Sex-based differences in inguinal hernia factors

BACKGROUND

Much of our knowledge about inguinal hernias is based on males. Meanwhile, it is established that women have worse outcomes after inguinal hernia repair, with more chronic pain and higher recurrences. Pediatric literature shows inguinal hernias in females are more likely to be bilateral, incarcerated, and carry a stronger genetic predisposition than males. We aimed to evaluate sex-based differences in inguinal hernia factors in adults, to help supplement the paucity of literature in the adult population.

METHODS

An institutional database of patients undergoing repair of primary inguinal hernias was queried with focus on preoperative risk factors and operative characteristics. Multivariate analysis was performed looking for independent variables associated with a greater number of hernia defects found intraoperatively.

RESULTS

Among 494 patients, 202 (40.9%) were female. Number of risk factors among females was significantly higher than males (1.53 vs 1.2, p = 0.003). Females had significantly more constipation, GERD, and asthma and lower BMI than males. Family history of hernias was similar between both sexes. As expected, females had significantly less direct hernias (12.9% vs 32.9%, p < 0.001) and more femoral hernias (38.5% vs 12.2%, p < 0.001) than males. Bilaterality was similar. Females undergoing inguinal hernia repair averaged 1.23 prior deliveries. Regression analysis showed age, sex, BMI, and number of deliveries were not correlated with the number of defects.

CONCLUSIONS

Females undergoing primary inguinal hernia repair had more preoperative risk factors for inguinal hernia than males. In our population, there was no higher incidence of bilaterality or significant genetic predisposition in females as noted by family history of hernias. Age, sex, BMI and number of deliveries did not correlate with the number of hernia defects found. Our study promotes awareness of inguinal hernias in females and presents new data to quantify sex-based differences and predispositions to inguinal hernias.

New Traditional Chinese Medicine Supplement Reduces Pain Faster than Conventional Pain Pills Alone: A Phase I/II Prospective, Double-Blinded Placebo-Controlled Randomized Trial

BACKGROUND

The opioid crisis demands novel solutions for postoperative pain control. Traditional Chinese medicine (TCM) has used herbs for the treatment of pain for thousands of years. We studied whether a synergistic multimodal TCM supplement could reduce the need for conventional pain pills for low risk surgical procedures.

METHODS

In a Phase I/II, prospective, double-blind, placebo-controlled, randomized clinical trial (PRCT), 93 patients were randomized to either TCM supplement or placebo oral medication for low-risk outpatient surgical procedures. Study medications began 3 days preoperatively and continued for 5 days postoperatively. Conventional pain pill use was not restricted. Patients were monitored postoperatively for all forms of pain pill use (Pain Pill Scoring Sheet) and subjective pain ratings (Brief Pain Inventory Short Form). Primary outcomes included type and number of pain pills used and subjective pain ratings. Secondary outcomes included an assessment of mood, general activity, sleep, and enjoyment of life.

RESULTS

TCM use well tolerated. Conventional pain pill use was similar between groups. Linear regression analysis revealed that TCM reduced postoperative pain 3 times faster than placebo (P < .0001) with a 4-fold greater magnitude of relief by postoperative day 5 (P = .008). TCM also significantly improved sleep habits (P = .049) during the postoperative period. TCM effect was independent of type of surgery or amount of preoperative pain.

DISCUSSION

This PRCT is the first to show that a multimodal, synergistic TCM supplement is safe and can effectively reduce acute postoperative pain more rapidly, and to a lower level, than conventional pain pills alone.

Patients With Systemic Reaction to Their Hernia Mesh: An Introduction to Mesh Implant Illness

In our practice, we have noticed an increased number of patients requiring mesh removal due to a systemic reaction to their implant. We present our experience in diagnosing and treating a subpopulation of patients who require mesh removal due to a possible mesh implant illness (MII). All patients who underwent mesh removal for indication of mesh reaction were captured from a hernia database. Data extraction focused on the patients' predisposing medical conditions, presenting symptoms suggestive of mesh implant illness, types of implants to which reaction occurred, and postoperative outcome after mesh removal. Over almost 7 years, 165 patients had mesh removed. Indication for mesh removal was probable MII in 28 (17%). Most were in females (60%), average age was 46 years, with average pre-operative pain score 5.4/10. All patients underwent complete mesh removal. Sixteen (57%) required tissue repair of their hernia; 4 (14%) had hybrid mesh implanted. Nineteen (68%) had improvement and/or resolution of their MII symptoms within the first month after removal. We present insight into a unique but rising incidence of patients who suffer from systemic reaction following mesh implantation. Predisposing factors include female sex, history of autoimmune disorder, and multiple medical and environmental allergies and sensitivities. Presenting symptoms included spontaneous rashes, erythema and edema over the area of implant, arthralgia, headaches, and chronic fatigue. Long-term follow up after mesh removal confirmed resolution of symptoms after mesh removal. We hope this provides greater attention to patients who present with vague, non-specific but debilitating symptoms after mesh implantation.

Expert Consensus for Key Features of Operative Reports of Ventral Hernia

BACKGROUND

Operative reports are important documents; however, standards for critical elements of operative reports are general and often vague. Hernia surgery is one of the most common procedures performed by general surgeons, so the aim of this project was to develop a Delphi consensus on critical elements of a ventral hernia repair operative report.

STUDY DESIGN

The Delphi method was used to establish consensus on key features of operative reports for ventral hernia repair. An expert panel was selected and questionnaires were distributed. The first round of voting was open-ended to allow participants to recommend what details should be included. For the second round the questionnaire was distributed with the items that did not have unanimous responses along with free text comments from the first round.

RESULTS

Eighteen surgeons were approached, of which 11 completed both rounds. Twenty items were on the initial questionnaire, of which 11 had 100% agreement. Of the remaining 9 items, after the second questionnaire an additional 7 reached consensus.

CONCLUSION

Ventral hernia repairs are a common and challenging problem and often require reoperations. Surgeons frequently refer to previous operative notes to guide future procedures, which requires detailed and comprehensive operative reports. This Delphi consensus was able to identify key components needed for an operative report describing ventral hernia repair.

An anti-inflammatory bundle may help avoid opioids for low-risk outpatient procedures

BACKGROUND

Currently, over half of drug overdose deaths are due to opioids. Opioid alternatives may be prescribed to help curb the opioid epidemic. However, little is known about their efficacy for acute postoperative pain.

METHODS

We studied patients who underwent low-risk outpatient surgery. Perioperatively, all patients were started on an anti-inflammatory bundle consisting of multimodal pain remedies. Opioids were available to the patients postoperatively. Pain scores and opioid use were recorded.

RESULTS

Over 18 months, 120 patients underwent low-risk outpatient surgery and all used the anti-inflammatory bundle. All patients had a significant decrease in postoperative pain scores (p = 0.001). There was no significant difference in postoperative pain scores between those who followed the anti-inflammatory bundle alone and those who also used opioids (mean 2.2 vs 3.1/10). Twenty-five (21%) patients were using opioids preoperatively and 50 (42%) postoperatively. Of those using opioids preoperatively, six (24%) patients used the anti-inflammatory bundle alone and avoided opioids postoperatively.

CONCLUSIONS

For 58% of our patients, an anti-inflammatory bundle alone provided adequate pain control after a low-risk outpatient operation, such as hernia repair. Our practice uses the anti-inflammatory bundle for all patients. Our goal is to reduce both the need for opioids and the surgeon's contribution to the opioid epidemic.

OC-008 TRENDS IN INGUINAL HERNIA REPAIR: A TAILORED APPROACH

Aim

Inguinal hernias (IH) can be repaired via open, laparoscopic, and robotic approaches, with or without mesh. We aim to understand the changing trends in IH repair that may serve as a guideline toward a tailored approach for hernia repair.

Materials & Methods

All patients undergoing primary IH repair from 2009–2021 by a single surgeon at a specialty hernia center were included. Temporal differences were evaluated using Chi-squared, Fisher's exact test, and logistic linear regression.

Results

Over 12 years, 533 patients underwent primary IH repair. Most were males (59.1%), average age 51.7 years, and average BMI 26.6 kg/m2. IHs were repaired via open (28.3%) or minimally invasive (MIS) approaches (71.7%), either with (93.4%) or without mesh (6.6%).

Trends showed a significant increase in females undergoing IH repair (p&lt;0.001) and increase in MIS approach (p&lt;0.001). There was a significant decrease in open approach (p&lt;0.001) and an overall trend away from mesh-based repairs and toward tissue-based repairs (p&lt;0.001).

Conclusions

We present our hernia specialty center's best practices for IH repair, which is a result of a tailored approach. Our 12-year study shows a significant trend toward the use of MIS approach for IH repair. This is aligned with international consensus guidelines, especially for females. While mesh use remains the standard of care in the US, we show a progressive and significant trend away from the overuse of mesh in IH, especially for females.

OC-020 INCISIONAL HERNIA REPAIR WITH MESH REIMAGINED: PILOT STUDY USING ABDOMINOPLASTY AS PERMANENT AUTOLOGOUS BIOLOGICAL REINFORCEMENT IN HERNIA REPAIR

Aim

EHS consensus recommends mesh implantation for all incisional hernia (IH) repairs, regardless of size. We propose considering abdominoplasty in the algorithm for IH repairs wherein the plicated fascia functions as a permanent autologous biologic onlay repair over the primary repair of the IH.

Materials & Methods

Four patients with midline IHs underwent abdominoplasty. Their IHs were first closed primarily with #2–0 permanent suture. Next, a two-layer anterior plication of the overlying fascia was performed with permanent suture. No mesh was implanted. Patients were followed up post operatively to monitor for hernia recurrence.

Results

All patients were female with average age 51 years. All had at least one midline IH (1cm-1.7cm wide). Three (75%) had recurrent IHs. Three (75%) had diastasis recti. Patients were followed at 1 year, with no (0%) recurrence.

Conclusion

Abdominoplasty may be a safe and effective alternative for IH repair compared to traditional mesh-based repair. In effect, the patient's own plicated fascia functions as a permanent autologous biologic onlay reinforcement to the IH repair. Meanwhile, the plication may reduce tension off the primary defect closure, thus reducing recurrence. Our pilot study in small IHs showed no hernia recurrence one-year postoperatively after abdominoplasty. Thus, abdominoplasty may serve as an alternative surgical option to a subset of patients with IH. We aim to judiciously expand indications for abdominoplasty for IH repair to address wider defects in select candidates. We hope our experience will supplement the current algorithm for IH repairs by providing a non-mesh alternative.

Outcomes from laparoscopic versus robotic mesh removal after inguinal hernia repair

INTRODUCTION

Preperitoneally placed mesh for inguinal hernia repair may require removal to address hernia recurrence, mesh reaction, meshoma, or other chronic pain. These are best approached either laparoscopically or robotically, but there is no consensus on which is the best approach for mesh removal nor are there any studies to evaluate and compare their outcomes.

METHODS

All patients who underwent inguinal mesh removal via laparoscopic and robotic approaches from 2011 to 2020 were analyzed. Data regarding demographics, preoperative, intraoperative, and postoperative outcomes were collected.

RESULTS

Over 9 years, 62 patients underwent 24 laparoscopic and 50 robotic operations. Laparoscopic cases had a shorter operative time by a mean of 55 min (p = 0.02). There were no differences in intraoperative complications or postoperative outcomes between the two groups. Patients in both groups showed significant improvement after mesh removal (p = 0.02, p < 0.01) within 2 weeks postoperatively and at long-term follow up (p < 0.01, p < 0.01).

CONCLUSION

It is our experience that both laparoscopic and robotic approaches are viable options for removal of retroperitoneally placed inguinal mesh. Operative time with the laparoscopic approach was significantly shorter than the robotic approach. Patients on average had significant reduction in their preoperative pain, regardless of the approach. Minimally invasive mesh removal is a technically challenging operation, with risk of vascular and nerve injuries regardless of the approach. These findings demonstrate that both modalities are safe and effective with experienced surgeons.

Risks of therapeutic versus prophylactic neurectomies

INTRODUCTION

Neuralgia due to a peripheral nerve injury may result in chronic pain, requiring a therapeutic surgical neurectomy. Meanwhile, some neurectomies are performed prophylactically, such as during inguinal mesh removal. Outcomes and risks associated with neurectomies are largely unknown despite consensus panels recommending them.

METHODS

All patients who underwent neurectomy 2013-2020 were analyzed. Data collection included demographics, preoperative symptoms, and postoperative outcomes. Indications for neurectomy were categorized as "therapeutic" if the patient had preoperative neuralgia or "prophylactic" if neurectomy was deemed necessary intra-operatively.

RESULTS

66 patients underwent 80 operations and a total of 122 neurectomies. On average, 1.5 neurectomies were performed per operation. Therapeutic neurectomies were performed in 42 (64%) patients and prophylactic in 34 (52%). The most commonly transected nerve was the ilioinguinal nerve. Average preoperative pain score was 5.8/10. On paired analysis, there was a significant reduction in pain after prophylactic neurectomy (2.5 points, p = 0.002) but not after therapeutic neurectomy. None of the nerves transected prophylactically had postoperative neuralgia, whereas 35% of the nerves transected therapeutically resulted in persistent or recurrent neuralgia (p < 0.001). To treat this, 21% required only nerve blocks and 9% required ablation or reoperative neurectomy. Three patients had complex regional pain syndrome (CRPS), a severe complication; all three were diagnosed with chronic pain syndrome pre-operatively.

DISCUSSION

We demonstrate that prophylactic neurectomy is largely safe. In contrast, a therapeutic neurectomy had a 35% risk of persistent or recurrent neuralgia, 9% required additional ablative or reoperative neurectomy. Three patients advanced from chronic pain syndrome to CRPS. We recommend the decision to perform a neurectomy be judicious and selective, especially in patients with known chronic pain syndrome. Prior to planning surgical neurectomy, other less invasive modalities should be exhausted and patients should be aware of its risks.

Surgical Society Podcasts: A Novel Way to Engage and Educate the Community

BACKGROUND

Podcasts are increasingly being utilized in the surgical field as an asynchronous educational resource. This article discusses podcasts devoted to the field of surgery and their growing contribution to surgical education.

METHODS

We provide examples of current podcasts and their varied structures, including those that distribute clinical and educational content, discuss recent literature and advancements, interview leaders in the field, and/or showcase unique perspectives on topics such as career development, diversity, and wellness.

RESULTS AND CONCLUSIONS

Podcasts generated from surgical societies stand on unique ground to educate and engage the surgical community.

Leveraging Twitter and its Unique #HashTag Capability: A Novel Social Media Resource From the European Hernia Society

Background: Digital and Social Media (#SoMe) platforms have revolutionized the way information is shared, classified and accessed among medical professionals worldwide. The aim of this study was to review the hashtags used on Twitter by @EuroHerniaS to provide a practical roadmap for easier social media utilization for hernia surgery stakeholders. Methods: The hashtags used in tweets and retweets of the @EuroHerniaS Twitter feed were collated since its foundation in November 2016. Results: The first hashtag used was #HerniaSurgery. Since foundation to July 2021, the @EuroHerniaS Twitter feed has used 90 separate hashtags. The number of new hashtags per year was increasing leading to the development of an online library. The increasing diversity of hernia related hashtags allows for the more detailed posting and searching of hernia related information on the #SoMe platform Twitter. Conclusion: The more detailed use of hashtags on Twitter is to be encouraged. Hernia surgeons can make use of them both when posting and reviewing posts to aid the categorization of posts.

P084 MESH USE IN THE UNITED STATES: MESH TYPES AND THEIR INDICATIONS

Aim

Synthetic non-absorbable mesh repair is considered standard of care for most hernias in the United States (US). The introduction of biologic absorbable mesh in the 2000’s has changed this practice and now novel synthetic absorbable and hybrid meshes are available. We aim to describe US trends of mesh use.

Material and Methods

We surveyed the Abdominal Core Health Quality Collaborative database for all repairs using mesh from 2012 to 2021. Mesh types and indications were analysed.

Results

Among 47,555 patients who underwent hernia repair with mesh, the majority were with synthetic non-absorbable meshes (96%). Absorbable mesh was placed in 2,039 (4%) patients and included biologic absorbable (893, 44%), synthetic absorbable (1,070, 52%), and hybrid (76, 4%) meshes. Synthetic non-absorbable mesh use was significantly predominant in all wound classes, including dirty/contaminated wounds (P &lt; 0.01) [Figure 1]. Over time, we noted a trend toward lower incidence of absorbable and hybrid mesh use, from 18% to 2% (P &lt; 0.01). Interestingly, we noted a relative increase in annual incidence of absorbable and hybrid mesh use in clean wounds, from 20% to 63% (P &lt; 0.01) [Figure 2]. Figure 1Mesh type used in each wound classFigure 2Absorbable mesh use in clean vs. not clean wounds.

Conclusions

In the United States, synthetic non-absorbable meshes are commonly used during hernia repairs in dirty and contaminated fields. At the same time, there is a significant increase in the use of absorbable and hybrid meshes in the repair of hernias with clean wound classification. The costs and long-term outcomes of such surgeon choices have yet to be validated.

Diagnostic techniques for diastasis recti

Diastasis recti (DR) is an abnormality of the anterior abdominal wall, characterized by a separation of the rectus abdominis muscles along the linea alba. A thorough history and physical exam can diagnose most cases of diastasis recti. Classification schemes for diastasis recti have been created based on inter-rectus distance and location of the defect, which can help with management decisions. Imaging modalities such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can aid in the classification of diastasis recti and guide surgical planning. Planning is most important when contemplating the plan of care for the repair of hernias within a rectus diastasis.

#Mesh: Social Media and Its Influence on Perceptions in Hernia Repair

Social media can influence public perception in health care. By 2016, social media discussion against the use of transvaginal mesh influenced changes in Food and Drug Administration (FDA) regulations. We propose that the fate of hernia mesh will follow that of transvaginal mesh. Thus, we compare the trend of social media discussion of hernia and transvaginal mesh. Posts on Twitter and public Facebook groups were tracked for keywords "hernia," "hernia mesh," and "pelvic/vaginal mesh." Posts were categorized based on sentiment. On Facebook, 16 public groups with 14 526 members expressed negative sentiments in 95% of their 750 daily posts. Meanwhile, of the 1.1 million tweets on Twitter, those about hernia mesh were more negative (36.5%) than those about pelvic/vaginal mesh (29.2%). Three of the 5 top tweeters about hernia mesh and pelvic/vaginal mesh were linked to law firms involved in mesh-based lawsuits. The negative sentiments and steering of social media discussion by lawyers may directly affect surgical care. As surgeons, we may adapt our informed consent to acknowledge our patients' apprehensions about mesh. We may also be more involved in social media discussions ourselves. Meanwhile, we await FDA decisions in the regulation and availability of hernia mesh.

Thou shalt not trust online videos for inguinal hernia repair techniques

BACKGROUND

Videos are used by surgeons when learning new techniques; however, online videos are often not vetted. Our aim is to review online videos of laparoscopic inguinal hernia repairs based on a benchmark for critical view of the myopectineal orifice (MPO) and safe inguinal hernia repair as defined by Daes and Felix and commonly referred to as "the 9 Commandments."

METHODS AND MATERIALS

YouTube^Ⓡ was queried for "laparoscopic inguinal hernia repair." The top 50 videos were ranked based on number of views. Those endorsed and/or vetted by surgical societies were excluded (n = 4). Three expert hernia surgeons scored the videos based on adherence to the 9 Commandments.

RESULTS

The 50 videos originated from 11 countries. They had 72,825 mean views and a mean runtime of 14 min. Videos obeyed a median of 77.8% of commandments shown. Eight videos (16%) obeyed all 9 (100%) commandments. Three videos (6%) failed to obey any commandments. Operations employed TEP (18, 36%), TAPP (28, 56%), and rTAPP (4, 8%) approach. Stratification by approach showed significant variance in commandments obeyed (Kurskal-Wallis, p = 0.016) with significant difference between TEP and rTAPP scores (p = 0.008) and no significant difference between TEP and TAPP or rTAPP and TAPP scores. Twenty-three videos (46%) displayed unsafe techniques including: threatened critical structures (16, 32%), rough tissue handling (15, 30%), and dangerous placement of fixation (9, 18%).

CONCLUSION

Online surgical videos on YouTube are not reliable in demonstrating best practices for minimally invasive inguinal hernia repairs. In our study, only 16% of the most viewed videos followed all 9 Commandments for critical view of the MPO. Many showed suboptimal repairs with significant safety concerns. While a significant number of online videos are a free and readily available resource for surgeons around the world, we recommend caution in relying on non-vetted videos as a form of surgical education.

Robotic iliopubic tract (r-IPT) repair: technique and preliminary outcomes of a minimally invasive tissue repair for inguinal hernia

PURPOSE

The iliopubic tract repair was first introduced by Nyhus in 1959, as an open non-mesh posterior preperitoneal repair for inguinal hernia. We have adapted this repair using a robotic approach to offer a minimally invasive (MIS) non-mesh inguinal hernia repair, termed the robotic iliopubic tract (r-IPT) repair. The aim of this pilot study is to evaluate the safety and effectiveness of this new technique.

METHODS

Starting in 2015, patients were enrolled in a Phase I trial of r-IPT repair. Inclusion criteria included low-risk patients with small inguinal hernias. Using a robotic TAPP approach, the direct and/or indirect defects were repaired by approximating the transversalis arch to the iliopubic tract. This trial was then expanded in Phase II to include a wider range of patients. Outcomes were collected prospectively.

RESULTS

Twenty-four inguinal hernias were repaired in 13 patients via r-IPT as outpatients. Patients were followed for a mean of 24.9 months (range 2.7-55.3, median 24). There were no surgical site occurrences and no recurrences. One (7.7%) patient had acute post-operative genital branch neuralgia, which self-resolved. One (7.7%) patient has chronic pain.

CONCLUSION

The Nyhus-inspired robotic iliopubic tract (r-IPT) repair is an MIS approach to provide a non-mesh repair in inguinal hernia. The repair is safe with acceptable preliminary outcomes in low-risk patients. We propose the r-IPT repair to be a MIS option for non-mesh inguinal hernia repair in low-risk patients.

Acronyms Use in Abdominal Wall Reconstruction: Introduction to a New Language

BACKGROUND

The use of acronyms in medicine is widespread, aiming to simplify and condense communication. Online communication in social media platforms seems to enhance the use of acronyms, but their efficiency in message delivery may be negated by their abundance and unfamiliarity, causing more confusion than clarity. We analyzed the use of acronyms in a closed Facebook group dedicated to abdominal wall reconstruction (AWR), as the rapid recent development of this field has resulted in many new acronyms. Our aim was to classify the different acronyms and create a public reference.

METHODS

The International Hernia Collaboration, a hernia-related Facebook group, now communicating more than 7500 surgeons from 99 countries, was studied, by extracting acronyms used since its inception in 2012. Acronyms were categorized and interpreted, to create a small dictionary comprised of several tables.

RESULTS

Commonly used acronyms were identified, as well as commonly used prefixes that modify the acronyms' meaning. Tables were created, classifying acronyms by their subject: 1.Anatomy2.Diseases and clinical conditions3.Techniques and materials.

CONCLUSION

The use of acronyms increased in social media-based communication. Aiming to simplify the language, the inflation of terms may have achieved the opposite, by adding a multitude of unfamiliar and confusing terms. We have created a public reference for AWR-related acronyms. Limiting the liberal creation of new acronyms is recommended, especially in a rapidly changing field as AWR.

Current Trends in the Management of Iatrogenic Cervical Carotid Artery Injuries

This study was undertaken to elicit the opinion of experts regarding the management of iatrogenic injury to the carotid artery. A text questionnaire was transmitted by electronic mail to members of the Western Vascular Society concerning management of iatrogenic injury to the cervical carotid artery. Participants were asked to submit information regarding practice status and their preferred choices for the management of different clinical scenarios. The scenarios were: (1) large bore sheath (> 8.5F) cannulation of the carotid artery in anesthetized patients, (2) large bore sheath cannulation of the carotid artery in an awake patient, (3) delayed recognition of a misplaced sheath by > 4 hours, and (4) arterial puncture was recognized after only the entry needle (16-gauge) was introduced but before sheath insertion. Finally, the members were asked to comment on the management of abnormal findings on duplex scanning, such as intimal flap or pseudoaneurysm. A response rate of 42% was obtained (45/106 active members). Eighty-two percent of respondents had been in practice for longer than 10 years. Eighty-nine percent had seen this complication and 29% had cared for patients in whom subsequent neurologic deficit developed. The institutional incidence of such injury was 1-5 cases per year for 82% of respondents. Sixteen-gauge needle injury was managed by immediate removal and applied pressure by 98% of respondents. When large-bore sheath injury is recognized within 1 hour of insertion, 62% of respondents would remove the sheath and hold pressure, with or without obtaining a duplex ultrasound examination. However, if injury recognition was delayed for > 4 hours, 82% would proceed to surgery. Only 26% operated on asymptomatic carotid flap found on ultrasound, while the remaining 74% would base their decision on size and flow characteristics on ultrasound. The management of pseudoaneurysm differed significantly. Whereas 31% of respondents would manage this finding expectantly, 69% would proceed to surgery regardless of size or symptoms. Despite awareness of iatrogenic injury to the cervical carotid artery, the institutional incidence remains high. Two thirds of respondents would manage a misplaced sheath in the carotid artery nonoperatively if the injury was recognized immediately. However, if injury recognition was delayed for > 4 hours, the majority of respondents would remove the sheath surgically. While the management of intimal flap largely depended on size and flow characteristics, 69% of respondents would operate on a pseudoaneurysm regardless of size or symptoms. The results of this survey may serve as a guideline for the management of this potentially devastating injury.

Criteria for definition of a complex abdominal wall hernia

PURPOSE

A clear definition of "complex (abdominal wall) hernia" is missing, though the term is often used. Practically all "complex hernia" literature is retrospective and lacks proper description of the population. There is need for clarification and classification to improve patient care and allow comparison of different surgical approaches. The aim of this study was to reach consensus on criteria used to define a patient with "complex" hernia.

METHODS

Three consensus meetings were convened by surgeons with expertise in complex abdominal wall hernias, aimed at laying down criteria that can be used to define "complex hernia" patients, and to divide patients in severity classes. To aid discussion, literature review was performed to identify hernia classification systems, and to find evidence for patient and hernia variables that influence treatment and/or prognosis.

RESULTS

Consensus was reached on 22 patient and hernia variables for "complex" hernia criteria inclusion which were grouped under four categories: "Size and location", "Contamination/soft tissue condition", "Patient history/risk factors", and "Clinical scenario". These variables were further divided in three patient severity classes ('Minor', 'Moderate', and 'Major') to provide guidance for peri-operative planning and measures, the risk of a complicated post-operative course, and the extent of financial costs associated with treatment of these hernia patients.

CONCLUSION

Common criteria that can be used in defining and describing "complex" (abdominal wall) hernia patients have been identified and divided under four categories and three severity classes. Next step would be to create and validate treatment algorithms to guide the choice of surgical technique including mesh type for the various complex hernias.

When it is not a Spigelian Hernia: Abdominal Cutaneous Nerve Entrapment Syndrome

Abdominal wall pain at the linea semilunaris is classically the result of a Spigelian hernia. If no hernia is detected, these patients may be left with chronic pain without a diagnosis or treatment. A retrospective review was performed of patients presenting with abdominal wall pain at the linea semilunaris between 2009 and 2012. Of the 14 patients, three (21%) were diagnosed with a Spigelian hernia confirmed by imaging. The remaining patients were eventually diagnosed with abdominal cutaneous nerve entrapment syndrome (ACNES). The average delay in diagnosis was 4 years with patients with ACNES suffering twice as long with chronic pain. Patients with a Spigelian hernia and ACNES had different demographics and presenting complaints. Physical examination findings were nondiagnostic. Of the patients with ACNES, five (50%) had resolution of pain with serial nerve blocks alone; another five proceeded to surgical neurectomy with resolution of their pain. Thus, to prevent delay in diagnosis and treatment, patients with chronic abdominal wall pain at the linea semilunaris should first be ruled out for Spigelian hernia. Then, they should be evaluated and treated for ACNES.

When it is not a Spigelian hernia: abdominal cutaneous nerve entrapment syndrome

Abdominal wall pain at the linea semilunaris is classically the result of a Spigelian hernia. If no hernia is detected, these patients may be left with chronic pain without a diagnosis or treatment. A retrospective review was performed of patients presenting with abdominal wall pain at the linea semilunaris between 2009 and 2012. Of the 14 patients, three (21%) were diagnosed with a Spigelian hernia confirmed by imaging. The remaining patients were eventually diagnosed with abdominal cutaneous nerve entrapment syndrome (ACNES). The average delay in diagnosis was 4 years with patients with ACNES suffering twice as long with chronic pain. Patients with a Spigelian hernia and ACNES had different demographics and presenting complaints. Physical examination findings were nondiagnostic. Of the patients with ACNES, five (50%) had resolution of pain with serial nerve blocks alone; another five proceeded to surgical neurectomy with resolution of their pain. Thus, to prevent delay in diagnosis and treatment, patients with chronic abdominal wall pain at the linea semilunaris should first be ruled out for Spigelian hernia. Then, they should be evaluated and treated for ACNES.

Outreach in surgery at the undergraduate level: an opportunity to improve surgical interest among women?

Medical career choice is often formed at the premedical level, thus surgeons must reach out to undergraduates to enhance interest in surgery. Because there is a predominance of women among undergraduates (57%), this outreach also serves as an opportunity to introduce women to a surgical career. We developed an undergraduate course ("Surgery 99") offering course credit for participation in clinical research projects in surgery, shadowing surgeons in the operating room, and receiving mentorship for a surgical career. Six surgeons (50% women) served as course instructors. The final exam was a thesis with oral presentation. For enrollment, 132 students applied and 13 were accepted each quarter. Eleven students (85%) were women. None of the students had prior exposure to surgery. All but one student (93%) found the experience met or exceeded their expectations. Upon exit, knowledge attained was ranked highest, followed by observation in the operating room, and clinical research experience. All found that the course affirmed their decision to attend medical school and promoted their interest in surgery residency. We demonstrate a successful model for outreach in surgery at the undergraduate level that can positively influence interest in a surgical career, especially among women.

Outreach in Surgery at the Undergraduate Level: An Opportunity to Improve Surgical Interest among Women?

Medical career choice is often formed at the premedical level, thus surgeons must reach out to undergraduates to enhance interest in surgery. Because there is a predominance of women among undergraduates (57%), this outreach also serves as an opportunity to introduce women to a surgical career. We developed an undergraduate course (“Surgery 99”) offering course credit for participation in clinical research projects in surgery, shadowing surgeons in the operating room, and receiving mentorship for a surgical career. Six surgeons (50% women) served as course instructors. The final exam was a thesis with oral presentation. For enrollment, 132 students applied and 13 were accepted each quarter. Eleven students (85%) were women. None of the students had prior exposure to surgery. All but one student (93%) found the experience met or exceeded their expectations. Upon exit, knowledge attained was ranked highest, followed by observation in the operating room, and clinical research experience. All found that the course affirmed their decision to attend medical school and promoted their interest in surgery residency. We demonstrate a successful model for outreach in surgery at the undergraduate level that can positively influence interest in a surgical career, especially among women.

Significant reduction of wound infections with daily probing of contaminated wounds: a prospective randomized clinical trial

HYPOTHESIS

Local wound management using a simple wound-probing protocol (WPP) reduces surgical site infection (SSI) in contaminated wounds, with less postoperative pain, shorter hospital stay, and improved patient satisfaction.

DESIGN

Prospective randomized clinical trial.

SETTING

Academic medical center.

PATIENTS

Adult patients undergoing open appendectomy for perforated appendicitis were enrolled from January 1, 2007, through December 31, 2009.

INTERVENTIONS

Study patients were randomized to the control arm (loose wound closure with staples every 2 cm) or the WPP arm (loosely stapled closure with daily probing between staples with a cotton-tipped applicator until the wound is impenetrable). Intravenous antibiotic therapy was initiated preoperatively and continued until resolution of fever and normalization of the white blood cell count. Follow-up was at 2 weeks and at 3 months.

OUTCOME MEASURES

Wound pain, SSI, length of hospital stay, other complications, and patient satisfaction.

RESULTS

Seventy-six patients were enrolled (38 in the WPP arm and 38 in the control arm), and 49 (64%) completed the 3-month follow-up. The patients in the WPP arm had a significantly lower SSI rate (3% vs 19%; P = .03) and shorter hospital stays (5 vs 7 days; P = .049) with no increase in pain (P = .63). Other complications were similar (P = .63). On regression analysis, only WPP significantly affected SSI rates (P = .02). Age, wound length, body mass index, abdominal circumference, and diabetes mellitus had no effect on SSI. Patient satisfaction at 3 months was similar (P = .69).

CONCLUSIONS

Surgical site infection in contaminated wounds can be dramatically reduced by a simple daily WPP. This technique is not painful and can shorten the hospital stay. Its positive effect is independent of age, diabetes, body mass index, abdominal girth, and wound length. We recommend wound probing for management of contaminated abdominal wounds.

A multicentre, open-label, randomized comparative study of tigecycline versus ceftriaxone sodium plus metronidazole for the treatment of hospitalized subjects with complicated intra-abdominal infections

Tigecycline (TGC) has demonstrated clinical efficacy and safety, in comparison with imipenem/cilastatin in phase 3 clinical trials, for complicated intra-abdominal infection (cIAI). The present study comprised a multicentre, open-label, randomized study of TGC vs. ceftriaxone plus metronidazole (CTX/MET) for the treatment of patients with cIAI. Eligible subjects were randomized (1:1) to receive either an initial dose of TGC (100 mg) followed by 50 mg every 12 h or CTX (2 g once daily) plus MET (1-2 g daily), for 4-14 days. The primary endpoint was the clinical response in the clinically evaluable (CE) population at the test of cure (TOC) assessment. Of 473 randomized subjects, 376 were CE. Among these, clinical cure rates were 70.4% (133/189) with TGC vs. 74.3% (139/187) with CTX/MET (95% CI -13.1 to 5.1; p 0.009 for non-inferiority). Clinical cure rates for subjects with Acute Physiological and Chronic Health Evaluation II scores > or =10 were 56.8% (21/37) with TGC vs. 58.3% (21/36) with CTX/MET. The microbiologic response was similar between the two treatment arms, with microbiological eradication at TOC achieved in 68.1% (94/138) of TGC-treated subjects and 71.5% (98/137) of CTX/MET-treated subjects. (The most frequently reported adverse events (AEs) for both treatment arms were nausea (TGC, 38.6% vs CTX/MET, 27.7%) and vomiting (TGC, 23.3% vs CTX/MET, 17.7%). Overall discontinuation rates as a result of an AE were 8.9% and 4.8% in TGC- and comparator-treated subjects, respectively. The results obtained in the present study demonstrate that TGC monotherapy is non-inferior to a combination regimen of CTX/MET with respect to treating subjects with cIAI.

A new and standardized approach for trocar placement in laparoscopic Roux-en-Y gastric bypass

INTRODUCTION

Super-morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) present unique technical challenges. In our experience the ease of the operation and the operative time seem to be more dependent on body habitus than body mass index (BMI). We hypothesized that the distance between the xyphoid process and the umbilicus (the XU distance) correlated with surgical difficulty and described an original modification of trocar placement based on this measurement to improve the ease of the operation.

METHODS

Seven hundred and seventy-four patients underwent LRYGB, and the XU distance was measured in a subset of 38 patients midway through the experience. The need for additional trocars was assessed intraoperatively and the relationship between the XU distance and the need for extra trocars was subsequently analyzed. A standardized approach for trocar placement was implemented in the second half of our series. The operative time was compared between the standardized and nonstandardized groups.

RESULTS

Fifty percent of the patients required a five-trocar technique. Median XU distance in this group was 21.4 cm (range 17-25 cm). In the remaining 19 patients additional trocars were added; median XU distance was 27.3 cm (range 24-33 cm). From the 774 patients included in the study period, the operative time for the first 322 patients who were completed with a nonstandardized trocar approach was significantly longer than the subsequent 452 cases in which the standardized trocar approach was used (210 versus 173 min, p < 0.001).

CONCLUSIONS

We define XU distance as the key element in determining the choice of trocar placement. When XU distance is less then 25 cm, the basic approach should be used and if it is greater than 25 cm, the advanced trocar approach is recommended. This standardized technique leads to decreased operative time and improved ease of operation.

Obesity should not influence the management of appendicitis

BACKGROUND

Obesity implies an adverse effect on outcome after appendectomy. This study aimed to determine whether obese patients with appendicitis should be managed differently than nonobese patients.

METHODS

After appendectomy, all patients were enrolled in a prospective clinical pathway and followed from initial presentation to full outpatient recovery.

RESULTS

In 1 year, 272 adults underwent appendectomy, 55 (22%) of whom were obese. The obese patients were slightly older (35 vs 33 years; p < 0.001). The time to diagnosis (8.5 vs 8.6 h), and the need for computed tomography (CT) scanning (40% vs 49%) was similar in both populations. The obese patients had similar rates of perforation (35% vs 35%) and laparoscopy (47% vs 41%). The median hospital length of stay (LOS) (2 days) and complications, including wound complications (9.1% vs 10.9%) and intraabdominal abscesses (3.6% vs 3.1%), were similar. Subgroup analysis showed a longer LOS for the obese patients with perforation than for the nonobese patients (6 vs 5.5 days; p = 0.036).

CONCLUSION

Obese patients had no greater delay in diagnosis, had no greater need for CT scan, gained no additional benefit from laparoscopy, and did not incur significantly worse outcomes after appendectomy except for an increased LOS among those with perforation.

Breast Abscess Bacteriologic Features in the Era of Community-Acquired Methicillin-Resistant Staphylococcus aureus Epidemics

HYPOTHESIS

Increasing rates of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections have also affected the microbial profile of breast abscesses.

OBJECTIVE

To update the decade-old bacteriologic description of breast abscesses to improve the choice of initial antibacterial drug therapy.

DESIGN

Retrospective case series.

SETTING

County hospital emergency department.

PATIENTS

Forty-four women (mean age, 41 years; age range, 20-63 years) with breast abscesses.

METHODS

All cultures from the breast abscesses of patients were reviewed.

MAIN OUTCOME MEASURES

The microbiologic features and sensitivities of breast abscesses.

RESULTS

Of 46 specimens only 28 showed bacterial yield (61%). Of these, 11 (39%) were polymicrobial, for an average of 1.4 isolates per specimen. The most common organism was S aureus, present in 12 of 37 aerobic cultures (32%), with MRSA in 7 (58%). The remaining organisms included coagulase-negative Staphylococcus (16%), diphtheroids (16%), Pseudomonas aeruginosa (8%), Proteus mirabilis (5%), and other isolates (22%). All MRSA was sensitive to clindamycin, trimethoprim-sulfamethoxazole, and linezolid. Only 2 patients (29%) were sensitive to levofloxacin. Two anaerobic cultures were positive for Propionibacterium acnes and Peptostreptococcus anaerobius.

CONCLUSIONS

Staphylococcus aureus is the most common pathogenic organism in modern breast abscesses. Many breast abscesses have community-acquired MRSA, with more than 50% of all S aureus and 19% of all cultures being MRSA. This finding parallels the local and national increases in MRSA reported in other soft-tissue infections. With increasing bacterial resistance and more minimally invasive management of breast abscesses, understanding the current bacteriologic profile of these abscesses is essential to determining the correct empirical antibiotic drug therapy.

Hyperbilirubinemia in appendicitis: a new predictor of perforation

This study examines the relationship between hyperbilirubinemia and appendicitis. It was hypothesized that an association exists between the presence of appendiceal perforation and hyperbilirubinemia. Patients with liver function tests on admission and pathologically confirmed appendicitis were included in the study. Age, duration of symptoms, temperature, white blood cell counts, systemic inflammatory response score, and bilirubin levels were independent variables in a logistic regression analysis assessing factors predicting the presence or absence of appendiceal gangrene/perforation. Elevated total bilirubin levels (>1 mg/dl) were found in 59 (38%) of 157 patients. Patients with gangrene/perforation were significantly (p = 0.004) more likely to have hyperbilirubinemia than those with acute suppurative appendicitis. No statistical differences were observed for any of the other variables. On logistic regression the only significant relationship between the presence or absence of appendiceal gangrene and perforation was the presence of hyperbilirubinemia (p = 0.031, 95% confidence interval 1.11-7.6). The odds of appendiceal perforation are three times higher (odds ratio 2.96) for patients with hyperbilirubinemia compared to those with normal bilirubin levels. Hyperbilirubinemia is frequently associated with appendicitis. Elevated bilirubin levels have a predictive potential for the diagnosis of appendiceal perforation.

The use of cognitive task analysis to improve the learning of percutaneous tracheostomy placement

OBJECTIVE

The purpose of the current study was to determine the effectiveness of using cognitive task analysis (CTA) to develop a curriculum to teach the behavioral skills and the cognitive strategies of a percutaneous tracheostomy (PT) placement.

METHODS

Postgraduate 2, 3, and 4 general surgery residents were randomly assigned to either the CTA group (N = 9) or the control group (N = 11). The CTA group was taught percutaneous tracheostomy placement using the CTA curriculum. The control group received the traditional curriculum.

RESULTS

The CTA group performed significantly higher on the PT procedure at 1 month (CTA: 43.5 +/- 3.7, control 35.2 +/- 3.9, P = .001) and at 6 months post-instruction (CTA: 39.4 +/- 4.2, control: 31.8 +/- 5.8, P = .004). In addition, the CTA group demonstrated superior cognitive strategies than the control group (CTA: 25.4 +/- 5.3, control: 19.2 +/- 2.0, P = .004).

CONCLUSIONS

The use of CTA was effective in improving the cognitive processes and technical skills of performing a PT for surgical residents.

A Surgical Skills Elective Can Improve Student Confidence Prior to Internship

BACKGROUND

A focused surgical resident readiness curriculum for senior medical students can improve confidence in surgical skills compared to current surgical interns.

MATERIALS AND METHODS

A 3-week surgical skills lab elective enrolled senior medical students applying to surgical residency programs, with the purpose of improving surgical skills and easing anxiety prior to surgical internship. Students were surveyed before and after the elective regarding their confidence in performing 21 skills covered by the curriculum. A similar confidence survey was administered to the incoming surgical intern class. Interns were also surveyed regarding prior skills lab instruction during medical school. Statistical analyses included Student's paired t-test and two-way analysis of variance.

RESULTS

Six medical students and 23 interns were surveyed. All medical students significantly improved their confidence by the end of the resident readiness curriculum (P = 0.0004). Although students initially had lower confidence than surgical interns in performing surgical skills and in their knowledge of anatomy prior to the course, their confidence after the course was significantly higher than that of the incoming surgical interns (P = 0.035). Surgical interns with prior skills lab experience in their medical school reported higher confidence than those who did not have a skills lab experience (P = 0.019). Among all subgroups, medical students with skills lab experience had the highest confidence score, followed by interns with previous skills lab experience, then by interns with no previous skills lab experience, and last, by medical student with no skills lab experience.

CONCLUSION

Surgical interns often feel unprepared to perform skills necessary for residency. A focused skills lab elective during medical school can bridge the gap and improve confidence prior to internship.

Laparoscopic appendectomy significantly reduces length of stay for perforated appendicitis

INTRODUCTION

Though ruptured appendicitis is not a contraindication to laparoscopic appendectomy (LA), most surgeons have not embraced LA as the first-line approach to ruptured appendicitis. In fact, in 2002, the Cochrane Database Review concluded: 1) the clinical effects of LA are "small and of limited clinical relevance," and 2) the effects of LA in perforated appendicitis require further study.

OBJECTIVE

To study the effects of LA vs open appendectomy (OA) among adults with appendicitis.

METHODS

In 2003, 272 adults underwent appendectomy at a large County hospital, and were enrolled in a prospective clinical pathway that detailed their hospital course from time of diagnosis to discharge. Data included patient demographics, time elapse from diagnosis to surgery, surgical technique (LA vs. OA), operative diagnosis (acute vs perforated appendicitis) and post-operative length of stay (LOS).

RESULTS

Complete data was obtained for 264 (97%) patients. Patient demographics were similar in the LA and OA groups (p > 0.05). Patients with LA had a significantly shorter LOS than OA by 1.6 days (p < 0.05). This LOS was significantly shorter among those with ruptured appendicitis vs. non-ruptured appendicitis (2.0 days vs. 0.3 day reduction, p = 0.0357). Rank-order multiple regression analysis, controlling for all other factors, showed laparoscopy to have a significant effect on postoperative LOS in all appendicitis cases, especially ruptured appendicitis.

CONCLUSIONS

The two-day reduction in LOS among those with ruptured appendicitis who underwent LA was significant enough to overcome the smaller benefit of LA in acute appendicitis. From a hospital utilization point of view, LA should be considered as the first-line approach for all patients with appendicitis.

Laparoscopic versus open appendectomy: a prospective randomized double-blind study

SUMMARY BACKGROUND DATA

The value of laparoscopy in appendicitis is not established. Studies suffer from multiple limitations. Our aim is to compare the safety and benefits of laparoscopic versus open appendectomy in a prospective randomized double blind study.

METHODS

Two hundred forty-seven patients were analyzed following either laparoscopic or open appendectomy. A standardized wound dressing was applied blinding both patients and independent data collectors. Surgical technique was standardized among 4 surgeons. The main outcome measures were postoperative complications. Secondary outcome measures included evaluation of pain and activity scores at base line preoperatively and on every postoperative day, as well as resumption of diet and length of stay. Activity scores and quality of life were assessed on short-term follow-up.

RESULTS

There was no mortality. The overall complication rate was similar in both groups (18.5% versus 17% in the laparoscopic and open groups respectively), but some early complications in the laparoscopic group required a reoperation. Operating time was significantly longer in the laparoscopic group (80 minutes versus 60 minutes; P = 0.000) while there was no difference in the pain scores and medications, resumption of diet, length of stay, or activity scores. At 2 weeks, there was no difference in the activity or pain scores, but physical health and general scores on the short-form 36 (SF36) quality of life assessment forms were significantly better in the laparoscopic group. Appendectomy for acute or complicated (perforated and gangrenous) appendicitis had similar complication rates, regardless of the technique (P = 0.181).

CONCLUSIONS

Unlike other minimally invasive procedures, laparoscopic appendectomy did not offer a significant advantage over open appendectomy in all studied parameters except quality of life scores at 2 weeks. It also took longer to perform. The choice of the procedure should be based on surgeon or patient preference.

Use of Serum Bicarbonate Measurement in Place of Arterial Base Deficit in the Surgical Intensive Care Unit

HYPOTHESIS

Serum bicarbonate (HCO(3)) measurement may accurately and reliably be substituted for the arterial base deficit (BD) assay in the surgical intensive care unit (ICU).

DESIGN

Retrospective criterion standard analysis.

SETTING

Surgical ICU in a tertiary care facility.

PATIENTS

Consecutive sample of non-trauma-related surgical ICU admissions from January 1996 to January 2004 with simultaneously obtained serum HCO(3) and arterial BD levels.

MAIN OUTCOME MEASURES

Correlation between HCO(3) and BD at admission and during the ICU stay; predictive value of serum HCO(3) for significant metabolic acidosis and ICU mortality.

RESULTS

The study included 2291 patients with 26 063 sets of paired laboratory data. The mean +/- SD age was 52 +/- 16 years and mean ICU stay was 5.8 +/- 9.8 days. There were 174 ICU deaths (8%). Serum HCO(3) levels showed significant correlation with arterial BD levels both at admission (r = 0.85, R(2) = 0.72, P<.001) and throughout the ICU stay (r = 0.88, R(2) = 0.77, P<.001). Serum HCO(3) reliably predicted the presence of significant metabolic acidosis (BD > 5) with an area under the receiver operating characteristic curve (AUC) of 0.93 at admission and 0.95 overall (both P<.001), outperforming pH (AUC, 0.80), anion gap (AUC, 0.70), and lactate (AUC, 0.70). The admission serum HCO(3) level predicted ICU mortality as accurately as the admission arterial BD (AUCs of 0.68 and 0.70, respectively) and more accurately than either admission pH or anion gap.

CONCLUSIONS

Serum HCO(3) provides equivalent information to the arterial BD and may be used as an alternative predictive marker or guide to resuscitation. Low HCO(3) levels should prompt immediate metabolic acidosis evaluation and management.

Peptide YY exhibits a mitogenic effect on pancreatic cells while improving acute pancreatitis in vitro

BACKGROUND

Peptide YY (PYY), a gastrointestinal regulatory peptide, improves survival and histologic parameters in animal models of acute pancreatitis. Its effects on pancreatic cell growth and acute pancreatitis in pancreatic acinar and ductal cells are unknown. We hypothesized that PYY would affect cell growth and attenuate acute pancreatitis in pancreatic acinar and ductal cells in vitro.

METHODS

Rat pancreatic acinar and ductal cells were cultured in the presence of 1) cerulein, a synthetic cholecystokinin analog that induces pancreatitis, 2) PYY, or 3) a combination group pretreated with PYY prior to addition of cerulein. Cell survival was measured at 48 h using MTT assay. Amylase secretion, as marker for pancreatitis, was measured at 48 h using an amylase activity assay. Statistical significance was calculated using analysis of variance and the Student's t test.

RESULTS

Peptide yy significantly increased cell growth and decreased amylase secretion compared with control and cerulein groups. Pretreatment with PYY significantly protected against the pancreatitis effects of cerulein.

CONCLUSIONS

We have shown for the first time that PYY has a mitogenic effect on pancreatic acinar and ductal cells in vitro. In addition, it directly protects against cerulein-induced pancreatitis. Its potential therapeutic benefit in acute pancreatitis would therefore be twofold: amelioration of the inflammatory process, and augmenting growth of normal pancreas to replace necrotic or apoptotic cell loss.

Outcomes from Peptic Ulcer Surgery Have Not Benefited from Advances in Medical Therapy

Given the advancements in medical treatment of peptic ulcer disease such as Helicobacter pylori eradication and proton-pump inhibitors, we sought to assess their impact on the need for surgical intervention. Patients who underwent peptic ulcer surgery between 1981 and 1998 were evaluated in a retrospective chart review from a tertiary-care hospital (n = 222). The number of operations performed for peptic ulcers decreased annually (24 vs 11.3). Seventy-seven per cent of all cases were done urgently; most were performed for acute perforated ulcers. The overall 30-day mortality rate was 13 per cent, which remained unchanged over the past two decades. The highest mortality rate (82%) was in the transplanted population (n = 11). Our institutional experience demonstrates that despite the lower volume of patients requiring operative management a greater percentage of these patients are presenting with urgent need for surgery. Also despite the aggressive endoscopic management of acutely bleeding ulcers there was no change in the percentage of patients taken to the operating room for uncontrollable hemorrhage. Improvements in medical management of peptic ulcer disease have decreased the surgical volume; nevertheless we show a rising proportion of urgent operations performed annually, and mortality remains high.

Outcomes from peptic ulcer surgery have not benefited from advances in medical therapy

Given the advancements in medical treatment of peptic ulcer disease such as Helicobacter pylori eradication and proton-pump inhibitors, we sought to assess their impact on the need for surgical intervention. Patients who underwent peptic ulcer surgery between 1981 and 1998 were evaluated in a retrospective chart review from a tertiary-care hospital (n = 222). The number of operations performed for peptic ulcers decreased annually (24 vs 11.3). Seventy-seven per cent of all cases were done urgently; most were performed for acute perforated ulcers. The overall 30-day mortality rate was 13 per cent, which remained unchanged over the past two decades. The highest mortality rate (82%) was in the transplanted population (n = 11). Our institutional experience demonstrates that despite the lower volume of patients requiring operative management a greater percentage of these patients are presenting with urgent need for surgery. Also despite the aggressive endoscopic management of acutely bleeding ulcers there was no change in the percentage of patients taken to the operating room for uncontrollable hemorrhage. Improvements in medical management of peptic ulcer disease have decreased the surgical volume; nevertheless we show a rising proportion of urgent operations performed annually, and mortality remains high.