Risk factors, outcomes, and complications associated with combined ventral hernia and enterocutaneous fistula single-staged abdominal wall reconstruction

PURPOSE

To compare two cohorts of patients; those with isolated ventral hernias (VH) and those with VH and enterocutaneous fistulas (ECF). Risk factors for surgical complications (including recurrent ECF) and outcomes during single-stage VH with ECF surgical reconstruction were analyzed.

METHODS

A retrospective review was performed from 2008 to 2019. We compared two cohorts of patients with single-stage VH repairs: (1) ventral hernia repair alone (hernia alone), and (2) combined VH repair and ECF repair (hernia plus ECF). Inclusion criteria were patients ≥ 18 years of age with pre-operative VH either with or without an ECF, who underwent open hernia repair and ECF repair in a single-stage operation, with a minimum follow-up of 12 months. Patient risk factors, operative characteristics, outcomes and surgical-site complications were compared using univariate and multivariate analyses.

RESULTS

We included 442 patients (hernia alone = 401; hernia plus ECF = 41) with a median follow-up of 22 months (12-96). Hernia plus ECF patients were more likely to have inflammatory bowel disease (IBD)(OR 4.4, 95% CI 1.1-17.5, p = 0.037), a history of abdominal wound infections (OR 3.4, 95% CI 1.5-7.9, p = 0.004), reoperations (OR 4.9, 95% CI 1.6-15.4, p = 0.006), superficial soft tissue infections (OR 2.5, 95% CI 1.1-6.1, p = 0.044) and hematomas (OR 8.4, 95% CI 1.2-58.8, p = 0.031), compared to hernia alone patients. ECF recurrence was associated with diabetes mellitus (DM) (n = 8, 73% vs. n = 6, 20%; p = 0.003) and surgical-site complications (n = 10, 91% vs. n = 16, 53%; p = 0.048), compared to ECF resolution.

CONCLUSION

Risk factors for developing ECF were IBD and history of abdominal wound infections. Single-staged combined ECF reconstruction was associated with reoperations, soft tissue infections and hematomas. DM and surgical-site complications were associated with ECF recurrence.

Acute kidney injury after open ventral hernia repair: an analysis of the 2005-2012 ACS-NSQIP datasets

PURPOSE

Acute kidney injury (AKI) is a serious postoperative complication, negatively impacting mortality rates, extending length of stay, and raising hospital costs. The purpose of this study was to examine AKI following open ventral hernia repair (OVHR) using a large, heterogeneous database to determine the incidence and identify risk factors for this complication.

METHODS

Using the 2005-2012 ACS-NSQIP database, patients undergoing open ventral hernia repair were identified by CPT codes. Patients with acute kidney injury within 30 days of surgery were compared to controls by multivariate logistic regression across preoperative and intraoperative characteristics.

RESULTS

Of 48,629 open ventral hernia repair patients identified in the dataset, AKI developed in 1.4% (681 patients). Multivariate logistic regression determined a number of factors associated with AKI. These include WHO Class III obesity (OR = 2.57, p < 0.001), history of cardiovascular disease (OR = 1.81, p < 0.001), diabetes (OR = 1.29, p = 0.028), hypoalbuminemia (OR = 1.42, p = 0.004), and chronic kidney disease (for a baseline GFR of 60-89 mL/min/1.73 m2, OR = 1.62, p = 0.001; for 30-59 mL/min/1.73 m2, OR = 2.25, p < 0.001; for 15-29 mL/min/1.73 m2, OR = 4.96, p < 0.001). Intraoperative factors include prolonged operative time (for ≥1 SD above the mean, OR = 1.68, p = 0.002; for ≥2SD above the mean, OR = 2.76, p < 0.001) and intraoperative transfusion (OR = 2.44, p < 0.001).

CONCLUSIONS

Patients with a history of obesity, chronic kidney disease, cardiovascular history, diabetes, and hypoalbuminemia are at increased risk for AKI when undergoing OVHR. Intraoperative variables such as prolonged operative times and blood transfusions may also suggest increased risk. Preoperative identification of patients with these characteristics and perioperative hemodynamic stabilization are important first steps to minimize this complication.

Quadrimembral amputation: indications and contraindications for vascularized composite allotransplantation

INTRODUCTION

Quadrimembral amputees, as patients who have lost both upper and lower extremities, may benefit greatly from hand transplantation. The objective of this study is to evaluate the indications and contraindications for transplantation in this subset of patients.

METHODS

A retrospective review was conducted of five quadrimembral amputees evaluated by our program for transplantation. Information collected included age, sex, level of amputations, time since amputations, etiology, level of dependence, medical stability, psychosocial status, and the ability to tolerate immunosuppression. Indications and contraindications for transplantation were reviewed for each patient.

RESULTS

All etiologies were based in extremity ischemia: three from septic shock, one from myocardial infarction, and one from drug overdose. All patients are completely dependent. Of the five patients, two needed further reconstructive surgery and two others had a history of resolved hepatic/renal insufficiency. After thorough evaluation, two patients were selected as potential transplant candidates. They demonstrated strong psychosocial support systems, a thorough understanding of hand transplantation, along with its risks and postoperative requirements. They had also completed a full regimen of rehabilitation along with prosthetic fitting and utilization.

CONCLUSIONS

Clearance for transplantation is based on medical stability, absence of infection or systemic diseases, and strong psychosocial support systems. Contraindications for transplantation are drug dependence and noncompliant behavior. Relative contraindications include a history of hepatic/renal insufficiency which if not resolved may preclude the use of postoperative immunosuppression.

Gamma probe-confirmed laparoscopic accessory splenectomy

The simultaneous occurrence of idiopathic thrombocytopenic purpura (ITP) and Hodgkin's disease in the same patient is uncommon. There have been only a limited number of reported cases of newly diagnosed ITP following Hodgkin's disease. Even more uncommon is the development of ITP after splenectomy for Hodgkin's disease. Of the reported cases of ITP following splenectomy for Hodgkin's disease, all have been successfully treated with medical therapy. We report an unusual case of an accessory spleen causing ITP in a patient who had undergone a splenectomy for Hodgkin's disease 10 years earlier. The patient underwent hand-held gamma-probe-assisted laparoscopic accessory splenectomy.

Inhibition of alcohol dehydrogenase blocks enhanced Gi-protein expression following ethanol treatment in experimental hepatocellular carcinoma in vitro

OBJECTIVE

Chronic alcohol abuse is one of the major contributors to the onset and progression of hepatocellular carcinoma (HCC). We have previously identified increased expression and function of inhibitory guanine nucleotide regulatory proteins (Gi-proteins) in primary human and animal models of HCC. Stimulation of Gi-proteins in HCC stimulates cell mitogenesis, an effect not observed in hepatocytes. The aim of this study was to determine the effect of ethanol and ethanol metabolism on Gi-protein expression in an experimental model of HCC.

DESIGN

Pharmacological agents that inhibit alcohol metabolism were used in conjunction with ethanol or ethanol metabolites. We were also able to assess the relative contribution of alcohol and acetaldehyde, the major metabolite of alcohol, on Gi-protein expression in HCC and hepatocytes.

METHODS

These studies used the rat hepatic tumorigenic H4IIE cell line in conjunction with isolated rat hepatocytes. Cells were cultured in vitro and exposed to ethanol, ethanol in the presence of an alcohol dehydrogenase (ADH) inhibitor, or acetaldehyde for varying lengths of time. Ethanol metabolism and changes in Gi-protein expression were subsequently determined by assay.

RESULTS

Exposure to ethanol alone led to significant dose and time dependent increases in Gialpha1/2 and Gialpha3 protein and mRNA expression in HCC cells. In contrast, ethanol failed to alter Gialpha1/2, and only moderately affected Gialpha3 protein expression in isolated cultured hepatocytes. Pretreatment of HCC cells and hepatocytes with 4-methyl pyrazole (4-MP, 10 microm) significantly inhibited alcohol metabolism. Treatment of HCC cells with 4-MP inhibited changes in Gi-protein expression following exposure to ethanol (25 mm, 24 h). In addition, the increased expression of Gi-proteins observed after exposure to ethanol in HCC were mimicked by direct exposure of HCC cells to acetaldehyde in a dose and time dependent manner.

CONCLUSIONS

These data suggest that alcohol metabolites, not alcohol, lead to increased Gi-protein expression in HCC in vitro. Ethanol and ethanol metabolites, in contrast, fail to significantly alter Gialpha1/2 protein expression in hepatocytes. These data may have significant implications in HCC progression in vivo.