, Colavita PD, Kercher KW, Augenstein VA, Heniford BT. Preservation of deep epigastric perforators during anterior component separation technique (ACST) results in equivalent wound complications compared to transversus abdominis release (TAR). Hernia 2023; 27:819-827. [PMID: 37233922 DOI: 10.1007/s10029-023-02811-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/21/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE The use of component separation results in myofascial release and increased rates of fascial closure in abdominal wall reconstruction(AWR). These complex dissections have been associated with increased rates of wound complications with anterior component separation having the greatest wound morbidity. The aim of this paper was to compare the wound complication rate between perforator sparing anterior component separation(PS-ACST) and transversus abdominus release(TAR). METHODS Patients were identified from a prospective, single institution hernia center database who underwent PS-ACST and TAR from 2015 to 2021. The primary outcome was wound complication rate. Standard statistical methods were used, univariate analysis and multivariable logistic regression were performed. RESULTS A total of 172 patients met criteria, 39 had PS-ACST and 133 had TAR performed. The PS-ACST and TAR groups were similar in terms of diabetes (15.4% vs 28.6%, p = 0.097), but the PS-ACST group had a greater percentage of smokers (46.2% vs 14.3%, p < 0.001). The PS-ACST group had a larger hernia defect size (375.2 ± 156.7 vs 234.4 ± 126.9cm2, p < 0.001) and more patients who underwent preoperative Botulinum toxin A (BTA) injections (43.6% vs 6.0%, p < 0.001). The overall wound complication rate was not significantly different (23.1% vs 36.1%, p = 0.129) nor was the mesh infection rate (0% vs 1.6%, p = 0.438). Using logistic regression, none of the factors that were significantly different in the univariate analysis were associated with wound complication rate (all p > 0.05). CONCLUSION PS-ACST and TAR are comparable in terms of wound complication rates. PS-ACST can be used for large hernia defects and promote fascial closure with low overall wound morbidity and perioperative complications.
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Affiliation(s)
- J M Sacco
- Department of Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - S A Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - M J Salvino
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - G T Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - D Ku
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - R Tawkaliyar
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - K Brown
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - P D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - K W Kercher
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - V A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - B T Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
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Katzen M, Sacco J, Ku D, Scarola GT, Colavita PD, Heniford BT, Augenstein VA. The incidence and impact of enterotomy during laparoscopic and robotic ventral hernia repair: a nationwide readmissions analysis. Surg Endosc 2023:10.1007/s00464-023-09867-1. [PMID: 37277520 DOI: 10.1007/s00464-023-09867-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 01/04/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Our aim was to define the national incidence of enterotomy (ENT) during minimally invasive ventral hernia repair (MIS-VHR) and evaluate impact on short-term outcomes. METHODS The 2016-2018 Nationwide Readmissions Database was queried using ICD-10 codes for MIS-VHR and enterotomy. All patients had 3-months follow-up. Patients were stratified by elective status; patients without ENT (No-ENT) were compared against ENT patients. RESULTS In total, 30,025 patients underwent LVHR and ENT occurred in 388 (1.3%) patients; 19,188 (63.9%) cases were elective including 244 elective-ENT patients. Incidence was similar between elective versus non-elective cohorts (1.27% vs 1.33%; p = 0.674). Compared to laparoscopy, ENT was more common during robotic procedures (1.2% vs 1.7%; p = 0.004). Comparison of elective-No-ENT vs elective-ENT showed that elective-ENT patients had a longer median LOS (2 vs 5 days; p < 0.001), higher mean hospital cost ($51,656 vs $76,466; p < 0.001), increased rates of mortality (0.3% vs 2.9%; p < 0.001), and higher 3-month readmission (10.1% vs 13.9%; p = 0.048). Non-elective cohort comparison demonstrated non-elective-ENT patients had a longer median LOS (4 vs 7 days; p < 0.001), higher mean hospital cost ($58,379 vs $87,850; p < 0.001), increased rates of mortality (0.7% vs 2.1%;p < 0.001), and higher 3-month readmission (13.6% vs 22.2%; p < 0.001). In multivariable analysis (odds ratio, 95% CI), higher odds of enterotomy were associated with robotic-assisted procedures (1.386, 1.095-1.754; p = 0.007) and older age (1.014, 1.004-1.024; p = 0.006). Lower odds of ENT were associated with BMI > 25 kg/m2 (0.784, 0.624-0.984; p = 0.036) and metropolitan teaching vs metropolitan non-teaching (0.784, 0.622-0.987; p = 0.044). ENT patients (n = 388) were more likely to be readmitted with post-operative infection (1.9% vs 4.1%; p = 0.002) or bowel obstruction (1.0% vs 5.2%;p < 0.001) and more likely to undergo reoperation for intestinal adhesions (0.3% vs 1.0%; p = 0.036). CONCLUSION Inadvertent ENT occurred in 1.3% of MIS-VHRs, had similar rates between elective and urgent cases, but was more common for robotic procedures. ENT patients had a longer LOS, and increased cost and infection, readmission, re-operation and mortality rates.
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Affiliation(s)
- Michael Katzen
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Jana Sacco
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - David Ku
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Gregory T Scarola
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA.
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Katzen MM, Kercher KW, Sacco JM, Ku D, Scarola GT, Davis BR, Colavita PD, Augenstein VA, Heniford BT. Open preperitoneal ventral hernia repair: Prospective observational study of quality improvement outcomes over 18 years and 1,842 patients. Surgery 2023; 173:739-747. [PMID: 36280505 DOI: 10.1016/j.surg.2022.07.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study aimed to describe progressive evidence-based changes in perioperative management of open preperitoneal ventral hernia repair and subsequent surgical outcomes and to analyze factors that affect recurrence and wound complications. METHODS Prospective, tertiary hernia center data (2004-2021) were examined for patients undergoing midline open preperitoneal ventral hernia repair with mesh. "Early" (2004-2012) and "Recent" (2013-2021) groups were based on surgery date. RESULTS Comparison of Early (n = 675) versus Recent (n = 1,167) groups showed that Recent patients were, on average, older (56.9 ± 12.6 vs 58.7 ± 12.1 years; P < .001) with a lower body mass index (33.5 ± 8.3 vs 32.0 ± 6.8 kg/m2; P = .003) and a higher number of comorbidities (3.6 ± 2.2 vs 5.2 ± 2.6; P < .001). Recent patients had higher proportions of prior failed ventral hernia repair (46.5% vs 60.8%; P < .001), larger hernia defects (199.7 ± 232.8 vs 214.4 ± 170.5 cm2; P < .001), more Center for Disease Control class 3 or 4 wounds (11.3% vs 18.6%; P < .001), and more component separations (22.5% vs 45.7%; P < .001). Hernia recurrence decreased over time (7.1% vs 2.4%; P < .001), as did wound complication rates (26.7% vs 13.2%; P < .001). Comparing respective multivariable analyses (Early versus Recent), wound complications were associated with panniculectomy (odds ratio [95% confidence interval]: 2.9 [1.9-4.5], P < .001 vs 2.1 [1.4-3.3], P < .01), contaminated wounds (2.1 [1.1-3.7], P = .02 vs 1.8 [1.1-3.1], P = .02), anterior component separation technique (1.8 [1.1-2.9], P = .02 vs 3.2[1.9-5.3], P < .01), and operative time (per minute: 1.01 [1.008-1.015], P < .01 vs 1.004 [1.001-1.007], P < .01). Diabetes (2.6 [1.7-4.0], P < .01) and tobacco (1.8 [1.1-2.9], P = .02) were only significant in the early group. In both groups, recurrence was associated with wound complication (8.9 [4.1-20.1], P < .01 vs 3.4 [1.3-8.2]. P < .01) and recurrent hernias (4.9 [2.3-11.5], P < .01 vs 2.1 [1.1-4.2], P = .036). CONCLUSION Despite significant increased patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center's outcomes has significantly improved patient care results.
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Affiliation(s)
- Michael M Katzen
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Kent W Kercher
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Jana M Sacco
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Dau Ku
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Gregory T Scarola
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Bradley R Davis
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Katzen MM, Colavita PD, Sacco JM, Ayuso SA, Ku D, Scarola GT, Tawkaliyar R, Brown K, Gersin KS, Augenstein VA, Heniford BT. Observational study of complex abdominal wall reconstruction using porcine dermal matrix: How have outcomes changed over 14 years? Surgery 2023; 173:724-731. [PMID: 36280507 DOI: 10.1016/j.surg.2022.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/21/2022] [Accepted: 08/11/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Our center has adopted many evidence-based practices to improve outcomes for complex abdominal wall reconstruction with porcine dermal matrix. This study analyzed outcomes over time using porcine dermal matrix in complex abdominal wall reconstruction. METHODS Prospective, tertiary hernia center data was examined for patients undergoing complex abdominal wall reconstruction with porcine dermal matrix. Early (2008-2014) and Recent (2015-2021) cohorts were defined by dividing the study interval in half. Multivariable analyses of wound complications and recurrence were performed. RESULTS Comparing 117 Early vs 245 Recent patients, both groups had high rates of previously repaired hernias (76.1% vs 67.4%; P = .110), Centers for Disease Control and Prevention class 3 or 4 wounds (76.0% vs 66.6%; P = .002), and very large hernia defects (320 ± 317 vs 282 ± 164 cm2; P = .640). Recent patients had higher rates of preoperative botulinum injection (0% vs 21.2%; P < .001), posterior component separation (15.4% vs 35.5%; P < .001), and delayed primary closure (23.1% vs 38.8%; P < .001), but lower rates of concurrent panniculectomy (32.3% vs 27.8%; P = .027) and similar anterior component separation (29.1% vs 18.2%; P = .060). Most mesh was placed preperitoneal (74.4% vs 93.3%; P < .001). Recent patients had less inlay (9.4% vs 2.1%; P < .01) and other mesh locations as fascial closure rate increased (88.0% vs 95.5%; P < .001). Over time, there was a decrease in wound complications (42.1% vs 14.3%; P < .001), length of stay (median [interquartile range]:8 [6-13] vs 7 [6-9]; P = .003), and 30-day readmissions (32.7% vs 10.3%; P < .001). Hernia recurrence decreased (10.3% vs 3.7%; P = .016) with mean follow-up of 2.8 ± 3.2 and 1.7 ± 1.7 years, respectively. Respective multivariable models(odds ratio, 95% confidence interval) demonstrated an increased risk of wound complications with diabetes (2.65, 1.16-5.98; P = .020), panniculectomy (2.63, 1.21-5.73; P = .014), and anterior component separation (5.1, 1.98-12.9; P < .001), with recurrence risk increased by wound complication (3.8, 1.4-2-7.62; P = .032). CONCLUSION Porcine dermal matrix in complex abdominal wall reconstruction performs well with low recurrence rates. Internal assessment and implementation of evidence-based practices improved outcomes such as length of stay, wound complications, and recurrence rate.
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Affiliation(s)
- Michael M Katzen
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Jana M Sacco
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Sullivan A Ayuso
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Dau Ku
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Gregory T Scarola
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Rahmatulla Tawkaliyar
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Kiara Brown
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Keith S Gersin
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Marturano MN, Ayuso SA, Ku D, Raible R, Lopez R, Scarola GT, Gersin K, Colavita PD, Augenstein VA, Heniford BT. Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study. Surgery 2023; 173:756-764. [PMID: 36229258 DOI: 10.1016/j.surg.2022.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/14/2022] [Accepted: 07/05/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study. METHODS A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated. RESULTS Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm2 vs botulinum toxin A 289.7 ± 162.4 cm2; P = .73) (mean volume: 1,498.3 + 2,043.4 cm3 vs 2,914.7 + 6,539.4 cm3; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13). CONCLUSION In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.
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Affiliation(s)
- Matthew N Marturano
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. https://twitter.com/MarturanoMd
| | - Sullivan A Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. https://twitter.com/SAyusoMD
| | - David Ku
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | | | | | - Gregory T Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Keith Gersin
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. https://twitter.com/PDColavita
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC. https://twitter.com/VedraAugenstein
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Katzen MM, Sacco J, Ku D, Scarola GT, Colavita PD, Heniford BT, Augenstein VA. Hernia recurrence after primary repair of small umbilical hernia defects. Am J Surg 2022; 224:1357-1361. [PMID: 36182599 DOI: 10.1016/j.amjsurg.2022.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND An evidence-based approach to the repair of umbilical hernias (UH)<1 cm has yet to be defined. METHODS A prospectively maintained, institutional hernia database was queried for patients undergoing primary suture repair of UH ≤ 1 cm. The primary outcome was recurrence and secondary outcomes were wound complications. RESULTS Of 332 patients included (226-primary, 106-incisional), recurrence was identified in 4 (1.8%) primary versus 8 (7.5%) incisional-UH (p = 0.022), with follow-up of 4.7 ± 4.4 years. There were 10 (3.0%) wound complications: 4 (1.2%) superficial wound infections, 1 (0.3%) superficial wound dehiscence, and 5 (1.5%) seromas. On multivariable analysis of recurrence, incisional-UH had an odds ratio of 4.2 compared to primary. Suture choice, diabetes, BMI, tobacco-use history, and wound complications were not significant. CONCLUSIONS With long term follow-up, recurrence after primary suture repair of UH ≤ 1 cm occurred in 1.8% of primary and 7.5% of incisional UH. On multivariable analysis, incisional-UH increased recurrence odds by 4.2 times compared to primary.
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Affiliation(s)
- Michael M Katzen
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Jana Sacco
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - David Ku
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Gregory T Scarola
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA.
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Katzen M, Ayuso SA, Sacco J, Ku D, Scarola GT, Kercher KW, Colavita PD, Augenstein VA, Heniford BT. Outcomes of biologic versus synthetic mesh in CDC class 3 and 4 open abdominal wall reconstruction. Surg Endosc 2022; 37:3073-3083. [PMID: 35925400 DOI: 10.1007/s00464-022-09486-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/13/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Abdominal wall reconstruction (AWR) in a contaminated field is associated with an increased risk of wound complications, infection, and reoperation. The best method of repair and mesh choice in these operations have generated marked controversy. Our aim was to compare outcomes of patients who underwent AWR with biologic versus synthetic mesh in CDC class 3 and 4 wounds. METHODS A prospective, single-institution database was queried for AWR using biologic or synthetic mesh in CDC Class 3 and 4 wounds. Hernia recurrence and complications were measured. Multivariable logistic regression was performed to identify factors predicting both. RESULTS In total, 386 patients with contaminated wounds underwent AWR, 335 with biologic and 51 with synthetic mesh. Groups were similar in age, sex, BMI, and rate of diabetes. Biologic mesh patients had larger hernia defects (298 ± 233cm2 vs. 208 ± 155cm2; p = 0.004) and a higher rate of recurrent hernias (72.2% vs 47.1%; p < 0.001), comorbidities(5.8 ± 2.7 vs. 4.2 ± 2.4, p < 0.01), and a nearly fivefold increase in Class 4 wounds (47.8% vs. 9.8%, p < 0.001), while fascial closure trended to being less common (90.7% vs 96.1%; p = 0.078). Hernia recurrence was comparable between biologic and synthetic mesh (10.4% vs. 17.6%, p = 0.132). Wound complication rates were similar (36.1% vs. 33.3%, p = 0.699), but synthetic mesh had higher rates of mesh infection (1.2% vs 11.8%; p < 0.001) and infection-related resection (0% vs 7.8%, p < 0.001), with 66% of those synthetic mesh infections requiring excision. On logistic regression, wound complications (OR 5.96 [CI 1.60-22.17]; p = 0.008) and bridging mesh (OR 13.10 [CI 2.71-63.42];p = 0.030) predicted of hernia recurrence (p < 0.05), while synthetic mesh (OR 18.6 [CI 2.35-260.4] p = 0.012) and wound complications (OR 20.6 [CI 3.15-417.7] p = 0.008) predicted mesh infection. CONCLUSIONS Wound complications in AWR with CDC class 3 and 4 wounds significantly increased mesh infection and hernia recurrence; failure to achieve fascial closure also increased hernia recurrence. Use of synthetic versus biologic mesh increased the mesh infection rate by 18.6 times.
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Affiliation(s)
- Michael Katzen
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Sullivan A Ayuso
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Jana Sacco
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Dau Ku
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Gregory T Scarola
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Kent W Kercher
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA.
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Ayuso SA, Aladegbami BG, Kercher KW, Colavita PD, Augenstein VA, Heniford BT. Coated Polypropylene Mesh Is Associated With Increased Infection in Abdominal Wall Reconstruction. J Surg Res 2022; 275:56-62. [DOI: 10.1016/j.jss.2022.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 01/09/2022] [Accepted: 01/28/2022] [Indexed: 01/02/2023]
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Ayuso SA, Elhage SA, Okorji LM, Kercher KW, Colavita PD, Heniford BT, Augenstein VA. Closed-Incision Negative Pressure Therapy Decreases Wound Morbidity in Open Abdominal Wall Reconstruction With Concomitant Panniculectomy. Ann Plast Surg 2022; 88:429-433. [PMID: 34670966 DOI: 10.1097/sap.0000000000002966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Patients undergoing abdominal wall reconstruction (AWR) with concomitant panniculectomy (CP) may be at higher risk for wound complications due to the need for large incisions and tissue undermining. The aim of this study was to evaluate whether the use of closed-incision negative pressure therapy (ciNPT) decreases wound complications in AWR patients undergoing CP. METHODS Beginning in February 2018, all patients at this institution who underwent AWR with CP received ciNPT. These patients were identified from a prospectively maintained institutional database. A standard dressing (non-NPT) group was then created in a 1:1 fashion by identifying patients who had AWR with CP immediately before the beginning of ciNPT use (2016-2018). A univariate comparison was made between the ciNPT and non-NPT groups. The primary outcome was wound complication rate; however, other perioperative outcomes, such as requirement for reoperation, were also tracked. Standard statistical methods and logistic regression were used. RESULTS In total, 134 patients met criteria, with 67 patients each in the ciNPT and non-NPT groups. When comparing patients in the ciNPT and non-NPT groups, they were demographically similar, including body mass index, smoking, and diabetes (P < 0.05). Hernias was large on average (289.5 ± 158.2 vs 315.3 ± 197.3 cm2, P = 0.92) and predominantly recurrent (58.5% vs 72.6%, P = 0.14). Wound complications were much lower in the ciNPT group (15.6% vs 35.5%, P = 0.01), which was mainly driven by a decrease in superficial wound breakdown (3.1% vs 19.7%, P < 0.01). Patients in the ciNPT group were less likely to require a return trip to the operating room for wound complications (0.0% vs 13.3%, P < 0.01). In logistic regression, the use of ciNPT continued to correlate with reduced wound complication rates (P = 0.02). CONCLUSIONS In AWR with CP, the use of ciNPT significantly decreased the risk of postoperative wound complications, particularly superficial wound breakdown, and lessened the need for wound-related reoperation.
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Affiliation(s)
- Sullivan A Ayuso
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
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14
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Elhage SA, Ayuso SA, Deerenberg EB, Shao JM, Prasad T, Kercher KW, Colavita PD, Augenstein VA, Todd Heniford B. Factors Predicting Increased Length of Stay in Abdominal Wall Reconstruction. Am Surg 2021:31348211047503. [PMID: 34965157 DOI: 10.1177/00031348211047503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs have become increasingly popular in general surgery, yet no guidelines exist for an abdominal wall reconstruction (AWR)-specific program. We aimed to evaluate predictors of increased length of stay (LOS) in the AWR population to aid in creating an AWR-specific ERAS protocol. METHODS A prospective, single institution hernia center database was queried for all patients undergoing open AWR (1999-2019). Standard statistical methods and linear and logistic regression were used to evaluate for predictors of increased LOS. Groups were compared based on LOS below or above the median LOS of 6 days (IQR = 4-8). RESULTS Inclusion criteria were met by 2,505 patients. On average, the high LOS group was older, with higher rates of CAD, COPD, diabetes, obesity, and pre-operative narcotic use (all P < .05). Longer LOS patients had more complex hernias with larger defects, higher rates of mesh infection/fistula, and more often required a component separation (all P < .05). Multivariate analysis identified age (β0.04,SE0.02), BMI (β0.06,SE0.03), hernia defect size (β0.003,SE0.001), active mesh infection or mesh fistula (β1.8,SE0.72), operative time (β0.02,SE0.002), and ASA score >4 (β3.6,SE1.7) as independently associated factors for increased LOS (all P < .05). Logistic regression showed that an increased length of stay trended toward an increased risk of hernia recurrence (P = .06). CONCLUSIONS Multiple patient and hernia characteristics are shown to significantly affect LOS, which, in turn, increases the odds of AWR failure. Weight loss, peri-operative geriatric optimization, prehabilitation of comorbidities, and operating room efficiency can enhance recovery and shorten LOS following AWR.
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Affiliation(s)
- Sharbel A Elhage
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Sullivan A Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Eva B Deerenberg
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Jenny M Shao
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Kent W Kercher
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
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Ayuso SA, Katzen MM, Aladegbami BG, Nayak RB, Augenstein VA, Heniford BT, Colavita PD. Nationwide Readmissions Analysis of Minimally Invasive Versus Open Ventral Hernia Repair: A Retrospective Population-Based Study. Am Surg 2021; 88:463-470. [PMID: 34816757 DOI: 10.1177/00031348211050835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Minimally invasive ventral hernia repair (MISVHR) has been performed for almost 30 years; recently, there has been an accelerated adoption of the robotic platform leading to renewed comparisons to open ventral hernia repair (OVHR). The present study evaluates patterns and outcomes of readmissions for MISVHR and OVHR patients. METHODS The Nationwide Readmissions Database (NRD) was queried for patients undergoing OVHR and MISVHR from 2016 to 2018. Demographic characteristics, complications, and 90-day readmissions were determined. A subgroup analysis was performed to compare robotic ventral hernia repair (RVHR) vs laparoscopic hernia repair (LVHR). Standard statistical methods and logistic regression were used. RESULTS Over the 3-year period, there were 25 795 MISVHR and 180 635 OVHR admissions. Minimally invasive ventral hernia repair was associated with a lower rate of 90-day readmission (11.3% vs 17.3%, P < .01), length of stay (LOS) (4.0 vs 7.9 days, P < .01), and hospital charges ($68,240 ± 75 680 vs $87,701 ± 73 165, P < .01), which remained true when elective and non-elective repairs were evaluated independently. Postoperative infection was the most common reason for readmission but was less common in the MISVHR group (8.4% vs 16.8%, P < .01). Robotic ventral hernia repair increased over the 3-year period and was associated with decreased LOS (3.7 vs 4.1 days, P < .01) and comparable readmissions (11.3% vs 11.2%, P = .74) to LVHR, but was nearly $20,000 more expensive. In logistic regression, OVHR, non-elective operation, urban-teaching hospital, increased LOS, comorbidities, and payer type were predictive of readmission. CONCLUSIONS Open ventral hernia repair was associated with increased LOS and increased readmissions compared to MISVHR. Robotic ventral hernia repair had comparable readmissions and decreased LOS to LVHR, but it was more expensive.
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Affiliation(s)
- Sullivan A Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Michael M Katzen
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Bola G Aladegbami
- Division of General Surgery, Department of Surgery, 22683Baylor University Medical Center, Dallas, TX, USA
| | - Raageswari B Nayak
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
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Abstract
Smoking and obesity are commonly encountered problems in the elective, perioperative setting. This article reviews the risks posed by smoking and diabetes and explores way to mitigate such risks. Other means of perioperative optimization are also discussed in an effort to describe perioperative strategies that can improve patient outcomes.
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Affiliation(s)
- Sullivan A Ayuso
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC 28204, USA
| | - Jordan N Robinson
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC 28204, USA.
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Ayuso SA, Aladegbami BG, Nayak RB, Kercher KW, Augenstein VA, Heniford TB, Colavita PD. Nationwide Readmissions Analysis of Minimally Invasive Hiatal Hernia Repair. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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Ayuso SA, Colavita PD, Augenstein VA, Aladegbami BG, Nayak RB, Davis BR, Janis JE, Fischer JP, Heniford BT. Nationwide increase in component separation without concomitant rise in readmissions: A nationwide readmissions database analysis. Surgery 2021; 171:799-805. [PMID: 34756604 DOI: 10.1016/j.surg.2021.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The use of component separation technique (CST) in complex abdominal wall reconstruction (AWR) increases the rate of primary musculofascial closure but can be associated with increased wound complications, which may require readmission. This study examines 3-year trends in readmissions for patients undergoing AWR with or without CST. METHODS The Nationwide Readmissions Database was queried for patients undergoing elective AWR from 2016-2018. CST, demographic characteristics, and 90-day complications and readmissions were determined. CST versus non-CST readmissions were compared, including matched subgroups. Standard statistics and logistic regression were used. RESULTS Over the 3-year period, 94,784 patients underwent AWR. There was an annual increase in the prevalence of CST: 4.0% in 2016; 6.1% in 2017; 6.7% in 2018 (P < .01), which is a 67.5% upsurge during that time. Most cases (82.3%) occurred at urban teaching hospitals, which had more comorbid patients (P < .01). The yearly 90-day readmission rate did not change: 16.0%, 18.2%, and 16.9% (P = .26). Readmissions were higher for CST patients than non-CST patients (17.1% vs 15.7%), but not in the matched subgroup (17.0% vs 16.4%; P = .41). Most commonly, readmissions were for infection (28.3%); 14.3% of readmitted patients underwent reoperation. Smoking, morbid obesity, diabetes, chronic lung disease, urban-teaching hospital status, and increased length of stay increased the chance of readmission (all P < .05). CONCLUSION From 2016 to 2018, the use of CST increased 67.5% nationwide without an increase in readmissions. As we look toward clinical targets to reduce risk of readmission, modifiable health conditions, such as smoking, morbid obesity, and diabetes should be targeted during the prehabilitation process.
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Affiliation(s)
- Sullivan A Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Bola G Aladegbami
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Raageswari B Nayak
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Bradley R Davis
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Jeffrey E Janis
- Department of Plastic and Reconstructive Surgery, Ohio State University Wexner Medical Center, Columbus, OH
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, Philadelphia, PA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Elhage SA, Kao AM, Katzen M, Shao JM, Prasad T, Augenstein VA, Heniford BT, Colavita PD. Outcomes and CT scan three-dimensional volumetric analysis of emergent paraesophageal hernia repairs: predicting patients who will require emergent repair. Surg Endosc 2021; 36:1650-1656. [PMID: 34471979 PMCID: PMC8409264 DOI: 10.1007/s00464-021-08415-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/23/2021] [Indexed: 12/02/2022]
Abstract
Introduction Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair. Methods A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software. Results Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm3, p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm2, p < 0.001). In multivariate analysis, HSV increase of 100cm3 (OR 1.17 CI 1.02–1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence. Conclusions Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.
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Affiliation(s)
- Sharbel A Elhage
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Angela M Kao
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Michael Katzen
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Jenny M Shao
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
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Shao JM, Ayuso SA, Deerenberg EB, Elhage SA, Prasad T, Colavita PD, Augenstein VA, Heniford BT. Biologic mesh is non-inferior to synthetic mesh in CDC class 1 & 2 open abdominal wall reconstruction. Am J Surg 2021; 223:375-379. [PMID: 34140156 DOI: 10.1016/j.amjsurg.2021.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/29/2021] [Accepted: 05/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Biologic mesh has historically been used in contaminated abdominal wall reconstructions (AWRs). No study has compared outcomes of biologic and synthetic in clean and clean-contaminated hernia ventral hernia repair. METHODS A prospective AWR database identified patients undergoing open, preperitoneal AWR with biologic mesh in CDC class 1 and 2 wounds. Using propensity score matching, a matched cohort of patients with synthetic mesh was created. The objective was to assess recurrence rates and postoperative complications. RESULTS Fifty-eight patients were matched in each group. Patient in the biologic group had higher rates of immunosuppression, history of transplantation, and inflammatory bowel disease (p ≤ 0.05). Operative variables were comparable for biologic vs synthetic, including defect size (230.5 ± 135.4 vs 268.7 ± 194.5 cm2, p = 0.62), but the synthetic mesh group had larger meshes placed (575.6 ± 247.0 vs 898.8 ± 246.0 cm2 p < 0.0001). Wound infections (15.5% vs 8.9%, p = 0.28) were equivalent, and recurrence rates (1.7% vs 3.4%, p = 1.00) were similar on follow up (19.3 ± 23.3 vs 23.3 ± 29.7 months, p = 0.56). CONCLUSIONS In matched, lower risk, complex AWR patients with large hernia defects, biologic and synthetic meshes have equal outcomes.
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Affiliation(s)
- Jenny M Shao
- Department of Gastrointestinal Surgery, University of Pennsylvania, Philadelphia, PA, 19107, USA
| | - Sullivan A Ayuso
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Eva B Deerenberg
- Department of Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, the Netherlands
| | - Sharbel A Elhage
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Tanu Prasad
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA.
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21
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Ayuso SA, Elhage SA, Aladegbami BG, Kao AM, Kercher KW, Colavita PD, Augenstein VA, Heniford BT. Delayed primary closure (DPC) of the skin and subcutaneous tissues following complex, contaminated abdominal wall reconstruction (AWR): a propensity-matched study. Surg Endosc 2021; 36:2169-2177. [PMID: 34018046 DOI: 10.1007/s00464-021-08485-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Wound complications following abdominal wall reconstruction (AWR) in a contaminated setting are common and significantly increase the risk of hernia recurrence. The purpose of this study was to examine the effect of short-term negative pressure wound therapy (NPWT) followed by operative delayed primary closure (DPC) of the skin and subcutaneous tissue after AWR in a contaminated setting. METHODS A prospective institutional hernia database was queried for patients who underwent NPWT-assisted DPC after contaminated AWR between 2008 and 2020. Primary outcomes included wound complication rate and reopening of the incision. A non-DPC group was created using propensity-matching. Standard descriptive statistics were used, and a univariate analysis was performed between the DPC and non-DPC groups. RESULTS In total, 110 patients underwent DPC following AWR. The hernias were on average large (188 ± 133.6 cm2), often recurrent (81.5%), and 60.5% required a components separation. All patients had CDC Class 3 (14.5%) or 4 (85.5%) wounds and biologic mesh placed. Using CeDAR, the wound complication rate was estimated to be 66.3%. Postoperatively, 26.4% patients developed a wound complication, but only 5.5% patients required reopening of the wound. The rate of recurrence was 5.5% with mean follow-up of 22.6 ± 27.1 months. After propensity-matching, there were 73 patients each in the DPC and non-DPC groups. DPC patients had fewer overall wound complications (23.0% vs 43.9%, p = 0.02). While 4.1% of the DPC group required reopening of the incision, 20.5% of patients in the non-DPC required reopening of the incision (p = 0.005) with an average time to healing of 150 days. Hernia recurrence remained low overall (2.7% vs 5.4%, p = 0.17). CONCLUSIONS DPC can be performed with a high rate of success in complex, contaminated AWR patients by reducing the rate of wound complications and avoiding prolonged healing times. In patients undergoing AWR in a contaminated setting, a NPWT-assisted DPC should be considered.
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Affiliation(s)
- Sullivan A Ayuso
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Sharbel A Elhage
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Bola G Aladegbami
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Angela M Kao
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Kent W Kercher
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA.
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Kao AM, Ayuso SA, Huntington CR, Sherrill WC, Cetrulo LN, Colavita PD, Heniford BT. Technique and Outcomes in Laparoscopic Repair of Morgagni Hernia in Adults. J Laparoendosc Adv Surg Tech A 2021; 31:814-819. [PMID: 33979533 DOI: 10.1089/lap.2021.0038] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Morgagni hernias (MHs) are rare anteromedial congenital diaphragmatic hernias. This study describes the effectiveness of a laparoscopic approach for these defects. Methods: A prospectively collected institutional database at a tertiary referral center was queried for patients (≥18 years) with MHs. Results: Fifteen adults underwent laparoscopic MH repair. Abdominal pain was the most common presentation (71.5%), and 2 patients (13.3%) presented with acute obstruction. Laparoscopic bridged mesh repair was the most common approach (66.7%) and was achieved by suturing a bridged synthetic mesh to the diaphragmatic portion of the defect and fixing it with transfascial sutures and/or tacks to the anterior abdominal wall. Primary suture repair was utilized for smaller defects. No mortalities or recurrences occurred after 20.2 months median follow-up. Conclusions: Laparoscopic synthetic mesh repair of adult MHs offers an effective hernia repair with minimal complications and no detected recurrences in long-term follow-up of this patient sample.
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Affiliation(s)
- Angela M Kao
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Sullivan A Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Ciara R Huntington
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - William C Sherrill
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Lawrence N Cetrulo
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
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Shao JM, Elhage SA, Colavita PD. Asymptomatic intrathoracic stomach: elective repair versus watchful waiting. Ann Laparosc Endosc Surg 2021. [DOI: 10.21037/ales.2020.03.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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24
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Shao JM, Deerenberg EB, Prasad T, Dunphy C, Colavita PD, Augenstein VA, Heniford BT. Adoption of enhanced recovery after surgery and intraoperative transverse abdominis plane block decreases opioid use and length of stay in very large open ventral hernia repairs. Am J Surg 2021; 222:806-812. [PMID: 33674036 DOI: 10.1016/j.amjsurg.2021.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/26/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The effect of an enhanced recovery after surgery (ERAS) pathway including liposomal bupivacaine transversus abdominus plane (TAP)-blocks for abdominal wall reconstruction (AWR) on opioids use is not clear. METHODS A prospective, tertiary hernia center database of patients undergoing AWR before and after ERAS and operative TAP-blocks was matched in large ventral hernias. RESULTS In 106 patients, non-TAP-block and TAP-block groups were comparable in mean BMI (p = 0.694), hernia defect size (p = 0.424), components separation (p = 0.610), complete fascial closure (p = 1.0), and panniculectomy (p = 1.0). The total morphine milligram equivalents (MME) used during hospitalization was reduced by 3-fold in the TAP-block group (p < 0.001), and opioid usage decreased by 35%-71% during days 1-5. Length of stay (LOS) was shorter in the TAP-block group by average of 1 day (p = 0.011). CONCLUSION ERAS and TAP-block in AWR leads to a decrease in mean opioid usage by 65% and decreased LOS by an average of 1 day.
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Affiliation(s)
- Jenny M Shao
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Eva B Deerenberg
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Tanu Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Colleen Dunphy
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA.
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25
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Shao JM, Deerenberg EB, Elhage SA, Prasad T, Davis BR, Kercher KW, Colavita PD, Augenstein VA, Heniford BT. Recurrent incisional hernia repairs at a tertiary hernia center: Are outcomes really inferior to initial repairs? Surgery 2020; 169:580-585. [PMID: 33248712 DOI: 10.1016/j.surg.2020.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Recurrent ventral hernia repairs are reported to have higher recurrence and complication rates than initial ventral hernia repairs. This is the largest analysis of outcomes for initial versus recurrent open ventral hernia repairs reported in the literature. METHODS A prospective, institutional database at a tertiary hernia center was queried for patients undergoing open ventral hernia repairs with complete fascial closure and synthetic mesh placement. RESULTS A total of 1,694 open ventral hernia repairs patients were identified, including 896 (52.9%) initial ventral hernia repairs and 798 (47.1%)recurrent ventral hernia repairs. Recurrent ventral hernia repair patients were more complex: older (P = .003), higher body mass index (P < .001), higher American Society of Anesthesiologists class (P < .001), incidence of diabetics (P = .003), comorbidities (P < .001), and larger hernia defects (133.3 ± 171.9 vs 220.2 ± 210.0; P < .001). Recurrent ventral hernia repairs also had longer operative times (161.6 ± 82.4 vs 188.2 ± 68.9 minutes; P < .001), increased use of preoperative botulinum toxin A injection (4.3% vs 10.1%; P = .01), components separation (19.2% vs 39.5%; P < .001), and panniculectomy (20.3% vs 35.8%; P < .001). The overall hernia recurrence rate was 4.4% at a mean follow-up of 36.6 ± 45.5 months. Between the initial ventral hernia repairs and recurrent ventral hernia repairs, the hernia recurrence rates were equivalent (4.2% vs 4.7%, P = .63). Rates of wound infection, seromas, hematomas, mesh infections, and wound related reoperations (P > .05) were nonsignificant. CONCLUSION At a tertiary hernia center, despite higher-risk patients, larger hernia defects, and increased components separation in recurrent ventral hernia repairs, early recurrence rates, wound complications, and reoperations are similar to initial ventral hernia repairs.
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Affiliation(s)
- Jenny M Shao
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Eva B Deerenberg
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Sharbel A Elhage
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Tanu Prasad
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Bradley R Davis
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Kent W Kercher
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Elhage SA, Marturano MN, Deerenberg EB, Shao JM, Prasad T, Colavita PD, Kercher KW, Heniford BT, Augenstein VA. Impact of panniculectomy in complex abdominal wall reconstruction: a propensity matched analysis in 624 patients. Surg Endosc 2020; 35:5287-5294. [DOI: 10.1007/s00464-020-08011-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 09/16/2020] [Indexed: 01/20/2023]
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27
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Elhage SA, Shao JM, Deerenberg EB, Prasad T, Colavita PD, Kercher KW, Augenstein VA, Todd Heniford B. Laparoscopic Ventral Hernia Repair in the Geriatric Population : An Assessment of Long-Term Outcomes and Quality of Life. Am Surg 2020; 86:1015-1021. [PMID: 32856944 DOI: 10.1177/0003134820942149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Laparoscopic ventral hernia repair (LVHR) has been shown to decrease wound complications and length of stay (LOS) but results in more postoperative discomfort. The benefits of LVHR for the growing geriatric population are unclear. The aim of our study is to evaluate long-term outcomes and quality of life (QOL) after LVHR in the geriatric population. METHODS A prospectively collected single-center database was queried for all patients who underwent LVHR (1999-2019). Age groups were defined as <40 (young), 40-64 (middle age), and ≥65 years (geriatric). QOL was assessed with the Carolinas Comfort Scale. RESULTS LVHR was performed in 1181 patients, of which 13.4% were young, 61.6% middle aged, and 25.0% geriatric. Hernia defect size (64.2 ± 94.4 vs 79.9 ± 102.4 vs 84.7 ± 110.0 cm2) and number of comorbidities (2.2 ± 2.1 vs 3.2 ± 2.2 vs 4.3 ± 2.2) increased with age (all P < .05). LOS increased with age (2.9 ± 2.5 vs 3.8 ± 2.9 vs 5.2 ± 5.3 days, P < .0001). Rates of postoperative cardiac events, pneumonia, respiratory failure, wound complication, reoperation, and death were similar (P > .05). Geriatric patients had increased rate of ileus and urinary retention (all P < .05). Overall recurrence rate was 5.7% with an average follow-up of 43.5 months, with no differences in recurrence between groups (P > .05). Geriatric patients had better overall QOL at 2 weeks (P = .0008) and similar QOL at 1, 6, and 12 months. DISCUSSION LVHR offers excellent results in the geriatric population. Despite having increased rates of comorbidities and larger hernia defects, which may relate to LOS, rates of complications and recurrence were similar compared with younger cohorts, with better short-term QOL.
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Affiliation(s)
- Sharbel A Elhage
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Jenny M Shao
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Eva B Deerenberg
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Kent W Kercher
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Abstract
Umbilical hernia repair (UHR) is one of the most commonly performed hernia operations with reported recurrence rate from 1% to 54%. Our aim was to describe an open, laparoscopic-assisted (OLA) technique and its outcome in an institutional review board-approved prospective study at a tertiary hernia center from 2008 to 2019. All patients underwent a standard periumbilical incision, open dissection of the hernia, and closure of the fascial defect with laparoscopic intraperitoneal onlay mesh (IPOM) fixation with permanent tacks. A total of 186 patients were identified who underwent an OLA UHR repair. Patient characteristics are as follows: average age 52.8 ± 12.5 years, male gender 79.6%, body mass index 31.4 ± 8.0 kg/m2, and average hernia defect size of 2.8 ± 4.8 cm2. Forty-one (22.0%) patients had previous failed repair. Sixty-nine (37.1%) patients had another procedure performed at the time of the UHR, most commonly a laparoscopic transabdominal inguinal hernia repair (58%). The mean operative time was 87.3 ± 51.2 minutes, but only 63.9 ± 31.9 minutes for patients undergoing an OLA repair. There were no recurrences (0%) on abdominal physical or radiographic examination with an average follow-up of 16.5 ± 17.7 months. Postoperative complications included wound erythema (2.7%), hematomas (1.1%), seromas (2.7%), and 4.3% received postoperative oral antibiotics. One person was readmitted for seroma drainage, and another required reoperation for small bowel obstruction unrelated to the hernia repair. One patient had chronic pain requiring tack removal. With moderate follow-up, an OLA UHR with mesh appears to be a durable repair with favorable results, including those patients with recurrent hernias.
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Affiliation(s)
- Jenny M Shao
- Department of Minimally Invasive and Gastrointestinal Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Sharbel A Elhage
- Department of Minimally Invasive and Gastrointestinal Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Tanu Prasad
- Department of Minimally Invasive and Gastrointestinal Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Paul D Colavita
- Department of Minimally Invasive and Gastrointestinal Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Vedra A Augenstein
- Department of Minimally Invasive and Gastrointestinal Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Department of Minimally Invasive and Gastrointestinal Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Shao JM, Elhage SA, Prasad T, Gersin K, Augenstein VA, Colavita PD, Heniford BT. Best reoperative strategy for failed fundoplication: redo fundoplication or conversion to Roux-en-Y gastric diversion? Surg Endosc 2020; 35:3865-3873. [PMID: 32676728 DOI: 10.1007/s00464-020-07800-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution. METHODS A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed. RESULTS 180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m2 (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m2 and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001). CONCLUSIONS RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.
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Affiliation(s)
- Jenny M Shao
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Sharbel A Elhage
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Tanu Prasad
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Keith Gersin
- Atrium Health Weight Management, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA.
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Schlosser KA, Maloney SR, Thielan ON, Prasad T, Kercher KW, Augenstein VA, Heniford BT, Colavita PD. Sarcopenia in Patients Undergoing Open Ventral Hernia Repair. Am Surg 2020. [DOI: 10.1177/000313481908500940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Radiologic indicators of sarcopenia have been associated with adverse operative outcomes in some surgical populations. This study assesses the association of radiologic indicators of frailty with outcomes after open ventral hernia repair (OVHR). A prospective, institutional, herniaspecific database was queried for patients undergoing OVHR from 2007 to 2018 with preoperative CT. Psoas muscle cross-sectional area at L3 was measured and adjusted for height (skeletal muscle index (SMI)). L3 vertebral body density (L3 VBD) was measured. Demographics and outcomes were evaluated as related to SMI and L3 VBD. Of 1178 patients, 9.7 per cent of females and 15.8 per cent of males had sarcopenia and 11.6 per cent of females and 9.2 per cent of males had osteopenia. Neither sarcopenia nor osteopenia were associated with outcomes of wound infection, read-mission, reoperation, hernia recurrence, or major complications. When examined as continuous variables or by quartile, SMI and L3 VBD were not associated with adverse outcomes, including in subsets of male or female patients, the elderly, contaminated cases, and the obese. Radiologic markers of sarcopenia and osteopenia are not associated with adverse outcomes after OVHR. Further study should examine age or other potential predictors of outcomes in this patient population, such as independent status.
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Affiliation(s)
| | - Sean R. Maloney
- From the Carolinas Medical Center, Charlotte, North Carolina
| | - Otto N. Thielan
- From the Carolinas Medical Center, Charlotte, North Carolina
| | | | - Kent W. Kercher
- From the Carolinas Medical Center, Charlotte, North Carolina
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Williams KB, Bradley JF, Wormer BA, Zemlyak A, Walters AL, Colavita PD, Lincourt AE, Tsirline VB, Belyansky I, Heniford BT. Postoperative Quality of Life after Open Transinguinal Preperitoneal Inguinal Hernia Repair Using Memory Ring or Three-dimensional Devices. Am Surg 2020. [DOI: 10.1177/000313481307900819] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A transinguinal preperitoneal (TIPP) approach has become a common technique for inguinal hernia repair. Our goal was to compare the impact of the two mesh designs for this operation: a flat mesh with a memory ring device (MRD) or a three-dimensional device (3DD) containing both onlay and preperitoneal mesh components. The prospective International Hernia Mesh Registry (2007 to 2012) was queried for MRD and 3DD inguinal hernia repairs. Outcomes and patient quality of life (QOL), using the Carolinas Comfort Scale (CCS), were examined at 1, 6, 12, and 24 months. Standard statistical methods were used, and multivariate logistic regression was performed using a forward stepwise selection method. TIPP was performed in 956 patients. Their average age 57.4 ± 15.3 years, 94.0 per cent were male, and mean body mass index was 25.7 ± 3.2 kg/m2. MRD was used in 131 and 3DD in 825. Follow-up was 97, 82, 87, and 80 per cent at 1, 6, 12, and 24 months, respectively. Complications were not significantly different ( P > 0.05). Recurrence was 0.8 per cent for MRD and 2.1 per cent for 3DD ( P = 0.45). Comparing patient outcomes of MRD with 3DD at 1 month, 18.9 versus 11.5 per cent had symptoms of mesh sensation ( P = 0.02); 28.7 versus 14.8 per cent had movement limitations ( P < 0.01). MRD use was a significant independent predictor of movement limitation (odds ratio, 2.3; confidence interval, 1.4 to 3.7). No significant differences in CCS scores were seen at 6, 12, and 24 months. TIPP repair is safe and has a low recurrence rate. Early postoperative QOL is significantly improved with a 3DD mesh compared with MRD.
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Schlosser KA, Maloney SR, Gbozah K, Prasad T, Colavita PD, Augenstein VA, Heniford BT. The impact of weight change on intra-abdominal and hernia volumes. Surgery 2020; 167:876-882. [PMID: 32151368 DOI: 10.1016/j.surg.2020.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/05/2020] [Accepted: 01/14/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Weight loss is often encouraged or required before open ventral hernia repair. This study evaluates the impact of weight change on total, intra-abdominal, subcutaneous, and hernia volume. METHODS Patients who underwent open ventral hernia repair from 2007 to 2018 with two preoperative computed tomography scans were identified. Scans were reviewed using 3D volumetric software. Demographics, operative characteristics, and outcomes were evaluated. The impact of weight change on intra-abdominal, subcutaneous, and hernia volume was assessed using Spearman's correlation coefficients and linear regression models. RESULTS A total of 250 patients met the criteria with a mean defect area of 155.6 ± 155.4 cm2, subcutaneous volume of 6,800.0 ± 3,868.8 cm3, hernia volume of 915.7 ± 1,234.5 cm3, intra-abdominal volume equaling 4,250.2 ± 2,118.1 cm3, and time between computed tomography scans 13.9 ± 11.0 months. Weight change was associated with change in hernia, intra-abdominal, total, and subcutaneous volume (Spearman's correlation coefficients 0.17, 0.48, 0.51, 0.45, respectively, P ≤ 0.03 all values) and not associated in hernia length, width, or area (P ≥ 0.18 all values). A Δ5 kg was significantly associated with Δintra-abdominal volume (164.1 ± 30.0 cm3/Δ5 kg,P < .0001), Δtotal volume (209.9 ± 33.0 cm3/Δ5 kg, P < .0001), and Δsubcutaneous volume (234.4 ± 50.8 cm3/Δ5 kg, P < .0001). Per Δ5 kg, male patients had more than double the Δintra-abdominal, Δtotal, and Δsubcutaneous volume than did female patients. A weight change of 5 kg to10 kg was associated with approximately double the change in computed tomography parameters/Δ5 kg than any weight change after 10 kg. Regardless of weight change, all measured hernia parameters increased over time, with mean hernia volume of +40.6 ± 94.9 cm3/mo and area of +7.8 ± 13.3 cm2/mo (Spearman's correlation coefficient -0.03 to 0.07, P value 0.37-0.96). CONCLUSION Weight change is linearly correlated with intra-abdominal and subcutaneous fat gain or loss. Males show greater abdominal-related response to weight gain or loss. Hernia dimensions increase over time regardless of weight change.
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Affiliation(s)
- Kathryn A Schlosser
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Sean R Maloney
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Korene Gbozah
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Tanushree Prasad
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Schlosser KA, Maloney SR, Thielan O, Prasad T, Kercher K, Colavita PD, Heniford BT, Augenstein VA. Outcomes specific to patient sex after open ventral hernia repair. Surgery 2020; 167:614-619. [DOI: 10.1016/j.surg.2019.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/07/2019] [Accepted: 11/11/2019] [Indexed: 12/14/2022]
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Maloney SR, Dugan N, Prasad T, Colavita PD, Mckillop IH, Gersin KS, Kuwada T, Barbat S, Roberts A, Nimeri A. Correction to: Impact of age on morbidity and mortality following bariatric surgery. Surg Endosc 2020; 34:4193. [PMID: 32076855 DOI: 10.1007/s00464-020-07390-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This article was updated to correct the spelling of Nicholas Dugan's first name: it is correct as displayed here.
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Affiliation(s)
- Sean R Maloney
- Division of Gastrointestinal & Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Nicholas Dugan
- Divison of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, 2630 E. 7th Street, Charlotte, NC, 28204, USA
| | - Tanushree Prasad
- Division of Gastrointestinal & Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Paul D Colavita
- Division of Gastrointestinal & Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Iain H Mckillop
- Surgical Research, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith S Gersin
- Division of Gastrointestinal & Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.,Divison of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, 2630 E. 7th Street, Charlotte, NC, 28204, USA
| | - Timothy Kuwada
- Division of Gastrointestinal & Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.,Divison of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, 2630 E. 7th Street, Charlotte, NC, 28204, USA
| | - Selwan Barbat
- Divison of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, 2630 E. 7th Street, Charlotte, NC, 28204, USA
| | - Amanda Roberts
- Divison of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, 2630 E. 7th Street, Charlotte, NC, 28204, USA
| | - Abdelrahman Nimeri
- Division of Gastrointestinal & Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA. .,Divison of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, 2630 E. 7th Street, Charlotte, NC, 28204, USA.
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Schlosser KA, Maloney SR, Horton JM, Prasad T, Colavita PD, Heniford BT, Augenstein VA. The association of penicillin allergy with outcomes after open ventral hernia repair. Surg Endosc 2020; 34:4148-4156. [PMID: 32016513 DOI: 10.1007/s00464-019-07183-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/30/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Up to 11% of patients report a penicillin allergy (PA), with 1-2% demonstrating a true IgE mediated allergy upon testing. PA patients often receive non-beta-lactam antibiotic surgical prophylaxis (non-BLP). This study evaluates the relationship of PA to outcomes after open ventral hernia repair (OVHR). METHODS A prospective institutional database was queried for patients undergoing OVHR. Demographics, operative characteristics, and outcomes were evaluated by the reported PA and the administration of beta-lactam prophylaxis (BLP). RESULTS Allergy histories were reviewed in 1178 patients. PA was reported in 21.6% of patients, with 55.5% reporting rash or hives, 15.0% airway compromise or anaphylaxis, and 29.5% no specific reaction. BLP was administered to 76.3% of patients, including 22.1% of PA patients and 89.9% of patients without PA. PA patients were more often female (64.6% PA patients vs. 56% non-PA, p = 0.01), with higher rates of chronic steroids, MRSA, anxiety, asthma, COPD, chronic pain, and sleep apnea (p < 0.03 all values). PA patients had higher rates of contaminated cases, including mesh infection and fistula. Of the 683 clean cases, 82.1% received BLP. Of the 117 clean contaminated cases (CDC wound class 2), 82.9% received BLP, which was associated with reduced long-term readmission for hernia complications (21.5 vs. 55%, p = 0.002, OR 0.27, CI 0.09-0.83). In the 120 CDC wound class 3 and 4 patients, 65.8% received BLP. In multivariate analysis, BLP was associated with lower rates of reoperation (OR 0.31, CI 0.12-0.76) and recurrence (OR 0.32, CI 0.11-0.86). BLP was given to 22.1% of the PA patients with no adverse reactions noted. CONCLUSION PA patients had more comorbidities and complex ventral hernias. When controlling for contamination and MRSA history, BLP is associated with improved outcomes particularly in contaminated cases. PA may be a risk factor for patient complexity, and further studies are warranted to determine if allergy testing can be warranted in known or anticipated contaminated cases.
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Affiliation(s)
- Kathryn A Schlosser
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Sean R Maloney
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - James M Horton
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA. .,Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
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Schlosser KA, Maloney SR, Prasad T, Colavita PD, Augenstein VA, Heniford BT. Too big to breathe: predictors of respiratory failure and insufficiency after open ventral hernia repair. Surg Endosc 2019; 34:4131-4139. [PMID: 31637601 DOI: 10.1007/s00464-019-07181-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Increased intra-abdominal pressure in open ventral hernia repair (OVHR) is hypothesized to contribute to postoperative respiratory insufficiency (RI) or failure (RF). This study examines the impact of abdominal volumes on postoperative RI in OVHR. METHODS OVHR patients with preoperative CT scans were identified. 3D volumetric software measured hernia volume (HV), subcutaneous volume (SQV), and intra-abdominal volume (IAV). The ratio of hernia to intra-abdominal volume (HV:IAV) was calculated. A principal component analysis was performed to create new component variables for collinear volume and hernia variables. RESULTS There were 1178 OVHR patients with preoperative CT scans. Demographics included a mean BMI of 34.2 ± 7.7 kg/m2, age of 58.5 ± 12.4 years, and 57.8% were female. RI occurred in 8.3% of patients, including 4.0% requiring > 24 h respiratory support with ezPAP, CPAP, or biPAP (RI), and 4.3% requiring intubation (RF). Patients who developed RI had a higher BMI (33.8 ± 7.5 vs. 38.2 ± 9.1 kg/m2, p < 0.0001), older age (58.1 ± 12.5 vs. 62.8 ± 10.4 years, p = 0.0001), larger defects (140.9 ± 128.4 vs. 254.0 ± 173.9 cm2, p < 0.0001), HV (865.8 ± 1200.0 vs. 2005.6 ± 1791.7 cm3, p < 0.0001), and HV:IAV (0.26 ± 0.45 vs. 0.53 ± 0.58, p < 0.0001). Three PC variables accounted for 85% of variance: hernia volume PC consists primarily of HV (61.8%), ratio HV:IAV (57.7%), and defect size (50.1%) and accounts for 38.3% variance. Extra-abdominal volume PC consists primarily of SQV (63.7%) and BMI (60.8%) and accounts for 32.5% variance. Intra-abdominal volume PC is primarily IAV (75.8%) and accounts for 14.9% variance. In multivariate analysis, predictors of RI included asthma and COPD (OR 4.04, CI 1.82-8.96), hernia PC (OR 1.47, CI 1.48-1.98), EAV PC (OR 1.24, CI 1.04-1.48), increased age (OR 1.04, CI 1.01-1.06), and diabetes (OR 1.8, CI 1.11-2.91). Component separation, fascial closure, contamination, and panniculectomy were not associated with RI. CONCLUSION The impact of defect size, BMI, HV, SQV, IAV, and HV:IAV on respiratory insufficiency after OVHR is collinear. Patients with large defects and a large ratio of HV:IAV (greater than 0.5) are also at significantly increased risk of RI after OVHR. While BMI impacts these parameters, it is not directly predictive of postoperative RI.
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Affiliation(s)
- Kathryn A Schlosser
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Sean R Maloney
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Tanushree Prasad
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Department of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA. .,Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
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Maloney SR, Augenstein VA, Oma E, Schlosser KA, Prasad T, Kercher KW, Sing RF, Colavita PD, Heniford BT. The use of component separation during abdominal wall reconstruction in contaminated fields: A case-control analysis. Am J Surg 2019; 218:1096-1101. [PMID: 31630827 DOI: 10.1016/j.amjsurg.2019.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 10/06/2019] [Accepted: 10/10/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Component separation technique (CST) allows fascial medialization during abdominal wall reconstruction (AWR). Wound contamination increases the incidence of wound complications, which multiplies the incidence of repair failure. The aim of this study was to compare the impact of CST on AWR outcomes in contaminated fields in comparison to those operations without CST. METHODS A prospective, single institution hernia database was queried for patients undergoing AWR with CST and contamination. A case control cohort was identified using propensity score matching. RESULTS There were 286 CSTs performed in contaminated cases. After propensity score matching, 61 CSTs were compared to 61 No-CSTs. These groups were matched by defect area (CST:287.1 ± 150.4 vs No-CST:277.6 ± 218.4 cm2, p = 0.156), BMI (32.0 ± 7.0 vs 32.2 ± 6.0 kg/m2, p = 0.767), diabetes (26.2% vs 32.8%, p = 0.427), and panniculectomy (52.5% vs 36.1%, p = 0.068). Groups had similar rates of wound complications (42.6% vs 40.7%, p = 0.829) and recurrence (4.9% vs 13.1%, p = 0.114). CONCLUSIONS The use of CST in the face of contamination is not associated with an increase in wound complications, mesh complications, or recurrence.
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Affiliation(s)
- Sean R Maloney
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | - Erling Oma
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Tanushree Prasad
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Kent W Kercher
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Ronald F Sing
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Paul D Colavita
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Maloney SR, Schlosser KA, Prasad T, Kasten KR, Gersin KS, Colavita PD, Kercher KW, Augenstein VA, Heniford BT. Twelve years of component separation technique in abdominal wall reconstruction. Surgery 2019; 166:435-444. [DOI: 10.1016/j.surg.2019.05.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/29/2019] [Accepted: 05/01/2019] [Indexed: 10/26/2022]
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Schlosser KA, Maloney SR, Thielan ON, Prasad T, Kercher KW, Augenstein VA, Heniford BT, Colavita PD. Sarcopenia in Patients Undergoing Open Ventral Hernia Repair. Am Surg 2019; 85:985-991. [PMID: 31638511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Radiologic indicators of sarcopenia have been associated with adverse operative outcomes in some surgical populations. This study assesses the association of radiologic indicators of frailty with outcomes after open ventral hernia repair (OVHR). A prospective, institutional, hernia-specific database was queried for patients undergoing OVHR from 2007 to 2018 with preoperative CT. Psoas muscle cross-sectional area at L3 was measured and adjusted for height (skeletal muscle index (SMI)). L3 vertebral body density (L3 VBD) was measured. Demographics and outcomes were evaluated as related to SMI and L3 VBD. Of 1178 patients, 9.7 per cent of females and 15.8 per cent of males had sarcopenia and 11.6 per cent of females and 9.2 per cent of males had osteopenia. Neither sarcopenia nor osteopenia were associated with outcomes of wound infection, readmission, reoperation, hernia recurrence, or major complications. When examined as continuous variables or by quartile, SMI and L3 VBD were not associated with adverse outcomes, including in subsets of male or female patients, the elderly, contaminated cases, and the obese. Radiologic markers of sarcopenia and osteopenia are not associated with adverse outcomes after OVHR. Further study should examine age or other potential predictors of outcomes in this patient population, such as independent status.
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Kao AM, Ross SW, Otero J, Maloney SR, Prasad T, Augenstein VA, Heniford BT, Colavita PD. Use of computed tomography volumetric measurements to predict operative techniques in paraesophageal hernia repair. Surg Endosc 2019; 34:1785-1794. [DOI: 10.1007/s00464-019-06930-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
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Schlosser KA, Maloney SR, Prasad T, Augenstein VA, Heniford BT, Colavita PD. Mesh reinforcement of paraesophageal hernia repair: Trends and outcomes from a national database. Surgery 2019; 166:879-885. [PMID: 31288936 DOI: 10.1016/j.surg.2019.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/09/2019] [Accepted: 05/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Placement of paraesophageal type of "mesh" in paraesophageal hernia repair is controversial. This study examines the trends and outcomes of mesh placement in paraesophageal hernia repair. METHODS The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent paraesophageal hernia repair with or without mesh (2010-2017). Demographics, operative approach, and outcomes were compared over time. RESULTS Of 25,801, most paraesophageal hernia repair cases were elective (89.3%), without mesh (61.9%), and performed laparoscopically (91.3%).When compared with open paraesophageal hernia repair patients, the patients undergoing laparoscopic paraesophageal hernia repair had lesser rates of reoperation, readmission, mortality, overall complications and major complications (2.7% vs 4.8%, 6.2% vs 9.6%, 0.6% vs 2.9%, 7.1% vs 21.3%, 3.8% vs 11.1%, respectively; all P < .0001). Mesh placement was more common in laparoscopic paraesophageal hernia repair (38.9 vs 29.7, P < .0001) than opern paraesophageal hernia repair. During 2010-2017, mesh placement decreased from 46.2% to 35.2% of laparoscopic paraesophageal hernia repair (P < .0001). Operative times for laparoscopic paraesophageal hernia repair decreased over time, and laparoscpic paraesophageal hernia repair without mesh was consistently less (with mesh: 176.0 ± 71.0 to 149.9 ± 72.5 min, without mesh: 148.6 ± 71.4 to 134.6 ± 70.4). We observed no changes in comorbidities or adverse outcomes over time. Using multivariate analysis to control for potential confounding factors, chronic obstructive pulmonary disease was associated most strongly with adverse outcomes, including mortality (OR 2.53, CI 1.55-4.14), any complications (OR 1.80, CI 1.51-2.16), major complications (OR 1.80, CI 1.51-2.16), readmission (OR 1.63, CI 1.33-1.99) and reoperation (OR 1.49, CI 1.10-2.02). Mesh placement was not associated with adverse outcomes. CONCLUSION The placement of mesh during laparoscopic paraesophageal hernia repair is not associated with adverse outcomes. Use of mesh with laparoscopic paraesophageal hernia repair is decreasing with no apparent adverse impact on short-term patient outcomes. Further research is needed to investigate patient factors not captured by this national database, such as characteristics of the hernia, patient symptoms, and hernia recurrence.
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Maloney SR, Schlosser KA, Prasad T, Colavita PD, Kercher KW, Augenstein VA, Heniford BT. The impact of component separation technique versus no component separation technique on complications and quality of life in the repair of large ventral hernias. Surg Endosc 2019; 34:981-987. [DOI: 10.1007/s00464-019-06892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 06/04/2019] [Indexed: 11/29/2022]
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Kao AM, Schlosser KA, Arnold MR, Kasten KR, Colavita PD, Davis BR, Sing RF, Heniford BT. Trauma Recidivism and Mortality Following Violent Injuries in Young Adults. J Surg Res 2019; 237:140-147. [DOI: 10.1016/j.jss.2018.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/16/2018] [Accepted: 09/04/2018] [Indexed: 11/15/2022]
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Arnold MR, Schlosser KA, Otero J, Prasad T, Lincourt AE, Gersin KS, Heniford BT, Colavita PD. Laparoscopic Weight Loss Surgery in the Elderly: An ACS NSQIP Study on the Effect of Age on Outcomes. Am Surg 2019; 85:273-279. [PMID: 30947773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In an era of rising obesity and an aging population, there are conflicting data regarding outcomes of laparoscopic weight loss surgery in older Americans. The aim of this study was to characterize the short-term outcomes of laparoscopic weight loss surgery in the elderly. The ACS NSQIP database was queried for obese patients aged ≥40 years undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. Patients were subdivided into age groups: 40 to 49, 50 to 59, 60 to 64, 65 to 69, and ≥70 years, and compared with univariate and multivariate analyses. Fifty-three thousand five hundred thirty-three patients were identified. Roux-en-Y gastric bypass was performed in 57.5 per cent of cases and was more common than sleeve gastrectomy in all age groups (P < 0.05). Comorbidities increased significantly with increasing age. There was an increase in minor (4.6% vs 9.1%; P < 0.0001) and major complications (2.2% vs 6.3%; P < 0.0001), and 30-day mortality (0.1% vs 0.5%; P = 0.0001) between the 40 to 49 and ≥70 years age groups. Increased age was independently associated with major complications. Mortality also increased with age. Older patients undergoing laparoscopic weight loss surgery have increased morbidity and mortality. When controlling for comorbidities, increases in age continued to impact major and minor complications and mortality.
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Otero J, Arnold MR, Kao AM, Schlosser KA, Prasad T, Lincourt AE, Heniford BT, Colavita PD. Short-term Outcomes of Esophagectomies in Octogenarians—An Analysis of ACS-NSQIP. J Surg Res 2019; 235:432-439. [DOI: 10.1016/j.jss.2018.07.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/01/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
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Arnold MR, Schlosser KA, Otero J, Prasad T, Lincourt AE, Gersin KS, Heniford BT, Colavita PD. Laparoscopic Weight Loss Surgery in the Elderly: An ACS NSQIP Study on the Effect of Age on Outcomes. Am Surg 2019. [DOI: 10.1177/000313481908500331] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In an era of rising obesity and an aging population, there are conflicting data regarding outcomes of laparoscopic weight loss surgery in older Americans. The aim of this study was to characterize the short-term outcomes of laparoscopic weight loss surgery in the elderly. The ACS NSQIP database was queried for obese patients aged ≥40 years undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. Patients were subdivided into age groups: 40 to 49, 50 to 59, 60 to 64, 65 to 69, and ≥70 years, and compared with univariate and multivariate analyses. Fifty-three thousand five hundred thirty-three patients were identified. Roux-en-Y gastric bypass was performed in 57.5 per cent of cases and was more common than sleeve gastrectomy in all age groups ( P < 0.05). Comorbidities increased significantly with increasing age. There was an increase in minor (4.6% vs 9.1%; P < 0.0001) and major complications (2.2% vs 6.3%; P < 0.0001), and 30-day mortality (0.1% vs 0.5%; P = 0.0001) between the 40 to 49 and ≥70 years age groups. Increased age was independently associated with major complications. Mortality also increased with age. Older patients undergoing laparoscopic weight loss surgery have increased morbidity and mortality. When controlling for comorbidities, increases in age continued to impact major and minor complications and mortality.
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Affiliation(s)
- Michael R. Arnold
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kathryn A. Schlosser
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Javier Otero
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Tanu Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Amy E. Lincourt
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Keith S. Gersin
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - B. Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Paul D. Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Arnold MR, Wormer BA, Kao AM, Klima DA, Colavita PD, Cosper GH, Heniford BT, Schulman AM. Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial. Pediatr Surg Int 2018; 34:1257-1268. [PMID: 30218170 DOI: 10.1007/s00383-018-4343-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis. METHODS This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared. RESULTS Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001). CONCLUSION Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.
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Affiliation(s)
- Michael R Arnold
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Blair A Wormer
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Angela M Kao
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - David A Klima
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Paul D Colavita
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Graham H Cosper
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA.,Hemby Children's Hospital, Novant Health, 200 Hawthorne Ln., Charlotte, NC, 28204, USA.,Pediatric Surgical Associates, 1900 Randolph Road, Suite 210, Charlotte, NC, 28207, USA
| | - Brant Todd Heniford
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Andrew M Schulman
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA. .,Hemby Children's Hospital, Novant Health, 200 Hawthorne Ln., Charlotte, NC, 28204, USA. .,Pediatric Surgical Associates, 1900 Randolph Road, Suite 210, Charlotte, NC, 28207, USA.
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Arnold MR, Coakley KM, Fromke EJ, Groene SA, Prasad T, Colavita PD, Augenstein VA, Kercher KW, Heniford BT. Long-term assessment of surgical and quality-of-life outcomes between lightweight and standard (heavyweight) three-dimensional contoured mesh in laparoscopic inguinal hernia repair. Surgery 2018; 165:820-824. [PMID: 30449696 DOI: 10.1016/j.surg.2018.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/01/2018] [Accepted: 10/12/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mesh weight is a possible contributor to quality-of-life outcomes after inguinal hernia repair. This study compares lightweight mesh versus heavyweight mesh in laparoscopic inguinal hernia repair. METHODS A prospective, single-center, hernia-specific database was queried for all adult laparoscopic inguinal hernia repair with three-dimensional contoured mesh (3-D Max, Bard, Inc, New Providence, NJ) from 1999 to June 2016. Demographics and outcomes were analyzed. Quality of life was evaluated preoperatively and after 2 weeks, 4 weeks, 6 months, 12 months, and 24 months, using the Carolinas Comfort Scale. Univariate analysis and multivariate logistic regression were performed. RESULTS A total of 1,424 laparoscopic inguinal hernia repair were performed with three-dimensional contoured mesh, with 804 patients receiving lightweight mesh and 620 receiving heavyweight mesh. Patients receiving lightweight mesh were somewhat younger (52.6 ± 14.8 years vs 56.3 ± 13.7 years, P < .0001), with slightly lower body mass indices (26.4 ± 9.9 vs 27.1 ± 4.3, P < .0001). Lightweight mesh was used less often in incarcerated hernias (12.5% vs 16.8%, P = .02). There were a total of 3 surgical site infections. There were no differences in complications between groups except for seroma. Although on univariate analysis, seromas appeared to occur more frequently with heavyweight mesh (21.5% vs 7.9%). On multivariate analysis, heavyweight mesh was not independently associated with seroma formation. Average follow-up was 20 months. Recurrence rates were similar between lightweight mesh and heavyweight mesh (0.7 vs 0.6% P > .05). At all points of follow-up (4 week to 3 years), quality-of-life outcomes of discomfort, mesh sensation, and movement limitation scores were similar between lightweight mesh and heavyweight mesh. CONCLUSION Contoured lightweight mesh and heavyweight mesh in laparoscopic inguinal hernia repair yield excellent recurrence rates and no difference in postoperative complications or quality of life. Considering the lack of outcome difference with long-term follow-up, heavyweight mesh may be considered for use in laparoscopic inguinal hernia repair patients.
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Affiliation(s)
- Michael R Arnold
- Carolinas Medical Center, Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC
| | - Kathleen M Coakley
- Carolinas Medical Center, Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC
| | - Eric J Fromke
- Carolinas Medical Center, Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC
| | - Steve A Groene
- Carolinas Medical Center, Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC
| | - Tanu Prasad
- Carolinas Medical Center, Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC
| | - Paul D Colavita
- Carolinas Medical Center, Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC
| | - Vedra A Augenstein
- Carolinas Medical Center, Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC
| | - Kent W Kercher
- Carolinas Medical Center, Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC
| | - B Todd Heniford
- Carolinas Medical Center, Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Charlotte, NC.
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Schlosser KA, Arnold MR, Otero J, Prasad T, Lincourt A, Colavita PD, Kercher KW, Heniford BT, Augenstein VA. Deciding on Optimal Approach for Ventral Hernia Repair: Laparoscopic or Open. J Am Coll Surg 2018; 228:54-65. [PMID: 30359827 DOI: 10.1016/j.jamcollsurg.2018.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/06/2018] [Accepted: 09/14/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The decision to perform laparoscopic or open ventral hernia repair (VHR) is multifactorial. This study evaluates the impact of operative approach, BMI, and hernia size on outcomes after VHR. STUDY DESIGN The International Hernia Mesh Registry was queried for VHR (2007-2017). A predictive algorithm was constructed, factoring the impact of BMI, hernia size, age, sex, diabetes, and operative approach on outcomes. RESULTS Of the 1,906 VHRs, 58.8% were performed open, patient mean age was 54.9 ± 13.5 years, BMI was 31.2 ± 6.8 kg/m2, and defect area was 44.8 ± 88.1 cm2. Patients undergoing open VHRs were more likely to have an infection develop (3.1% vs 0.3%; p < 0.0001), but less likely to have a seroma develop (6.8% vs 15.3%; p < 0.0001) at mean follow-up 23.2 ± 12.0 months. With multivariate regression controlling for confounding variables, patients undergoing laparoscopic VHR had increased risk of seroma (odds ratio [OR] 1.78; 95% CI 1.05 to 3.03), a decreased risk of infection (OR 0.05; 95% CI 0.01 to 0.42), and had worse quality of life at 1, 6, 12, and 24 months postoperatively compared with patients undergoing open repair. Recurrent hernias were associated with subsequent recurrence (OR 2.69; 95% CI 1.24 to 5.81) and need for reoperation (OR 4.93; 95% CI 2.24 to 10.87). Multivariate predictive models demonstrated independent predictors of infection, including open approach, recurrent hernias, and low ratio of BMI to defect size. CONCLUSIONS Ideal outcomes are dependent on both patient and operative factors. Open repair in thin patients with large defects should be considered due to reduced complications and improved quality of life. Laparoscopic repair in obese patients and recurrent hernias can decrease the associated risk of infection.
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Affiliation(s)
- Kathryn A Schlosser
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Michael R Arnold
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Javier Otero
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Amy Lincourt
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Kent W Kercher
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Otero J, Cox TC, Huntington CR, Prasad T, Davis BR, Kasten KR, Kercher KW, Colavita PD, Augenstein VA, Heniford BT. Development of the Carolinas Equation for Determining Associated Risks Application and its Effects on Patient Outcomes and Potential Financial Savings in Open Ventral Hernia Repair. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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